COLUMBIA LIBRARIES OFFSITE ^i-.^lf-.-^ STArjDAR r>r»«. . HX64062481 RD31 L591 1910 Glneralsurgeryapr Columbia ^nibersiitp v , intfjeCitpofiBtetoliorfe ^-!^0 College of ^tJPsficiansi anb burgeons 3^titxtntt Hitiratp "\ GENERAL SURGERY // PRESENTATION OF THE SCIENTIFIC PRINCIPLES UPON WHICH THE PRACTICE OF MODERN SURGERY IS BASED BY ERICH LEXER, M.D. PROFESSOR OF SURGERY, UNIVERSITY OF KONIOSBESO AMERICAN EDITION EDITED BY ARTHUR DEAN BEVAN, M.D. PROFESSOR AND HEAD OF THE DEPARTMENT OF SUROERY, RUSH MEDICAL COLLEGE IN AFFILIATION WITH THE UNIVERSITY OF CHICAGO AN AUTHORIZED TRANSLATION OF THE SECOND GERMAN EDITION BY DEAN LEWIS, M.D. ASSISTANT PROFESSOR OF SURGERY, RISH MEDICAL COLLEGE IN AFFILIATION WITH THE UNIVERSITY OF CHICAGO WITH FOUR ifUNDRED AND FORTY-NINE ILLUSTRATIONS IN THE TEXT, PARTLY IN COLOR, AND TWO COLORED PLATES D. APPLE TON AND COMPANY NEW YORK AND LONDON 1910 Copyright, 1908, 1910, by D. APPLETON AND COMPANY PRINTED AT THE APPLETON PRESS NEW Y'ORK, U. S. A. PREFACE My associate, Dr. Lewis, and myself have undertaken the translating and editing of this text-book on General Surgery, written by Prof. Erich Lexer, because we believe that it presents the present status of the subject of general surgery in a more thorough and complete way than any other text-book. This work is a presentation of the scientific principles upon which the practice of modern surgery is based. In text-books on surgery in all languages two great divisions of the subject are made, and to these two divisions of the subject various names have been given. In England and America, the terms the Science and Art of Surgery and the Principles and Practice of Surgery have been generally employed. On the Continent, the terms General and Special Surgery are used. These latter seem to me preferable, and we have therefore retained the term General Surgery in our American edition of Professor Lexer's work, and hope that this may be adopted by the American and English profession. There are certain general principles of pathology and thera- peutics and operative technic which apply to all fields of surgery, and when these are thoroughly mastered by the student or practitioner their application to special surgical conditions becomes at once intelligent and easy and scientific. For him who lacks this knowledge the practice of surgery becomes a handicraft. The subject of General Surgery should be studied by the student before regional or special surgery is taken up. In our own surgical department, the ground covered in this book is studied in the third year in a course extending over a period of six months, three hours each week being devoted to recitations, conferences, and laboratory work. This work, with the addition of a six months' course in surgical anat- omy, is made prerequisite to the study of regional and special surgery. Practitioners who are interested in surgery will find, I believe, great interest and profit in studying this book. The advances in the science of surgery in the last few years have been so rapid and so great that it has been difficult for the surgeon engaged in active practice to keep abreast of the increasing knowledge. As an example one might men- V VI PREFACE tion the significance and importance of the modern conception of infec- tion and immunity, and the application of this knowledge to surgery. Professor Lexer has presented these modern views in a clear, concise, and practical way. This English translation will offer to those who do not read German a most complete presentation of the present status of the Science of Surgery, a department in which our German colleagues excel. Dr. Lewis and I have not hesitated to make such additions and changes as seemed to us desirable to make the book more complete. Special attention is called to the excellent chapter on Blastomycosis, written by Dr. Oliver Ormsby. This disease has been especially studied in America. The Continental authorities have not had much experi- ence with the disease, and have been rather skeptical about it. I hope that Dr. Ormsby 's chapter will be included in the next German edition. The chapters by Dr. Rosenow, on blood examinations in surgery, and also on the subject of opsonins and the Wright vaccination treatment, are a distinct addition. Dr. George Crile has kindly allowed us to publish an abstract of his recent work on the direct transfusion of blood. We have retained most of the illustrations of the German edition, and have added a number of plates taken largely from our own clinic. I desire to express my appreciation of the w^ork of D. Appleton & Company, the publishers, who kindly undertook this publication at my suggestion, and who have spared no pains to make the work acceptable in every w-ay. I feel that Professor Lexer's book is most valuable and timely, and in offering this English edition to the profession I desire to express the hope that it will be widely read, and that those who read it may find it as profitable and instructive as I have. Arthur Dean Bevan. 100 State Street, Chicago, III. TABLE OF CONTENTS PART I /. WOUNDS, THEIR TREATMENT AND REPAIR Chapter I. — Wounds. pacje Different Kinds of Wounds 1 Pain in Wounds, Haemorrhage 3 Chai'tkk II. — Treatment of Wounds. Temporary Control of ILumorrhage 5 Artificial Ischa>niia 6 Definitive Control of ILvmorrhage 9 Diseases of the Blood 12 Loss of Blood, Dangers of. Death from 14 Blood-letting 15 Transfusion of Blood, of Salt Solution 16 Harmful Agents 18 Suture of Wounds 22 Tampon of Iodoform Gauze 27 Moist Dressings 28 Carbolic Acid Necrosis 29 Iodoform Intoxication 31 Drainage 32 Removal and Encapsulation of Foreign Bodies .... 32 Chapter III. — Wound Repair. Primary ITnion 35 Secondary Union 39 Healing Beneath a Scab 41 Unhealthy Granulation Tissue 43 Action of Foreign Bodies 45 Healing of Transplanted Tissues 46 //. ASEPTIC TECHNIC Introduction 51 Chapter I. — Preparation of Surface of the Body. a, Hand Sterilization 53 b, Sterilization of the Field of Operation 59 c, Sterilization of Mucous Membranes 59 Chapter II. — Sterilization of Instruments 60 vii viii TABLE OF CONTENTS PAGE Chapter III. — Sterilization of Sponges, Dressings, and Linen . . 63 Preparation of Iodoform Gauze 66 Chapter IV. — Sterilization of Sutures and Ligatures. a, Silk 67 b, Silkworm Gut 68 c, Metal Sutures 68 d, Catgut ' 68 Chapter V. — Operating Room 71 Chapter VI. — The Aseptic Operation 73 Chapter VII. — Asepsis and Aseptic Technic in Private Practice . . 79 ///. GENERAL AND LOCAL ANESTHESIA Chapter I. — Chloroform Anesthesia 86 Chapter II. — Ether Anesthesia 99 Chapter III. — Nitrous Oxid Anesthesia 105 Chapter IV. — Accidents During Anesthesia and Ways to Meet Them 107 Chapter V. — Different Methods of Inducing Anesthesia. Choice of Methods 113 Chapter VI. — Local Anesthesia 119 IV. GENERAL PRINCIPLES OF PLASTIC OPERATIONS Chapter I. — Classification op Plastic Procedures 127 Chapter II. — Fundamental Rules for Plastic Operations . . . 133 Chapter III. — Plastic Operations with Compound Flaps and Transplan- tation of Mucous Membrane, Cartilage, and Bone . 139 PART II WOUND INFECTIONS AND SURGICAL INFECTIOUS DISEASES I. NATURE OF INFECTION, LOCAL AND GENERAL REACTION Chapter I. — Nature of Infection 143 Chapter II. — Local Reaction. Inflammation 147 Different Forms of Inflammation 150 Chapter III. — General Reaction. Natural Protective Substances 155 Phagocytosis 158 Ehrlich's Side-chain Theory 159 Antitoxic and Bactericidal Immune Sera 159 Chapter IV. — Fever. Aseptic Fever 167 TABLE OF CONTENTS ix //. WOUXD INFECTIONS CAUSED BY PYOGENIC AND PUTREFACTIVE BACTERIA AND THEIR RESULTS Chapter I. — The Most Important Pyogenic Bacteria. p^^p a, Staphylococci 170 b, Streptococci I73 c, Diplococcus Pneuinoniic 178 d, Micrococcus Tetrageiuis 13q e, Micrococcus Gonorrhccic, Gonococcus 181 /, Bacillus Pyocyaneus 183 g, Bacterium Coli Commune 186 h, Bacillus Typhosus 188 Chapter II. — Infection Atria of Pyogenic Bacteria 192 Chapter III. — Pyogenic Infections and their Treatment .... l!)6 Chapter IV. — Pyogenic Infections of Different Tissues. a, Pyogenic Infections of Skin and Subcutaneous Tissues . . 202 Furuncle 202 Subcutaneous Abscess 208 Subcutaneous Phlegmon 210 Erysipelas 213 Erysipeloid 220 6, Pyogenic Infections of Mucous Membranes .... 221 c, Pyogenic Infections of Lymphatic Vessels and Nodes . . 226 Lymphangitis 226 Lymphadenitis 230 d, Pyogenic Infections of Blood Vessels 233 Arteritis 233 Phlebitis 234 e, Pyogenic Infections of Bone 236 Hematogenous Suppurative Osteomyelitis .... 238 Bacterial Forms 256 TjTihoid Osteomyelitis 257 Secondary Osteomyelitis 258 Phosphorus Necrosis . - 258 /, Pyogenic Infections of Joints 262 Synovitis 263 Arthritis 265 Bacterial Forms (Gonorrhoea, Pneumonia, Tyjihoid) . . 268 g. Pyogenic Infections of Tendon Sheaths and Bursaj . . 272 h, Pyogenic Infections of Muscle and the Subfascial and Inter- muscular Phlegmons 275 Myositis 275 Subfascial and Intermuscular Phlegmons .... 277 Woody Phlegmon 277 i, Pyogenic Infections of Serous Cavities and Different Viscera. 278 Chapter V. — Gener.\l Py'ogenic Infections. a, General Pyogenic Infection with Metastases .... 282 b, General Pyogenic Infection without Metastases . . . 287 Blood Examinations for Bacteria 292 Fever Curves 292 X TABLE OF CONTENTS Chapter VI. — Putrefactive Infections. ^^^^^ a, Putrefactive Wound Infections and General Infections . . 293 Putrefactive Bacteria 29t b, Allied Processes 304 Gas Phlegmon, Malignant (Edema 304 Noma (Water Cancer, Gangrene of the Cheek) . . . 30/ Hospital Gangrene 30^ Chapter VII. — Supplement to Treatment of Acute Inflammation. Bier's Passive Hypersemia 31 Treatment by Suction Glasses 314 Chapter VIII. — Surgical Hematology 316 ///. WOUND INFECTIONS OF DIFFERENT ORIGINS AND SURGICAL INFECTIOUS DISEASES Chapter I. — Wound Infections Caused by Poisons. Snake Venom 326 Arrow Poison, Cadaveric Poisons 330 Chapter II. — Hydrophobia 331 Chapter III. — ^Tetanus 335 Chapter IV. — Diphtheria. Diphtheria of Mucous Membranes 348 Diphtheria of Skin 353 Chapter V. — Anthrax 354 Chapter VI. — Glanders 361 Chapter VII. — Actinomycosis 365 Chapter VIII. — Madura Foot 375 Chapter IX. — -Blastomycosis 376 Chapter X. — Tuberculosis. Local Surgical Tuberculosis 403 a, Tuberculosis of the Skin . 403 6, Tuberculosis of the Subcutaneous Tissues . . . 408 c, Tuberculosis of the Muscles 408 d, Tuberculosis of Mucous Membranes 409 e, Tuberculosis of Lymphatic Vessels and Nodes . . .411 /, Tuberculosis of Bones 416 g, Tuberculosis of Joints 428 h, Tuberculosis of Tendon Sheaths and Bursa3 . . . 442 i, Tuberculosis of Serous Cavities and Different Viscera . 444 General Treatment of Local Tuberculosis 444 Acute General Miliary Tuberculosis 445 Chapter XL — Leprosy Lepra Tuberosa 450 Lepra Maculo-Ansesthetica 452 TABLE OF CONTENTS xi Chapter XII. — Syphilis. pack It, Syphilis of the Skin 460 ( b, Syphilis of the Mucous Meinl>r:ine 403 c, Syi)hilis of Muscle 4(io (/, Syphilis of Lymphatic Vessels and Nodes and Blood Vessels . 466 e, Syphilis of Bone 469 /, Sy})hilis of Joints 477 g, Syj)hilis of Tendon Sheaths and Bursa* 478 h, Syj)hilis of DifTerent Visceia 479 Prognosis an«l General Treatment 479 Ch.\pter XIII. — Rhinosc'lekal Forms of Arteriovenous Aneurysm; (li) SjU'cial Forms (Wil) 250. — The Interior of a Fusiform Aneurysmal Sac, Showitifij Opemiijjs and (Iroove of Main Vessel and Opening of Collateral Braneh .... 672 2r)l. — The Fusiform Aneurysm. The First Row of Sutures ("iosinj; the- Orifices . 673 252. — The Fusiform Aneurysm. The Second Row of Sutures, Interrupted or ('ontinuetl 674 253. — The Fusiform Aneurysm. 'J'he Second Row of Sutures (Continuous) In- troduced (■)74 254. — The Fusiform Aneurysm. The Deej) Sui)porting Sutures in Place . 675 255. — The Sacciform Aneurysm, Its Main Office and the Dotted Outline of the Main Vessel 676 256. — The Sacciform Aneurysm. The CI(jsure of Main Orifice by (Continuous Sutures 676 257. — The Sacciform Aneiuysm. Closure of the Main Orifice by Interrui)ted Sutures 677 258. — The Sacciform Aneurysm. Obliteration of Orifice Completed . . . 678 259. — ^The Sacciform Aneurysm with Catheter Introducetl to Maintain Caliber of Lumen; Sutures Over Catheter 678 260. — The Sacciform Aneurysm. The Removal of Catheter Before Final Closure of the Main Channel 679 261. — Resected Piece of the Long Saphenous Vein 681 262. — Varicose Veins of the Lower Extremity 682 263. — Dieffenbach's Tenotome and Subcutaneous Tenotomy of the Tendo Achillis 708 264. — Anderson's Double-flap Method 709 265. — A. Poncet's Accordion Method 710 266. — Incision Method 710 267. — Tendon Lengthened in Incision Method 710 268. — Lengthening Tendo Achillis 710 269. — Plication of a Tendon 711 270. — Chronic Arthritis of the Joints of the Fingers 715 271. — Free Bodies Removed from a Knee in a Case of Arthritis Deformans . . 720 272. — Arthritis Neuropathica (Tabica) of the Right Knee and Ankle Joints . . 721 273. — Roentgen-Ray Picture of Case Represented by Preceding Figure . . . 722 274. — Pathological Changes in Elbow Joint in a Case of Syringomyelia . . . 723 275. — Arthritis ITrica (Gout) Involving the Interphalangeal Joints of the Little Finger 724 276. — Ganglion of the Dorsum of the Foot 731 277. — Leontiasis Ossea 737 278. — Coronal Section Through the Lower End of the Fenmr of a Ciiild Suffering with Rickets 740 279. — Genu Valgum Adolescentiuni 741 280.— Rickets 743 281. — X-Ray Picture of Deformed, Rachitic Bones of the Leg .... 745 282. — Gynircomastia (Right Side), Male Patient Eighteen Years Old . . . 766 283. — ^Hard Fibroma with Few Vessels 779 284. — Fibromata Mollusca of the Skin and Sarcoma of the Left Axillary Fossa . 780 285. — Lobulated Elephantiasis 781 286.— Fibroma Pendulum 782 xx\ i LIST OF ILLUSTRATIONS FIGURE PAGE 287. — Fungiform, Hard Fibroma of the Skin with Section of the Same . . . 783 288. — Fibroma of the Skin, with a Broad Base, as it Appears upon Section . 784 289. — Keloid which Developed upon the Forearm of a Child After a Scald, and Section Through the Same 785 290. — Keloid Developing in a Laparotomy Wound 786 291. — ^A Keloid Avhich Developed in a Sutured Wound of the Arm After the Ex- cision of a Keloid 787 292. — Recurrence After Excision of a Spontaneous Keloid 788 293. — Another Recurrence After Four Years 789 294. — Fibroma of the Internal Oblique Muscle of the Abdomen in a Female Patient 790 295. — Fibrous Naso-pharyngeal Polyp which has Invaded the Antrum of Highmore 791 296. — ^The Same Tumor Showing Invasion of the Skull Cavity .... 792 297. — Nerves Dissected Free from a Subcutaneous Plexiform Neuroma Removed from the Occipital Region of a Child 793 298. — Plexiform Neuroma of the Subcutaneous Nerves of the Thorax in a Boy . 794 299. — Large Fibroma Removed from the Mesentery of a Male Patient . . . 795 300. — Extirpated Subcutaneous and Intermuscular Lipoma 797 301. — Section of a Subcutaneous Fibrolipoma of the Gluteal Region . . . 797 302.— Subcutaneous Lij^oma of the Arm 798 303. — Subcutaneous Lipoma in the Region of the Hip 799 304. — Subcutaneous and Partly Intermuscular LiiJoma of the Back . . . 800 305. — Subcutaneous Lipoma which has been Growing Gradually for Fifteen Years 800 306.- — Liiioma of the Forehead 801 307. — Diffuse Symmetrical Lii^omas 803 308. — Multiple Enchondromas of the Bones of the Hand ...... 805 309. — Enchondroma of the Thumb 805 310. — Roentgen-Ray Picture of a Cortical Enchondroma 806 311. — Enchondroma of the Second Metacarpal Bone, Externally and upon Sec- tion 806 312. — Cystic Enchondroma of the Scapula of an Adult 807 313. — Cystic Enchondroma of the Upper Metaphysis of a Child, Healed by Curet- ting 808 314. — -Bone Cysts in the Humerus of a Boy Fourteen Years of Age . . . 809 315. — Enchondromas of the Upper Metaphyses of Both Bones of the Thigh . . 810 316. — Enchondromas and Exostoses of the Lower Ends of the Bones of the Fore- arms 811 317.^-Cartilaginous Exostosis of the Femur 813 318. — Cartilaginous Exostosis of the Proximal Phalanx of the Third Finger . . 814 319. — Cartilaginous Exostosis of the Medial Side of the Upper Metaphysis of the Tibia 815 320. — Multiple Cartilaginous Exostoses of the Metaphysis of the Femur and Tibia 816 321. — Subungual Exostosis . . 817 322. — Enormous Exostosis of the Temporal Bone 817 323. — Progressive Ossifying Myositis 819 324. — Ha?mangioma Simplex Cutis 823 325. — Simple Cutaneous and Subcutaneous Ila-maiigioma 824 326. — Siin])le Lobulated HsBmangioma 825 327. — Cavernous IIa;mangioma of the Subcutaneous Fat 826 328. — Cavernous Hu'inangioma of the Ear 826 329. — Cirsoid Aneurysm of the Face 829 LIST OF ILLUSTKATKJNS xxvii FICiDRF, PAf.E li'.H). — Cirsoid Aneurysm of tlic Hand and Forearm S^iO '.i'M. — Racemose Ha'miuifiiionia of the Scalp 8'-H) 3',i'2. — Macronielia Caused l>y a Congenital Cavernous Lymphangioma . . . 833 333. — Congenital Cavernous Lymphangioma of the F'ar 833 334. — Lymphangioma of the Tongue (Macroglossia), Magnified .... 833 335. — Cystic and Cavernous Lymjihangioma 834 336. — Congenital Cystic Lymphangioma (Cystic Hygroma of the Xeck) . . 835 337. — Specimen Removed frona Patient Represented in Fig. 336 .... 836 338. — Fibrosarcoma 838 330.— Large Spindle-cell Sarcoma 839 340.— Round-cell Sarcoma of the Skin 840 34L— Soft, Vascular Sarcoma of the Left Half of the Face 841 342. — Sarcoma Tissue which has Invade\iis Pigmentosus Verrucosus 883 384. — Congenital Hairy Nsevus 884 385. — ^A Young Woman with Multiple Nsevi and an Elevated, Hairy Verrucous Nsevus 88i) 386. — Leiomyoma of the ITterus 887 387. — Uterus with Subserous Myoma, Frontal Section 888 388. — ^Fibromyoma of the Posterior Wall of the Rectum 889 389. — Malignant Leiomyoma of the Bladder 890 390.- — Rhabdomyoma of the Temisoral Region 292 391. — Papilloma of the Skin which has Been Growing for Thirty Years . . 899 392. — Section of the Papilloma Represented in Fig. 391 899 393. — Section from the Border of a Fissured Papilloma of the Skin . . . 900 394.— Multiple Papillomas of the Larynx . 900 395.— Villous Polyp of the Urinary Bladder 901 396. — Cutaneous Horn of the Ear 901 397. — Cutaneous Horn of the Nose 901 398. — Cutaneous Horn of the Lip as Seen from Without and upon Section . . 902 399. — Section from the Summit of a Rectal Polyp 906 400.— Cystic Adenoma of the Parotid Gland 908 401. — Cystadenoma of the Mammary Gland 909 402. — -Malignant Hyisernephroma of the Kidney 910 403.^ — -Section from a Hypernephroma 911 404. — Dermoid Cyst at the Outer End of the Supraorbital Ridge .... 914 405.— Traumatic Epithelial Cyst of the Palm of the Hand 918 406. — ^Traumatic Epithelial Cyst of the Index Finger 918 407. — Cholesteatoma of the Skull Bones, which has Invaded the Orbit . . 920 408. — Multilocular Cystoma of the Mandible (Adamantinoma) .... 922 409. — Adamantinoma 923 410. — Metastatic Foci in the Axillary Lymph Nodes Secondary to a Carcinoma of the Breast 932 411. — Carcinomatous Lymph Nodes 933 412. — Scirrhus of the Breast with Secondary Nodules in the Skin .... 934 413. — Metastatic Foci in the Liver, Secondary to a Carcinoma of the Rectum . 936 414. — Section from an Epithelioma of the Lower Lip, Showing Epithelial Pearls 938 415. — Superficial Carcinoma of the Skin of the Nose 939 416. — Superficial Carcinoma of the Skin 941 417. — Superficial Carcinoma of the Nose of Ten Years' Standing .... 942 418. — Superficial Basal ('ell Carcinoma of the Skin 943 419. — Nodular ('arcinoma DeveloiJed upon a Varicose IHcor of the Leg . . 946 420. — Cauliflowerlike Carcinoma of the Back of the Hand 947 421. — Carcinoma of the Neck, Secondary to a Carcinoma of the Lip . . . 948 422. — Carcinoma of the Tongue 949 423. — Papilloma, and Carcinomatous Ulcer 950 424. — Papillary Carcinoma of the Corona Glands and I'leinue .... 950 425. — Nodular Carcinoma of the Maxilla 951 426. — Deep Carcinoma of the Penis, with Destruction of the (Jlans . . . 952 427. — Carcinoma of the I^)Wer Lip 952 428. — Cylindrical-cell Carcinoma of the Rectum 953 LIST Ol'' JLLUSTRATIONS XXIX PIlTtIRR 429. — (Jolloid (^-irciiioiiKi of Mi(> Jiccluiii .... 4;i(). — Nodulur iuid l*;ii)ill()iii;i(()Us C'arciiioinii of (lie Uccliiiii 431. — ("ollciid ('iirciiioiiui of (he llcctuiu 432. — Nodular, Circular Carcitiouui of the ("a-cum 433. — UlceraU'd Supcrfioial ("art-iuoiua of (he Kectuin 434. — Section Through CarciiKHiia llei)resen(('d iu Vif^. 433 435. — Carcinoma of the Breast (Scirrhus) 436. — Section Through a Carcinoma of the Breast 437. — Lyniphaiigio-endothelioma of the Skin 438. — IlaMuanfijio-ondothelionia of the Kidney 439. — Perithelioma of the Thyroid (iiand 440. — Psanunonia of the Dura .... 441. — Cylindroma of the Orbit .... 442. — Mixed Tumor of (he Parotid (iiand 443. — Benign Mi.xed Tumor of the Sof( Pahde . 444. — A Teratoma 445. — Hydrops of the Gall-bladder 446. — Atheroma of the Ear 447. — Enucleated Sebaceous Cysts 448.— Multiple Atheromas of the Scalp 449. — Large Echiiiococcus Cyst m the Muscles of the Back PAfiK 954 954 955 956 956 957 958 959 964 965 966 967 968 971 972 983 988 989 990 990 998 PART I I. WOUNDS, THEIR TREATMENT AND REPAIR CHAPTER I WOUNDS Definition. — A wound is a solution of continuity of the external cov- erings of the body, its mucous membranes, or the surfaces of organs. Wounds are classified as simple if the deeper structures are not injured, as complicated if they are (viz., associated injury of muscles, nerves, large vessels, bones, body cavities, and joints; cf. Part IV). Different Kinds of Wounds and Causes. — The form of the wound de- pends upon the character of the vulnerating force, whether sharp, blunt, cutting, crushing, or lacerating. The principal forms of wounds are the incised, contused, and lacerated. Incised wounds produced by a sharp instrument or object (fragment of glass) have well-defined smooth edges and surfaces, the tissues of which are not otherwise injured. The edges of the wound may, how- ever, be bluish in color, bruised and infiltrated with blood, and the adjacent area swollen, if the wound has been made by an imperfectly sharpened instrument or dull object, or if the blow has been delivered with considerable force, or tangentially, or if a gash has been made with a sharp weapon. The extent to which a wound gapes depends upon its relation to the tension planes of the skin. If the wound crosses these at right angles, for example, if it is transverse on the extremities, longitudinal on the sides of the thorax and abdomen, its edges will be widely sepa- rated. The edges of even a large wound 'may be closely approximated if its direction corresponds to the course of the elastic fiber bundles of the skin. In operative incisions this fact should always be borne in mind, as the resulting scar will be better if the incision follows tension planes (Kocher). (Fig. 1.) In incised wounds and gashes in which the skin is divided ob- liquely instead of vertically, flaps are formed which are connected with the body by pedicles of different widths. If the pedicle is entirely cut 2 1 WOUNDS, THEIR TREATMENT AND REPAIR Fig. 1. — Directions of the Tensiox Planes of the Skin. across there is then a loss of substance or a defect. Such wounds are produced by blows which are de- livered almost par- allel to the surface of the body. Punctured wounds have the character- istics of incised wounds. They are al- ways narrow and deep, corresponding somewhat in diame- ter to the penetrating weapon or instrument (viz., needle, nail, dagger, sword, lance, arrow, trocar). They gape little because they are so narrow that their edges often adhere. Their edges are contused and lac- erated only when the wound is produced by a blunt object, such as a picket, a cane, or an umbrella. The borders of contused wounds are irregular, discolored, and raised by the ex- udation of blood into the tissues. Abra- sions of the skin, sub- cutaneous hcemor- rhages, ischemia, and loss of sensibility in- dicate the extent of the cutaneous area in- volved in the injury WOUNDS 3 produced by the blunt force. If in addition the subcutaneous tissue is crushed and separated from the skin by an oblique thrust or blow, the edges of the wound may be raised from the subjacent tissues and large pockets filled with blood coagulum formed. Contused wounds are more frequent where bones lie near the surface than where a large amount of soft tissue intervenes. The gaping of contused wounds depends not only upon their direction, but also upon the amount of cutaneous and subcutaneous blood infiltration. In sub- cutaneous injuries of the abdomen contusions of the stomach and intes- tines and of those viscera which may be forced against the vertebral column are relatively common. Lacerated wounds are produced by blunt objects, the force being applied obliquely, with a resulting tearing and rupture of the skin or mucous membrane. Their edges are irregularly torn, but the sur- rounding area is less involved than in contused wounds. Bursting wounds and rupture of organs resemble lacerated woimds. Such wounds of the skin are produced by explosions, as, for example, lacera- tions of the cheeks caused by the discharge of a weapon into the mouth with suicidal intent. Lacerations of vascular organs or those filled with fluid contents (spleen, liver, kidney, heart, bladder, stomach, intestine) are produced by the application of blunt force to their surfaces, or by projectiles penetrating with great velocity. Many wounds are produced by the simultaneous contusion and lacer- ation of tissues, and are then frequently accompanied by the formation of flaps or the loss of substance. INIachine injuries, bites, scratches, and gunshot wounds belong to this class. In gunshot wounds, the grooved or grazing wound in which the projectile passes parallel to the skin is differentiated from the penetrating wound, which has a wound of en- trance, and, if the projectile perforates, a wound of exit. Contusions and lacerations are common in large wounds of exit, in those cases in which the projectile strikes transversely, and in injuries produced by fragments of a bomb. Immediate Symptoms. — The immediate symptoms caused by a simple wound are local and consist of pain and haemorrhage. General symp- toms (shock, anaemia) more frequently accompany complicated wounds and those associated with profuse haemorrhage. The pain at the time of the injury and following it varies in intensity, depending upon the susceptibility of the patient, the cause of the injury, and the part of the body involved. The more rapid the separation of tissues, the sharper the penetrating object, the less the pain is. Wounds of the lips, tongue, tips of the fingers, external genitalia, and anal region are especially painful. The pain in the wound caused by the exposure of sensory nerve fibers is perceived as a burning or throbbing sensation. 4. WOUNDS, THEIR TREATMENT AND REPAIR Pain disappears after the application of a dressing or rest of the wounded part; most quickly in clean, rapidly agglutinating wounds and sutured incised wounds (operation-wounds). After gunshot wounds and severe contusions, the wound and adjacent area may be completely insensitive for some hours or days (local wound-stupor, tissue-shock). This condition, due to the concussion of peripheral nerves, is frequently accompanied by symptoms of mild shock (paleness, cold sweat, apathy, and unrest) ; (cf. Shock, Part IV). Haemorrhage. — Haemorrhage in a simple wound is greatest if the sepa- ration of tissue is produced by a sharp instrument. The troublesome hsemorrhage following a superficial razor cut is well known to every- one. The greater the contusion and the laceration, the less the haem- orrhage, for the contused and lacerated vessels do not remain open so long as when cut transversely. They are closed by agglutination in contusions and by the inversion of their walls in lacerations; also by the coagulation of the blood discharged into the tissues. This differ- ence in closure is found even in large vessels. Punctured and gunshot wounds with fine, narrow channels rarely bleed, as they are occluded by blood clots and closed by muscle tension. Classification. — Haemorrhage may be classified as capillary or paren- chymatous, venous and arterial. In capillary haemorrhage the blood oozes steadily from the wound surfaces. Separate bleeding points which may be seen after sponging and become rapidly lost in the general oozing, correspond to small vessels. Arterial hasmorrhage is recognized by the bright red blood, which is discharged in spurts which increase with the pulse beat. Only in dyspncea is dark blood discharged from the arteries. Venous haemorrhage is recognized by the dark blood which is discharged in feeble spurts from the large veins. Venous hemorrhage is greatest when there is an obstruction to the return venous flow, resulting in stasis. The most severe venous haemorrhage, aside from that due to injury of large veins, follows in- juries of venous plexuses (pampiniform, pterygoid, corpora cavernosa penis). Primary hgemorrhage, which follows immediately the reception of a wound, is differentiated from secondary haamorrhage, which may fol- low after some days (six to ten) the mechanical separation or destruc- tion by suppuration of the thrombus occluding the vessel. The prognosis of repair is most favorable in incised wounds, for here there are no recesses or niches to harbor bacteria and no contused or detached particles to become necrotic and disturb healing. Wounds with contused and lacerated edges and surfaces afford the most un- favorable prognosis. Inflammation easily arises, and the separation of necrotic fragments leads to protracted healing with the formation of THE TREATMENT OF WOUNDS 5 j^i'jimiliil ion iissiic. 'I'hc iiiosl, iiiiportaiit rcciuirciriciit in opcralion- wounds is that they be clean-cut, and tliat contusion and laceration of the tissues be avoided. CHAPTER II THE TREATMENT OF WOUNDS CONTROL OF HiEMORRHAGE The first indication in the treatment of wonnds concerns the haemor- rhage, the control of which may be temporary and permanent. Temporary Control of Hsemorrhage. — The temporary control of ha^m- orrha<^e in accidents is the duty of the first aid. He who performs this, whether layman or doctor, should know that he does more harm than good if he infects the wound. This consideration may be neglected only in haMHorrhages from large vessels which threaten life. Compression of the wound with the bare hand, handkerchiefs, sponges, and other articles favors and increases the dangers of infection. The popular method of irrigation with haemostatic agents (cold spring water, ice water, vinegar, alum, salt solution, zinc chloride) by which bacteria are carried from the surrounding area into the wound or from its surface into its deptlis, and the resulting eschar formation favor the develop- ment of infection. For these reasons the irrigation and the tamponing of wounds are to be avoided, and the control of the haemorrhage by direct compression to be permitted only when sterile dressings are at hand. Without wiping away the dirt and coagulated blood, gauze is laid upon the wound, care being taken that the part of the gauze touched by the fingei's does not come in contact with the wound surfaces. Control of Haemorrhage by Pressure. — In wounds of the extremities a few turns of a roller bandage applied over the gauze from the pe- riphery afford sufficient pressure to control the hannorrhage from small arteries. In case of necessity freshly laundered cloths may be used in- stead of sterile gauze. If this s-ibstitute is wanting, it is better to leave the wound alone than to cover it with soiled dressings. In severe arterial haemorrhage digital compression nnist be ap]ilied immediately to the injured artery proximal to the wound. After the division of the small arteries of the extremities (digitales or dorsalis pedis) or subcutaneous veins, elevation to the vertical position generally suffices to control haemorrhage. In the constriction of the extremity by Esmarch's elastic bandage, which has found practical application and extensive use in the constrictor named after him, we have a method WOUNDS, THEIR TREATMENT AND REPAIR never to be neglected in controlling haemorrhage. Several turns of the constrictor are applied to the elevated limb close to the trunk, and then it is noted whether the htemorrhage ceases or increases, whether the skin is white or cyanotic. If the con- strictor produces a ve- nous stasis it should be removed immediately and reapplied more tightly. Any kind of a rope or strap, cloth, or strip of linen may be used in place of the elastic constrictor, and if its ends are tied about a cane or an um- brella, torsion can be made until the constric- tion controls the haem- orrhage. The simple and easily procured Esmarch constrictor has supplanted the old and unreliable tourniquet and similar devices by which a pad or other resistant object was buckled or bound over the trunk of the artery to compress it against bone. Control of Hsemor- rhag-e from Mucous Membranes. — In severe hsemorrhage from mu- cous membranes (nose, gums, tongue) rinsing with cold water or vine- gar, or preferably with a five per cent solution of hydrogen peroxide frequently suffices in case there is no consti- tutional condition like haemophilia. The Use of Esmarch's Elastic Constrictor, — In operations upon the extremities a temporary control of haemorrhage by artificial ischaemia, Fig. 2. — Digital Pressure on Femoral. Fig. 3. — Digital Compression of the Brachial Against the Bone. THE TREATMENT OF WOUNDS Fig. 4. — Elastic Bandage. introduced by Esmarch in 1873, is of great advantage, as the blood is excluded from the part and an excellent view of the bloodless tissue can be had. Constriction of an extremity, according to Esmarch, consists in the application of a thin India-rubber bandage from the periphery to the trunk to force out the blood. This })rocedure may, how- ever, be omitted, for the ele- vation of the extremity for some minutes (preferably during the process of steril- ization) accomplishes the same purpose. The applica- tion of this bandage from the periphery to the trunk may be dangerous in inflammation and thrombosis, as harmful materials may be forced into the circulation by it. This seems, however, to be more a theoretical danger than an actual one, and should not prevent the use of the bandage when it is greatly needed. India rubber, silk or cotton web- bing, provided with a clasp or hooks and eyes, can be used for purposes of constriction. For the more massive portions of the limbs (thigh, shoulder) rub- ])er tubing of a finger's thickness provided wdth an apparatus for fastening can be used. The band or tubing is applied under tension near the trunk, several turns are made, care being taken that the skin does not intervene between the separate turns of the constrictor. Constriction of the forearm and leg is best accomplished with the rubber webbing .. or a thin pure rubber band- age (Martin's bandage). A thin rubber tubing suffices for the fingers, toes, penis, and scrotum. During the operation or at its completion (viz., amputation, joint resection, seques- trotomy, incision of phlegmon), all l>loodless tissue should be seized and Fig. 5. — Elastic Band- age Applied. Fig. (J. — Mautin'.s Bandage. vessels which are visi])le in the ligated. After procedures in which the wound is not sutured, but tarn- 8 WOUNDS, THEIR TREATMENT AND REPAIR poned because of inflammation, the ligation of the larger vessels suffices, if a well-padded and firm bandage is applied before the constrictor is re- moved, and the extremity then suspended or elevated for the succeeding twenty-four hours. When the circulation is reestablished considerable haemorrhage may occur as the result of a temporary paralysis of the ves- sel wall due to the constriction. For this reason Esmarch's method has been condemned by some in spite of the fact that such ha?morrhage can be easily controlled. If even pressure with a large gauze compress is made while the constrictor is being removed, and is continued for some minutes while the extremity is elevated, the capillary haemorrhage (following removal of the constrictor) can be controlled. If the compress is re- moved the small spurting vessels and bleeding points can be seized and li gated. When the wound is dry it can be sutured. If the constriction is applied longer than two and a half or three hours, or the rubber tubing applied to weak extremities with consider- able force, nerve injuries, ischaemic muscle paralysis, and necrosis of the skin may follow. These results are seen most often in patients who have been transported some distance after their injury or after opera- tion, when the constrictor has not been removed. Esmarch's ischajmia is to be avoided unless very necessary in lymphangitis, thrombosis, and thrombo-phlebitis, because of the danger of separation of the thrombus. The permanent control of heemorrhage is obtained by the use of aseptic tampons, compresses, and ligatures. Other methods, such as eschar formation by actual cautery and ha2mostatic agents, and angio- tripsy, are to be recommended for certain cases only. Control of Capillary Haemorrhage and Haemorrhage from Venous Plexuses. — In accidental wounds, one may proceed to the control of the haemorrhage after sterilization of the adjacent area. If necessary the Esmarch constrictor may be applied and the wound covered temporarily with sterile gauze while the field of injury is being sterilized. After the removal of the constrictor the bleeding points are ligated as in opera- tion-wounds. Capillary haemorrhage and haemorrhage from venous plexuses (not controlled by ligature) are easily controlled by a tampon of iodoform gauze, which also stops hremorrhage by the gradual absorp- tion of fluids by the gauze and resulting swelling, without injuring the tissues or delaying repair. This gauze is therefore the most important agent in controlling haemorrhage from cavities, from the mucous mem- branes of the nose, vagina, and rectum, and in parenchymatous haemor- rhage following the rupture of vascular organs (liver, spleen, and kid- ney). The actual cautery has likewise a haemostatic action in these cases, but is not equal to the f/auze, because it is more apt to interfere with wound repair. Transfixion suture is frequently of great value in con- trolling haemorrhage from vascular organs, kidney, etc. THE TllEATMExNT UF WOUNDS 9 The Actual Cautery as a Haemostatic Agent. — The actual cautery, in the form of a platiiumi point maintained at red heat by benzine vapor, has rephieed the hot iron (ferrum eandeusj which was used in olden times to control luumorrhage during operations (amputation with red- hot knife). The cautery is valual)le in controlling luemorrhage from mucous membranes, where the tampon cannot be applied — viz., from buccal cavity, hiemorrhoids, and from superficial vascular tumors (ha'iiiaugiomas. sarcomas, carcinomas). Where a superficial action only is necessary, the cautery may be replaced by Hollaender's hot-air appa- FiG. 7. — Paquelin's Thermo-Cautery. ratus, by which hot air is blown upon the bleeding surfaces. Cauteri- zation of bleeding wounds is to be avoided unless indicated, as the eschar retards healing and favors inflammation. The cautery is being em- ployed less and less each year as a haemostatic agent. The same may be said of other haemostatic agents, such as compresses saturated with liquor ferrisesquichlorati, which forms with the coagu- lated blood and cauterized w^ound surfaces a firm eschar which prevents the discharge of wound secretion. Control of Haemorrhage in Operation-Wounds. — In operation-wounds any haemorrhage which is not capillary or parenchymatous is immedi- ately controlled by artery forceps and by ligation. This may be effected in different ways. 10 WOUNDS, THEIR TREATMENT AND REPAIR Fig. 8. — Forceps, Serre-fine Artery clamps (Frick, von Langenbeck, von Bergmann) or artery- forceps (Koeberle, Pean, Kocher, etc.) are used for this purpose. They are differently construct- ed. The extremity which grasps the tissue is ribbed or provided with inter- locking teeth. The scis- sorlike handle is provided with a ratchet lock or clasp. As soon as a vessel is cut it is seized with an ar- terj' forcep. The instrument is applied vertically to the wound surfaces, not parallel or obliquely. In this way as little of the surrounding tissue as possible is grasped. If the number of clamps or forceps interferes with the progress of the operation, the vessels can be firmly ligated with catgut and the instruments removed. In case of small vessels the sim- ple is better than the surgi- cal knot; the granny knot should not be used, for it slips easily. It makes little difference what technic is employed in tying the liga- ture. The fingers should not, however, come in con- tact with the wound. In deep parts of the wound artery forceps may be used to tighten the liga- tures. Silk may be used in place of catgut in wounds which are not to be closed by sutures. Catgut is gen- erally to be preferred. Large vessels should be drawn out from the sur- rounding tissues with the artery forceps and isolated by blunt dissection. A second artery forcep should then be applied transversely, and the first Fig. 9. — I>igatiox by Transfixion. Till] TREATMENT OF WOUNDS 11 i'oi'ccp I'ciiiovcd pciulcd li^jitcd. Fic. 10. — Tying I.igA' TUHK AFTER TllANS- FIXION. Tlic liujiJurc tlicii Jipplicd lo Iho vossol can bo d(3- poii, I'or ()iil>' tho vessel and not the surr()niidinress of the operation or give rise to secondary ha?niorrha'ie. In these cases transfixion is valuable; a needle, carrying a catgut ligature, is passed through the tissue close to the point of the forcep, and tied singly on one side, doubly on the other. All visible vessels in loose tissue (subcutaneous, intermuscular, omentum, mesentery, dura) should l)e seized with two artery forceps before division. The division is then made l)etween the forceps. In this way an oi)eration may be performed with but little loss of blood. Larger vessels are best ligated in con- tinuity, as practiced in courses in operative surgery. The vessel is sepa- rated a short distance by blunt dissection from its sheath and bed, and two ligatures are passed around the artery by an aneurysm needle. The ligatures are then tied and the artery cut between them. In the so-called mass ligature the artery is not directly exposed, but the ligature is carried by a needle or ligature car- rier directly through the tissue (viz., omentum, mesentery, peritoneal ad- hesions) and the struc- tures are ligated in mass. Control of Haemor- rhage by Torsion of Ves- sels, Angiotripsy, etc. — Control of hemorrhage l)y torsion, by twisting of the applied artery for- ceps, is too unsafe to sup- plant ligation. It may be used to the best advan- tage where small arteries have been seized. Like- wise angiotripsy,by which is understood a crushing of a vessel with powerful forceps, is unreliable. This procedure was formerly practiced as forced compression (forci- pressure). Haemorrhage does not occur after removal of the forceps, but Fig. 11. — Passing of LiGATunE beneath WITH Aneurysm Needle. Artery 12 WOUNDS, THEIR TREATMENT AND REPAIR sponging of the wound or muscular action frecjuently provokes it. In deep, inaccessible wounds (e. g., vaginal operations) long, crushing for- ceps are used. In order to guard against intermediate haemorrhage from the uterine arteries they are allowed to remam from twenty-four to forty- eight hours. The control of haemorrhage by compression of the wound with sterile gauze is made use of as much as possible in every operation. In large wounds the gauze may be pressed against the wound surfaces by the hand, in small wounds by the finger. In skin grafting it is neces- sary to compress the wound so that the healing of the grafts will not be interfered with by subsequent ooz- ing. Complete dryness of the woiuid after ligation of all spurting vessels and bleeding points is secured by an even compression of its surfaces, for about ten minutes, with com- presses saturated with physiological salt or a solution of three to five per cent hydrogen peroxide. The tissues are not injured by these appli- cations. The Iodoform Gauze Tampon. — The iodoform gauze tampon is indi- cated after operations in which there are bleeding cavities with resistant walls (sequestrotomies, resection of the maxilla) or wounds with deep sinuses, in which a collection of blood is to be avoided; also after incision of acutely inflamed tissue, for its capillarity not only controls hemorrhage, but also prevents post-operative absorption {vide Treat- ment of Pyogenic Infections, Part II). Haemophilia. — The control of hsemorrhage is most difficult even in the small superficial wounds in patients with diseases of the blood or haemophilia. By the latter is understood an abnormal condition char- acterized by a marked predisposition to spontaneous and traumatic ha'm- orrhages. The essential cause is not known. Lessened coagulability of the blootl, abnormal thinness of the vessel walls which are not other- wise changed, and a dilatation of the vessels through vaso-motor in- fluences have all been suggested. The disease is most frequently congenital, and the male sex is prin- cipally afflicted; thirteen times more frequently than the female. Trans- ference from the diseased father, or from the grandfather through a healthy mother, can occur. Fig. 12. — -Torsion of an Artery. THE TREATMENT OF WOUNDS 13 Spontaneous haemorrhages occur especially from the mucous mem- branes of the nose, mouth, intestine, and bladder, and into the joints, producing often severe changes in the latter {vide Ihemarthrosis). Be- sides, ha?morrhages may occur in the bursie, the subcutaneous tissue, and kidneys. The slightest injury of the skin or mucous membrane, such as a needle prick, incised or lacerated wound of the fingers, laceration of the gums in cleaning or extracting teeth, may be followed by severe haemor- rhage, which may continue with slight interruption for days and weeks, and even terminate fatally. The Control of Haemorrhage in Haemophilia. — Often a firm iodoform tampon applied after preliminary cauterization of the wound with the actual cautery will control the hiemorrhage. The pressure by bandages and elevation of the extremity should of course be combined with this treatment. Among the many metho^ls which have been suggested, gelatin has of late received the most thorough trial. According to Dastre and Floresco gelatin increases the coagulability of the blood. It may be used locally in the form of a five or ten per cent solution heated to 104° or 140° F., which is applied to the wound by saturated gauze compresses, or injected into joints. For systemic effects it is injected subcutaneously into the skin of the thorax or abdomen. One to two hundred c.c. of a one to two per cent solution heated to 99° F. are injected daily until the haemorrhage ceases. The solution consists of gelatin ajid physiological (0.9 per cent) salt solution. It is sterilized by heating twice to 248° F., with an interval of one or two days between sterilizations. It is warmed over a water bath each time before using. The use of gelatin is at present a very limited one. Spontaneous Cessation of Haemorrhage. — The organism is not defense- less against loss of blood. It is possessed of a number of means of checking and stopping it, which are only successful, however, when the blood is discharged slowly, and not in severe haemorrhage resulting from the transverse division of large arteries. It is well known that a simple wound, even an incised wound, ceases to bleed after some time. This is true in operation-wounds, and there- fore it is a rule in all operations to grasp bleeding points immediately, not only to limit the amount of blood lost, but also to guard against sec- ondary haemorrhage from the small vessels, which cease bleeding spon- taneously during the operation and would therefore be overlooked. The change in the size of the lumen of the vessel is the first factor in the spontaneous cessation of haemorrhage. The lumen is narrowed by the contraction of the circular fibers of the vessel walls; the capillaries are narrowed by the swelling of their endothelium. Vessels, because of 14 WOUNDS, THEIR TREATMENT AND REPAIR their elasticity, retract from the wound surfaces, and the blood is then forced into the protruding tissues and the vessel sheath. The blood co- agulates rapidly and closes the lumen and the lateral wounds of the vessels {vide Injuries of Arteries and Veins, Traumatic Aneurysms, etc.)- The spontaneous cessation of hemorrhage after the transverse divi- sion of large vessels depends upon the lowering of blood pressure and changes in cardiac action. A slight loss of blood produces at first a tran- sitory lowering of blood pressure, which is again rapidly restored by a contraction of the vessel walls resulting from an irritation of the vaso- motor centers produced by the anemia. If a large amount of blood is lost, which in animal experiments amounts to more than one fourth of the total quantity, the blood pressure sinks rapidly and the heart beat becomes more feeble. If the hemorrhage ceases, the lumen of the vessel is closed by a thrombus since the coagulability of the blood is increased. The lymph, either because the tension of the tissues exceeds the blood pressure or because of the dilatation of the capillaries by vaso-motor influences (Grawitz), flows into the blood, carrying with it numerous leucocytes, and restores the lost fluids. According to Goltz, death from hemorrhage results from the empty condition of the heart. The blood pressure becomes so low and the amount of blood is so reduced that no blood is received from the venous system, and after systole the heart does not dilate again. Dangers of Haemorrhage Relative to Age, etc. — The dangers of hem- orrhage are greatest in children. The loss of a few c.c. in the new born and of 250 c.c. in a child one year old is dangerous. In the adult a similar danger arises as a rule only after the loss of one half the total amount. Women recover from hemorrhage more rapidly than men. It is difficult to determine how much of the total quantity of blood (amounting, as a rule_, to one thirteenth of the body weight) may be lost without proving fatal, as a number of factors have to be considered. In the first place the rapidity of loss is a factor, as the danger in- creases with it. Diseases of the heart and arteries (arterio-sclerosis), anemia of the brain as in shock, severe anemias following exhausting diseases, the effects of long operations, and narcosis increase the dangers of hemorrhage. AFTER-TREATMENT OF HEMORRHAGE Restoration of the Blood. — Tlie blood is restored by absorption of fluids from the tissues; this accounts for the feeling of thirst expe- rienced in hemorrhage. After a short time the leucocytes (post-hemor- rhagic leucocytosis) increase, after a longer time the red blood cor- THE TREATMENT UF WOUNDS 15 puscles. The time required for complete restoration of the blood depends upon the age, the nutrition, and the condition of the patient. This restoration is to be expected in from two to five days after slight haemorrhages; in from fourteen to thirty after severe. Venesection. — Bleeding (venesection), a method current among physi- cians of an early period, Unds no place in surgical practice, which always endeavors to prevent htvmorrhage. In passive congestion, resulting from diseases of the heart or lungs, in chlorosis, urannia, and eclampsia, bleed- ing thins the blood temporarily and thus improves the circulation. The composition of the l)lood is improved by a regeneration of blood cells. The urinary secretion is also increased. Bleeding belongs therefore to the therapeutic measures of internal medicine. Tccliitic of Bleeding. — Bleeding is performed in the following way : A constrictor is applied to the arm to produce a venous stasis; the radial pulse should not be obliterated. After the field of operation is properly prepared, the skin covering the distended median basilic vein is incised. The vein is exposed at the bend of the elbow and opened for the distance of about 1 cm. The blood is caught in a receptacle and measured; not more than one per cent of the body weight (500-1.000 g.) should be taken. An aseptic dressing is then applied w^hen the l)leeding is finished. The old method of puncturing with the lancet should be discarded, as injuries of nerves and arteries may be produced, and neuralgia and arterio-venous aneurysms result. In every field of surgery incisions should be made layer by layer. Rather make an incision too large and suture it than produce unnecessary injuries.. After some experience the veins can be punctured through the skin with a syringe, as in taking of blood for bacteriological investigation {fide Blood Examination in General Pyogenic Infections), and the de- sired amount of blood removed. Symptoms of Hasmorrhage and their Treatment. — The principal symp- toms of anaemia resulting from haemorrhage are pallor, pinched features, spots before the eyes, ringing in the ears, weariness, weakness, thirst, rapid, scarcely perceptible pulse, restlessness, anxiety, vomiting, and faintness. Dyspnoea, dilated pupils, loss of consciousness, cold sweat, convulsions, involuntary discharge of urine and fai'ces indicate the gravest danger. Action must be immediate if this condition is to be suc- cessfully treated. At the same time that attempts to control the haemor- rhage are made, agents which strengthen the heart, raise blood pres- sure, and increase the amount of blood must be used. The horizontal or, better, partially inverted position of the patient, elevation of the arms and legs and envelopment of the same in an elastic bandage applied with little tension (autotransfusion), wrapping with "warm blankets, subcutaneous injection of severel hypodermic syringe- 16 WOUNDS, THEIR TREATMENT AND REPAIR fills of camphorated oil, clysters of warm red wine mixed with cloves combat this condition. In patients who are conscious and do not vomit, hot coffee, champagne, mulled wine, hot extract of beef, and other rap- idly acting agents may be given, but, most important, normal salt solu- tion slowly and continuously per rectum. If these do not avail, and threatening symptoms are present, salt solution should be given sub- cutaneously to supply the body with fluids. Transfusion of Physiological Salt Solution. — The transfusion of physi- ological salt solution has supplanted the transfusion of blood. The lat- ter is little used to-day, but was practiced in the seventeenth century, particularly by Dieffenbaeh and Martin. In this method from 140- 200 c.c. of blood were removed from a healthy man by bleeding; the blood was then thoroughly defibrinated, filtered through a cloth, warmed over a water bath, and injected into one of the arm veins of the patient. In spite of complete asepsis, chills and fever (so-called transfusion fever, the equivalent of aseptic fever accompanying the absorption of blood exudates) and severe general symptoms (dyspnoea, cyanosis, hemoglo- binuria, bloody diarrhoea, disturbances of consciousness) often followed. Alterations in the composition of the blood and extensive capillary thrombosis caused these symptoms. Embolism of the vessels of-the heart and lungs frequently produced death. The fatal accidents caused by the transfusion of blood can be ex- plained in two ways. Firstly, aside from the entrance of air into the veins during the injection, small clots, in spite of the filtration of the defibrinated blood, could be injected. Hueter attempted to overcome this by injecting the defibrinated blood into the radial artery, with the idea that the small clots would be retained in the capillaries. Secondly, defibrinated blood contains enough fibrin ferment to make it dangerous because of the possibility of the formation of fibrin. The direct transfusion ^ of blood from the radial artery of the giver into the arm vein of the receiver has been tried to overcome the disad- vantages of fibrin ferment intoxication, a procedure which, however, carries with it the dangers of embolism, for clots readily form about the tube connecting the vessels. Sheep's blood, employed in earlier times, is even more dangerous than human blood. Its cells and those of the blood of any other species are immediately destroyed and produce extensive coagulation. The dangers of blood transfusion and the recognition of the fact that the principal cause of death from haemorrhage is the decrease in blood pressure rather than the alteration of the component parts of the blood have led to the use of physiological salt solution as suggested by ' See Appendix. THE TREATMENT OF WOUNDS 17 Kronecker and Sander. The advantages of the salt solution are that its administration is simple, its action immediate, its safety absolute if rightly used. Preparation of Physiological Salt Solution and Technic of Adminis- tration. — Salt solution may be given intravenously or subcutaneously. Where rapid action is necessary and the solution is ready, it is given in- travenously. The 0.9 per cent solution can be prepared in any hospital M-ith the boiling water of the steam sterilizer, water being received in sterile pitchers and held in readiness. In practice outside of a hospital, it may be necessary to filter the tap water through gauze and to boil it one half hour in case a sterile solution cannot be obtained from the apothe- cary. The solution is warmed to 104° F. and poured into a sterile irri- gator, to the tubing of which is attached a hollow needle. After a slight stasis is produced in the arm by the pressure of the hand or a bandage, the canula, the air bubbles having been previously forced out of it, is introduced into the most prominent vein (most fre- quently the median basilic). If it is feared that the vein will not be found, it may be exposed by a small incision and punctured or opened if a blunt canula is used. In the latter case the vein should be ligated dis- talward, and a second ligature passed about it proximal to the opening. The solution should be allowed to run into the vein slowly until one or two liters have been given. After the transfusion is completed and the proximal end of the vein is tied and the wound sutured, an aseptic dress- ing should be applied. In severe cases transfusion may be repeated two or three times in twenty-four hours, and two liters given each time. The subcutaneous injections are given with large syringes into dif- ferent parts of the body, most frequently the external surfaces of the thighs, the abdomen, and under the breasts. Too great distension of the skin and too much pressure are to be avoided, because of the severe pain and the danger of necrosis. From one to two liters should be injected, as in the intravenous procedure, and if necessary the injections may be repeated many times. A very simple and safe method of using the salt solution is to inject it into the rectum, where it is usually readily absorbed, and this is the method to be adopted except in the severe cases where immediate action is imperative. The success of the transfusion is seen immediately in the improve- ment of the circulation, and the organism gains time, except in the severest cases, to recover and to gradually restore the quality of the blood. In the severest cases salt solution cannot replace the constituent parts of the blood, and the administration of fluids cannot prevent a fatal issue. In spite of this, transfusion of salt solution has in many cases a life-saving action. 3 18 WOUNDS, THEIR TREATMENT AND REPAIR Indication for the Use of Physiological Salt Solution. — Its use is indi- cated in all haemorrhages with threatening symptoms without exception, and is often necessary during major operations or at their completion. Accidents resulting from cardiac paralysis and the cardiac weakness accompanying shock may be successfully combated in this way. The increase of tissue fluids following injections of salt solution im- proves the general condition when there is deficient absorption of food (e. g., carcinoma cardiac, vomiting after chloroform, peritonitis). It is used to advantage before operations on poorly nourished patients. The increased diuresis following the transfusion of salt solution has led to its use in intoxications (e. g., iodoform, carbonic-acid gas, illu- minating gas, also ureemia) and in general infections. Combined Use of Physiological Salt Solution and Oxygen. — In order to better the results of the transfusion of salt solution in severe hemor- rhages, Kuettner has suggested to increase the reduced oxygen content of the blood by the simultaneous administration of oxygen gas. A reser- voir is filled with 1,000 c.c. of salt solution, and oxygen gas is allowed to flow in from a tank until 100 c.c. of the solution is displaced. The reservoir is then closed and shaken until the oxygen is absorbed by the solution. Twenty c.c. of oxygen can be introduced with one liter of the solution. The salt-soda solution (7.5 per cent salt plus 2.5 per cent calcined sodium) recommended by Tavel and used subcutaneously has caused extensive necrosis of the skin. MECHANICAL, CHEMICAL AND THERMAL INJURIES Prevention of Infection in Mechanical, Chemical, and Thermic In- juries. — In the care and treatment of a wound there are other important considerations besides the control of haemorrhage: The prevention of the entrance of injurious agents, and the restoration of conditions favorable to wound repair. "Wounds should be protected from bacteria, from me- chanical, chemical, and thermal injuries. Operation-wounds should be protected from infection by the rigid observance of an aseptic technic. Every accidental wound should be regarded as infected, for at the time of the injury, more frequently, how- ever, during the period immediately following, bacteria, most often pyogenic and putrefactive varieties, are introduced into the wound. These primary wound infections only become severe, however, if the wound is improperly handled; for example, if an accidental wound, in a condition unfavorable for healing (because of contusion and exuda- tion of blood), is treated as an aseptic operation-wound and closed by sutures. As a rule the secondary infections are much more grave. He THE TREATMENT OF WOUNDS 19 who touches the wound \vith his fingers, dresses it with soiled gauze, examines its recesses and tract with a probe, other instrument, or finger, washes sinuiltaneousl}' the bleeding wound and its unclean adjacent area, introduces an infection which is of much more significance than the wound itself. It is as much the duty of the first aid to prevent these secondary infections as it is of those who have charge of the after-treat- ment. In the treatment of the wound the primary infections should not be permitted to develop. In order to prevent infection during the performance of the first aid a small packet has been devised for use in military practice which consists of a sterile compress and an attached bandage. The arrange- ment (Perthes, Korteweg) is so simple and ingenious that when opened the gauze comes directly in contact with the wound. These packets, as introduced, for example, by Utermoehlen for emergency dressings into the Dutch army, are of great practical significance, for any wound can be immediately covered with sterile gauze without the danger of infec- tion with unclean hands. AVhile the clothes of the patient are being removed, the emergency dressing should be allowed to remain, or the wound should be protected by sterile gauze, held in position by a bandage or adhesive strips. The wound should be covered by a dressing while the adjacent area is shaved, washed, and sterilized. If, after the haemorrhage is controlled and the wound cared for, a dry aseptic dressing is applied, and the examination of the wound Avith a probe or the finger, even though both are steril- ized, and the irrigation or wiping out of its recesses be omitted, the most important thing to prevent secondanj infection has been done. There are many ways in which mechanical insults may do harm. Gross mechanical insults naturally do not favor wound repair, as they produce new injuries and cause haemorrhage. The effects of such in- juries produced in treating wounds are rarely seen at the present time, but similar conditions are produced by muscular action, the separation of the edges of the wound, and l)y the wiping and curetting away of particles of dirt. These insults not only carry the bacteria into the depths of the wound, but also favor their development by injuring the tissues. Cautious treatment of the wound, and the application of a firm, well- fitting bandage, are most important in the prevention of mechanical injur}'. The effects of chemical and thermal influences are seen only when improper or antiquated methods are employed in the treatment of wounds. They injure the tissues, decrease their natural resistance to bacterial invasion, and produce conditions which favor the develop- laent and progression of severe inflanimations. 20 WOUNDS, THEIR TREATMENT AND REPAIR The Actual Cautery and Caustics in the Treatment of Wounds. — The effort to destroy completely the cause of inflammation or wound infec- tions led in olden times to the use of a radical measure which we to-day use little for this purpose — the hot iron or Ferrum Candens. All caus- tics (concentrated carbolic acid, nitric acid, and zinc chloride) have a similar action. The foe is destroyed, but with it the tissue to a great extent, and for this reason cauterization is only occasionally employed in the treatment of wounds. It is used most frequently in those cases in which there is a highly virulent and dangerous infection, for example, in wounds received during the post-mortem examination of fresh cada- vers with acute suppurative or general pyogenic infections or anthrax, also in snake bites, hydrophobia, and tetanus. Cauterization of the wound is only reliable if immediate. If the infection is caused by highly virulent bacteria with a short period of incubation, or if time has been allowed for the bacteria to enter the lymph and blood, or if it does not destroy the infectious material, it is dangerous, for the necrotic tissue or eschar closes the wound, and the inflammatory exu- date forming behind it cannot find exit, and the inflammation spreads into the tissues. This is the reason why the knife is better than the cau'^ery, and why severely infected wounds should be excised as quickly as possible after the injury. If a tampon is applied after the wound is excised, the dry gauze takes up and removes the remaining infectious material by its capillarity, and limits the spreading of the inflammation by the removal of the exudate. Action of Antiseptic Solution. — The weaker the solution of antiseptics (two to three pei- cent carbolic acid, one half to one per cent bichloride of mercury) used for sterilization, the less the injury to the tissue; like- wise, the less the effect upon bacteria. The irrigation of a wound with antiseptic solution never destroys bacteria ; it removes mechanically only those lying superficially and attached to blood clots or particles of dirt. Antiseptic solutions never reach bacteria lying within or below the layer of fibrin covering the surfaces of the wound, for the antiseptics form a chemical compound with the albuminous wound secretion by which their action is reduced or destroyed. The bacteria remain, therefore, unin- fluenced, while the resistance of the tissues is lowered or destroyed. Mechanical Removal of Dirt, Hair, etc., from Accidental Wounds. — The cleansing of wound surfaces with chemicals which are injurious should be avoided. The grosser particles of dirt and hair should be removed with forceps, blood clots with sterile gauze, without producing further injury. This can be done by gently irrigating with physiological salt solution, which is allowed to drop from saturated gauze, or more thoroughly with a three or five per cent solution of hydrogen peroxide. THE TREATMENT OF WOUNDS 21 The latter, eoniiii^ in contact with blood, wound secretion, or pus, liber- ates oxygen and develops a white foam which, slowly rising- from the wound, removes all the superficial dirt with it in the best mechanical way. The solution has the great advantage that it do(;s not injure the tissues, and bcsich'S cleansing controls capillary hannorrhage. According to Ilonsell the liberated oxygen has no bactericidal action. The use of the cautery or of antiseptics in the treatment of nifected accidental wounds may be compared to the conduct of a campaign by a general, who devastates and danmges his own land to undo the enemy. The aseptic treatment of a wound, however (and operation- wounds are placed in this category), attempts to destroy the invading foe by sparing the tissues, and to produce conditions in which he cannot survive. The Object of the Treatment of Wounds, — The restoration of condi- tions favorable to wound repair is the object of the treatment of the wound. When one considers all the conditions which favor the develop- ment of bacteria in tissues, it is easily understood why the coagulated blood and the necrotic tissue (separated fragments and contused edges of wounds) must be removed, and the wound secretion consisting of blood, lymph, and other exudates drained away. The former is the best culture medium for bacteria ; the latter by its accumulation increases the tension of the tissues and drives the infectious materials into the spaces of the surrounding tissues. Therefore the hemorrhage should be completely controlled and the coagulum removed. Deep recesses should be made accessible by enlarging the wound or making counter openings. Contused and lacerated edges and surfaces of wounds should be trimmed off smoothly with knife and scissors. In old wounds the crust composed of dried wound secretion should always be removed. The conditions of the wound, together with the possibilities of in- fection, determine whether it should be sutured or tamponed and drained. Any incised wound may be sutured provided it has not been improp- erly treated before being seen by the surgeon, in which case the possibility of infection must be taken into consideration. The clean-cut surfaces of incised wounds do not provide conditions favorable for the retention and growth of bacteria. Some of the bacteria which may have already en- tered the wound are destroyed by the bactericidal substances in the tissue fluids, while others are removed by the hemorrhage. In the in- cised wounds there is no necrosis, and if the control of the hasmorrhage has been complete enough to prevent the formation of a blood clot the conditions are not favorable for the development of bacteria. The same conditions are present in opera tion-woujids made in tissues which are not infected. Contused and lacerated wounds should be sutured only in exceptional 22 WOUNDS, THEIR TREATMENT AND REPAIR Fig. 13. — Interrupted Suture. cases. If the wound can be rendered clean-cut or excised, it may be sutured completely or partially, when the accumulation of wound secre- tion is not feared. The lacerated and contused margins of the orifices of the body (lips, nose, eyelids, anus, vagina) should be accurately united, after the edges of the wound have been vivified, to prevent dis- placement and distortion. Other wounds, if the conditions are not favor- able for sutures, should be treated by the open method. Sutures and Technic of Inserting and Tying. — Interrupted sutures of silk or horsehair are used in closing wounds of the skin. Other suture material, such as silkworm gut, catgut, silver wire, is used but little for skin sutures. The interrupted suture is the most important, as it can be used any- where. The method of its application may be seen in the accompany- ing figures. The sutures as a rule are passed vertically to the edges of the wound; only in exceptional cases, in plastic surgery, where there is a dis- placement of the skin edges, are they passed obliquely. Sutures used to draw the tissues together under ten- sion are called tension sutures. The following technic is employed in the application of the suture. The border of the wound is raised with a toothed forceps, and the needle is pushed through it some millimeters from its edge. When tension sutures are applied the needle should enter the skin about two centimeters from the edges of the wound. The needle is then pushed through the skin until its point appears in the depths of the wound. The other border is then raised and the needle is pushed from the depths of the wound through it. The needle should pierce the skin at the same distance from the edge as on the opposite side. If both borders are pierced too superficially, dead spaces filled with blood are formed, which delay wound healing. If the borders are pierced at too great a distance from the edges of the wound and too superficially, the edges will not Fig. 14. — Elevation of be approximated, for one will be turned in, Edge of Wound with I I ^ _ ' Rat-tooth Forcep the other out (Fig. 15). If in a symmetrical while Passing Suture. wound one border is pierced deeply, the other superficially, the latter will be turned in and covered by the former (Fig. 16). THE TREATMENT OF WOUNDS 23 In superficial wounds both edges may be pierced at the same time, provided they are held together with tissue forceps by an assistant. Fig. 15. Fig. 16. The surgical knot should be tied. The necessary manipulations may be performed differently, and are a matter of practice. The beginner may practice with thick twine, tying knot after knot, until finally he can do so without paying attention to it. Fig. 17a. Fig. 176. In tying a suture both ends should be made tense and held parallel, not crossed, at least a hand's breadth from the wound, as the knot is formed by carrying one end of the suture twice around the other end. 24 WOUNDS, THEIR TREATMENT AND REPAIR It is impossible to tie the knot quickly if the suture is not made tense, and if tied too close to the wound. This first loop is tightened over the wound until its edges are approximated. Better approximation of the skin edges may be secured if the knot be not tied too tightly. The ends of the suture should then be drawn to the side and the knot dis- placed, so that it does not rest on the wound; a second simple knot is tied. The ends of the sutures must be changed from one hand to the other while tying the knot, for if they are not a poorly placed ' ' granny knot " will be formed. If any fat protrudes between the edges of the skin, a superficial suture should be placed at this point. If the edges are turned in, a deep suture should be placed to raise them. If the edges are irregular, the inverted edge should be pierced by a deep suture and the raised edge by Fig. 19. Fig. 20. Fig. 22. a superficial one placed near the margin to equalize the displacement. The same procedure should be used when the edges of a wound are not symmetrical. The interval between the separate sutures should be on an average about one centimeter. The sutures should be placed at greater intervals when, because of hemorrhage or contusion, a large amount of wound secretion is feared. In wounds of the face, eyelids, or lips, where a very accurate approximation is demanded, the finest sutures should be used and they should be placed closely together. The advantage of THE TREATMENT OF WOUNDS 25 Fig. 23. — Continuous Suture Uniting Stomach and Intestine. the interrupted suture is that it is easily applied under different con- ditions. If the skin and mucous membrane are cut at the same time, the through and through suture should never be used, for the mucous mem- brane is usually folded into the wound, and bacteria from its sur- face pass through the stitch holes. The su- ture should be passed through the skin to the mucous membrane and out on the other side, not entering on the mucous surfaces, which should be united by a separate row of super- ficial interrupted su- tures. Buried sutures of absorbable catgut, or, where tension is to be prevented, of silk or aluminum bronze should be used in deep wounds, where the ana- tomical relations of the deeper struc- tures are to be restored or the forma- tion of dead spaces under the skin suture to be avoided. In these cases layer sutures should be used; for ex- ample, in closing an incision in the abdominal wall the peritoneum should be sutured first, then the fasciae and muscles, and finally the skin. Concerning the suture of complicated wounds (nerves, ten- dons, bones, arteries, etc.) see Injuries of Soft Parts. The continuous suture ( glover 's or whip stitch) is about the only one of the remaining methods that is used to-day. It is used especially in intestinal work, as it may be ciuickly applied. After the first stitch is inserted a surgeon's knot is tied; if the suture Fig. 24. — Mattress Suture. Fig. 25. — Halsted's Subcuticular Stitch. 26 WOUNDS, THEIR TREATMENT AND REPAIR is not continued to the starting point as in circular intestinal sutures and anastomosis, the stitch is terminated by passing the needle twice H Fig. 26. — Quilled Suture. Fig. 27. — Leaded Suture. under the last loop. If so continued the two ends of the suture are tied. At the point where the sutures end and where there is tension, inter- FiG. 28. — Twisted Suture. rupted sutures may be applied for safety. The mattress, plaited, quilled, and harelip sutures are but rarely used. Halsted's subcuticular suture is more often employed. The Use of Metal Clamps and Fasteners to Close Wounds. — To ob- viate the cutting of the skin which occurs from the use of sutures dif- ferent forms of metal clamps or fasteners were introduced b}^ Vidal and others. These were applied to the wound borders with compli- cated instruments. They can be used only in wounds with symmetrical borders which involve the sldn, as they do not grasp the deeper tissues. Dressing of a Sutured Wound. — The line of suture should be covered with sterile gauze by which the oozing tissue fluids are taken up and dried. The gauze should be held in place by adhesive plaster or col- lodion, the latter being applied to the edges of the gauze and not directly over the wound. The direct application of collodion pastes or powders Fig. 29. — Ixtestix.^l Suture, a, Inner la^'er of suture.'s; b, outer layer of su- tures (serous layer) ; the inner sutures are tied; c, position of the edges of the wound after tying both laj'ers of sutures. THE TREATMENT OF WOUNDS 27 to the wound (iodofonii, dennatul) is not to be recommended, for they prevent the discharge of wound secretion, resulting from sliizht inflam- mation or suppuration in a stiteh hole. Skin sutures should be removed between the fifth and eighth days. If silk sutures are allowed to remain longer they act as a foreign body, and bacteria from the skin invade the tissues surrounding them. Buried non-absorbable sutures become encapsulated in sterile wounds. If not encapsulated, because of mild infection, a narrow fistula is formed from which the non-absorbable suture of silk or silver wire is discharged, if not previously removed by a dilatation of the fistula. The fundamental difference between the cutaneous and the intes- tinal suture is that in the former the separate layers of the wound sur- faces are approxinuited, while in the latter a broad approximation of the serous coats must be obtained by an inversion of the edges of the wound. In intestinal work two rows of sutures should be employed ; the first should include all the coats, or the serosa and muscularis, and is haemostatic; the second the serosa. (Fig. 30.) Every wound of the stomach or intestine, even if the laceration or contusion does not extend into the lumen, should be sutured, because of the danger of perfora- tion. Fine silk or Pagen- stecher 's celluloid linen are the suture materials generally employed in in- testinal Avork. Iodoform Gauze Tam- pon. — If the conditions for wound repair are not fa- vorable, as is frequently the case in contused and lacerated wounds, the open treatment with the the tampon is employed to drain off the infectioiLS material with the wound secretion and to prevent, by allowing free access of air, the development of anan*obic bacteria (putrefactive bacteria, tet- anus bacilli). In gunshot and punctured wounds the use of sterile gauze serves a double purpose: (1) It drains away wound secretion, and (2) pre- vents the development of secondary infections, so that wounds of the deeper structure may heal as subcutaneous wounds without the dangers of inflammation. Iodoform gauze is used as an aseptic tampon. (Con- cerning its preparation, vide Preparation of Aseptic Dressings.) Fig. 30. — The Ixterxal Coxxixrors Suture Is In- verted BY AX EXTERX.\L INTERRUPTED I.AYER. 28 WOUNDS, THEIR TREATMENT AND REPAIR The iodoform gauze should be hiid upon the fresh wound or intro- duced into wound cavities with sterile instruments and gentle pressure made. After some minutes it becomes firmly attached, controls the haem- orrhage, and removes from the surfaces of the wound by its capillarity (capillary drainage) blood and lymph exudates, and infectious materials (bacteria and toxins), which are drained into the dressings, where they become dry and harmless. Iodoform gauze has but little antiseptic action, and this action is not exerted upon the bacteria in the wound, but upon those drawn up into the gauze. The use of iodoform gauze can therefore be looked upon as an aseptic method of wound treatment. When used as a tampon the gauze should be placed in all the recesses of the wound. In small gunshot and punctured wounds, the gauze should merely be laid over the wound and not forced into the tract, as in this way a secondary infection might be produced. Large and deep wounds with cavities, such as are produced in gunshot wounds by the explosive force of the projectile (dum-dum), should be covered with layers of iodoform gauze and the remaining spaces filled with sterile gauze to avoid the use of too much iodoform and resulting iodoform intoxication. If the deepest point of the wound is not favorably situated for capillary drainage, the tampon is often combined with tubular drain- age, counter-openings frequently being required for this purpose. In many cases the tampon must be sutured in position to prevent its displacement (in the buccal cavity, pharynx, larynx, also in the abdom inal cavity). [Cigarette drains are used very extensively in surgical work at the present time. In preparing such a drain the gauze is loosely rolled until the size required is prepared. The gauze is then wrapped in a layer of gutta percha and the drain is ready for use. The size of cigarette drains usual] 3^ employed corresponds to that of the little and ring fingers. If it is desirable, tubular drainage may be combined with the capillary drainage in a cigarette drain, a piece of small rubber tubing being in- closed in the gauze. The advantage of the cigarette drain is that it can be easily removed from wounds without causing pain and injuring granulating surfaces, and it acts as efficiently as unprotected iodoform gauze packed into a wound. Iodoform or plain gauze may be used in the preparation of the cigarette drain.] The rapid reduction of the number of bacteria in infected wounds and the prevention of progressive inflammations are usually due to the capillarity of iodoform gauze. Moist Dressings. — The number of bacteria in a wound rapidly in- creases when a moist tampon or dressing is used, for example, if gauze saturated with antiseptic solutions is placed in or upon a wound (Gon- Till'] TREATMENT OF WOUNDS 29 termann). The treatment with moist compresses, evaporation from which is prevented by rubber tissue or paraffin paper, should be dis- carded for this reason. The bacteria multiply not only in the wound, but also in the gauze, in spite of the fact that it contains antiseptics and spread to the surrounding skin and invade the infection atria caused by maceration, producing pustules, furuncles or lymphangitis. The con- ditions within a moist dressing, evaporation from which is prevented, have rightly been compared to those of an incubator, and Schlange has demonstrated how bacteria will penetrate all the layers of a gauze dress- ing, evaporation from Avhich has been prevented, wliih' in dry aseptic gauze they are unable to multiply as a result of the drying of the secretion. On the other hand, moist dressings uncovered by rubl)er tissue and permitted to evaporate, acquire a strong capillary action. Of course this action begins later in moist than dry dressings, which begin to absorb as soon as applied. The capillarity of unprotected moist dressings is not, however, as Notzel thinks, greater than the dry. A greater number of bacteria may be found in the moist dressings than in the dry after a time, but the bacteria multiply in the former. For this reason we prefer the dry dressing, or tamponade, to the moist in the treatment of infected wounds, such as acute suppurative inflammations (vide General Rules for the Treatment of Pyogenic In- fections), and only use the moist evaporating dressings in the treatment nf wounds from which is discharged a thick secretion, or where there IS necrosis and the separation of the dead tissue is to be favored. In these cases the irritation of the antiseptic (preferably a three per cent solution of aluminum acetate) increases and thins the secretion, cleanses the surface, and hastens the formation of granulation tissue. [In America warm moist dressings of a saturated solution of boric acid are used very extensively in the treatment of infected wounds, and clinical experience seems to show that they have a very favorable influ- ence.] Alcohol Dressings. — An alcohol compress is a good agent for cleansing wounds and infected granulating surfaces if evaporation is not prevented by rubber protective. The growth of bacillus pyocyaneus ceases if such a compress is applied three or four times, during a period of twenty- four hours. On the other hand, alcohol compresses covered with rubber protective may cause gangrene, such as frequently follows the use of car- bolic acid and lysol compresses (with or without evaporation). Carbolic Acid Compresses and Carbolic Acid Gangrene. — The moist carbolic acid compress and drassing is often used by the laity as a prophylactic measure against inflanunation in accidental wounds. The harmful action of the antiseptic is best seen in cases where the dressing 30 WOUNDS, THEIR TREATMENT AND REPAIR has been allowed to remain some time, when not only the wound surfaces, but also the skin and deeper lying tissues may be affected. Numbness may follow after a short time the application of the compress ; this numbness may later pass into complete aneesthesia. If the treatment is dis- continued at this time, recovery with necrosis of the epithelium only may occur. After a longer application, and even with a one per cent solu- tion after twenty-four hours, the whitish discol- oration of the skin may pass into the black of necrosis — the tissues in contact with the car- bolic acid becoming mummified. The necrosis of the skin is limited to the area in contact with the dressing. Frequently in the fingers and toes the necrosis extends deeper, involving tendons, joints, and bones, and the entire digit dies and must be amputated. The ITse of Iodoform Gauze to Stimulate the Formation of Granulation Tissue and Adhesions. — The use of iodoform gauze is not limited to wounds from which infectious materials are to be drained away or hsemorrhage controlled. The stimulating action of iodoform causes a rapid development of granulation tissue after the tampon has been in position some days, and the formation of adhesions in serous cavities, which are of great surgical importance. By it inflammatory foci are walled off from healthy serous surfaces, and for this reason the tampon is often applied some days before deep ab- scesses (lung abscess or deeply situated abdominal abscess) are opened, or where the perforation of a contused part of the stomach or intestine or suture line is feared. During operations a tampon of iodoform gauze placed about the point of opening of an abscess or the point of incision of an intestinal loop protects the adjacent area from infection with pus and fajces. Iodoform gauze is usually employed in the form of doubled strips, 20 cm. in width. These can be used for practically all purposes. The von Mikulicz Drain. — Von Mikulicz introduced into abdominal surgery the Mikulicz tampon or drain, a large quadrangular piece of gauze, the center of which is invaginated to form a pouch which may be filled with sterile gauze or di-ainage tubes, as the case demands. The length of time that an iodoform gauze tampon should be allowed Fig. 31. — Carbolic Acid Gangrene or the Great Toe, Following the Ap- plication OF A Compress Saturated with a Two Per Cent Solution of Carbolic Acid for Taventy - four Hours. Compress applied to a small lacerated wound. THE TREATMENT OF WOUNDS 31 to remain in silu (Icpciids upon tlic eondition of the wound and the ])urposo for which it has been applied. In fre.sli wounds it may bo removed alter a few (hiys, anil if conditions are favorable tlie wound nuiy be sutured. If the tampon has been used to control a severe hasm- orrhasre (e. g. in luemophilia, or wounds of plexuses oi- sinuses) it should be removed only after it has been loosened by the seci-etion of the jrranu- lations. In serous cavities in which adhesions are to be pi-oduced, the tampon nnist remain at least a week. In wounds which secrete thick pus or are beiiiiniino; to frranulate-, and after incision of acutely inflamed tissues, the iodoform pauze should be replaced by moist compresses which are not covered by rubber tissue. The compress should be made of several layers of g:auze saturated with three per cent aluminum acetate, two per cent boric acid solution or sixty per cent alcohol, and should be evenly applied. In some cases ointments may also be used. Layers of fjauze evenly arranged should be spread with a mildly stimulating or inditferent oint- ment (mercury, zinc, berated vaseline, or lanolin) and then applied to the wound. Iodoform Intoxication. — Iodoform gauze may give rise to unpleasant local and dangerous general after etfects. These occur rarely, and then most frequently in patients with an idiosyncrasy, or where an excessive amount of iodoform has been used. The so-called iodoform eczema rap- idly spreads from the wound over an extensive area, and is accompanied by the formation of vesicles and severe itching. The edges of the wound become swollen and its surfaces coated. The itching may be controlled by zinc oxide ointment, and in most eases the healing is complete within a week. The patient's attention should be drawn to this fact, so that in later treatment the attention of the physician may be directed to this idiosyncrasy. INIucli more dangerous is the rare iodoform intoxication, which may develop even after careful use of the drug. It is caused by the absorption of the decomposition products of iodoform and occurs most freipiently when iodoform is used in deep wounds which have not been protected from putrefactive infections (operations al)out rectum) and in wounds in which the reduction processes cause a rapid divompo- sition of the iodoform. The symptoms in the beginning or in mild cases are persistent nausea, vomiting, and headache. These usually rapidly subside when the gauze is removed. In severe cases the symptoms, consisting of psychical dis- turbances, maniacal excitement, and delirium, are rapidly progressive, and are often accompanied by a cardiac weakness which may prove fatal. The urine contains iodine ; often albumen and blood. The danger of iodoform intoxication and the unpleasant odor of the powder, which is increased to an unpleasant garliclike odor by its de- 32 WOUNDS, THEIR TREATMENT AND REPAIR Fig. 32. Rubber Draixage Tube, Thread Fastexixg. composition when coming in contact with metal (tracheotomy tube, where the dressing comes in contact with eating utensils in wounds of the hand), have led to the preparation and introduction of a number of sub- stitutes. These may be divided into those which contain iodine, such as airol, aristol, europhen, iodol, iodoformal, iodoformin, loretin, nosophen, sozoidol, vioform, etc., and into those which do not, such as alumnol, amyloform, dermatol, thioform, xeroform, etc. The great number indi- cates how little satisfaction these substitutes have given, although some have found ardent supporters. Tubular Drainage. — The drainage of a wound with glass or rub- ber tubes provided with lateral openings to permit of the escape of wound secre- tion is called tubular drain- age in contradistinction to the capillary drainage obtained by the tampon. Tubes should be so placed in deep wounds as to render easy the escape of secretions from any of their parts. The outer end of the drainage tube should be provided with a sterilized safety pin or with a silk suture, which should be fastened to the skin with adhesive plaster. In this way the tube may be prevented from slip- ping into the wound. -^ — ' ^"° - ^ ^ The pressure of the safe- ty pin may be avoided by placing gauze between it and the skin. Often the drainage tube and tampon are combined. In this way the tube may be retained in position better and the wound kept open. Drainage tubes should not be allowed to remain in position longer than a few days. Their lumina easily become occluded by disintegrated blood clots and pus. AYhen the dressings are changed new rubber drains should be inserted, glass tubes should be removed, and sterilized by boil- ing. As soon as the secretion diminishes and granulations become abun- dant, the drain may be gradually shortened, and finally removed. Eemoval and Encapsulation of Foreign Bodies.— Finally the removal or encapsulation of a foreign body mr.st be considered in the care and treatment of a wound. Fig. 33. — Rubber Draixage Tube, Fix Fastexixg. THE TREATMENT OF WOUNDS 33 All visible particles of dirt and foreign bodies should be removed from the wound with tissue or dressing forceps. If allowed to remain wound repair will be prolonged by suppuration. A different problem confronts us when we consider the removal of deeply penetrating foreign bodies, such as needles, fragments of glass, wood and bombs, broken-oft' points of knives, swords, and daggers, bullets with accompanying pieces of clothing, pieces of a metal helmet, etc. According to the experiments of jNIessner, Brunner, and others, the bac- t(^ria upon a bullet or carried from the surface of the skin are rarely of the highly pathogenic variety. The experience of von Bergmann in the Kusso-Turkish war has become highly significant in the treatment of bullet wounds, both in military and civil practice. He demonstrated that bullet wounds might pursue a perfectly normal clinical course, in spite of encapsulation of the bullet, if dry aseptic dressings were ap- plied and the wound protected from secondary infections frequently introduced by probing, iri-igation, etc. The primary infections of the tract of the wound are usually trivial and limited to its outer parts, and the bactericidal properties of the tissues overcome them. Tetanus, putrefactive and suppurative inflammations may follow the penetration of a foreign body. In these cases the foreign body (e. g. a splinter of wood) has almost always rough surfaces, to which a great number of bacteria are attached. Inflammation may develop about an encapsulated foreign body after some years if the connective tissue cap- sule surrounding the foreign body and the bacteria carried in with it are ruptured by a trauma or if bacteria are deposited from the blood in the scar. Indications and Contraindications for the Bemoval of Foreign Bodies. — Clinical experience has established the following fundamental principles in the treatment of penetrating foreign bodies. Foreign bodies should be removed : 1. If they are visible in the wound. 2. If the foreign body, such as a splinter of wood, has rough surfaces, and is frequently followed by inflammation or tetanus. 3. If the foreign body can be felt directly beneath the skin and its removal is a trivial procedure. 4. If the foreign body immediately, or later after being displaced by muscular action, presses upon or is situated within a nerve, if it irritates mucous or synovial membranes, or causes pain by its point or sharp surface when pressed upon during movement (as needle, frag- ment of glass, etc.). 5. If a phlegmon or tetanus develops in the tissue surrounding the tract of the foreign body. Unless there are positive indications no effort should be made to 4 34 WOUNDS, THEIR TREATMENT AND REPAIR loeate the foreign body with a probe or remove it with forceps, as there is danger of introducing secondary infection. Incisions for the removal of foreign bodies should be made some distance from the wound if it is infected or should be delayed until healing has occurred. The position of metallic foreign bodies and glass may be accurately determined by the use of the X-ray, at least two views from different known angles being necessary. Information can also be gained by pal- pation, location of the pain, and the disturbance of function. Encapsulation is to be encouraged in all cases in which the foreign body is smooth and deeply situated, gives rise to no disturbance, and in which there is no inflammation of the tract of the wound. If after encapsulation there is pain or interference with function, the benefits to be derived from an operation are to be carefully weighed against the gravity and dangers of the same (for example, foreign body in the brain or vertebral column or in the thorax). The most important rules for the treatment of accidental wounds may be shortly summarized as follows : Emergency Dressing. — Immediate covering of the wound with dry sterile gauze. Definitive Dressing. — Cover the wound with sterile gauze while the surrounding area is being sterilized. If haemorrhage is severe, apply Esmarch's elastic constrictor. Preparation of area about wounds, the same as the field of operation in an aseptic procedure. Cover the sur- rounding area with sterile towels. Anaesthesia if necessary and not con- traindicated. Cautious separation of the edges of the wound with re- tractors to permit of inspection. Removal of dirt and foreign bodies A^'ith forceps, of blood clots with gauze. Irrigation of dirty wounds with a three per cent solution of hydrogen peroxide, application of artery • forceps and ligation of vessels, removal of fragments of tissue, trimming off of contused edges of wounds, tampon, drainage or suture, dry aseptic, and immobilizing dressing. Literature. — Basis. Erfolge und Gefahren der Gelatineapplikation. Zentralbl. f. d. Grenzgebiete, 1904, p. 818. — Bierfreund. Ueber den Hamoglobingehalt bei chir. Erkrankungen, mit besonderer Riicksicht auf den Wiederersatz von Blutverlusten. Chir.-Kongr. VerhaAdl., 1890, II, p. 159. — Brunner. Ueber die Infektion der Schuss- wunden durch mitgerissene Kleiderfetzen. Korresp.-Rlatt f. Schweiz. Aerzte, Bd. 26, 1896. — V. Esmarch. Ueber kiinstliche Blutleere. Cliir.-Kongr. Verhandl., 1896, II, p. 1. — Gontermann. Experim. Untersuchungen liber die Ab- oder Zunahme der Keime in einer accidentellen Wiinde unter rein aseptischer trockener u. antiseptischer feuchter Behandlung. Arch. f. klin. Chir., Bd. 70, 1903.— //ei7e. Ueber die antiseptische Wirkung des Jodoforms. Chir.-Kongr. Verhandl., 190.'!, II, p. 376.— Honsell. Experim. u. klin. Untersuchungen iiber die Verwendbarkeit des Wasserstoffsuperoxydes. Beitr. z. klin. Chir., Bd. 27, 1900, p. 127. — A. Kohler. Transfusion u. Infusion seit 1830, Gedenkschr. f. v. Leuthold. Berlin, 1906, Bd. 2, p. 27] . — Kronecker u. Sander. Bemerk. iiber lebensrettende Transfusion von anorgan, Kochsalzlosung. Berlin, klin, Wochen- WOUND REPAIR 35 schr., 1879, No. 52. — Kultner. Zur Frage ties kiinstlichen Blutersatzes. Chir.-Kongr. VerhantU., 19U3, I, p. 24; — 1st die piiysiol. Kochsalzliisung tlurch die Tavelsche Sodasalzlosung zu ersetzen? Beitr. z. klin. Chir., Bd. 35, 1902, p. 272. — Landois. Blutverlust, Transfusion. Lehrb. d. Physiol, d. Menschen. — Leonpacher. Ueber Kochsalzinfusion. Mitt, aus d. Grenzgebieten, Bd. 6. — Lossen. Die Bluterfamilie Mampel. Deutsche Zeitschr. f. Chir., Bd. 75, 1905, p. 1. — M edizinalabteilung des k. preuss. Kriegsniinisteriums, Ueber die Wirkung u. kriegschir. Bedeutung der neuen Haudfeuerwaffen, Berlin, 1894. — Mcssner. Wird das Geschoss (lurch die im Gewehrlauf stattfindende Erhitzung sterilisiert? Miinch. med. Woch., 1892, p. 401. — Xotzel. Ex{)erini. Studie zum antisept. Wundverband. Arch. f. klin. Chir., Bd. 71, 1903, p. 165. — Pcrman. Die Angiotri})sie in der operativen Chirurgie. Zentralbl. f. Chir., 1904, p. 1098. — Pjuhl. Ueber die Infektion der Schusswunden durch niitgerissene Kleiderfetzen. Zeitschr. f. Hygiene, Bd. 13, 1893, p. 487. — Schimmelbusch. Anleitung zur asept. Wundbehandlung, Berlin, 1893. — Schlange. Ueber sterile ^'erbandstoffe. Chir.- Kongr. Verhandl., 1887, II, p. lil.—Stempel. Die Hamophilie. Zentr. f. Grenzgebiete, 1900, No. 18. — Strubell. Der Aderlass, Sammelreferat mit Lit. Zentr. f. Grenzgebiete, 1903, p. 1. — Zimmermann. 6 Falle von Hautgangriin nach subkutaner Infusion von Kochsalzlosung. I.-D. Tiibingen, 1900. CHAPTER III WOUND REPAIR There are two methods of wound healins:. If the surfaces and edges of wounds are closely approximated or held in contact by sutures union occurs within a few days. If, on the other hand, the wound gapes or there is an actual loss of substance, new tissue must be formed to fill in the defect. The covering of this new tissue with epithelium com- pletes the process of healing. Healing by the first method is called primary wound healing or healing per primam intentionem; by the sec- ond method, secondary wound healing or healing jKr secundam inten- tioncm. Primary Wound Healing. — Primary healing occurs, if not prevented by suppurative infiannnation, necrosis, or the exudation of blood, when the edges of the wound are approximated. The union of a superficial incised wound or of a sutured wound requires from a week to ten days. When the crust which covers the line of union and the desquamated epithelium of the edges of the wound fall off, a delicate reddish epithelial membrane covering the space between the edges of the wound is seen. Gradually the newly formed epithelium cornifies and the firm, red scar becomes soft and white. The white color and smooth surface of the scar are permanent. Only very superficial scars disappear completely after some years. 36 AVUUNDti, THEIR TREATMENT AND REPAIR Primary wound healing is more complete and rapid if the edges of the wound are accurately approximated, but even then it is a compli- cated process. Only in wounds of the epithelium do we find a direct luiion of the edges by newly formed cells which replace those injured and destroyed. In all vascular tissues such a union by simple regenera- tion is impossible. Blood and tissue fluids which are poured out into the wound prevent, even in smallest amounts, the approximation of the wound edges, and besides, in all, even incised wounds, the tissues are injured considerably by the trauma, and whole groups of cells are de- stroyed by the subsequent circulatory and nutritional disturbances, by the exposure to the air, and, if the w^ound has been improperly treated, by the contact with water and antiseptics. The accumulation of blood and tissue fluids and the death of tis- sues prevent a direct union, but incite processes which provide for heal- FiG. 34. — Isolated Cells from GrantjtvAtion Tissue, a, Lyinphocytes or mononuclear leucocytes; b, different forms of mononuclear connective tissue cells; c, polynuclear connective tissue cells; d, connective tissue cells forming fibrilla-; e, fully developed connective tissue. (After Ziegler.) ing of the wound. The irritation resulting from the trauma, secondary injuries, and degenerating cell masses gives rise to the symptoms of inflammation which, because of its etiology, is known as mechanical or traumatic inflammation. During this stage the edges of the wound become united by a layer of fibrin which is formed by the coagulation of the blood, lymph and wound secretion. (Agglutination is the first step in primary wound healing; the earlier it begins, the more rapid and complete the urxion.) WOUND REPAIR 37 Even when a wound heals by j^rimary union, granulation tissue, the ger- minal tissue which fills in the defect, is formed, but in minimal amounts. During the process of agglutination the neighboring blood vessels become congested. There is a peripheral stasis and emigration of leuco- FiG. 3o. — Healing of a Sutured Incised Wound of the Skin Six Days Old. (After Ziegler.) a, Epidermis; b, corium; c, fibrinous part of the exudate; d, newly formed epidermis which contains numerous karyokinetic figures and epithelial processes which have penetrated the exudate beneath it; e, karyokinetic figures in the epithelium somewhat removed from the line of incision; /, germinal tissue developing from the connective tissue which also contains proliferating vessels; g, proliferating germinal tissue with leucocytes; h, groups of leucocytes in the inner part of the wound; i, fibroblasts lying in the exudate; A;, sebaceous glands; I, sweat glands. cytes, and some exudation, which assists in the formation of the fibrin layer. The accumulation of polymorphonuclear leucocytes, which can be demonstrated in from three to four hours, is well marked in twenty- four hours (Marchand). The number of leucocytes in the wound de- pends upon the amount of injury and degeneration. Functions of Leucocytes. — These cells perform many functions. They secrete a ferment which digests albumen and liquefies the degener- 38 WOUNDS, THEIR TREATMENT AND REPAIR ating tissues and they produce bactericidal bodies, which destroy the pathogenic bacteria. The latter are attenuated in aseptic operation- and accidental wounds (Schloffer, Riggenbach, Brunner). Leucocytes have phagocytic properties also. Their protoplasm is motile, and they are able to surround and ingest particles of tissue and the products of degenera- tion. The 3^oung fixed tissue cells (tissue-phagocytes or macrophages) rich in protoplasm are more actively phagocytic than the leucocytes. These ingest fat and pigment granules and become transformed into the so-called fat or pigment granule globules, which may pass through the lymph stream into the glands. The leucocytes rapidly degenerate and are replaced by new cells ; often they are found in the cytoplasm of the large phagocytes. Proliferation of Fixed Tissue Cells. — The proliferation of the fixed tissue cells goes hand in hand with the changes above described. Nu- merous karyokinetic figures indicate the activity of growth in the deep layers of the epithelium, in the endothelium of the vessels, and in the fixed tissue cells. Large cells of different forms with one, two, or many nuclei (the latter are called giant cells) grow from the tissues into the wound cleft. These cells are the formative connective tissue cells and are called fibroblasts. They infiltrate the agglutinating layer of fibrin, and later form the fibrillae of the new connective tissue, which holds the edges of the wound together and is known as a scar. Formation of New Blood Vessels. — This connective tissue is composed not only of fibroblasts, but also of leucocytes, lymphocytes, and plasma cells (vide Inflammation, Part II). The formation of new blood vessels accompanies the proliferation of fixed tissue cells, and is the result of the actual sprouting of solid, arched, protoplasmic processes from the walls of preexisting vessels. These protoplasmic processes later become united with each other, and their interior becomes liquefied, hollow, and patent. 2'ime Bcqinred for Healing of Clean Incised Wound. — A clean-cut M'ound with an undisturbed clinical course heals, as a rule, in about one week or ten days. With the development of the fibrillar ground substance, the newly formed scar, which in the beginning is vascular and rich in cells, contracts. It becomes paler and narrower. The firm- ness of the scar is gradually lost as the newly formed connective tissue bundles separate. The scar can be distinguished microscopically from the surrounding tissue for some time by its firmer texture and by the absence of elastic fibers. The less the amount of injury, and therefore the less the inflammation, the finer and more nearly perfect the scar will be. Broader and more resistant scars remain after the primary healing of contused and lacerated wounds than after the primary healing of incised wounds. WOUND REPAIR 39 Secondary Wound Healing. — SecoiRlaiy avouiuI healiuy;, character- ized by the (l(V(l(i|)iii('iit of a reddish, jj;:ranular tissue Avliich bleeds easily, differs from piimary wound healing-. It depends upon the same, but Fig. 3G. — Section fko.m a Scar in the Skin Twenty-six Days Old. (After Marchand.) The scar (n) consists of a fibrillar ti.ssue containing numerous oval nuclei of connective tissue cells and newly formed blood ve.ssels; (g) the connective tissue bundles of the cutis arc intiniatel}' interwoven with the newlj' formed tissue. Some of the old elastic fibers pass beyond the margins of the .scar. considerably exaggerated, proee.sses. The germinal tissue — called granu- lation tissue, because of its granular appearance — lies exposed in the wound, fills all the spaces of the wound, and replaces the lost tissues. This granulati(m ti.ssue develops in all wounds in which primary w^ound healing: has been prevented by the accumulation of blood or wound secretion or by extensive necrosis of the tissues following trauma or infection. Soon after the injury a layer of fibrin mixed with some blood forms upon the surface of the wound. Within two days this fibrin layer be- comes quite firmly attached to the hypern?mic swollen tissues of the wound and transformed into a yellowish, cheesy, fibrino-purulent mem- brane as a result of superficial necrosis or bacterial inflammation ac- companied by the accumulation of leucocytes. The secretions discharged from such a surface may present all the transitional forms between the serous and sero-purulent. Earliest after three days, often after one week, the membrane becomes penetrated at different points by small red 40 WOUNDS, THEIR TREATMENT AND REPAIR granules, each granule corresponding to a small blood vessel surrounded by germinal tissue. Finally the necrotic particles are separated and cast off by this tissue, and the entire surface of the wound covered by it. Healing of granulating surfaces may be hastened by drawing the edges of the defect together with adhesive strips or inserting tension su- tures. Where the granulating surfaces come in contact they will unite. c '■- - .. «. <9 -/ 0.. vfi i € - C Fig. 37. — Section from Wound Four Days Old, Following Amputation of a Dog's Tongue. (After Marchand.) The ends of the divided connective tissue bundles (6) ex- tend into the layer composed of fibrinous exudate /; within and beneath the fibrinous exudate are numerous polynucl ear leucocytes ; g, small vessel which becomes continuous with a dilated blood space; d, small artery with proliferating wall; c, enlarged fusiform, irregular connective tissue cells. Granulation tissue secretes an exudate rich in cells which resembles pus. This exudate, if it does not dry and form a crust, cleanses mechan- ically the surface of the wound, and has a bactericidal action (cf. Pyo- genic Infections, Part II, p. 155). It is especially profuse if the tissue is infected. The fibrillfe formed by the fibroblasts are arranged parallel to the surface in the deeper parts of the wound. From here they pass ver- tically along with the vessels (Figs. 37 and 38) into the upper, but less dense, layers. The covering over of a granulating surface with skin proceeds gradu- ally from the margin of the wound in the form of a bluish border. The WOUND KErAIK 41 new epithelium grows into tlic (l('i)ilis hclweeii tlic vascular loops of the granuhitions. Small islands of ei)ithelium also develop in the eenter of the jii'anulating surfaces from the ducts of sweat glands and from hair folliek's whieh were not totally destroyed by the injury or infection. Thick connective tissue bundles form as the scar develops. By the contraction of these bundles the scar is reduced in size and neighboring structures are often drawn out of place, causing unsightly deformities (ectropion of the lids and lips). Movements of the fingers, toes, and larger parts of the extremities may be interfered with (cicatricial con- tractures). Elastic fibers, nerves, and the appendages of the skin are not found in the scar. The contracting scar becomes extremely pale as the vessels become obliterated. The surface of a scar is smooth and white and remains so. After the loss of a large amount of tissue the scar may be depressed. .9r e- riphery toward its center. The changes occurring in the pigment of the skin are interesting and remarkable. If skin is transplanted from a negro to a white man, the pigment gradually disappears and the graft becomes white, while if the graft is taken from a white man and placed upon a negro, it gradually becomes pigmented. Early Appearance of the Grafted Area. — The grafted area appears bluish red in color and slightly depressed at first. Gradually the color becomes paler, and as contraction occurs a smooth scar, covering the site of the former defect, develops; sometimes, however, disfiguring keloid-like masses develop upon the surface. The wound resulting from the removal of the grafts heals in from one to two weeks under a dry dressing (healing beneath a scab), and after this time grafts may again be taken from the same area, which remains of a reddish color for some time and later becomes pigmented. Transplanted cutis strips contract but little, when the process of healing is undisturbed; contracting the least when they contain a thin layer of fat. In about five weeks they resemble closely the surrounding skin, are movable, and are easily displaced over the subjacent tissue {vide Plastic Operations). The healing of secondary defects may be hastened by suture and the grafting of epidermal strips. Transplantation of Mucous Membrane. — The transplantation of mu- cous membrane was successfully attempted by Czerny in 1871. It has been used particularly by Wolfler, Uhthoff, and others to repair con- junctival defects and replace eyelids; the mucous membrane being taken preferably from the lips or cheeks. If the epithelium of the grafts des- quamates, it is rapidly regenerated. Transplantation of Cartilage and Bone. — Cartilage may be success- fully transplanted if the ])eriehondrium is attached. Kredel used a piece of the auricular cartilage to support the altv nasi; von INIangoldt introduced subcutaneously a costal cartilage to raise a sunken nasal bridge; Fritz Koenig used with excellent results a cimeiform piece of 48 WOUNDS, THEIR TREATMENT AND REPAIR the pinna to replace the alfe nasi. If the perichondrium is not trans- planted the cartilage is gradually absorbed (Marchand). The transplantation of bone to overcome a bony defect is of great surgical importance. Attempts had been made at the beginning of the last century to close trephine openings, by replacing the button of bone removed. The experimental and practical . work of Oilier has extended the usefulness of bone transplantation in a number of different ways. nk Fig. 41. — Bone Formation at the Margin of a Medullary Cavity and About the Ha- versian Canals (Freshly Transplanted Bone as It Appears Microscopically After Forty-nine Days). (After Marchand.) o, Osteoblasts; k, newly formed bone ; nk, bone which has become necrotic; g, an injected blood vessel. It makes little difference whether tha bone is transplanted with or without periosteum and medulla, whether it is taken from the patient, from another person, or from a lower animal, whether it is living or dead (and in the latter case sterilized by boiling or flaming). Bone differs in this respect from all other tissues. Barth and Marchand offer the following explanation of this difference : Transplanted bone is never completely preserved, being for the most part absorbed and replaced by newly formed bone. The salts of bone play an important role in its WOUND REPAIR 49 regoiioration, for wliilo (Iccalcificd hone is (luickly ahsorlx'd, llic Ixxic ash stimiihitcs Ilic ciu-apsiihitiii^' connective tissue to form thin hiiiu-lhi' of hone (Hartli). Pieces of hone with periosteum attached, which are taken from the same person and immediately transi)lanted, otter con- ditions most favorahle for encapsulation. In the process of encapsulation a layer of fihrin is formed tirst which later hecomes infiltrated by newly formed connective tissue. The nuclei of tlie bone corpuscles and marrow cells degenerate and they die, only the most superficial layers of cells in the transplanted bone being pre- served, unless injured during transplantation. As early as the fifth day young connective tissue cells, developing from the adjacent actively pro- liferating connective tissue, and young blcod vessels grow into the medul- lary spaces and Haversian canals. On the eighth day, as a rule, the entire piece of transplanted bone is surrounded and infiltrated by con- nective tissue, the replacement of the dead medullary tissue in the inte- rior of the transplanted bone requiring a longer time. [The transplanted bone is gradually absorbed, being replaced by granulation tissue which eventually forms new bone. The transplanted bone then acts merely as a scaffolding or framework for the rapidly pro- liferating bone tissue. These newly formed cells infiltrate the Haversian canals and the bone marrow and aid in the absorption of the trans- planted tissue. Giant cells are also found, especially upon the surface of the transplanted bone, which correspond to the osteoclasts found in normal bone formation. These giant cells also perform apparently the same function in transplanted as in developing bone, digesting the bone and aiding in its removal. The giant cells usually lie in deep depres- sions upon the surface, which correspond to Ilowship's lacuna?. The more rapidly this granulation tissue forms, the more rapidly the layers of bone containing degenerated nuclei are destroyed and replaced. The space between the transplanted bone and the edges of the bone is soon filled with this tissue.] The time required for absorption and replacement usually depends upon the thickness of the piece of bone transplanted, being most rapid wlien frt'sh material is used. If some of the periosteum about the bony de- fect is raised and laid over the transplanted bone, r(^pair will be hastened. The Use of Ivory Pegs to Fix Fragments of Bone. — Ivory, which is used mostly in the form of pegs to unite fraetun^s, is acted upon in much the same way as dead bone tissue. The surface of the ivory peg is gradually worn away and the small depressions are filled with newly formed granulations, which are firmly united with the surrounding tissue, and the ]ieg is eventually encapsulated if sterile. Transplantation of Muscles and Nerves. — Strictly speaking, muscles and nerves are not used for transplantation. If separated from their 50 WOUNDS, THEIR TREATMENT AND REPAIR connections they degenerate completely, even if healing occu,rs. By muscle, tendon, and nerve transplantations are understood operations in which functioning, living structures are united with diseased, nonfunc- tioning structures; the connections of the living tissue, however, never being completely divided (cf. Injuries and Diseases of Soft Tissues). Czerny used successfully a lipoma to replace a breast which he had amputated for an adeno-fibroma and hypertrophy. The transplantation of parts of blood vessels has been successfully performed by Hoepfner and Carrel and Guthrie in animals. Hoepfner used the technic advised by Payr in making the arterial anastomoses (cf. Injuries of Arteries). The defect in the artery was replaced by a piece of an artery from the same animal or another of the same species. The transplantation of parts of organs is of practical importance. Thyroid gland tissue has been transplanted in cases of myxcedema fol- lowing operations, and although encapsulation with regeneration is pos- sible, the results are not satisfactory. Feeding of thyroid preparations is more simple and just as effective. The Use of Foreign Inorganic Materials. — Foreign inorganic mate- rials (alloplasty) have been used for some time to close defects in bone, particularly in the skull, to raise the sunken nasal bridge in saddle- nose, or to close large hernial rings. Plates of amber, platinum, cellu- loid, ivory, gold foil, and silver wire filigree are inferior to living bone for purposes of transplantation. These foreign bodies will become en- capsulated if they have been previously thoroughly sterilized, and if the operation is performed aseptically. If, however, they produce pressure upon or rub against the skin, fistula? will form. Liquid or solid par- affin has been used to raise the skin in saddle-nose, to reinforce a poorly functioning sphincter ani, to make an artificial testicle, etc. (Gersuny, Eckstein, Stein). Literature. — W. Braun. Ivlin.-histol. Untersuchungen iiber die Anheilung ungestielter Hautlappen. Beitr. z. klin. Chir., Bd. 25, 1899, p. 211. — Brunner. Wund- infektion u. Wundbehandlung II, Frauenfeld, 1898. — Eckstein. Hartparaffinprothesen. Berl. klin. Wochenschr., 1902, p. 315. — -Kredel. Die angeborenen Nasenspalten und ihre Operation. Deutsche Zeitschrift fiir Chirurgie, Bd. 47, 1898, p. 237. — v. Mangoldt. Die Einpflanzung v. Rippenknorpel, etc. Chir.-Kongr. Verhandl., 1900, II, p. 460. — Marchand. Der Prozess der Wundheihmg. Deutsche Chir., 1901. — Payr. Implanta- tion der Schilddriise in die Milz. Chir.-Kongr. Verhandl., 1906. — Reinbach. Unter- suchungen menschlicher Granulationen. Zieglers Beitr. z. pathol. Anatomie, Bd. 30, 1901, p. 102. — Ribhert. Ueber Transplantation auf Individuen anderer Gattung. Verhandl. d. Deutsch. Pathol. Gesellsch. Zentralbl. f. allg. Pathol., Bd. 15, 1905. Ergan- zungsheft, p. 104. — Riggenbach. Ueber den Keimgehalt accident. Wunden. Deutsche Zeitschr. f. Chir., Bd. 47, 1898, p. SZ.—Schloffer. Ueber Wundsekrete und Bakterien bei der Heilung per primam. Arch. f. klin. Chir., Bd. 57, 1898, p. 322. — Stein. Paraffin- Injektionen, Theorie u. Praxis, Stuttgart. Enke, 1904. 11. ASEPTIC TECHNIC All the methods employed in the treatment of wounds, before the nature and causes of wound infectious were recognized, were unsuccess- ful. AVluit were ill-directed attempts to determine the cause of and prevent wound infections, l)ecame definite and direct with Pasteur's dis- covery (18(j1) that fermentation and putrefaction of organic masses were caused by ferments of a vegetable or animal nature. Lister's sug- gestion (1867) that wound infections nnist have a similar cause has been most fruitful for the entire field of surgery, and remains to-day the most important milestone in its history. The result of Lister's work was that an attempt was made to sterilize everything coming in contact with the wound, even the air. Lister used carbolic acid for this purpose, after it had been demonstrated that it would destroy the odor of sewerage and the intestinal worms which in- jured grazing cattle. It had, however, been used independently by an Italian surgeon since 1863. In the method as originally devised by Lister the skin, hands, instruments, sponges, sutures, and ligatures were sterilized with a five per cent solution of carbolic acid, and a spray of a two and a half per cent solution of carbolic acid was kept playing dur- ing the operation to prevent air infection, which was particularly feared. The temporary and permanent dressings were also saturated with a solution of this acid. Lister's experiment was a success, and with one blow operative surgery was rid of its worst enemies — hospital gangrene and flic srror and frequently fatal putrefactive and pyogenic in- fections. In the antiseptic method of wound treatment, originally introduced by Lister, an attempt was made to prevent the development of wound infections and to combat those already developed by the use of different antiseptics. The year 1886 marks the beginning of the aseptic method of wound treatment, special emphasis being laid upon the prevention of wound infections, mechanical and physical methods of sterilization being chiefly relied npon. As in any innovation, a number of different com- plicated aseptic methods and procedures w^ere introduced. Later inves- tigations have shown that many of these are superfluous, and have com- pelled a return to simpler but as efi:'ective methods. 5 51 52 ASEPTIC TECHNIC The science of bacteriology, whicli began with Koch's discovery of the anthrax bacillus (1876) and the introduction of solid culture media, required for making pure cultures of bacteria (1881), and was placed upon a firm basis by Rosenbach (1884), has shown how extensively the pathogenic bacteria are distributed. It is little wonder, after the brilliant confirmation of Pasteur's germ theory and the justification of Lister's suggestion that wound infections were caused by bacteria, that the latter 's method as originally employed or modified by him was extensively used. In the early period of antisepsis the operating room resembled a carbolic acid bath. The carbolic acid spray was soon discarded in order to prevent infection through the air cur- rents produced hy its use. It was soon demonstrated, however, that the dangers of air infection were much less than those of contact infec- tion through the hands, instruments, and dressings, and although the spray was discarded, antiseptic solutions, sometimes carbolic acid, at other times sublimate solution, which is active in much weaker solution, were still permitted to run over the wound during the course of the operation, the use of these antiseptics during the operation being con- sidered very essential. Later improved methods of investigation (Geppert) demonstrated that the bactericidal action of the antiseptic solutions in wounds and upon the surface of the body had been greatly overestimated. It was shown that antiseptics did not reach bacteria lying in the superficial epithelium and attached to foreign bodies ; that they were inactive in wounds form- ing chemical union with the albuminous secretions; and that they de- stroyed the superficial bacteria only after long contact, injuring at the same time the tissues and viscera, thus reducing the natural resistance of the organism. In addition it was demonstrated that the antiseptic dressings, because of the volatility of the agents employed, had no marked bactericidal powers and even harbored bacteria (Schlange) ; that operation wounds treated with antiseptic solutions secreted more profusely and healed more slowly than those treated by the dry method (Landerer, von Bergmann), and that irrigation of severely inflamed tissues favored the extension of the infection (von Bergmann). Guided by -the results of bacteriological investigations of Koch, Gaffky, and Loffier (1881), surgeons turned to physical methods, of which sterilization by live steam and boiling water, excepting, of course, mechanical cleansing, are the most important. The entire procedure, to the perfection of which von Bergmann, von Esmarch, Landerer, Neuber, and Schimmelbusch have contributed most, is known as asepsis, and has replaced chemical sterilization by the use of antiseptics. Even at the present time antiseptics are indicated and required in certain cases, but they no longer as formerly are depended upon alone, being merely inci- PREPARATION OF THE SURFACE OF Til 10 BODY 53 dental as coiitri))utiii.u,- to the success of aseptic technic. It would be more correct to speak of physical and chemical antisepsis. It would be impossible in a book of this character to discuss at length the different features of aseptic technic as employed by different sur- geons, and besides it would be tiresome and confusing to the reader. Each method differs as to detail, but there is a general principle which is conunon to all. In the following chapters a simple but effective aseptic technic will be described. It can be easily followed by physicians and surgeons, who are often reijuired to ojierate in private homes and do not have access to the conveniences of a hospital. [A number of surgeons regard the use of head pieces, covering the hair and -protecting the mouth and nose, as superfluous. Clinical expe- rience, however, seems to indicate that the best results are obtained when the mouth and nose are covered either with a special mask or with sterile gauze and the head is covered with gauze or a cap. Rubber gloves are being very extensively used, being the best safeguard against infection of the patient, and at the same time protecting and preserving in good order the surgeon's hands. Rubber gloves can easily be prepared for any operation in private practice, and special masks for the head and face may be so easily procured or made when needed that they should be used in every case.] CHAPTER I PREPARxVTION OF THE SURFACE OF THE BODY The skin is the habitat of numerous varieties of bacteria, among which the ordinary pyogenic and putrefactive bacteria are most com- monly found. The removal of these bacteria from the skin of the hands and the field of operation is a most difficult task, but one that is indis- pensable to successful results in surgery. The bacteria are hidden not only in the fat covering the skin, but also in the superficial layers of the epidermis, in the outer parts of the hair follicles, in the ducts of the sweat glands, and even in the most insignificant wounds and fissures of the epidermis. Haegler, after rubbing a culture of bacteria upon the skin, could demonstrate bacteria at all the points above mentioned, and they can be demonstrated in normal skin. Sterilization of the Hands. — The results of the investigations of von IMikuliez, Ilaegler, Paul and Sarwey, Gottstein, and others have shown that it is impossible to completely sterilize the hands in a bacteriological sense for an entire operation. The surgeon and his assistants should 54 ASEPTIC TECHNIC attempt to approach the ideal as closely as possible, and even when sterilization has been as thorough as possible, should regard the hands as very unreliable and exercise due precaution to prevent infections. The difficulties of hand sterilization may be easily recognized if the skin is examined under the lens, when all the fissures, which resemble the furrows in a newly plowed field, may be recognized, and one remembers that all the roughened areas, still more the small wounds and fissures, afi:ord the best resting place for bacteria. Of the different methods of hand sterilization which have been intro- duced, that of Fiirbringer is the most extensively used, and is to be recommended. It is practiced in the von Bergmann clinic at the present time in the following way : * 1. iMechanical cleansing of the hands and forearm for ten minutes in hot water with soap and brush ; of the space beneath the free margin of the nail and nail folds with a nail file or cleaner. 2. Thorough drying of the hands and forearm with a sterile towel. 3. Washing for three minutes in from seventy to eighty per cent alcohol. 4. "Washing for three minutes in 1 to 2,000 sublimate solution. The first act is the most important. The hot water and soap and the ^ngorous rubbing with the brush remove the fats covering the skin, and loosen and separate the upper cornified layers of the epidermis. [In the Bevan clinic the same methods are employed with two excep- tions: (1) The bichloride has been entirely dispensed with, and (2) rub- ber gloves are invariably worn by the surgeon, assistants, and nurses.] Simple bristle hand brushes are most valuable, and cannot be replaced by any other agent. Before using, a large number should be sterilized in a lead can or linen bag. In private prac- tice it is recommended that the brushes be boiled in water and then kept in a 1 to 5,000 bichloride solution. The brushes should be freed of all srap before being placed in the solution, as soap forms a chemi- cal compound with mercury, which is inactive. Five bi'ushes will do very well for minor operations, and ten usually suffice for major ones. Fig. 42. — Lead Box with Trays for Brushes FOR Sterilization in Steam. PREPARATION OF THE SURFACE OF THE BODY 55 AftiT WiishiiiL;-, cjH'li Itiusli coiitjiiiis niiiiicrous bacteria, especially in its deeper paits. While the (hui,t;t'r (if li'aiisferrinu: l)aeteria while wash- in^'- uiuler tlowiug water is probably not frreat, it has become a rule that a brush once used should not be used again until it has been sterilized. A number of brushes should be used in sterilizing hands to which grosser particles of dirt are attached, or which have been in contact with pus or fiL'ces. The dangerous space beneath the free margin of the nails and the nail folds demand especial attention. The grosser particles of dirt should be removed with a nail cleaner before washing is begun. Cleans- ing of the nails should l)e continued during the process of washing, as the finer particles to wliich the bacteria are attached become separated and may be removed with soap and brush. If the free margin of the nail is not longer than two millimeters, the space beneath can be cleaned very satisfactorily with the brush, as the bristles penetrate into all the depressions and recesses. The brush is far superior for this purpose to a number of substitutes such as orange-wood sticks, pumice stone, sand, different soap mixtures, etc., which have been introduced. Trimming the nails short has been recommended by some surgeons. It should be dis- couraged, however, as the space between the nail and the skin is then ex- posed, becomes rough and fissured, rendering sterilization more difficult. ^Mechanical sterilization of the hands is an art to be acquired by practice, deT)ending less upon the time actually spent in the process than upon the way and thoroughness with which the surface of the hands and forearm are washed and scrubbed. Haegler has recommended a method by which the thoroughness of the sterilization may be tested. After the fats are removed by washing, and the hands and forearms have been thoroughly dried, a few drops of liquid Chinese dye are rubbed into the skin. The surfaces are then scrubbed as usual with soap, water, and brush, and then examined with a lens. All the areas which have been neglected may be easily seen, as they will still be stained. One soon learns by these attempts how to wash his hands thoroughly. Special attention should always be paid to the space beneath the free margin of the nails, the deep furrows in the palm of the hand, the interdigital spaces, and the outer side of the forearm. The water should be used as hot as possible. In all large institu- tions provided with running water the hot water may be regarded as germ free, in spite of the fact that it contains a number of harmless varieties of micro-organisms. AVhere there is no running water it may be boiled in kettles ; after boiling for five minutes, it may be regarded as germ free. The arrangements for washing vary. In clinical institutions and hospitals the bowls should be so constructed that they may be easily 56 ASEPTIC TECHNIC cleaned, and that the water Avhich is discharged from a tap may be turned on or off, and that the amount of hot and cold water may be regulated by the foot or forearm. [It is preferable that the stopcock be so arranged that the flow of water can be controlled by foot pres- sure. This is much more convenient, and there is much less danger of soiling the hands and forearm in an endeavor to turn the water off or to regulate the amount of hot and cold water discharged.] In the simplest arrangement an attendant manipulates the stopcock, renewing the water when necessary, and regulating the amounts of hot and cold. In private practice an ordinary wash bowl which has previously been thoroughly cleaned with hot water may be used. In this case the water must be changed at least three times before the hands can be regarded as thoroughly sterilized. All soaps used by the surgeon should be alkaline, as these favor the separation of the superficial layers of the epidermis. The tincture of green soap and soft soap are very extensively employed. If in private practice one is compelled to use toilet soaps, mechanical sterilization must be more vigorous, in order to make up for the deficien- cies of the soaps, which usually are fatty and neutral and do not favor the separation of the superficial layers of the epidermis. After the hands and forearms have been washed and scrubbed thor- oughly for the required length of time, they should be dried with a sterile hand towel. In this way the epidermis which has become loos- ened as a result of the washing is removed. The towel should not be used again until sterilized, as it takes up numerous bacteria. Washing with Alcohol. — Washing with alcohol is a very important step in the procedure. When rubbed into the skin with sterile gauze or a brush it penetrates the deepest furrows, removing the fat and dehydrating the superficial layers of the epithelium, and prepares the skin for the action of the aqueous solution of the antiseptic which is used later. Alcohol, especially sixty to seventy per cent alcohol, has a certain sterilizing action. Alcohol of higher concentration has less bac- tericidal action, as it rapidly coagulates the albumen, forming a coat- ing which prevents penetration. The skin already contains some water, remaining after the washing, and seventy or eighty per cent alcohol is therefore used. After washing in alcohol the skin shrinks, and the small furrows and fissures in the epidermis in which the bacteria are lodged become closed. Cultures taken at this time would probably be sterile, but the hands should not be regarded as sterile in the surgical sense, for as soon as the hands come in contact with water or blood the fissures and furrows open and the bacteria are discharged upon the surface. For this reason the action of some antiseptic is required. PREPARATION OF THE SURFACE OF THE BODY 57 Bidiloricic of Mcrcuv}) Holuiion. — Bichloride of mercury, introduced into surgical practice by von Bergmann (1878) and later recommended by Sc'hedo, is still at the present the most powerful chemical anti- septic. A 1 to 2,000 solution of bichloride is employed, tablets prepared by any of the principal chemical manufacturers beinp; used for the piirpose. The addition of sodium chl(M-ide prevents the decomposition of the bichlo- ride by the alkalies of the tap water. Warm tap water, boiled water, or water taken from a reservoir may be used in making the solution, as the bacteria which are contained in the M^ater are killed by the bichlo- ride after the solution stands for some time. The tablets used in mak- ing the solution contain a stain, and the solution is colored so that it can readily be distinguished from other antiseptic solutions or from water. Other Methods of Ilaud sterilization. — Brief mention will be made of other methods of hand sterilization. Some surgeons, among whom Neuber may be cited as an example, regard washing wath hot water and soap as sufficient, while othei's, such as Ahlfeld, value the bactericidal action of alcohol so highly that they regard the use of other antiseptics as superfluous. Von Mikulicz attempted to combine the action of soap and alcohol by using a mixture consisting of 10.2 potassium soap, 0.8 unsaponified olive oil, 1.0 glycerin, 43.0 alcohol, and 45.0 water, which was rubbed into the skin with a brush. Haegler's investigations showed, however, that the bactericidal action of this mixture was only apparent, as it formed a thin layer of soap under which the bacteria were retained. It does not favor the separation of the upper layers of the epidermis to the extent that soap and alcohol do when used separately, and besides makes the hands slippery. Soap mixtures naturally prevent the bac- tericidal action of sublimate solutions, as the thin layer of soap, which remains attached to the skin, forms an insoluble, inactive compound with the mercury. In spite of these objections soap mixtures in solid form (Vollbrecht) or combined with pumice stone (Pfoerringer) may be used in case of emergency, where the water supply is low, espe- cially in battle. It should be remembered, however, that they form but poor substitutes for the Fiirbinger method. Lysol is preferred by obstetricians. It is seldom used by surgeons, as it renders the hands slippery and interferes with the manipulation of instruments. Cotton and Ruhher Gloves. — The sterilized cotton gloves introduced by von IMikulicz, which \vere put on after the hands had been sterilized, have found but few friends. When used they must be changed from five to ten times during an operation, as the bacteria which come to the surface of the hands during the operation become attached to the inner 58 ASEPTIC TECHNIC surface and may even be carried through to the outer surface. Von Bergmann, after a long and thorough trial, has discarded them for oper- ative work, using them only when changing dressings, handling sterile sheets or towels and dry instruments. Rubber gloves, recommended first by von Zoege-Manteufel, and per- fected later by Friedrich, have a number of advantages. Rubber gloves may at first interfere with the dexterity of the operator and the deli- cacy of touch, but these disadvantages are soon overcome when the sur- geon becomes accustomed to them. The hands should be sterilized be- fore the gloves are put on. Gloves may also be boiled at the time the instruments are sterilized. They are then filled with sterile water and put on wet. Some surgeons prefer the dry method, the hands being covered with sterilized talcum powder before the gloves are put on, while a number of others prefer the wet method of using gloves. After they have been used, they should be washed off with soap and water, filled with gauze, and dried. Gloves should not be kept in antiseptic solutions, as they then soon lose their elasticity. [Rubber gloves are being used very extensively by American sur- geons. Bacteriology has demonstrated that hand sterilization, regard- less of the method employed, cannot be entirely depended upon. Clin- ical experience has demonstrated the effectiveness of rubber gloves in preventing infections, and although it has frequently been demon- strated that the bacteria of the skin multiply beneath the rubber, they cannot reach the wound unless the glove is punctured and torn. Such accidents can be prevented by care, and after a little practice are rec- ognized so soon that there is but slight danger of infection. Gloves are especially valuable as a prophylactic measure, and should invariably be worn in making examinations of lesions which may be specific, and in examining or operating upon virulent infections. After gloves have been worn, the operator becomes accustomed to them, and they no longer interfere with the dexterity of the surgeon or his deli- cacy of touch. It is the belief of the editor that rubber gloves will be generally adopted, and that their introduction into surgery marks one of the greatest advances in aseptic technic] The Necessity of Washing the Hands in Suhlimate Solution During the Operation. — The hands, unless chapped or fissured, may be regarded as comparatively free from germs after sterilization according to Fiir- binger's technic, provided they have not been in contact with pus or other infectious material, as the most refined bacteriological methods fail to demonstrate any great number of bacteria in the skin. This condition does not persist, hoAvever, throughout an entire operation, even if the case is a clean one and the technic is good. Soon micro-organisms, espe- cially the white staphylococci, appear upon the surface of the skin. The PREPARATION OF THE SURFACE OF THE BODY 59 researches of von Mikulicz, Ilaeylor, Doedorlin, and others have thrown liyht upon the origin of these bacteria. A few are derived from the air; the majority come from the deeper layers of the skin, from the outer parts of the ducts of the sebaceous and sweat glands, the hair follicles, and the small fissures in the epidermis. These bacteria hidden within these retreats have not been reached by either mechanical or chemical sterilization, and are carried to the surface by movements and friction, for example, in tying ligatures and sutures. Therefore the hands nuist frequently be washed in a sublimate solution, which should often be renewed during the course of tlie operation, and should come in contact with the wound as little as possible, tissue forceps and other instruments being used when possible (Koenig). Care of the Hands. — The surgeon's hands should receive good care and be protected from inflections material. Prophylaxis is the best guar- antee against infections. Therefore, rubber gloves should be worn when infected eases are dressed or operations performed upon suppurating or putrefactive processes. In examinations of the mouth or rectum gloves, or at least a finger cot, should be worn. After the operation is eonij)leted, the bichloride which remains attached to the epidermis should be removed with hot water and sonp, as it may produce in susceptible people a vesicular eczema with secondary ulcers and crusts. After the last washing, when the hands have been thoroughly dried, glycerin or some hand lotion should be rub])ed into the skin to prevent chapping. An infusion of bran has also been recommended for this purpose (Ilaeg- ler). A surgeon whose hands ai'e very rough should rub glycerin into the skin or apply lanolin before retiring, and wear gloves during the night. Supi^urating wounds of the hands, and even the most insignilicant inflannnatory processes make an aseptic operation impossible even if gloves are worn. Sterilization of the Skin of the Field of Operation. — Each patient should be given a warm bath some time before the operation if there are no contraindications. Grosser particles of dirt (especially upon the hands and feet) should be removed by vigorous washing with ether, ben- zine, or petroleum ether. The field of operation and the surround- ing skin should be shaved. The skin should be shaved even where there is but little hair, as the upper loosened epidermis is most effec- tively removed in this way. After the shaving is completed the same teehnic is employed as has already been described for hand sterili- zation. Sterilization of Mucous Membranes. — Mucous membranes to be di- vided in the course of the operation can only be incompletely sterilized. Antiseptics have no efl'ect u])on bacteria contained in the secretion of 60 ASEPTIC TECHNIC mucous membranes, and besides they may irritate the latter and be absorbed, causing severe toxic symptoms (e. g., bicMoride poisoning after rectal and vaguial irrigations). Mechanical sterilization must be relied upon in these cases, a three per cent solution of hydrogen peroxide being used in the mouth cavity; sterile water or a bland, non-irritating solution (three per cent aluminum acetate, or two per cent boric acid solution) being employed for bladder and rectal irrigations. During operations upon the stomach and intestines the secretions of the mu- cous membranes, the stomach contents, and ftecal matter should be carefully wiped away with gauze sponges or laparotomy pads. The peritoneum should also be protected by laparotomy pads before the stomach or intestines are opened, and contamination of the peritoneum prevented. Mercurial poisoning, the sjTnptoms of which are salivation, colic, and persistent, often bloody diarrhoea, has not been observed after the use of 1 to 2,000 solutions. Haegler believes that surgeons who do not wash off the sublimate which becomes attached to the hands during sterili- zation may become slightly intoxicated by touchiug the lips with the fingers. CHAPTER II STERILIZATION OF INSTRUMENTS Instruments are no longer sterilized by placing them in a two and a half per cent solution of carbolic acid shortly before or during an opera- tion. At the present time they are sterilized by boiling, a rapid and efficient method. Pyogenic cocci are killed in a few seconds and the re- sistant anthrax spores in five minutes by boiling. Boiling for five min- utes is sufficient in all cases. Instruments which are sterilized frequently should be made entirely of steel without wood or horn handles, and should be thoroughly scrubbed before they are boiled. Those soiled during an operation should be rinsed off with cold water (preferably under the tap), and should then be allowed to remain for some time in a warm solution of soda and soft soap, scoured and well dried, and finally polished with alcohol and chamois skin. The more composite instruments (viz., artery clamps and forceps) should be taken apart each time for cleansing. Nickel plating of instruments is not necessarj^, and besides it is not per- manent. STERILIZATION OF INSTRUMENTS 61 Soda Solution and Apparatus for Boiling Instruments. — To prevent the rusting of steel instruments Schimniclbusch has introduced the use of ordinary cookinf; soda (1 to 100). The addition of an alkali not only prevents the rusting of instruments, but also aids in sterilization, for the attached pieces of dirt are more easily separated and penetrated. A tablespoonful of soda is used in a liter of water. The apparatus de- FiG. 43. — Schimmelbusch's Apparatus for Sterilizing Instruments. It consists of . three instrument tray.s, 14X18 inches, a graduate for making soda solution, wooden bracket for match safe, time glass and soda box. The apparatus is to be filled with water about two inches deep, to which a teaspoonful of soda is to be added. A large gas burner beneath sets the water boiling in a few minutes. vised by Schimmelbuseh, Avhich is made in different forms and sizes, and differently equipped, is used for boiling. The one per cent soda solu- tion which fills this boiler can be made to boil in a few minutes by an electric current, steam, gas, or spirit lamp. The instruments are placed in order in the flat, perforated tin tray, which is submerged in the solu- tion. The edges of sharp instruments must be protected. For this reason needles should be placed in small glass or metal boxes, and the knives kept in a frame or the blades wrapped with cot- ton. The cover of the apparatus fits tightly and the temperature of the solution may be brought to 220° F. After boiling for five minutes or longer, the tray is re- moved by two steel hooks which are used for the purpose, and is placed in the frame of an instrument table. The instruments may be cooled by pouring cold sterile water over them, or by placing the tray in a basin of cold sterile water or spreading them upon a sterile towel; in the latter case some minutes will be required before they be- come cool. Fig. 44. — Knv-8ciii;i:uku Stkkilizi.ng P.\n with Instruments for Use in Steam Sterilizer. 62 ASEPTIC TECHNIC Instrument Table. — The instruments which will be required should be placed upon a table which is covered by a sterile towel; the other instruments being left on a tray or in a basin. The table should be so con- structed that it can be easily placed near the surgeon or attached to an upright so that it may be swung over the patient. Instru- ments which have been used should be re- placed by clean ones and should then be rinsed off, scoured, and resterilized. The soda solution should be kept in readiness. A spoon holding 10 c.c. may be used to meas- ure the powdered soda or soda tablets may be used instead. Sterilization of In- struments in Private Practice. — The surgeon is always able by the use of this soda solution to ster- ilize instruments rapidly and thoroughly in patient's home. An ordinary kettle, if large enough, will suf- fice. If a large num- ber of instruments must be sterilized, an asparagus boiler or a fish kettle with perforated tray may be used. The kettle is placed in cold water after boiling, and the soda solution cools rapidly, and the instruments may then be removed. Instruments should not be washed or placed in sublimate solution, for they are soon blackened by a deposit of mercury. Syringes which are made of metal and glass and are provided with asbestos and glass pistons may be sterilized by boiling in the soda solution. To prevent Fig. 4.5. — Instrument Table on Which Sterile Instru- ments Required for Immediate Use Are Placed. The table is provided with rollers so that it can be easily moved about and placed where convenient for the operator. the STERILIZATION OF SPONGES, BANDAGES, Slll'.ins, AND TOW i;i.S 03 the si'lass from })r(';iUiii^' the syi-iii^o should l)e hall' (illcd Ijrlon' it is placed in the solution, and it should never be placed directly in boiling watei-. The catheter has been used its surface nuist be rubbed olf and its lumen cleaned by allowing ta]) water to run through it. The silk catheters covei-ed with shellac and india rubber catlu>ters should not be boiled, as lliey become soft and can no longer be used. Accord- ing to Claudius they stand boiling best in concentrated salt solution (4 NaCl : 10 water), or according to Ilernuin, in a concentrated solution of sul{)hate of annnonia (3:5 watc)-), a procedui-e reconnnended by Els- berg foi- the sterilization of catgut. The ordinary Nelaton catheter, used so extensively in America, stands boiling very well, and may be steril- ized with the instruments. CHAPTER III STERILIZATION OF SPONGES, BANDAGES, SHEETS, AND TOWELS; PREPARATION OP IODOFORM GAUZE Gauze, cotton, and roller bandages are required in the dressing of the ordinary wounds. Absorbent Gauze. — xVbsorbent gauze, which was introduced by Lister, is even to-day the most useful material for dressing wounds. It takes up wountl secretion and at the same time allows it to dry. None of the substitutes which have been tried has this property. The substitutes are cheaper, but the absorbent gauze is indispensable. It is made of loosely woven cotton from which the fat has been extracted, and is sold in large bolts. These are cut into square pieces of about 25 qcm. with heavy scissors. Some of these are irregularly folded to form fluffed gauze, some are regularly folded to form dressings and compresses, or cut into long strips for tampons. A part of the fluffed gauze is used for sponges by Avhich the blood is Aviped away during the operation, while large amounts are used in dressing the wound. Cotton. — Cotton packs easily when in contact with a wound, absorbs but little w'ound secretion, and forms a layer which prevents its discharge. It can never replace gauze, but it is soft and pliable and can be used to advantage in padding a bandage. It is made of bleached raw cotton 64 ASEPTIC TECHNIC from which the fat has been extracted, and is sold in rolls. These are cut into strips about 15 cm. in width, which are rolled. Cotton is cleaner and more easily handled than the substitutes which have been intro- duced. The substitutes are, how- ever, cheaper, and may be used for suppurating wounds which are discharging profusely. Wood cot- ton, made of wood wool and cotton, is rolled and used in the same way as cotton. Peat and moss, Fig. 47a. — Pressure Steam Dressing Sterilizer. Fig. 46. — Can for Sterilization of Dress- ings AND Sponges. (After Schimmel- busch.) wood wool, cellulose, and other substitutes are sewed up in sterile bags and used for dress- ings in the form of pads. Moss felt and moss pasteboard are prepared from moss by running it through a press. They are covered with gauze before using, and are espe- cially adapted for immobiliz- ing dressings. After moisten- ing, felt can be molded to the part to which it is to be ap- plied. Roller Bandages. — INIuslin and gauze bandages are used for maintaining the dressings in position. The former, made of English mull of strong STERILIZATION' OF SPONGES, BANDAGES, SHEETS, AXD TOWELS 65 fiber, are exix'iisivc ])ut. (liir;il)I(^, and can l)e Avaslied and used repeat- edly. The gauze rollers, made of loosely woven Cierman nuUl, are i iG. 476. — Combination Sterilizing Apparatus. cheap and pliable, but as a rule can be used but once. Roller bandages may be procured ready made from the dealers, or long pieces may be 66 ASEPTIC TECHNIC torn or cut from the piece and rolled by machine. A few turns of starch bandage may be applied over the roller bandage to make it firm and prevent loosening. Starch bandages may be prepared by impreg- nating wide-meshed gauze with starch paste and allowing it to dry while on tension. Sterilization of Dressings. — Materials used for dressings are sterilized by steam in an apparatus devised for the purpose. Tin cans of differ- ent forms and sizes are filled with gauze, cotton, and bandages, and are placed in the sterilizer. The can devised by Schimmelbusch is round or square. The cover, bottom, and sides of the cans are provided with a great number of holes which can be opened and closed at will by a strip of tin. These holes permit the steam to pass through the dress- ings. Sterilization is complete in three quarters of an hour after the steam begins to form (Schimmelbusch, Borchardt). After sterilization is completed the cans are allowed to remain in the sterilizer for a short time with the holes open in order to allow the materials to dry. The cans are then closed and are ready for use. In hospitals freshly sterilized cans, some filled with gauze, some with cotton, and some witTi bandages, are supplied each morning to the dressing and to the operating rooms. The sheets, the large and small towels which are used to bound the field of operation, to cover the patient, the operating table, and the small instrument table should be done up in packages and sterilized in the steam sterilizer. Moss, wood wool, and peat pads are handled in the same way. Large hospitals are provided with a second large sterilizer which is used for the larger pieces, the smaller, being sterilized in the apparatus which is used for the dressings. Some hospitals are provided with spe- cial steam sterilizers in which an entire bedstead may be sterilized by steam (viz., in epidemics). Sea sponges, which were formerly extensively employed, are rarely used to-day to sponge wounds or as tampons (viz., laparotomies, resec- tion of the maxilla). Aseptic gauze is used instead. Occasionally they are used upon artery forceps to wipe out the larynx and pharynx during anaesthesia, or with Beloque's tubes to tampon the nares in opera- tions upon the nose and in nosebleed. Even here sterile gauze or rolled iodoform gaaze may be used. Sea sponges do not stand physical sterili- zation well. Schimmelbusch has recommended that they be placed for one half hour in hot, but not' boiling, one per cent soda solution for sterilization. Preparation of Iodoform Gauze. — Iodoform gauze can be prepared in the following way: Long doubled strips of sterile gauze are spread out upon a sterile towel, the hands having been previously thoroughly STERILIZATION OF SUTURES AND LIGATURES 67 Fig. sterilized. The jiaiize is then powdci^-d evenly with iodoform powder. An ordinary salt shaker which has been sterilized may be used for this purpose. The iodoform is then gently rubbed into the gauze with a sterile sponge, and ironed with a glass weiglit provided with a handle (Fig. 48). The strips of gauze are then rolled and ai-c kept in a steril- ized can. If the strips of gauze are sprinkled with a little sterile water, the iodofoi-ni powder becomes more easily attached. When the gauze is rerjuired for a tamp(m, the requii-ed length is pulled out from the roll with tissue forceps and cut with scissors. The can is then inuiiediately closed. If the gauze contains too niucli iodoform, it can be shaken, and the gi'eater part of the powder removed in this way. For minor cases (accidents) the gauze may be i)repared, just before using, by si)i'inkling sterile gauze with iodoform powder. The method above described is preferable to those methods in which the gauze is prepared with glycerin and colophony or sterilized in steam. In the first method the capillarity of the gauze is decreased, in the second the iodoform is decomposed. Besides, it is not necessary to sterilize iodoform gauze, for virulent pathogenic bacteria have never been found in iodoform powder, and clinically bad results do not follow the use of iodoform gauze which is not sterilized by heat just before being used. The iodoform gauze sold by manufacturers is not to be recom- mended. It is difficult to handle, and furthermore the amount of iodo- form contained in the gauze cannot be estimated, and the sterilization (if the gauze cannot ])e depended upon. The gauze must be taken from the package with greatest care, to prevent contamination. It must be spread upon a sterile towel and the required length cut, and the re- mainder of the gauze must not be placed in the package again, but must be kept in a sterile can. CHAPTER IV STERILIZATION OF SUTURES AND LIGATURES Silk. — Silk may be sterilized by boiling or in steam. It may be rolled upon glass or metal spools and boiled with the instruments, and then kept in an antiseptic solution. Sehimmelbusch has devised for steam 6 68 ASEPTIC TECHNIC sterilization small tin boxes which hold many spools of silk. These are closed when the sterilization is completed. "When opened the end of the thread of each roll may be seen through a little opening in the side of the box. Sterilization of silk by heat alone is not sufficient. Later investiga- tions, particularly those of Haegler, have shown that in threading, tying, and passing sutures through the skin, bacteria become attached to the rough surface of the silk. These bacteria, while not very viru- lent, may develop in the silk and produce inflammation and suppura- tion about the stitch holes. If the suture is buried, a sinus may develop as the result of the inflammation, which continues to discharge until the suture is removed. For these reasons it is recommended that the heat and chemical methods be combined in the sterilization of silk. In the Kocher method the silk is treated for twelve hours with ether and alco- hol to remove the fat. It is then boiled for ten minutes in a 1 : 1,000 solution of bichloride of mercury, and rolled upon sterilized glass spools after the hands have been thoroughly sterilized. These spools of silk are again boiled in a 1 : 1,000 solution of bichloride just before using. The albumen of the silk forms a chemical union with the mercury, which is slowly extracted by the juices of the body. The mercury gradually dis- appears from the suture in five to ten days, depending upon its size. These small amounts of mercury cannot destroy bacteria, but they check their development (Haegler). Sublimate silk is especially adapted for buried sutures. In thread- ing and handling suture material, it should be drawn through the fin- gers to remove the crinkles which are often present. Rough silk should be handled as little as possible in this way. Silkworm Gut. — Silkworm gut is the fiber drawn out from the body of the silkworm killed just as it is ready to spin its cocoon. The sur- face of silkworm gut is smoother than that of silk, and therefore bacteria do not become attached to it so easily, and as it is more compact the bacteria do not penetrate into its interior. Silkworm gut is more expen- sive than silk and cannot be used for fine approximation sutures. It is used most extensively for tension sutures; silk or horsehair being used for the finer approximation of the edges of the skin. Silkworm gut may be sterilized by boiling with the instruments. Metal "Wire. — Metal wire is used especially in suturing bone and for buried tension sutures. Aluminum bronze wire is preferred, as it is duc- tile and durable. Silver wire is more rarely used. Wire can be sterilized with the instruments by boiling. Catgut. — Catgut has the advantage of being absorbable. It is ab- sorbed by the tissues within from two to four weeks, depending upon the size of the catgut. For this reason it is especially adapted for liga- STERILIZATKJX OF SUTURES AND LIGATURES 69 lurt's. The attempts to use catgut for sutures and ligatures date back to the time of Galen. Lister was the first to introduce it in a useful form. Catgut is not prepared, as the name suggests, from the small intes- tine of the cat, but from that of the sheep. The mucosa, serosa, and greater part of the muscularis are scraped away, so that only the elastic submucosa remains. After the gross cleaning, which is repeated several times, the whole intestine or long strips of it are twisted together like hemp rope. Rings of raw catgut, composed of strands from 3 to 5 m. in length, are sold by the dealers. The grade of the catgut varies a great deal. l\aw catgut contains all sorts of putrefactive bacteria and, besides, anthrax and tetanus bacilli. It must, therefore, be thoroughly sterilized before it is used. Catgut cannot be boiled in water, as it curls up and becomes brittle. Different methods, of sterilization, which are partly chemical and partly physical, have been introduced; new methods are always being tried. The method devised by Saul has been used in the von Bergmann clinic for eight years. The catgut is wound upon glass spools or slides, which are placed in eighty-five per cent alcohol ( alcohol, 85 ; acid-carbolic liquefact., 5; a(iua distil., 10). This solution is then slowly brought to the boiling point, which is about 168° F. (according to Saul between 172'' and 176° F.). The spools or slides of catgut are allowed to remain in the boiling fluid from five to fifteen minutes, and then are either pre- served in this solution or ninety per cent alcohol. Of the other methods Ilofmeister's may be mentioned. The catgut is allowed to remain twenty- four hours in a two to four per cent solution of formalin, and then is placed for twelve hours in water, after which it can be boiled in water from ten to thirty minutes, but its absorba- bility is decreased. The catgut is preserved in a sublimate-glycerin-alco- hol solution (0.1 : 5.0 : 100.0 ) . A simple method, which has been tested for a number of years in the von Bergmann clinic, and which is to be recommended for practical use, is the following: The catgut is wound loosely upon glass rods or spools, which are placed in ether for twenty-four hours to remove the fat, the ether being kept in a sterile vessel. The ether is then poured off and the spools of catgut are placed in the following solution: Bi- chloride of mercury, 10; absolute alcohol, 800; distilled water, 200. This solution is renewed from two to three times in twenty-four hours, and is then replaced by ninety per cent alcohol, in which the spools of catgut arc kept. If the catgut is too hard, glycerin (20:100) may be added. In the Claudius method the catgut is wound upon glass slides or rolls, and is then placed in an aqueous iodin- potassium-iodid solution 70 ASEPTIC TECHNIC (iodin 1, potassium iodid 1, water 100). This solution is prepared in the following way : The potassium iodid is first dissolved in a small amount of water, and then finely powdered iodin is added. The con- centrated solution is then diluted until a one per cent solution is made. After remaining for eight days in this solution the catgut is ready for use. Shortly before the catgut is used it should be placed for a while in a three per cent carbolic or other sterile solution to remove the excess of iodin. Catgut not used during an operation should be re- placed in the solution, which, according to Martina, should be changed each month. Catgut prepared by this method becomes black. It re- mains elastic, unless allowed to lie too long a time, when it becomes brittle. Bartlett, of St. Louis, has devised a method for sterilizing catgut which has proved to be highly satisfactory. Catgut prepared by his method is used by a number of prominent American surgeons. He describes the method as follows : ' ' The process can be divided into three stages : ( 1 ) The physical preparation of the material; (2) its sterilization; (3) its storage. " 1. The ordinary commercial ten- foot catgut strand is divided into four equal lengths, each of which is made into a little coil about one and a half inches in diameter. By twisting the last free end about four times around this little coil the latter will maintain its shape. These coils in any desired number (I usually make about a hundred and twenty at a time) are strung on a thread like beads, in order that the whole number may be handled at once. This string of coils is hung in a metal can — better still, in a beaker glass — but is not allowed to touch the bottom or sides. I suspend them by carrying the two ends of a thread through a small opening in a pasteboard cover which is placed on the receptacle. The same opening serves to admit a thermometer, which is carried down to exactly the point where the mercury bulb is on a level with the topmost coils. Liquid petrolatum is now poured in, the quantity being sufficient to immerse the catgut and the bulb of the thermometer. "2. The vessel is set on a pan of sand, under which is placed a tiny gas flame of merely sufficient intensity to raise the temperature of the oil to 212° F. within from one to two hours. A little practice enables one to guess the size of flame necessary for this purpose. This is best done in the evening, and the temperature allowed to remain at about 212° F. (a few degrees' variation does not matter) until morning. The heat is then increased to such an extent that the temperature will run up to 300° F. in an hour; the gas is then turned off and the temperature of the oil allowed to return to 212°. " 3. The pasteboard cover, together with the string of catgut coils, OPERATING ROOM 71 is lifted oil', the suportluous oil is a Unwed to drop oil', and tlii'ii the thread is cut, allowing the coils to drop into the following mixture: " Columbian spirits 100 parts ; lodin Hakes 1 part. " The catgut is now ready for innnediate use, and will keep without deteriorating for any length of time. The jar may be opened any number of times, so long as a sterile instrument is used for removing the coils, since the iodin protects the coils that are left behind from accidental contamination." — {Surgery, Gyncecology, and Obstetrics, Au- gust, 1906.) Reindeer tendon sutures, which are absorbable, have been used (Greife). Kangaroo tendon has also been employed. Some surgeons (Kocher, AVitzel, and others) have discarded catgut, and use sublimate silk for lio-atiou. CHAPTER V OPERATING ROOM Construction and Situation. — Every operating room should be so con- structed that it may be thoroughly cleaned, should be well lighted, and so situated that it may be easily reached from all parts of the hospital. In order to meet the first requirement the walls, floor, and all the objects in the room must be made of materials which will not be injured by frequent washing with soap and w^ashing soda. The walls should be made of tile, cement, glass or marble slabs, or should be enameled. The floor should be made of tile, cement, or other similar materials. The operating, instrument and bandage tables and the stands for basins should be made of enameled iron with wood, glass, or metal tops, and should be as simple as possible in construction. There should be no decorations on walls or ceiling, no corners or angles where dust might collect. The floor should be provided with a drain. Care should be exercised that grosser particles of dirt and highly infectious materials are not carried into the room where aseptic operations are performed. Rooms Reserved for Clean and Infected Cases. — For this reason every large hospital has two operating rooms-, one is reserved for clean cases, the other for infected cases. A suppurating wound should not even be dressed in a clean room. Larger hospitals have a large clinical amphi- theater, a small operating room, in which such operations as a trache- otomy upon a patient with diphtheria might be performed, and special dressing rooms. In this way the aseptic operating room is protected 72 ASEPTIC TECHNIC from contamination. Some surgeons demand that an adjacent room be used for Avashing, in order that they as well as the patient may be com- pletely prepared before entering the operating room. In clinical amphitheaters which are used for teaching purposes, it is impossible to divide the material into clean and suppurating cases. Quan- tities of dirt are always carried in by those attending the clinics, and the cleaning of the room must be more thoroughly done and the clean cases should be operated on first. Daily experience in a large clinic demon- strates that these precautions are sufficient. Cleaning of the Operating Rooms. — The operating rooms should be cleaned daily after the operations are completed. The floors and the walls to the height of about 2 m. should be scoured with washing soda and green soap and rinsed off with water. A garden hose attached to a faucet may be used for this purpose. The operating, instrument, and bandage tables and stands for basins should be cleansed in a similar way. The enameled basins should be washed with soap and water and sterilized in a large steam sterilizer. The windows of the operating room should be left open for some time after each cleaning. The air is purified in this way. Skylight and Arrangements for Artificial Light. — An operating room should be lighted by a skylight and wide side windows. If the ceiling is low and the windows high the skylight may be dispensed with. Usually the operating room is built so that it juts out, and thus three sides remain free and may be provided with large windows. As the glass is covered quickly with moisture and the water drips off, each window should be provided with a small drain. A double skylight is used to prevent the collection of moisture. Electric light is preferred for artificial illumination. This is used in the form of a large portable incandescent light, provided with a reflector, which can be brought near the fleld of operation. A large number of incandescent lights arranged in a circle under a reflector is the most convenient form. If gas must be used, a number of burners which are provided with glass globes should be grouped under a shield. Construction of Operating Tables. — Operating tables are differently constructed. They, likewise the instrument table and cabinets, must be so made that they may be easily cleaned, so that they will stand frequent scouring. Therefore only tables which are made of iron with glass, tin, metal, or wood tops should be used. The construction should be simple and strong. The table should be provided with a movable head piece, the middle piece so made that it may be elevated or depressed, the leg rests should be detachable, and provision should be made for the use of stirrups and for placing the patient in the Trendelenburg and other positions. THE ASEPTIC OPERATION 73 CHAPTER VI THE ASEPTIC OPERATION Preparation of the Patient. — The patient should be jriven a warm bath before the operation if bis condition permits. This is the first step in the preparation of the patient, excepting, of course, those which are required to prepare for anasthesia. He should be clothed in clean linen and placed upon an operating cart or in a freshly prepared bed, and taken to the anteroom of the operating room and angesthetized. When the stage of excitement is pa.ssed the clothes should be removed and the })atient covered with sterile towels and then lifted onto the operating table. This should be done slowly and carefully, the anaesthetist holding the head, an assistant taking the feet, and two strong as.sistants standing opposite placing corresponding hands upon the sacrum and himbar re- gion. In this way the heaviest patient may be lifted upon the operating table, and from the table to the bed. A broad rubber sheet, which should be changed before each operation should cover the table. A sterile sheet should be laid over this. The head roll which keeps the head in correct position during ana'sthesia should be placed in a sterile pillow slip and placed under the neck or head as required. Sandbags and rolls, which are often required to secure the proper positions in many operations (e.g., kidney operations), should be covered with sterile towels or with sterile bags. Sterilization of the Field of Operation. — A sterile assistant sterilizes the field of operation and the area surrounding it for some distance. In an operation upon the foot, the entire extremity ; in an operation on the breast, the thorax, half of the back, and the arm on the same side should be sterilized. Wounds, fistulae, ulcers, or ulcerated tumors which are present in the field of operation should be covered with sterile gauze while the surrounding area is sterilized. In this way the carrying of infection to the adjacent tissues will be prevented. Suppurating ulcers should be covered with iodoform gauze and adhesive plaster or thor- oughly cauterized with a Paquelin cautery. "WTien the cleansing is completed, the patient is elevated and the wet towels are removed. The rubber sheet and the patient's back are dried, and a warm sterile sheet which covers the entire table and the head roll is placed luider him. It is best to prepare the patient in the anteroom upon an operating cai-t, and when fully prepared he can be lifted onto the operating table. Sterile, warm towels are then spread over the pa- tient and the hair is covered with a hand towel. Only the face and the field of operation to the extent of the proposed incision should be exposed. 74 ASEPTIC TECHNIC The towels last applied should be fastened together by safety pins or artery forceps, being used in this way in preference to the ordinary laparotomy towels. Towels soiled during the operation should be re- placed by clean ones. Packages of clean sterile towels should be placed upon the top of the sterilizer. They become warm, and when applied prevent the patient from becoming cool, and render the use of a table which may be heated superfluous. The anaesthetist should hold a sterile towel in front of the patient's face to protect the wound from the patient's breath, particularly from expectoration, vomitus, and particles expelled by coughing. Preparation of Surgeon and Assistants, and Arrangement of Instru- ments, Sponges, etc. — All those taking part in the operation should put on sterile linen gowns after their hands are sterilized. Rubber aprons may be worn under the gowns to protect the clothing. Finger rings should, of course, be removed. The instruments and dressings should be placed near the operator. A trained nurse, who has been trusted with the preparation of the instru- ments, arranges them in order upon a table which is covered by a sterile towel. She replaces the instruments used during the operation by fresh ones, hands instruments, sutures, and ligatures. The sponge box should be placed near the surgeon, so that he can help himself to instruments and sponges as much as the character of the operation permits. Basins filled with sublimate solution should be placed near him, so that he can wash his hands repeatedly during the operation. The instruments and sponges should be handled as little as possible. Only the operator should put his hand in the wound, and he only in case it cannot be avoided (laparotomy, etc.). Many manipulations may be performed with tissue forceps and sterile gauze. For this reason many surgeons allow their assistants merely to hold retractors or to hold and steady tissues (flaps in plastic operations, intestinal loops) with layers of gauze. As a rule, the operator will be able to apply artery forceps and ligatures. We know that it is impossible to keep the hands sterile during the progress of an operation, and it should be an invariable rule to wash the hands and the skin adjacent to the incision frequently with sublimate solution or sterile water in order to remove the blood in which the bacteria lodge. Air Infection. — Besides the contact infection, which may be prevented by thoroughly sterilizing the hands and observing other precautions, air infection must be considered. Air infection is usually not to be feared, for the air of a thoroughly cleaned operating room contains but few pathogenic bacteria (Schimmelbusch, Symmes). The wound may be- come infected if the room is dusty or if drops of fluid from the patient's or surgeon 's mouth gain access to it. If the surgeon coughs, sneezes, or TJli: ASEPTIC Ol'lJKATlON 75 speaks, small drops oi' lluid iiuiy be carried into the wound, and he should therefore exercise due precautions. Experience has demonstrated that air infection may be prevented if the arrangements in the operating room are correct and due precautions are taken. The operating room should not be cleaned just before an operation, and it is not necessary between each operation. Soiled sponges and linen should not be thrown upon the floor, but in pails or basins, and dressings should not be changed just be- fore or during an operation. Anyone with a nasal or pharyngeal catarrh should rc'.nain at some distance from the operation, and in speaking, sneezing, or coughing, the head should be turned away from the field of operation. A towel should be held in front of the patient's mouth and there should be no draughts. [The mouth masks introduced by von ]\Iikulicz, and the gauze veils preferred by other operators, are of great importfuiee and should be worn l)y the surgeon and his a.ssistants.] The wound should b(i kept covered with gauze as ir.uch as possi])le. This is the best protection against infection, and besides it controls capil- lary haemorrhage and prevents the surface of the wound from the harm- ful effects of drying. Some surgeons prefer compresses which have been moistened Mith warm physiological salt solution. The more rapidly the operation is performed, the less the danger of hand and air infection. For this reason an operation should not be delayed by needless conversation and indecision. In this way the time of ancesthesia is lessened and the general condition improved. A super- ficial showy operation should, however, never be performed at the ex- pense of asepsis and thoroughness. Schloffer and Brunlier and others have demonstrated that even in wounds which heal by primary intention, large numl)ers of bacteria may be found a few hours after operation. These bacteria come especially from the skin of the hands, and fortunately are rarely pathogenic and virulent. It is difficult to pi'cdict how these bacteria will act, therefore it is a rule that the surgeon should not come in contact with pus, faeces, and highly infectious material. P^r this reason all examinations, oper- ations, and change of dressings, in which this is unavoidable, should be made with rubber gloves. Virulent bacteria, once having invaded the furrows and fissures of the skin, are as difficult to remove as the harmless bacteria ordinarily found there. These bacteria may reach the surface during the operation and ])e transplanted into the wound. Therefore it has become a rule, which is based upon clinical experience, never to open a phlegmon just before an aseptic operation. The Necessity of Avoiding Eough Manipulations, Lacerations, or Crushing of the Tissues. — The bacteria introduced into the Avound dur- ing an operation usually do not interfere with primary healing, as they are attenuated and are destroyed by the bactericidal properties of the 76 ASEPTIC TECHNIC tissues. If the tissues are roughly handled, torn, or crushed during the operation these bacteria may develop and cause inflammation. Accu- mulations of blood and wound secretion also favor their development. Incisions should therefore be clean cut, and blunt dissections with tissue forceps and gauze should be made only in loose tissues. Thorough control of haemorrhage and rational wound treatment counteract the groAvth of bacteria. The more one is compelled to handle wound sur- faces, the longer they are exposed, and the more they are contused, the greater the possibilities of infection. If it is probable that there will be a large amount of wound secretion, provision should be made for its escape, and for this purpose spaces left between the sutures and deep cavities should be drained and tamponed. The Duties of the Operator. — The operator is not only responsible for the operative work, but superintends, as far as he is able, the asepsis and the administration of the angesthetic. In order that he may do this, the discipline of his help must be perfect, and all his wants must be immedi- ately and correctly attended to. For this reason most surgeons prefer to operate with their o^ti assistants and nurses. Closure of the Wound. — An aseptic operation-wound is closed by su- tures or by a plastic operation after the haemorrhage has been con- trolled. Wherever it is probable that there will be a large amount of wound secretion, its accumulation should be prevented by leaving spaces between the sutures, in which should be inserted strips of iodoform gauze or gutta percha. This is necessary particularly after the division of a large number of lymphatics (axillary fossa, inguinal region, neck), and where haemorrhage cannot be perfectly controlled, as in operating upon a tumor. A tubular drain should be inserted in deep cavities, which experience teaches secrete profusely, as is the case after the axillary fcssa is cleaned out. There is no danger that bacteria will de- velop along the tube, for they do not pass against the current of wound secretion. Compression of the wound by bandages prevents the accumu- lation of wound secretion, and a graduated gauze compress exerting gen- tle pressure should be laid over the deep, sutured wound, such as is made in the extirpation of a tumor, and held in place by adhesive straps. The Dressing of Aseptic Operation Wounds. — As a rule, sutured opera- tion-wounds are covered with a sufficient number of sterile dressings, over which cotton is laid. The dressings are so arranged that evapora- tion of the wound secretion will not be interfered with. The gauze should dry the wound secretion to prevent the development of bacteria and decomposition. Bony prominences should be covered with cotton, and a roller bandage applied evenly, but with not too great pressure. On the extremities the roller bandage should always be applied from the pe- riphery toward the trunk. A few turns of a moist starch bandage may THE ASEPTIC OPERATION 77 be ;ii)pli('(l over llic collcr- l(t iii;il<<' il (inn. As any iiKtvciiiciii, may do liaian to opcral ioii-wouiids, iiiiiiiohili/iiiL;' papier iiiaclK', wood, or tin splints well padded vvitli cotton are often used. An anii'sthetized patient may be carefully beld in a balf-sittin of different sizes provided with tapes. Or for an operation upon bone : 3 bone knives. 1 periosteal elevator. 2 chisels. 1 mallet. 1 Esniarch constrictor or nibber tubinoj. For bone suture : 1 drill and aluminum - bronze ■wire. For amputation : 1 amputation knife. 1 amputation saw (or only wire saws). When the instruments are thoroughly sterilized the tray is taken out of the instrument boiler and is placed upon a large sterilized towel. The tray is then w ing are laid on top : Things required for anasthesia — 1 roll of iodoform gauze wrapped in a sterile hand towel. 6 pairs of rubber gloves wrapped in gauze. 1 bag containing 6 bristle brushes. 1 razor. 1 bottle of sublimate tablets. 1 jar of silk. 1 jar of catgut. 2 bars of good alkaline soap. 1 bottle of cocaine tablets. 1 sliarj) hook. 1 Bosescher retractor. 1 sharp spoon. 1 Luer bone-cutting forcep. 1 bone scissors. 5 wire saws. 1 keyhole saw. Fig. 50. — Bag Closed. rapped in the towel and the follow- 1 bottle of morphine tablets and cam- phorated oil. 1 bottle of 70-80 per cent alcohol (250 C.C.). Some rolls of gauze and roller bandages, which are wrapped in a sterile towel. 2 operating gowns. Operating and hand towels should also be added. The package is then placed in a tin-lined canvas bag, which may be easily sterilized in a steam sterilizer. The canvas bag is fastened by straps. One or two packages of gauze, depending upon their size, are put in another canvas bag. Another bag is often required for the sheets and linen used in major operations. 82 ASEPTIC TECHNIC Plaster of Paris bandages (also alum powder) should be carried in tin boxes in which the^^ are kept. Papier-mache splints may be carried under the straps of one of the canvas bags. If a number of operations are to be performed, it is well to take an instrument boiler along. When an operation is to be performed in a house, that room should be selected Avhicli has the bast light and is used the least, as the danger of air infection is thus reduced. The conditions in a sleeping room are unfavorable, for the air is contaminated with dust and, besides, it is dif- ficult, very often impossible, to perfcrm operations in bed. Only the most insignificant operations should be attempted in this way. Onlj' those things should be removed w^hich interfere with the opera- tion. The taking down of pictures and curtains, cleaning the floor, etc., raises so much dust that at least a day should intervene before the opera- tion is performed. An extension table (or two small tables may be placed end to end) should be placed near a window or under a chandelier, and covered with several blankets, the head of which is elevated by a cushion or roll. A rubber sheet should be placed over the blankets to protect them from the wet. A large, fresh sheet should be spread over the rubber sheet, and the improvised operating table is then complete. AYhile the operating table is being prepared, water should be boiled in a number of large kettles. Four or, better, six washbowls should be cleaned with green soap and rinsed with hot water. A good-sized table (a sewing table answers the purpose very well) covered Avith a sterile towel should be placed at the side of the table where the operator stands. After the hands have been sterilized, the contents of the tray above described should be emptied and arranged upon this table. The surgeon is then able to help himself to instruments, gauze, sutures, and ligatures, all of which should be covered with a sterile towel until required. Fre.shly washed linen sheets, tablecloths, and hand towels may be used for a number of different purposes. If time permits, they should be ironed with a hot iron just before being used. In this way the sterile sheets and towels may be saved and used for sterilizing the hands and drying and protecting the field of operation. "Washbowls containing alcohol, sublimate solution, and hot water .should be made ready. Water cans and pitchers filled with sterile water should be kept in readiness. An attendant, a nurse, and a physician are required in an operation performed without general anaesthesia. "When an anesthetic is given the surgeon should have another colleague or an assistant, who merely ASEPSIS AND THE ASEPTIC OPERATION IN PRIVATE PRACTICE 83 liolds the itI rnctors |)I;i('t'(l l)y tlic opci'ator oi' liaiids iiist niiiiciits, a nurse, and an attendant to pouf water, prepare sublimate solution, and hold basins. All the rules of asepsis should be rigidly observed. Long exposure of wound surfaees and touehinlets. 1 pair curved scissors. 1 coil silkworm gut. 1 pair strong scit-sors, 6 inches. 1 hard rubber iodoform duster. 1 pair Liston's bone forceps. 1 16-in. telescope case containing: 1 pair curved lithotomy forceps. 6 plaster of Paris bandages (3 in. by 6 1 bone curette. yards). 1 set Brainard's bone drills. 1 can of sublimate gauze. 1 thermometer. 1 can borated gauze. 1 metal case for 2 amputating knives. ^ pound of absorbent cotton. 1 metal case for 8 smaller knives. ^ dozen gauze bandages (2 in. by 10 1 razor in case. yards). 7 84 ASEPTIC TECHNIC ^ dozen cotton bandages (2 in. by 8 yards). 2 bottles of assorted catgut. 1 bottle kangaroo tendons. 1 Bouchard's syphon syringe. l|-ounce hard rubber syringe. 1 papier mache catheter case. 6 dressing splints. 2 plated male catheters. 1 Buck's lithotomy staff. 1 Rongeur forceps with spring. 1 pair Ferguson's bone-holding forceps. 1 lead mallet. 1 Van Buren's bone chisel. 1 Van Buren's bone gouge. 1 mastoid chisel. 1 Gait's trephine. 1 metacarpal saw (movable). 1 Kocher's director. 1 Sayre's periosteotome. 2 aneurysm needles (metal handled). 3 hard rubber trachea tubes. 2 mouse tooth forcjps (spring). 1 Volkmann's curette. 2 Nela ton's catheters (soft rubber). 3 filiform bougies. 2 Hunter's wedges. 1 bottle of assorted drainage tubes. 1 Esmarch's bandage. 1 8-oz. metal-cased bottle for chloro- form. 1 Esmarch's chloroform inhaler. '3 duck rolls for instruments. i Esmarch's tongue forceps. § dozen flannel bandages (4 in. by 8 yards) . 2 brass pulleys. 3 dozen safety pins. 1 pure rubber bandage (2^-in.). 2 rolls adhesive plaster (1 and 2J-in.). 6 sterilized laparotomy pads. 8 sterilized towels. 1 can of iodoform gauze (10 per cent). 20 tubes of sterilized silk. Needles for intestinal sutures. 2 aprons. 1 nail brush. Literature. — v. Bergmann. Zur Sublimatfrage. Therap. Monatshefte, February, 1887, p. 41. — Borchardt. Die Desinfektion unserer Verbandstoffe. Archiv f. klinische Chirurgie, Bd. 65, 1902, p. 516. — Brunner. Weitere Versuche iiber KatgutsteriHsation. Beitr. z. klin. Chirurgie, Bd. 7, 1891, p. 447. — Claudius. Eine neue Methode zur Sterili- sation der Seidenkatheter. Zentralblatt fiir Chirurgie, 1902, p. 465; — Eine Methode zur Sterilisierung und zur sterilen Aufhebung des Katgut. Deutsche Zeitschrift fiir Chirurgie, Bd. 64, 1902, p. 489 ;— Erf ahrungen iiber Jodkatgut. Ebenda, Bd. 69, 1903, p. 462. — Cleves-Symmes. Untersuchungen iiber die aus der Luft sich absetzenden Keime. Arbeiten aus der v. Bergmannschen Klinik, Part 6, 1892. — Elsberg. Ein neues und einf aches Verfahren der KatgutsteriHsation. Zentralbl. fiir Chir., 1900, p. 537. — Friedrich. Das Verhaltnis der experimentellen Bakteriologie zur Chirurgie. Leipzig, 1897. — Greife. Renntiersehnenfaden als Naht- und Ligaturmaterial an Stelle des Katguts. Miinch. med. Wochenschr., 1901, p. 1005. — Haegler. Handereinigung. Basel, 1900; — Ueber Ligatureiterungen. Chir.-Kongr. Verhandl., 1901, II, p. 258; — - , Wundverbandmittel in Kochers Enzyklopadie. — Herman. Ueber das Sterilisieren der Seidenkatheter. Zentralbl. f. Chir., 1901, p. 63. — Hofmeister. Ueber Katgut- steriHsation. Beitr. z. klin. Chir., Bd. 15 and 16, 1896. — Koch. Untersuchungen iiber die Aetiologie der Wundinfektionskrankheiten, 1878. — Kocher. Chirurgische Operationslehre. Jena, 1902. — Konig. Aseptik der Hiinde? Operationen ohne direkte Beriihrung der Wunde mit Finger u. Hand. Zentralbl. f. Chir., 1900, No. 36. — Fritz Konig. Das neue Operationshaus in Altona. Archiv fiir klin. Chirurgie, Bd. 70, 1903, p. 1078. — Martina. Die KatgutsteriHsation nach Claudius. Deutsche Zeitschr. f. Chir., Bd. 70, 1903, p. 140.^ — -v. Mikulicz. Ueber die jiingsten Bestrebungen, die aseptische Wundbehandlung zu verbessern. Chir.-Kongr. Verhandl., 1898, I, p. 8; im Anschlusse daran: Landerer, Perthes, Doderlein, und Diskussion. — Minervini. Zur Katgutfrage. Deutsche Zeitschrift f. Chir., Bd. 53, 1900, p. 1. — Neuber. Zur antisept. Wundbehandlung. Chir.-Kongr. Verhandl., 1892, II, p. 76. — Rosenbach. ASEPSIS A\U THE ASKI'TIC OPERATlOX IX PRIVATE PRACTRE S5 Milcroorganismen bei den Wundinfektionskrankheiten des Menschen, 1884. — Sarwey. Bakteriol. Untersuch. iiber Hiindedesiufektion. Berlin, 100.5. — Sard. Ein neuer Versuch zur Sterilisation des Katgut. Arch, fiir klin. Chir.. Bd. 52, 1896, p. 98. — Schinimelbu.-^ch. Die Durchfiihrung der .\septik in der v. Bergmannschen Klinik. Arch, fiir klin. Chirurgie, Bd. 42, 1891, p. 123; — Anltitung zur aseptischen Wund- behandl. Berlin, 1S9.3, 2d edition. — Sittler. Die Sterilisation elastischer Katheter. Zentralbl. f. Bakteriologie, Bd. 38, 190.5, p. 752. — Witzel. Chirurgische Hygiene, Aseptik u. Antiseptik. Die deutsche Klinik, Bd. 8, p 577. III. GENERAL AND LOCAL AN>«STHES1A GENERAL ANAESTHESIA Since the discovery of their anassthetic properties ether and chloro- form have contributed immeasurably to the advancement of surgery, and are to-day the most important general anaesthetics. The aneesthetic properties of ether were discovered first. An Ameri- can, Crawford Long, performed an operation under ether anaesthesia as early as 1842. Its anaesthetic properties were rediscovered by the chem- ist Jackson, and were employed by a dentist, Morton, in extracting a tooth; both lived in Boston, the work being done in 1846. Surgeons soon began to use ether (Warren in Boston, Liston in. London, Mal- gaigne in Paris, and Dieffenbach in Berlin, 1847). Chloroform ansesthesia was discovered by an Edinburgh obstetrician (Simpson). In 1847 he delivered a patient under chloroform after ex- perimenting for some time and comparing the action of chloroform with that of ether. He soon recommended its use, after having employed it in a number of cases. Like all other anaesthetics, ether and chloroform are poisonous. Their property of rendering patients unconscious and insensitive to pain after the inhalation of certain amounts is a blessing to the patient and a great help to the surgeon. In excess and in susceptible people they may cause death or produce lesions which eventually may end fatally. There- fore they must be used with the greatest caution. A physician should be intrusted with the administration of either angesthetic. Attention, practice, and experience, combined with coolness and self-control in emergencies, are required of an anaesthetist, who should meet rapidly and effectively any emergency which may arise. CHAPTER I CHLOROFORM AN/IOSTIIESIA Physical Properties of and Tests for Chloroform. — Chloroform, CHCI3, formyltrichloride, trichlormethane, is a clear, colorless, volatile fluid with 86 CHLOROFORM ANESTHESIA 87 ;i pcciiliiii' ai'oiiiJil ic odof .iiid sweet biii'iiin^' taste. It, boils at 142" F. It is (leconiposed by da.vli^lit and air into hydrochloric acid, chlorine, free fornii(! acid, pliosyi'ii, etc., and should therefore be kept in dark colored, tightly closed bottles. By the addition of one per cent absolute alcohol the decomposition of chloroform may be prevented. Unpleasant symptoms have followed the use of impure chloroform; death has been produced by its decomposition and su])stitution products. Only reliable, pure preparations should therefore be used for anesthesia. [In America Squil)b's chloroform, especially pi-epared for anu'sthesia, is generally preferrc-d. It comes in small stained glass bottles, which may be conveniently used for dropping the chloroform. Although a number of manufacturers have placed their chloroform upon the market, Squibb 's is still generally employed.] Ilepp's smelling test may be employed to determine whether chloro- form is pure or not. It is used in the following way : Some chloroform is dropped upon white filter paper and allowed to evaporate. If the chloroform is pure the paper has no odor; if impure, a penetrating, rancid odor remains, which is produced by the decomposition products. The Action of Chloroform Vapor when Inhaled. — Inhaled chloro- form vapors pass into the blood through the alveoli of the lung, and are then carried to all the organs, including the central nervous system. The paralysis of the nerve centers begins in the great lobes of the brain, then attacks the cerebellum, and finally the spinal cord, sensation being lost before motion. The centers in the medulla retain their function the longest ; if these are paralyzed death occurs. Chloroform in large amounts or with susceptible people paralyzes the ganglia situated within the heart which control the heart beat, and is toxic for heart muscle itself. A fall of blood pressure follows the paralysis of the vaso-motor center, and the heart has to perform an excessive amount of work and becomes exhausted (Kappeler). The direct action of chloroform upon the nasal and laryngeal mucous membrane may cause a reflex respiratory paralysis and influence the heart beat by irritation of the trigeminal branches supplying the nasal mucous membrane, and of the superior laryngeal nerve, supplying the laryngeal mucous mem- brane, and of the vagus. Like any other anaesthetic, chloroform passes into the blood of the foetus and into the milk of the nursing mother. Chloroform is excreted by the lungs, the skin, and the kidneys. It produces a transitory fatty degeneration of the myocardium, liver, and kidneys. These fatty changes may become more extensive and finally cause death, especially if the organs were previously diseased. Preparation of Patient for General Anassthesia. — Every patient should receive special preparation for an auiesthetic. 88 GENERAL AND LOCAL ANESTHESIA Washing the mouth and cleaning the teeth reduce the dangers of aspiration pneumonia. If possible the patient's stomach should be empty. This prevents the accidents resulting from vomiting, and lessens the distress and vomit- ing following the anaesthesia. Patients should not be allowed to take food for six hours before the operation, and if in an emergency an anaesthetic must be given shortly after meal time, the stomach contents should be removed by a stomach tube. Tight clothing, corsets, abdominal binders, and collars should be re- moved to prevent interference with respiration. The shirt should be left open at the neck, and foreign bodies (artificial teeth, tobacco, and candies) should be removed from the mouth. [Magaw, in a review of over fourteen thousand anaesthesias induced in the Mayo clinic at Rochester, Minn., gives some very practical sug- gestions regarding the administration of an anaasthetic. She employs almost exclusively the " open or drop method," and prefers ether to chloroform. She describes the method as follows: " Patients usually walk into the operating room and mount the table with assistance. All foreign bodies, such as artificial teeth, chewing gum, etc., are removed. The hands are fastened loosely across the chest with a wide gauze bandage, to prevent the arms falling over the sharp edges of the table, an accident which often causes musculospiral paraly- sis. A pad of moistened cotton is placed over the eyes to protect them from the angesthetic. If, during the course of the administration, some of the anesthetic should fall in the eye, drop a few drops of castor oil into the conjunctival sac to prevent the conjunctivitis that would other- wise follow. ** It is a mistake to think that the same elevation of the head will do for all patients. The anaesthetist should elevate the chin to such a position as not to bend the neck too far back or approximate the chin too near the sternum. Proper elevation of the head will relax all tis- sues of the neck and give more freedom in breathing. This also can be said of the jaw. Holding the jaw forward and keeping it in position, so that the patient gets the greatest amount of air possible, is an impor- tant feature in giving an angesthetie. While too much stress cannot be laid on this necessary requisite in giving an anaesthetic, all jaws cannot be handled in the same manner. AA^hen a patient has removed a double set of false teeth, the tongue will often cleave to the roof of the mouth during the administration, and raising the jaws sets the gums so firmly together that most of the air is shut out, and this may not be noticed until the patient is cyanotic. We have found in this class of cases that if the jaw is held but slightly up and forward, and the thumb at the same time inserted between the gums, thereby holding the tongue down. CHLOROFORM ANESTHESIA 89 faulty respiration will ho corrected at onee and color restored. This is one of the instances where holding up of the jaw too firmly may be overdone. " All patients have been anesthetized on the operating; table in the operatinji' room, and the preparation of the patient was gointjr on at the same time. Experience has taught us that preparation of the patient while going under the anaesthetic is one of the important factors in pro- ducing a rapid surgical narcosis, for it diverts his attention and much less anaesthetic is required. It matters not in what position the patient must be for operation, we fix him accordingly, and the preparation is begun at the same time as the anesthetic, and we feel certain that this procedure enables us to hasten narcosis. " In the Trendelenburg position, where the preparation is in progress during the administration of the anesthetic, the deep respiration, etc., empties the pelvis, so that by the time the operation is started the small bowel will be found in the upper abdomen and out of the way, and may be packed off. We have found this practice more helpful to the surgeon than placing the patient in position after the completion of narcosis, " In giving an anesthetic for this class of surgery, the skill and patience of the anesthetist is tried to the extreme, and the patient must be anesthetized, but not too profoundly. Patients having an acute peri- tonitis, as is so often found in this class of cases, require a much larger amount of anesthetic to produce relaxation of abdominal muscles. When the patient is prepared during the administration of an anesthetic, there is no time lost, the surgeon and his assistant being ready by the time the patient is surgically anesthetized. Another important reason for anesthetizing the patient on the operating table is that in lifting and shifting a patient about he is apt to regain consciousness, with vomit- ing, etc., and the anesthetist cannot be positive of the condition of his patient. Should ether produce difficult breathing, profuse secretion of mucus or cough, lift the mask from the face, allow a liberal amount of air, and then continue with ether. In giving plenty of air when needed and less anesthetic, we have found little use for an oxygen tank, a loaded hypodermic syringe, or tongue forceps. It is far better for the anes- thetist to become skillful in watching for symptoms and preventing them than to become proficient in the use of the three articles above men- tioned. An acute cold is a contraindication to any anesthetic, but as soon as a cold becomes chronic there is not much danger from etheriza- tion, and instead of operating during an acute cold and giving chloro- form (unless in an emergency), we wait a few days until the acute attack has passed, and then they are as good subjects for ether as for any other anesthetic. Chronic bronchitis is often improved by an anesthetic."] 90 GENERAL AND LOCAL ANiESTHESIA The anaesthetist should gain and retain the confidence of the patient, who should not be permitted to see the instruments or any blood-stained sheets or dressings. Patients frequently become excited and frightened upon entering the operating room, and for this reason it is the custom in a number of clinics to begin the anaesthesia in a small room immediately adjacent to it. Position in which Patient should be Placed for General Anaesthesia. — Before the administration of the ana?sthetic is begun the patient should be placed in a comfortable horizontal position ; the head, which should neither be extended nor markedly flexed, lying on a small roll or pillow. The head and trunk of weak, anaemic patients should never be elevated, especially if a major operation is to be performed. In these cases the head and trunk should be lowered, as in this way the dangerous effects of cerebral ana?mia may be avoided. If the position is comfortable, the patient should be asked to close his eyes, to breathe naturally, and to avoid swallowing saliva. In order to distract the attention of the patient he may be asked to count. The Different Stages of General Anaesthesia. — Chloroform anaesthesia, like all general ana-sthesias, passes through four stages : 1. Initial stage. 3. Stage of deep anaesthesia. 2. Stage of excitement. 4. Stage of awakening. 1. After the first few inspirations most patients begin to hold their breath and swallow air. The sweet taste and odor of chloroform vapor is disgusting to many, especially to children and patients who have been anaesthetized a number of times. During this stage patients frequently experience a sensation of suffocation and, crying for air, tear the mask from the face. Soon spots appear before the eyes, the patient becomes dizzy and has unpleasant, often terrifying dreams, the ears ring and the heart pounds. The face becomes reddened, the patient talks incohe- rently, alternately laughs and cries and acts like a drunken man. Con- sciousness and sensation are gradually reduced, and then rapidly lost. The salivary secretion is increased, the pulse is rapid and full, the res- piration rapid but deep ; the pupils are dilated but react to light, and when the eyelids are raised and the cornea touched a wink may be elicited. The reflex irritability is still considerably increased, and a painful examination or sometimes too early sterilization of the field of operation may excite violent and often dangerous struggles. 2. The stage of excitement is the more pronounced the more un- evenly and rapidly the anaesthetic is given. Children do not pass through this stage; women frequently do not. It is rarely absent in men, being most marked in the strontr and vigorous and in alcoholics. It begins with contraction of the muscles of the trunk which lasts but a short time, sud- CHLOROFORM ANAESTHESIA 91 den extension of the head and extremities, and it may end quickly. If the stage is more pronounced the patient acts as thouniiis hkmiMi <:,ji^' ni;iy be used. Ton^nie foreeps, steel .sponges, a towel, niul a. basin to e;it(^h the vouiitus should be provided. A clean handkerchief may be used instead of a chloroform mask. It should not be laid directly upon the face, for the chloroform may burn the skin, even if vaseline has previously been applied. A stand-up collar, buttoned in front and bent into an oval, may be placed upon the face and a handkerchief spread out over it. Apparatus for Determining Amount of Chloroform Administered, etc. — The dilTerent apparatus used in large clinics for the administr-ation of chloroform have .some advantages, as the amount of chloroform can be accurately measured and the amount of oxygen given with it controlled, and thus if the breathing is deep, the danger of giving too much chloi'oform is reduced. The Junker appa- ratus, improved by Kappeler (Fig. 53), is provided with a rubber bag, and by pressing it a mixture of chloroform and air is sup- plied to the patient. The Wohlgemuth and Roth-Drager apparatus are too large for practical purposes and are expensive. They supply a mixture of chloroform and oxygen, and in case of asphyxia oxygen alone may be given. Any apparatus has the disadvan- tage that the anaesthesia is induced slowly ; often it does not pass beyond the stage of excitement and nnist be continued with the ordinary mask. Dropping of Chloroform. — In administer- ing chloroform a dry mask should be laid upon the face, covering the mouth and nose, and then chloroform should be slowly dropped upon it, from 10 to (iO drops be- ing given in a minute, depending upon the age of the patient. This nuiy be increased up to even twice the amount, until the stage of excitement begins. A saturated mask should never be u.sed, because of the danger of inducing a violent stage of excitement and causing reflex cardiac or respiratory paralysis. This is often done, even by experienced ana'sthetists. If the patient is greatly excited the mask should be removed for one, two (;r more minutes to avoid administering too much when he begins to breathe deeply. After such interrui)tions the ana'sthesia should be continued. About 60 drops Fig. 53. — Junker's Appara- tus AS MODIFIKI) BY KaP- PELER. (From Dumont.) 94 GENERAL AND LOCAL ANESTHESIA should be given in a minute until the patient is relaxed. An expe- rienced ana'sthetist regulates the dropping of the chloroform by intui- tion or the carotid pulse. If the pulse is rapid one drop is given for every two to three beats; if slow, one drop for each beat. The chloro- form bottle should be held near the mask, so that if the patient moves the chloroform will not be dropped upon the skin or in the eye. The skin has been burned, and corneal opacities have been caused in this way. Such results may be avoided if the chloroform is wiped off the skin and the eye irrigated immediately after such an accident. During the stage of excitement the patient should not be forcibly restrained, as this merely increases the excitement, and fractures and dislocations may be produced. Different Methods of Holding the Jaw Forward. — If in deep anes- thesia the breathing becomes stertorous and labored the jaw should be drawn forward, and in adults, as a rule, it should be held in this posi- tion, for as the jaw drops backward, carrying the tongue with it, the relaxed epiglottis is pushed downward, closing the opening of the larynx. In pushing the jaw forward the von Esmarch-Heiberg method may be employed: The flat hand is placed over the ear, the tips of the index fingers behind the angle of the jaw and the thumbs upon the temporal or frontal regions, and the jaw is then gently pushed forward by the index fingers until the lower teeth project beyond the upper. The different steps in this method, the correct and false, are represented in Figure 54, a and h. Pressure should not be made upon the internal jugu- lar vein, and too much force should not be used, as the jaw may be dis- located or a contusion about the angle of the jaw produced. If the pa- tient's head is turned to the right, the jaw may be held in this way by the left hand alone, and the right hand be used for giving the anaesthetic. If this does ngt suffice to overcome the embarrassment of respiration, the mouth should be opened with the mouth gag and the tongue drawn for- ward. If it is necessary to hold the tongue forward for some time, it is advisable to pass a heavy silk ligature through it; in this way the injury produced by tongue forceps may be avoided. If the anaesthetist stands in front of the patient the jaw may be drawn forward by the Kappeler method : The thumbs being placed upon the maxilla; beside the nose, and the flexed index fingers behind the angle of the mandible, and the jaw drawn forward. Stage of Anaesthesia Which should be Maintained During an Operation. — It is the duty of the ancesthetist to keep the patient in the quiet stage of anaesthesia, permitting him neither to awake nor to be overcome by a fatal paralysis of the respiration or of the heart. The character of the pulse and respiration, the color of the face, and the condition of the pupil indicate the condition of the patient. ^- (^ueisier, del. 1903. Fig. 54. — PrsHixG thk Lowek J.^w 1"ohw.\rd. a, Incorrect nietliod; the jaw is not pushed far enough forward, the internal jugular vein is compressed; h, the correct method. 95 96 GENERAL AND LOCAL ANAESTHESIA To test the pupillary reflex both upper lids should be raised by the second and third fingers, after they have been tightly closed for a second. In the first and second stages of anaesthesia the pupil is dilated and re- acts slowly, because of irritation of the cervical sympathetic. In the beginning of the third stage the pupil becomes contracted but reacts quickly. As the anaisthesia becomes deeper the pupil becomes narrower and reacts less rapidly, until finally, as the result of irritation of the oculomotor nerve, it becomes fixed and pinhead in size. "When the pupil is in this condition the stage of deepest permissible anaesthesia has been reached. Anesthesia should not be carried to this so-called normal point, but should be maintained in that stage in which the pupils are contracted, but react to light. If the anesthesia is carried beyond the normal point, the pupils ■u-ill dilate, because of paralysis of the sphincter iridis, and will not react, and cardiac and respiratory paralysis will quickly occur. It is impossible to give any definite rules by vrhich anaesthesia may be main- tained at the proper stage. Each patient behaves ditferently; some re- quire a long, some a short time, to reach this point. (The danger zone varies, Czempin.) It is so rapidly reached and passed by many that it may be overlooked by the anesthetist. In children and weak adults two to four drops of chloroform in a minute are enough to maintain deep anesthesia. In adults about twenty drops are required, but sixty to eighty drops may be required, especially for men. Interrupted Anaesthesia. — It is most difficult to give an interrupted anesthesia, as is often required in operations about the head and face, and to avoid the dangers described above. Awakening with vomiting and the dangerous stage of inactive dilated pupils quickly follow each other, if the ane.sthetist is not skilled and attentive. In these cases the patient should be slowly anesthetized until the pupils contract, and then the mask should be removed so as to expose the field of operation. As soon as the refiexes return and the pupils dilate again, more anesthetic should be given. The disadvantages of this interrupted anesthesia may be avoided if the canula devised by Salzer is employed. This bent canula (Fig. 55) Fig. .55. • — Salzer's Chloroform Caxttla to Be Inserted ixto the Mouth ix Operations upox the Face axd Mouth. (From the Clinic of von Mikulicz.) is inserted into the mouth cavity at the angle, and is then attached to the Junker-Kappeler apparatus. [A rubber catheter or piece of rubber tubing may be passed through the nose into the nasopharynx, and the anesthetic administered through it after being attached to the apparatus CHLOROFORM ANAESTHESIA 97 ;il)()vo iMcntioiu'd. It is imicli sinipler and more convt'iiiriit tluiii the s})('('i;il caniila' which havf hccii devised.] Pupillary and Corneal Reflexes. — The testing of pupillary retiexes is unreliable in hysterical patients, as frequently the pupils do not con- tract. The pupillary retiex is also unreliable in all conditions character- ized by niyosis, such as morphinism, nicotine poisoning, locomotor ataxia, paretic dementia, diseases of the corpora (luadrigemina, meningitis. ^lor- phine is frequently given before a general anaesthetic is administered, and in these cases it should be remembered that no significance whatever can be attached to the pupillary reflex. [It is the belief of the editor that too much significance has been attached to both the pupillary and corneal reflex. The latter is unreliable and results following its elici- tation are often distressing; as severe conjunctivitis may follow the injury inflicted on the corneal epithelium. It is much more essential that the anaesthetist note carefully the respiration and the color of the patient. Cyanosis means danger, and the ana'sthetic should be withdrawn when the patient becomes dusky. Any interference with respiration should be instantly recognized and relieved.] It is occasionally neces- sary to administer an an- a-sthetic through a Halm or Trendelenburg tampon eanula. The apparatus rep- Fig. 56.— Chloroform Appar.^tu.s fok Admimster- _ IXG .\X Ax.ESTHETIC THROUGH A TrACHEOTOMT resented in Figure 06, tcbe. (From Dumout.) which consists of a metal funnel and a tube, may be used for this purpose. The funnel is covered or filled with gauze, upon which the anasthetic is dropped and the tube is attached to the eanula. The character of the pulse should be carefully noted during the entire anasthesia, as it indicates dangerous overexertion of the heart and is a good index as to the general condition of the patient, the effect of the anasthetic. and the operation. After Effects of Chloroform Anaesthesia. — The after effects of chloro- form anasthesia vary in diiferent patients, being largely dependent upon the amount of chloroform used. They oceur most frequently after long or frequently repeated anasthesias. Nausea and vomiting are the most constant, as the gastric mucous membrane is irritated by the saliva swallowed at the beginning of the anasthesia and by the chloroform va- por. The so-called ' ' chloroform distress ' ' persists, as a rule, for twenty- four hours, but may last from two to three days and render the patient very weak. Icterus fre(iuently follows chloroform anasthesia as the result of changes in the liver, and the destruction of red blood corpus- 98 GENERAL AND LOCAL ANAESTHESIA cles. The stomach symptoms may sometimes be prevented if a towel moistened with vinegar is applied to the nose immediately after the patient awakes (Lewin). Post-antesthetic nausea and vomiting may be prevented by washing out the stomach with lukewarm water or a one or two per cent soda, solution, and by withholding food. If not nauseated the patient may be given some nourishment in four or five hours after awakening. It is best to begin with teaspoonfuls of tea, warm soup, or red wine. Coffee and mineral waters should be avoided, as the former causes heartburn, the latter incite vomiting. If the vomiting continues for some time, rectal feeding is indicated (milk with eggs; in case of collapse, warm red wine with cloves) . The swallowing of air frequently incites vomiting. A small dose of morphine frequently controls the vomiting. The administration of favorite articles of food should be discouraged. Patients, as a rule, do not sleep the night following the operation. Nervous irritability, pain in the wound, unusual positions in bed, nau- sea, etc., are the usual causes. Weak patients should be given morphine to induce sleep. Hysterical and melancholic patients may have attacks of mania ; the nervous symptoms may last several days. Post-Anaesthetic Palsies. — The so-called post-ana;sthetic palsies are mostly peripheral. The musculospiral nerve may be paralyzed if the arm is allowed to hang over the sharp edge of the operating table. The nerves of the brachial plexus may be pressed upon and contused by the clavicle or the head of the humerus if the arm is strongly abducted. These palsies may last for some time. Central paralysis, the result of a haemorrhage into the brain during the stage of excitement, is rare. If the patient does not recover from the anaesthetic, he becomes pro- gressively restless, the pulse becomes weak and fluttering, the vomit- ing becomes uncontrollable, the urine contains albumin, the urinary secre- tion diminishes and ur^emic symptoms develop, and death from collapse may follow in from one to three days. If the post-mortem examination discloses fatty degeneration of heart muscle, fatty degeneration and necrosis of the cells of the kidney and liver, death should be attributed to the late effects of chloroform. It is often difficult, however, to exclude in these cases other causes of death, such as operative shock after long operations, anaemia following severe haemorrhage, and acute general infections. Broncho-pneumonia and bronchitis are rarely caused by chloroform, and M^hen they occur should be regarded as produced by the aspiration of saliva or vomitus, if pulmonary embolism can be excluded. Broncho- pneumonia and bronchitis follow quite frequently abdominal operations in which pain prevents coughing. They also follow anjesthesias admin- istered in rooms where there are unprotected kerosene or gas flames, as ETPIER ANESTHESIA 99 the eliloroi'oriii is decomposed into pli()S|»eii l^•lk of them very liiulily. Von Arnd has devised an appa- ratus with a com- pressible bag for operations about the face and mouth. A curved metal end piece at- tached to a piece of rubber tubing which is connected with the bag is in- troduced into the mouth. A mixture of air and ether is blown into the mouth by com- pressing the bag. As the ether is still further diluted by the inspired air there is but little irritation of the nuicous mem- branes. Increased Secretion of Saliva and Mucus during Ether Anaesthesia. — During ether ana'sthesia the respiratory passages nnist be kept free, as in this way the dangers of suffocation and aspiration pneumonia may be avoided. Gurgling respiration and cyanosis indicate danger, which is increased if the saliva flows into the larynx. The flowing of saliva into the phar- ynx and larynx may be pre- vented if the head is held on the side. The nu)uth should be kept open, and if there is an excessive amount of mucus and saliva the mouth should be cleaned out with gauze. The pharynx, if neeessarj'' the larynx, may be wiped out with sponges on forceps. The latter should not be employed unless absolutely necessary, as the mechanical irritation Fig. 62.- -SrRRorxDixG the Mask with a To-vtel. (From Dumont.) Fig. 63. — Benxett's Ether Inhaler. 104 GENERAL AND LOCAL ANESTHESIA produced by them often leads to the secretion of more mucus. If the jaw drops backward and interferes with respiration, it should be pushed and held forward. The tongue should be drawn forward if it drops backward and closes the larynx. Incomplete Ether Anaesthesia for Short Operations. — Incomplete ether anesthesia may be used for short operations. Kronecher recommends that in these cases the anaesthesia be stopped immediately after the stage of excitement, while Sudeck places the mask directly upon the face and performs minor operations after the first few inspirations in the so- called ' ' ether drunk. ' ' The after effects of ether are about the same as those of chloroform, and should be treated in the same way. Lung Complications following Ether Anaesthesia. — Broncho-pneu- monia, bronchitis, and oedema of the lungs are more common after ether than after chloroform anaesthesia. The lung complications are due to the aspiration of mucus and saliva, the use of impure ether, and too great concentration of the ether vapor. Other factors, which are also present in chloroform and local anesthesias, such as cooling of the surface of the body, the inability to cough and expectorate after abdominal operations, are also contributing factors. The symptoms of lung complications usually develop on the second or third day. Frequently they run a mild clinical course, yet they may end fatally, especially if the lungs were previously diseased (bronchitis, emphysema, tuberculosis) or if they develop in old and feeble patients. Ether and chloroform have about the same effect upon a preexisting nephritis, the albuminuria following ether angesthesia when the kidneys were previously sound is more rapidly recovered from. Central Anaesthetic Palsies. — Central ana3sthetic paralyses are more to be feared when ether is used, as it raises blood pressure. They occur only in patients who at the time the ether was administered had a high blood pressure ; most commonly in patients suffering with arterioscle- rosis, interstitial nephritis, and lead intoxication. Venous Thrombosis. — Thrombosis of the large veins of the pelvis and lower extremities is another complication which may follow the use of ether. It is often associated with inflammatory changes in the pelvis, other local and general causes, such as toxaemia, anosmia, cardiac weak- ness, etc. Ether increases the coagulability of the blood, and at times when injected, even in small amounts, into the veins of animals, produces ex- tensive thrombosis (Ilanau, Ribbert). According to the experimental researches of Lexer and Mulzer, thrombi are found in the small blood vessels and capillaries, especially of the lungs and kidneys, after the in- halation of either chloroform or ether. The thrombosis becomes more extensive the longer the anaesthetic is administered. NITROUS UXID ANAESTHESIA 105 CHAPTER III NITROUS OXID ANESTHESIA [Nitrous oxid, NoO, is usually obtained by heatinj? ammonium ni- trate, which decomposes at an elevated temperature and forms water and nitrons monoxid (NH^NO-j = 2H2O -f- NoO). The product is washed by passinjT: throufrh water, which soon becomes saturated with the gas. The jias is kept in retorts or tanks obtained from manufacturers, in which it is reduced to a liquid form by strong pressure. The bag from which the gas is administered is filled, and the amount of gas regulated by a stopcock. Anaesthesia is rapidly induced by nitrous oxid, and the gas must be given continuously or intermittently, the mask being removed for short intervals, when the patient becomes blue, in order to maintain surgical anipsthesia. Nitrous oxid gas, the safest of the anaesthetics, has been left until recently to the dentist and for minor operations, although years ago the feasibility of employing it for prolonged anaesthesia w'as thoroughly demonstrated by Bert, Andrews, and others. In the last eight or ten years nitroiLS oxid has been extensively used by the general surgeon in the secpience of nitrous oxid and ether. In this I believe it has no very great value, except that it offers an agree- able anavsthesia to the patient. During the last three or four years I have been employing nitrous oxid and air as a general anaesthetic in an increasing number of patients, and I have been so much impressed with its value and possibili- ties of wide application that I feel warranted in urging its more general use. Roughly speaking, chloro- form anaesthesia has a mor- tality of 1 in 2,000; ether, 1 in 5,000; and nitrous oxid gas, 1 in 50,000 to 1 in 100,000. Gas is the most agreeable anaesthetic to take, and is the most rapid ana'sthetic, taking usually about sixty seconds. It is seldom followed by nausea or vomiting, pneumonia or bronchitis or nephritis or secondary changes in the tissues. If properly administered with air, an anaesthesia of a half hour or an hour can be secured. Fig. 64. — liKxxETT's Nitrous Oxid Inhaler. 106 GENERAL AND LOCAL ANAESTHESIA I began using it in cases where ether and chloroform were specially contraindicated, as in operations on the kidneys, such as nephrotomy for anuria, abscess, etc. I then extended it to kidney stone operations and nephrectomies. And finding how easy it was to maintain satisfactory an- a?sthesia for long periods, I have gradually increased the range of its use until now I am employing gas in a large proportion of my general cases. It is the anaesthetic of choice in reducing fractures and dislocations, in opening abscesses and felons, in breaking up adhesions in joints, in draining empyemas and lung abscess, in exploratory laparotomies, in gall bladder work, removing stones and drainage in kidney work, nephrotomy, nephrectomy, and nephrolithotomy, in bladder work, suprapubic cystot- omy for stone and in suprapubic prostatectomy, in draining appendiceal abscesses and cases of general peritonitis, in colostomy, in gastrostomy, in enterostomy, in repair of typhoid perforation, in repair of perfo- rating gastric and duodenal ulcers, in hernia operations, especially for relief of strangulated hernia, in varicocele, in open operation for hydro- cele, in castration, in amputations, excepting the largest joints, in re- moving tumors, as fatty tumors. There are some operations in which it cannot be very well employed, especially in those about the perineum (hasmorrhoid operations, for in- stance), there being a great tendency for the patient to straighten the limbs out and interfere with the procedure. Operations where very complete relaxation of the muscles is desirable are not well suited for gas angesthesia. Gas anaesthesia has certain disadvantages. It is expensive ; this, how- ever, could be overcome in a large hospital by manufacturing the gas in an apparatus in the operating room, as is done in their offices by some dentists who make a specialty of extracting teeth and employ large amounts of the agent. The apparatus is a bit cumbersome to carry around in private oper- ating, and still this is not a matter of much moment, as two or three cylinders and a gas bag and mouthpiece can easily be carried in a small dress suit case. To one unaccustomed to the dark color of the patient's face and the dark blood in the wound, this method seems more dangerous than ether or chloroform ana,'sthesia. The angesthesia is not as profound as that of ether or chloroform, and the occasional talking of the patient may be disconcerting to one not familiar with the method. In spite of these disadvantages, the great safety of the anaesthesia, the great rapidity of its action, the great comfort with which the patient can take it, the great freedom from nausea, the almost immediate recov- ery from the anaesthesia, the great freedom from lung complication, the ACClDEiNTS DURING AN^STHEblA, AMJ llOW TU MEET THEM 107 ^reat freedom from kidney- complication, the j;reat freedom from exten- sive fatty degenerations of liver, kidney, and heart, which may follow chloroform ana'Sthesia and to a less degree ether ana-sthesia — all of these combined make anaesthesia by nitrons oxid gas and air the method of choice in a considerable proportion of general surgical cases.] CHAPTER IV ACCIDENTS DURIXG AN.IiSTHESLV, AND IKJW TO MEET TIIEM Every physician should have an intimate knowledge of the accidents which may occur during anesthesia, and should be thoroughly conver- sant with the methods which should be employed to combat them. All these accidents are grouped under the term asphyxia, although this term, from the .Greek o-^C^eiv, meaning to pulsate, refers only to the absence of the pulse. The discipline of the assistants must be perfect in order to prevent confusion and loss of time, and surgeons in charge should keep cool and collected. If an accident happens, the first thing that should be done is to remove the mask. The accidents that may arise are suffocation and respiratory and cardiac parahjsis. Suffocation. — Suffocation is the result of mechanical interference with the air passages leading to partial or complete occlusion. It may be produced b}^ mucus and saliva, which are secreted in large quantities when ether is given; by vomitus, which is expelled when the patient is awakening, or during ana-sthesia when the anaesthetic is not given evenly, and in intestinal obstruction when enormous quantities are discharged. [An anaesthetist should always remember this danger, which occurs so often in patients suffering with ileus. Large quantities of vomitus are raised, and unless the anaesthetist is careful and the patient is watched until fully awake, the vomitus may collect in the pharynx and flow into the larynx, literally drowning the patient.] If there is any interference with the air passages the head should be immediately lowered and turned to the side, and a mouth gag inserted, in order to permit the mucus and saliva or vomitus to flow out. If the operation is not yet completed, the anaesthesia should be continued in this posi- tion, and, as a rule, the vomiting quickly subsides. Materials which collect in the recesses of the cheeks should be removed Avith steel sponges. If gurgling respiration and cyanosis indicate that mucus and saliva or vomitus has entered the larynx, a steel sponge should be passed into this organ and the material removed by a twisting motion. In desperate 108 GENERAL AND LOCAL ANESTHESIA cases a tracheotomy may have to be performed, and the aspirated mate- rial sucked out by a catheter, or something introduced to incite coughing. A number of different methods may be employed to prevent blood flowing into the larynx during operations upon the jaws, cheeks, lips, nose, and floor of the mouth. This is a grave danger, as the aspiration of blood is frequently followed by broncho-pneumonia. This may be prevented by position, the head being allowed to hang over the end of the operating table, as advocated by Rose, or by performing a preliminary tracheotomy and inserting a tampon canula through which the anaes- thetic may be given. The pharynx and aperture of the larynx may then be tamponed. [It should be remembered, however, that tracheotomy is rather a serious procedure, accompanied by fairly high mortality. This should not be employed when simpler methods will suffice.] In operations upon the mouth the blood may be constantly wiped away with sponges on forceps, or the recesses of the cheek may be tam- poned, while in operations upon the nose the posterior nares may be tam- poned. In some cases it is well to induce only a partial anaesthesia ; the reflexes are then preserved and the patient can expectorate the blood. Foreign bodies, such as tobacco, artificial teeth, and candies, may pass into the air passages during anaesthesia and cause suffocation. Of course all foreign bodies should be removed before anaesthesia is begun, but if such an accident should happen, the mouth gag should be inserted and the foreign body removed with the finger or curved forceps. The tongue may be spasmodically pressed against the pharynx during the stage of excitement, embarrassing respiration ; usually this is asso- ciated with spasm of the diaphragm and the other muscles of respiration. The jaws should then be immediately opened and the tongue drawn for- ward with tongue forceps. If this does not suffice the hyoid bone should be elevated, using von Bergmann's method (vide p. 110) and artificial respiration begun. During deep anaesthesia respiration may be embarrassed by the suck- ing in of the lips, cheeks, and aloe nasi. The lips are drawn in, especially in people without teeth and patients who have had a harelip repaired. It may also be embarrassed by a kinking of the trachea, when the head is in a poor position. If the nasal passages are occluded by polypi, hypertrophied tur- binate bones, tonsils, or a tampon, the jaws must be kept separated by a mouth gag and the tongue held forward. The surgeon should be able to prevent deaths from suffocation occur- ring during anaesthesia. Respiratory Paralysis. — Respiration may cease in the first stage of anaesthesia, the diaphragm being in the position of expiration, perhaps associated with a spasm of the glottis. This condition is apparently of ACCIDENTS DURING ANESTHESIA, AND HOW TO MEET THEM 109 reflex oriuin, folluAviiii;- stimulation of the trigeminal branches supplying the nasal mucous membrane, and oeciu's most frequently when large quantities of ether are administered quickly. The pulse remains good and the pupillary reflex is retained. If artificial respiration is performed (|uickly, the patient may vomit and then begin to breathe again. If the ana'sthetie is then forced because the patient vomits, this con- dition may occur again. These cases are known as " bad anipsthesias. " If the condition occurs whenever the patient is anaesthetized, there is usu- ally syphilis, tuberculosis, or some other disease of the nose, pharynx, or larynx. Painting of the mucous membranes with a five per cent solution of cocain before the anaesthesia is begun may be of value in these cases. If the cessation of respiration occurring in the first stage of ana?s- thesia is overlooked and more anaesthetic administered, death may occur from cardiac paralysis, which is also probably of a reflex nature, follow- ing stimulation of the superior laryngeal nerve. Cessation of respiration, occurring in deep anaesthesia, the result of administering too much ancesthetic, is much more dangerous than that above described. The pupils become dilated and do not react, and the heart stops beating after some seconds or minutes. If artificial respira- tion and heart massage are begun immediately, the pulse returns and then the respirations, but the patient remains for a long time in deep ana'sthesia with contracted, fixed pupils. Cardiac Paralysis. — The worst and most serious accident is that of sudden cessation of the heart beat, which may occur as the so-called early syncope, even in the first and second stages of anaesthesia. It is most frequent when chloroform is given, and is probably caused by paralysis of the cardiac centers or acute dilatation of the heart develop- ing during the stage of excitement. It occurs most commonly in pa- tients with some lesion of the myocardium, such as fatty degeneration so common in chronic alcoholics and following severe infectious disease; in patients with a chlorotic and lymphatic constitution ; in ana?mias fol- lowing injury or internal hamorrhages, leukamia; in shock, and severe psychical excitement. It may be caused during deep anaesthesia by a reflex paralysis fol- lowing irritation of the sensory nerves (e. g., by traction upon the sper- matic cord, by rough manipulation of the abdominal viscera, being analo- gous to shock induced by Goltz tapping experiments) and by the admin- istration of too much anaesthetic, especially when there is an antemia of the brain, the result of severe haemorrhages or cardiac weakness.^ > The athetoid flexor movements of the fingers, which are regarded by Koblanck as a positive sign of approaching cardiac failure, are frequently present during perfectly normal anaesthesia, and the author does not attach much significance to them. 110 GENERAL AND LOCAL ANESTHESIA \ "When these accidents occur the pnlse becomes weak and irregular, the face pallid and corpselike, the pupils dilated and fixed. Irregular respira- tory movements continue for some minutes after the heart stops beating. Fortunately such accidents are but rarely seen when ether is used, being more frequent when chloroform is employed. If such an accident occurs the patient should be inverted immediately or, bet- ter, the foot of the table should be elevated to at least 45°, the object of the eleva- tion being to overcome the cerebral anaemia and to favor the return of the venous blood which has accumulated in the splanchnic area to the right side of the heart. Artificial respiration, massage of the heart, transfusion of salt so- lution should also be em- ployed. Action must be im- mediate. If after fifteen minutes there is no response to the treatment, the patient rarely recovers. The physician is not re- sponsible for deaths from cardiac paralysis if the an-. [esthetic has been properly given, if there were proper indications for general an- aesthesia {vide p. 117), and if effective measures were promptly instituted to relieve the conditions. The purpose of artificial respiration is to carry oxygen to the blood, to favor the flow of oxygenated blood to the respiratory and cardiac centers, and to hasten the excretion of the anassthetic from the lungs. Freeing of Air Passages. — Naturally the air passages must be free before artificial respiration is begun. The mouth should be opened with a mouth gag, of which there are. a number of different varieties. The Ileister or the Konig-Roser should be inserted behind the back teeth on one side, after the jaw has been pushed forward ; the von Bruns mouth gag if used should be applied between the incisor teeth. The index finger Fig. 65. — Showing Inversion of Patient and Method of Performing Artificial Respira- tion Simultaneously. (Hare.) From Park's Modern Surgery. ACCIDENTS DUUINC ANAESTHESIA, AND llOW TO M1:i:T I'llIOM III iiijiy llu'ii be |);iss('(l ovcf Ihc (lorsiiiii of llic toiio-ue and the epiglottis, until tlu" easily palpable hyoid bone is reached, whieh should be drawn forvvai-d and npwai'd. The tongue may be di-awn foi-ward more effeet- ively by this pi'ocedure, introtlueed by von Berginann, than by the use of tonuiic I'orct'ps. Artificial Eespiration. — Artificial i-cspiration is usiuUly performed according to the mclliod introduced l)y Silvester. The patient is })laced in a horizontal or slightly inverted position; the operator stands behind him, grasps the arms flexed at the elljows, presses them against the sides of the chest, and then draws them back- war-d until they are stretcluMl horizontally above the head. By this pro- cedure the ribs are raised by traction of the pectoral nuiscles and arti- ficial inspiration is produced. When the arms are depressed expiration is produced. [Ar- tificial respiration should never be performed more rapidly than the normal re- spiratory movements, eighteen to twenty complete movements being performed in a minute. If performed more rapidly and roughly, artificial respiration is apt to do about as nuich harm as good.] Care should be exercised not to fracture ribs, especially in old people with rigid thoracic walls. Cardiac Massage. — Heart massage, according to Konig and Maas, may be performed by the physician holding the tongue forward. He should stand upon the right side of the patient, using the left hand to hold the tongue, and should place the right hand fiat upon the pra^cordial re- gion, alternately raising and depressing the wrist joint and ball of the thuml), the number of com- ])lete movements corresponding to the number of heart beats. Artificial respiration and heart massage should be continued until lungs and heart resume spontaneous activity, or if there is no reaction Fig. 66.- -Same as Fig. 65. From Park's Modern Surgery. 112 GENERAL AXD LOCAL ANAESTHESIA for at least one hour. Intravenous infusion of physiological salt solu- tion should always be employed with these methods. Ehythmic Traction of the Tongue, Adrenalin, Faradism, Direct Mas- sage of Heart, etc. — Besides these important measures above noted others may be mentioned, such as stimulation of the respiratory musculature by rhythmic traction of the tongue (Laborde), faradic stimulation of the phrenic nerves, injection of a few c.c. of a one per cent solution of adrenalin (Gottlieb, Mankowskj^ ) , the injection of a few c.c. of cam- phorated oil, and direct massage of the heart. The latter recommended by Prus for desperate cases, was first employed by Tuffier. It has not been successful, although in a number of cases the heart has been stimu- lated to beat for a short time (Zesas, Sick). Death occurring during anaesthesia is generally ascribed to the effects of the ana'sthetic. If it occurs, a statement should be prepared concern- ing the indications for the operation and general anaesthesia ; the results of previous examinations, which should have excluded all conditions con- traindicating the use of ether or chloroform, or only permit of their use in case of emergency ; the operative technic, the accidents, and the meth- ods employed to counteract them. This statement should be signed by all present and by the anaesthetist or operator who is directly responsible. It is practically impossible to make a short synopsis of lines of treat- ment that should be instituted to meet the different accidents which may occur during anaesthesia, but the following suggestions may be made: 1. If the respiratory movements are spasmodic in character, with entrance of some air, there is marked cyanosis, the blood becomes dark, and respirations are embarrassed, but the pulse is still present, it is generally sufficient to open the mouth, draw the tongue forward, and clear the air passages. Prompt action, as a rule, removes the conditions. 2. If the respiratory movements have ceased, perhaps the result of reflex paralysis occurring at the beginning of anaesthesia, or anaemia of the brain, but the pulse is present and the pupils react, artificial respira- tion should be performed after the respiratory passages have been freed. Recovery with vomiting is, as a rule, rapid. 3. If the respiratory movements have ceased, the pulse is present but weak, the pupils dilated but do not react, anaesthesia having been carried beyond the normal point, the foot of the table should be elevated, arti- ficial resp)iration and heart massage begun. In favorable cases the pupils contract, the pulse becomes better, spontaneous respirations return in at least ten minutes, and the patient remains for some time in the stage of deep ana\sthesia with contracted, fixed pupils. In the worst cases the pulse doas not return and death is the result. 4. If the pulse is lost, the respirations superficial or suspended, there is maximum dilatation of the pupils and corpselike pallor, the foot DIFFERENT METHODS OF INDUCING ANAESTHESIA 113 of the table should be elevated, artificial respiration and heart massage performed, and transfusion of salt solution given. Patients in this con- dition rarely recover, even when correct treatment is instituted imme- diatelv. CHAPTER Y DIFFEREXT METHODS OF INDUCING .VN^STHESIA. CHOICE OF METHODS Anaesthesia by Sequence. — It is at times desirable and advantageous to change ana-stheties during anaesthesia. Anaesthesia may be started with chloroform or with some other anipsthetic, such as laughing gas or ethyl bromid. and continued with ether (Kocher) ; this method is to be especially recommended if during long operations the heart's action be- comes weak or cardiac weakness is feared in anaemic and Meak patients. Some surgeons (]\Iadelung, Kolliker) begin with ether and continue with chloroform, as the dangers of the latter, which are especially pro- nounced during the initial stage of ansesthesia, may be avoided in this way. The long stage of excitement accompanying ether ana?sthesia is often dangerous to patients with heart lesions, and in these cases a few drops of chloroform administered in the beginning quiets the heart and induces anaesthesia, Avhich should l)e continued with ether, rapidly. Administration of Morphin before General Anaesthesia. — In some cases a small dose of morphin may be given to advantage before chloro- form or ether anaesthesia is begun. One sixth to one ([uarter of a grain should then be injected subcutaneously from fifteen to thirty minutes before the anaesthesia is begun. It quiets the patient, and there is less reaction when the general anaesthesia is begun and less is required to maintain ana?sthesia. Morphin combined with atropin is especially to be recommended when alcoholics are to be ana?sthetized. It is frequently administered before ether is given as the atropin lessens the amount of secretion. The patient under the action of morphin falls into a semistupor. and but little anaesthetic is required; even if conscious, patients experi- ence but little pain. Often they react when spoken to loudly, and many operators attempt to maintain this condition during operations about the mouth, as the cough reflex is preserved and the blood may be pre- vented in this way from flowing back into the larjTix. It is probably better, however, in this case not to give morphin, as it is then difficult to keep the patient in this condition, as he passes rapidly into the deeper stages of ana-sthesia in which the reflexes are abolished. It is better to use chloroform and produce only a superficial anaesthesia. 114 GENERAL AND LOCAL ANESTHESIA Anaesthetic Mixtures. — Mixtures of different aniBsthetics have been recommended and used. The Billroth mixture is composed of three parts of chloroform, one of ether, and one of alcohol; the so-called Vienna mixture contains one part of chloroform and three of ether; the Linhart mixture, one part of alcohol and four of chloroform. Schleich's general anaesthetic contains ether, chloroform, and petroleum-ether, and has a boiling point which corresponds to body temperature. Braun has devised an apparatus for mixing ether and chloroform, by which the amount of each may be accurateh^ measured, and mixtures of different composition made, by which each anaisthetie may be givei separately or in sequence. Scopolamin-Morphin Anaesthesia. — Scopolamin-morphin anaesthesia has many disadvantages and dangers. It has been employed quite extensively of late, but the results have not been such as to warrant recommendation. In the cases reported up to the present time the death rate has been higher than that following the use of chloroform and ether. Both ether and chloroform have their advantages and disadvantages, their adherents and opponents. In America ether is used much more extensively than chloroform, and unless there is some positive contra- indication it should be employed. There is a possibility of death occurring whenever a general anass- thetic is administered, but when it does occur it is often difficult to determine whether the anaesthetic was the direct cause of death or not. It may have been due to the inexperience or gross ignorance of the ancEsthetist, but it should be remembered that fatal results have occurred even during minor operations when a general anaesthetic was not admin- istered. Some of these deaths are probably due to fright, others to pul- monary embolism. The first time Simpson was about to use chloroform, the flask broke and the chloroform was spilled. The operation was begun without any anaesthetic, and the patient suddenly died. It is probable that if chloroform had been administered in this case, it would never have been tried agnin as a general ana'sthetic. [Late Poisonous Effects of Anaesthetics. — A number of articles have appeared lately dealing with the late poisonous effects of anaesthetics. General anaesthetics, especially chloroform, produce changes in important viscera, resulting in metabolic changes which often prove fatal. The symptoms produced by these changes were grouped under different terms before their etiological and clinical significances were clearly recognized. The possibility of the late poisonous effects of anaesthesia developing should always be considered in determining the anaesthetic which should be used in each case. Bevan and Favill, after the observation of a fatal case and a com- DIFFERENT METHODS OF INDUCING ANESTHESIA 115 ])ar;itiv(' study of :i iiiiiiihcr of cases roported in the literature, come to the followiii'i' coiichisioiis: 1. Anu'stlietics, especially chloroform (ether to a very limited de- cree), ea» produce a destructive effect on the cells of the liver and kid- neys and on the muscle cells of the heart and other nniscles, resultin": in fatty tle«ieneration and necrosis, very similar to the etTects produced in phosphorus poisoning. 2. The constant and most important injury done is that to the liver. 3. This injury to the liver cells is in direct ]n-oportion to the amount of the ana'sthetic employed and the leniith of the aniesthesia. 4. Certain individuals exhibit an idiosyncrasy or a susceptibility to this form of poisoning which it is difficult to explain. 5. There are certain predisposing causes which favor this destructive efTPect of chloroform, among Avhieh are: (o) age — the younger the pa- tient the more susceptible; ih) causes which lower the general vitality of the individual and probably the vitality of the liver cells, such as dial)etes, previous recent anaesthesias, infections by pus germs, diph- theria, intoxications from a dead foetus in the uterus, a gangrenous mass in the abdominal cavity, etc.; (c) exhaustion due to haemorrhage; (d) ex- haustion due to starvation; (e) exhaustion due to wasting diseases, such as carcinoma; (/") lesions which have resulted in extensive fatty degener- ations, such as occur in the limbs in infantile paralysis; (g) chronic dis- eases involving both liver and kidney, such as cirrhosis and nephritis. 6. As a result of this fatty degeneration and necrosis of the liver cells, toxins are produced either by the liver cells themselves or as a result of the failure of these cells to eliminate substances which under normal conditions they do, but which under these abnormal conditions they fail to do, and these substances, therefore, may accumulate and produce toxic effects. 7. These toxins produce a definite symptom-complex which makes its appearance from ten to one hundred and fifty hours after the anaes- thesia. This symptom-complex consists of vomiting, restlessness, delir- ium, convulsions, coma, Cheyne-Stokes respiration, cyanosis, icterus in varying degree, and usually terminates in death. 8. It is probable that milder degrees of this poisoning are recovered from, and that the transient icterus noticed after chloroform anaesthesia without other evident cause is due to such poisoning, and many cases which exhibit restlessness, fright, mild delirium, drowsiness, etc., after anaesthesia may be due to the same cause. 9. This disease is an hepatic toxaemia; the toxins producing it, hepatic toxins; and possibly the previous condition making its development easily possible should be desci'ibed as liver insufficiency. Just as we have for a long time recognized a condition, uraemia, in w'hicli we find 9 116 GENERAL AND LOCAL ANESTHESIA arising from a variety of noxious agents — antpsthetics, poison, infections, pregnancy, etc., affecting the secreting cells of the kidney and preventing their normal function — a pathologic condition, accompanied with a cer- tain definite symptom-complex; so we must now, we believe, recognize a condition involving the liver which may be caused by a variety of noxi- ous agents (anesthetics, poisons, infections, pregnancy, etc.), affecting the secreting cells of the liver and preventing their normal function, a pathologic condition w-hich we must describe as hepatic toxaemia, accom- panied with a certain symptom-complex, and showing certain' definite changes post mortem. We believe that the condition of acute fatty degeneration of the liver with resulting hepatic toxaemia is as definite a pathologic entity as is acute pancreatitis with fat necrosis. 10. As by-products in this toxaemia, but not as the essential poisons, are found acetone, diacetic acid, and beta-oxybutyric acid in the blood and urine. 11. Post-mortem examination reveals fatty degeneration of the liver, fatty degeneration and mild degree of inflammation of the kidneys, and, in extreme cases, fatty degeneration of heart and other muscles. The lesion of the liver we believe to be the overshadowing and important one, and the one which is responsible for the symptoms and fatal result. The injury to the liver, in some cases, is so great as to result in practically a total destruction of the organ. 12. Somewhat similar hepatic toxEemias resulting from fatty degen- eration of the liver cells occur in other conditions, and are accompanied by very similar symptoms. These occur in iodoform and phosphorus poisoning, diabetes, puerperal eclampsia, and acute yellow atrophy of the liver. 13. This fatty degeneration of the liver with hepatic toxsBmia follow- ing ana-sthesia is almost invariably due to chloroform in the fatal cases. Ether is seldom the cause of a death of this kind. 14. This serious and even fatal late effect of chloroform, which has heretofore not been generally recognized, must still further limit the use of this powerful and dangerous agent. 15. The possibility of the development of hepatic toxaemia makes chloroform distinctly contraindicated in those cases in which there exist the conditions which seem to favor its development — i. e., diabetes, sepsis, starvation, haemorrhage, the presence of intoxication from dead material, the presence of fatty degenerations, as already cited, after infantile paralysis, and lesions of the liver. The susceptibility of children to this hepatic toxaemia must be recognized. That chloroform is capable of pro- ducing these serious late poisonous effects is a strong argument against its employment, and an argument in favor of the more general use of DIFFERENT METHODS OF INDUCING AN/ESTIIESIA 117 ether; and yet we are confronted at times with the Charybdis of ether pneinnoiiia on the one hand, and the Scylla of chloroform hepatic tox- u'liiia on the other. 16. The recognition of this danger of hepatic toxaemia is a strong argument against the employment of cliloroform for long ana'sthe.sia, as it can be shown tliat a two-hour chloroform ana'sthesia is almost invari- ably fatal to rabbits and guinea pigs, from fatty degeneration and necro- sis of the liver cells; and a two-hour chloroform ana-sthesia in m;in is an exceedingly (hingerons thing.] Mortality Following the Different Anaesthetics. — It is difficult to de- termine ])y statistical studies the value and safety of an ana'sthetic, as the efit'ects of operations, injury, and disease must also be taken into con- sideration. According to Gurlt's statistics (1890-97) one death oc- curred in 2,075 eases of chloroform and one death in 5,112 cases of ether amvsthesia. Williams's statistics, covering a period of ten years, show that one death occurred in 1,236 cases of chloroform, and one death in 4,860 cases of ether anaesthesia. The statistics collected by Julliard are as follows : Administrations Deaths Rate Chloroform 524,507 314,738 161 21 1 in 3,258 Ether 1 in 14,987 Statistics appear to favor ether. Konig, however, has not seen a fatal result in 7,000 cases of chloroform anaesthesia, and in von Berg- mann's clinic and polyclinic during an interval of twelve years, in which time about 8,000 chloroform anaesthesias were administered, the author saw but one fatal result. Indications and Contraindications for Ether and Chloroform. — Each anaesthetic has its contraindications, one being less dangerous under cer- tain conditions than the other. Chloroform is to be avoided and ether used instead whenever there is a disturbance of cardiac function or demonstrable disease of heart nuiscle. It should never be forgotten, however, that ether, and particu- larly the lung complications w'hich may follow its use, may be a source of danger if the heart is aft'ected. Chloroform may be used in valvular disease without danger if compensation is good. Chloroform is to be preferred to ether when the lungs are diseased or i-espiration interfered with, as the result of narrowing of the respira- tory passages (tracheal stenosis, goiter, inflammatory opdema of the mucous membranes, etc.) . These conditions also favor aspiration of saliva or vomitus. (ieneral ana'sthesia is contraindicated : (1) In all conditions 118 GENERAL AND LOCAL ANESTHESIA in which both ether and chloroform are contraindicated ; (2) if the pa- tient is greatly excited before the operation; (3) in constitutional dis- eases, in -which the bodily resistance is greatly reduced (diabetes, severe an£emias, leukaemia, obesity, status lymphaticus or thymicus, exophthal- mic goiter) ; (4) in general weakness (syncope, shock, hemorrhage, cachexia) ; and (5) advanced nephritis. Finally, angesthetics should not be given, unless unavoidable, to women in the second half of pregnancy, as an abortion may result. In all conditions in which general anaesthesia is associated with great danger, local anaesthesia should be used if possible. Death has resulted, however, from the use of local ana-sthetics in excitable, weakened sub- jects. Von Eiselberg saw a fatal result following immediately a strumec- tomy which was done with Schleieh's infiltration anesthesia for the re- lief of Basedow's disea.se. Yon Bergmann lost a diabetic patient while amputating a thigh under local anesthesia, and the author has seen many patients collapse when the same method has been employed. The physician must decide whether a local or general anesthetic is indicated, and must choose the anesthetic to be used in each individual ease. If he has studied the case carefully, and has noted the indications and contraindications, he cannot be held responsible for any accidents which may occur. Literature. — Blauel. Ueber den Blutdruck wahrend der Aether- und Chloroform- narkose. Beitr. z. klin. Chir., Bd. .31, 1901, p. 271. — Borntrdger. Strafrechtl. Verant- ■wortlichkeit d. Arztes bei Anwendung des Chloroforms. Berlin, 1891. — Braun. L'eber Mischnarkose u. deren Ration. Verwend. Chir.-Kongr. Verhandl., 1901, II, p. 136. — P. Bruns. Ein automat. Mundsperrer. Beitr. z. klin. Chir., Bd. 19, 1897, p. 253. — Czempin. Die Technik der Chloroformnarkose. Berlin, 1897. — Dumont. Handb. der allgem. und lokalen Anasthesie. L'rban u. Schwarzenberg, 1903. — Flatau. L'eber Narkosenlahmungen. Zentr. f. Grenzgeb., 1901, p. 385. — Gartner. Ueber ei/ien neuen Apparat zur optischen PulskontroUe in der Narkose. Zentralbl. f. Chir., 1903, No. 36. — Hofmann. Aethertropfnarkose. Deutsche Zeitschr. f. Chir., Bd. 65, 1903, p. 403. — Kappeler. Chloroformnarkose. Kochers Enzyklopadie, 1901; — Chloroformie- rung mit messbaren Chloroformlioftmischungen. Chir.-Kongr. Verhandl., 1890, II, p. 79. — Kionka. Narkose, in Eulenburgs Realenzyklopadie, 1898. — Koblarick. Die Chloroform- u. Aethernarkose in der Praxis. Wiesbaden, 1902. — Kocher. Chirurg. Operationslehre. Jena, 1902. — Kochmann. Zur Frage der Morphium-Skopolamin- Narkose. Miinch. med. Woch., 1905, No. 17. — Konig. Herzmassage. Chir.-Kongr. Verhandl., 1893, I, p. 21. — Kraske. Ueber kiinstl. Atmung und kiinstliche Herzbe- wegung. Chir.-Kongr. Verhandl., 1887, II, p. 279. — Laseck, Rys, Zahradnicky. Skopola- min-Morphium-Narkose. Zentralbl. f. Chir., 1905, p. 611, 612. — Lewin. Note zur I'emploi du vinaigre contre les vomissements consecutifs a la chloroformisation. Re\'ue de chirurgie, T. 15, 1895, p. 786. — v. Mikulicz. Ueber die Narkose. Deutsche Klinik, Bd. 8, 1901. — Benno Muller. Narkologie. Leipzig, WO^i.—Mrdzer. Sommer 1906 noch nicht erschienen. — Nettel. Ueber einen Fall von Thymustod bei Lokalanasthesie. Archiv f. klin. Chir., Bd. 73, 1904, p. 637. — v. Niederhdusern. Die Skopolamin-Mor- phium-Narkose. I.-D. Bern, 1905. — Offergeld. Experim. Beitrag zur toxischen Wirkung des Chloroforms auf die Nieren. Archiv f. klin. Chir., Bd. 75, 1905, p. 758. — LOCAL ANESTHESIA 119 Srhncidcrliii. Die Sk()i)()l:uniii-(nj'()sciii)-I\l()ri)hiuin-Nark()so. Miinch. nieil. Woch., I'.)03, p. :{7I. — /'. Sirk. Zur operativeu Hi-rzinassage. Zcntralbl. fiir Chir., 1903, p. USL — Zcnas. Uoljcr die Massage dcs fieigelegteii Herzens iiu Chloroforinkollaps. Zcntralbl. f. Chir., l'JU3, p. 588. CHAPTER VI LOCAL AN/ESTHESLV Attempts to diminish locally the pain sense, so that painless opera- tions mioht be performed, were made even in olden times. Constriction of the extremities or compression of large nerve trunks used in earlier times is no longer employed, because of the dangers of temporary or permanent paralysis. Anaesthesia Induced by Freezing — Ether Spray and Ethyl Chlorid. — ^At the present time physical and chemical methods of different kinds are employed. Anaesthesia by freezing is a physical method which has come into more general use since the ether spray was introduced by Richardson in 1866. It reduces the temperature of the cutaneous area upon which it plays to five degrees above zero (F.), and the skin, which must be perfectly dry before the spray is applied, suddenly becomes white after a few minutes, the nerves lose their excitability and conductivity, and sensation is lost. Anesthesia induced by the ether spray is superficial and lasts but a short time. When the area thaws out a burning sensation is experienced. Chlorid of ethyl, which £jir Fig. 67.-Chlorid of Ethyl. may be bought in glass or metal flasks provided with detachable tops, is simpler in its application than the ether spray. It boils at 52° F., and when the flask is held in the hand a fine stream is discharged, which evaporates rapidly. The flask should be held from 30 to 40 cm. from the area to be operated u])()n, and as the temperature is rapidly reduced it is frozen and rendered anaes- thetic more (|uickly than when the ether spray is employed. Anaesthesia by freezing is suited only for small superficial incisions or for the introduction of an aspirating needle, and is to be especially recommended for incisions into circumscribed cutaneous and subcutane- ous inflammatory processes. Cocain Hydrochlorate. — Cocain hydrochlorate is the most important chemical agent for producing kical anaesthesia. It was introduced into ophthalmology by Koller in 1884, and has become indispensable as a 120 GENERAL AND LOCAL ANESTHESIA local anaesthetic. It may be used in different ways in producing anses- thesia. Mucous membranes may be painted or sprayed with a solution of it; the drug may be injected around or directly into nerves, into the tissues, or subdural space of the cord. Anaesthesia by Spraying or Painting with Cocain Solutions. — The mucous membranes of the mouth, nose, pharynx, and larynx may be rendered ana?sthetic rapidly by spraying or painting them with a five or ten per cent solution of cocain. If inflamed the swelling rapidly diminishes as the vessels contract. Hollow organs such as the bladder may be rendered anesthetic by irrigating them with a one per cent solu- tion. The conjunctiva may be rendered anesthetic by dropping a few drops of a one per cent solution upon the cornea. Only the surfaces of mucous membranes are anesthetized in this way, but a number of opera- tions not involving deeper tissues, such as the removal of nasal polyps and small superficial tumors and the opening of abscesses, may be per- formed. Infiltration Anaesthesia. — Infiltration anesthesia is employed very ex- tensively in minor surgery. Schleich has done more by experimental work than anyone else to popularize and extend the usefulness of this form of local anesthesia. Infiltration anesthesia consists in the injec- tion of weak solutions into the tissues. Weak solutions of cocain are much preferred to the stronger solutions, as the former are more reliable, and larger quantities may be used without the fear of toxic symptoms. Schleich has three solutions of the following compositions: Solution No. 1 — Strong Cocain hydrochlorate gr. 3 Morphin hydrochlorate gr. § Chlorid of sodium gr, 3 Distilled sterilized water 3 3| Solution No. 2 — Normal Cocain hydrochlorate gr. li Morphin hydrochlorate g^*- f Chlorid of sodium gr. 3 Distilled sterilized water o 3| Solution No. 3 — Weak Cocain hydrochlorate gr. ^ Morphin hydrochlorate gr. f Chlorid of sodium gr. 3 Distilled sterilized water 3 3| LOCAL ANESTHESIA 121 Scliloicirs tablets may be boufxht already prepared, and when the solution is reciuin^d, the number of tablets required to make a solution of a certain strength should be added to a definite amount of water. Distilled sterilized water should be used for making the solution, as the cocain is deeomj)Osed and becomes incU'ective when it is boiled. Technic of Injecting Cocain Solution. — When the cocain solution is injected into the skin a definite technic must be employed. An ordinary hypodermic or larger syringe may be used for making the injection. The needle may be inserted at a point previously made antesthetic by freezing, Fig. 69. — Infiltuation of Dki:v Layer of Skin. and should then be passed almost parallel to the surface of the skin. The point of the needle should be kept in the cutis, and should not be passed into the subcutaneous tissues. If there is resistance to the piston when the injec- tion is made, the needle is in the correct position. The needle is then gradually inserted into the wheal previously raised until the entire line of incision is cocainized. Wherever the solution passes, a white hard Avheal is raised. When the cutis is sufficiently infiltrated, some of the solution should be injected into the subcutaneous tissues. If it is the intention of jB the operator to carry the incision deeper the solution should be injected into fascia^ and muscle, and if the bone is to be exposed it should be injected into the periosteum. Fig. G8. — Syringe Hold- ing 10 OR 15 c.c. Which May Be Used for In- jecting THE Cocain SOl^UTION. Fig. 70. — Infil- tration An.es- thesia. 122 GENERAL AND LOCAL ANAESTHESIA If a large amount of cocain is used the injected area is transformed into a hard tumor-like infiltration which is anaesthetic. The solution should be freshly prepared before being used. The needle should fit tightly and the barrel should be provided with a good handle, so that firm, even pressure may be exerted. A number of differ- ent apparatus have been devised for injection of the solution in which the air pressure in the flask containing the solution is raised by forcing in air with an ordinary syringe or bicycle pump. The solution is then slowly forced out of a rubber tube, to which a needle is attached, and the tissues are evenly infiltrated. [In the Bevan clinic a one tenth of one per cent solution of cocain is used for anesthesia of the skin, and a one per cent solution for nerve blocking. The ordinary hypodermic syringe has been found very satisfactory for injecting the solution.] Fig. 71. — Matas Apparatus, Introducing the Air. The strongest Schleich solution has the following advantages: The injections are less painful, and as less of the solution is required a better view of the tissues may be had and their anatomical relations may be more easily recognized. It has the disadvantage that enough of the solution cannot be employed with safety to render anaesthetic large areas. AA^hen the weakest solution is employed the injection may be painful, and so much of the solution is required that the appearance of the tis- sues may be so changed and the anatomical relations so altered that it may be practically impossible to find small subcutaneous tumors, glands, or foreign bodies. Infiltration anaesthesia may be employed when there is no acute in- flammation. The injury of the tissues by the needle, and the danger of forcing bacteria and their toxins into healthy surrounding tissues, pre- vent its use in infections. Besides, in acute inflammation it may be necessary to make the incision layer by layer, and this is practically impossible when infiltration ann?sthesia is used. Many major operations (removal of large tumors, thyroidectomy, her- niotomy, resection of ribs) may be performed under infiltration anges- thesia. Fre((uently, however, the patients become greatly excited, and general ana'sthesia is to be preferred when there are no contraindications. LOCAL ANAESTHESIA 123 Ansesthesia by Nerve Blocking^. — Aiifcsthesia l)y nerve blocking, in Avliieh the injections are made into the tissues surrounding the nerves or direetly into the hitter, has recently been improved by Braun and may be employed in a number of different ways. According to Corning and 01)erst, this method is especially suitable for producing antrsthesia of the fingers and toes. It should be em- ployed as follows: The finger or toe to be anaesthetized is first rendered bloodless by applying a constrictor about its base. Then four subcu- taneous injections of a one half or one per cent cocain solution are made about the base of the digit distalward to the constrictor until a circular swelling is raised by the solution. All the nerve connections are then blocked, the digit becomes auipsthetic in five minutes, and remains so until the constrictor is removed. This procedure can only be emi)loyed for the incision of acute in- fiamnuitory processes, when the injection can be made into healthy tissues. According to Hackenbruch, amesthesia may be induced by the subcutaneous injections of a one per cent solution of cocain about the field of oi)eration when only superficial operations are to be at- tempted. Larger parts of the extremities, such as the hand and foot, forearm, and leg, may be rendered completely anipsthetic, according to Braun and others, if after the application of an elastic constrictor a one per cent solution of cocain is injected distalward to the constrictor about the larger nerve trunks (perineural injection). Subcutaneous injections of Sehleich's solution may be combined with this method, the injections being made parallel to the extremity, completely or only partially about it, blocking efifectually the cutaneous nerves. The Use of Adrenalin in Cocain Solutions. — Bi-aun discovered that the action of cocain and cocain solutions could be prolonged and in- creased about fourfold if, just before being used, a few drops of a 1 : 1,000 solution of adrenalin were added to them. It also renders un- necessary the troublesome and often painful elastic constriction without which anaesthesia cannot be successfully produced wath one half to one per cent solutions. The vessels are constricted and an ischa?mia pro- duced by this agent, and therefore absorption is delayed. A complete anesthesia develops in thirty minutes after perineural injections. According to Braun, not more than five drops of the adrenalin solu- tion should be used, and it should be added to the cocain solution just before the latter is injected. For the perineural injection of the larger nerve trunks a syringeful of a one per cent solution of cocain or eucain, to which are added from one to three drops of adrenalin solution for each c.c. ; for the injection of subcutaneous nerves along their course a one half per cent solution 124 GENERAL AND LOCAL ANAESTHESIA with the addition of one drop of adrenalin sohition for each 10 c.c. should be employed. According to Braun, this procedure is best suited for producing an anjesthesia of the fingers, toes, hand, and foot, of the nerve trunks in the lower third of the forearm and leg, the ulnar nerve at the elbow, the peroneal and tibial nerves in the popliteal space, the long saphenous nerve, the superior clunial and supraclavicular nerves. The following nerves in the head and neck may be blocked by this method : the super- ficial cervical, the auricularis magnus, and the superior laryngeal, bi- lateral blocking of which produces a very satisfactory prolonged anaes- thesia of the entire larynx, the supra- and infraorbital nerves, and the long cutaneous nerves of the scalp. Spinal Anaesthesia. — [Lumbar or spinal aneesthesia was first employed by Corning; it was rediscovered and improved by Bier.] This form of anesthesia is produced by injecting weak solutions of cocain or closely allied drugs into the lumbar meningeal sac. The following technic is employed : The patient is either placed upon his side or seated upon a table with his back toward the operator, the body being somewhat flexed in order to separate the laminae and render the intervertebral spaces wider. A thin canula 10 c.c. in length is then inserted between the spinous processes of the third and fourth lumbar ver- tebrae, just above a line uniting the highest points of the cristae ilii (as in Quincke's lumbar puncture), or between the spines of the second and third lumbar vertebraB. This needle is then passed into the lumbar sac, and a few drops of cerebrospinal fluid are allowed to flow out, and then the solution is slowly injected. The solution mixes with the cerebro- spinal fluid and acts upon the intradural nerve roots and trunks, espe- cially upon sensory bundles lying in the posterior part of the cauda equina. Loss of sensation, often accompanied by some motor paralysis, occurs in from ten to fifteen minutes and lasts for different lengths of time, even up to two hours. The ansesthesia is most marked in the extremities, about the anus and the perineum, and is usually so complete that any operation may be performed below the level of the navel. In many cases the anesthesia is incomplete or does not develop ; sometimes, when the canula has been directed lateralward between the nerves of the cauda equina, the anaesthesia occurs only upon one side ( Donitz ) . Spinal angesthesia as first employed was not practical. The mortality was high, and unpleasant symptoms (chills, sweating, nausea, vomiting, collapse) and after effects (headache, dizziness, vomiting, fever, paresis of the muscles of the extremities, and paralysis of the muscles of the eye) were frequent, especially so when the anaesthesia extended above the level of the navel. LOCAL ANESTHESIA 125 Bier is of lilt' opinion tli;it tlif ailditioti of adi'cnnliii so]uti ) or a (Y). In the Celsus procedure proper the defect should always be quad- rangular in shape. The edges of the wound are mobilized by making Fig. 74. lateral parallel incisions passing out from the angles. If these incisions do not permit of approximation, a semilunar incision may be made on each side at some distance from the ends of the lateral liberating inci- sions. The semilunar incisions should only extend through the cutis, Fig. 75. and the concavity of the incision should be directed toward the wound (Fig. 75). It can be seen from the examples already cited that this principle may be employed in a number of different ways in closing differently shaped defects: for example, in closing a quadrangular defect lateral ff^mmm^rnwfp I Fig. 76. liberating incisions may be made upon only one, upon two, or even three sides. The defect should be thought of as composed of three right angles, each of which is to be covered by a mobilized flap. In this case two of the liberating incisions pass from the middle of the edge of th« defect as represented in Figure 76. DIFFERENT PLASTIC PROCEDURES 129 In trianuular (K't'ccts tlu- liberal iiij,' incisions are made along tlic line of the base of the trian«:le to one or both sides (Fig. 77). If necessary, incisions as represented in Figiu'es 7-4 and 75 may also be employed. 1111 ) M T ( C ■ C - TlG. As a rule, the edges of the defect can be approximated much more easily if one or both of the lateral incisions are curved (Fig. 78). Burow's method of closure of triangular defects is very ingenious, but is little employed at the present time. It consists in making lateral Fig. 78. incisions, each equal in length to at least two thirds of the width of the portion of the triangle to which they correspond. The flaps are then dissected up and approximated as indicated by the arrows in the accom- panying figures. The shape of the wounds after suture is represented at the right hand side of the figures, showing shape of defect (Fig. 79). In narrow rectangular defects a small triangular piece of skin can be excised upon the short sides to permit of linear closure (Fig. 80 a), ) J ) - i — ^ J I I ] \ } > Fig. 80 \ or the lateral liberating incisions of Celsus may be combined with Bu- row's method as represented in Figure 80 h. 130 GENERAL DISCUSSION OF PLASTIC OPERATIONS In closing elliptical defects an incision may be made from the middle of one edge of defect (Lisfranc) (Fig. 81 a), and, if necessary, curved ] ) I f -i ^ ) ^iV .--' h Fig. 81. incisions may be made upon both sides from the extremity of this incision (Fig. 81&). 2. The Covering of the Defect by Flaps taken from an Adjacent Area. — There are three different methods : a. The lateral displacement of the flap (Dieffenhach's method). h. "Jumping a flap," or torsion of the flap {Indian method). c. Inversion and eversion of the flap. a. The lateral displacement of a flap taken from the area immediately adjacent to the defect was devised by Dieffenbach, and was first prac- ticed by him in Lisfranc 's clinic in Paris in 1834 in the formation of an eyelid ( blepharoplasty ) . The defect should be triangular in shape, and in repairing the eye- lids or lips the base of the triangle should correspond to the palpebral Fig. 82. and interlabial fissures respectively. Upon one side of the defect a rec- tangular or rhomboidal flap is cut from the adjacent skin and dissected free from the subjacent tissues. The flap is then displaced, the corre- sponding sides of the defect and flap being sutured, while the side corre- sponding to the apex is not cut and forms the bridge or pedicle for the flap (Fig. 82). Fig. 83. After the flap is displaced, a triangular defect remains, which may be diminished in size by approximating the angles as represented in Figure 83. Double flaps may also be employed in Dieffenbach 's procedure, then DIFFERENT PLASTIC PROCEDURES 131 tlic siiiall lateral tiiaimular defects remaininf; after displacement of the Haps must be allowed to heal by granulation tissue. Elliptical defects may be closed by making curved incisions upon one or both sides, and forminu: flaps which may be displaced into the defect (Fiu'. S4 a after llasner, and 84 b after O. Weber). .^-^ ] } ] h Fig. 84. Flaps M-hich are dissected free from the sub.jacent tissues, but still remain attached to the surrounding tissues at one or both extremities, are called pedunculated flaps. h. The " jumping " or torsion of a flap corresponds to the old Indian methods in which pedunculated flaps from the cheek or forehead were nsed to repair nasal deformities. This so-called Indian method first be- came widely known through the writings of Carpue, an Englishman, in 1816. After it had been improved by von Graefe, it was perfected and extensively employed by Dieft'enbach and von Langenbeck. In this procedure pedunculated flaps of different forms are made from the adjacent skin, the pedicle of the flap being the only part of it which borders immediately upon the defect. In order to cover the de- fect the pedicle must be more or less twisted. (If the flap be not moved more than a quarter of a circle, twisting of the pedicle is not neces- sary-, Bryant.) The form of the flap should correspond approximately to the form of the defect. The wound resulting from the separation of the flap may be diminished in size by suturing, or closed by other pro- cedures. According to Diefl:'enbach, one extremity of the incision made in forming the flap should extend into the defect, as the flap is mobilized better in this way, and then the pedicle lies directly upon the defect, and is not separated from it by a piece of intact skin (Fig. 85). The other extremity of the incision should be curved somewhat outward from the pedicle, rendering torsion of the flap without tension possible. Von Langenbeck laid great stress upon this point in the technic. If the inner surface of the flap should be covered with epithelium, as in cheiloplasty, the flap should be folded upon itself and the wound surfaces held in approximation by sutures. c. The inversion or eversion of a flap taken from the tissues imme- 10 132 GENERAL DISCUSSION OF PLASTIC OPERATIONS diately adjacent to the defect relates to the employment of skin in the repair of mucous membranes. For example, a flap may be taken from the neck, and the surface of the flap turned toward the mouth cavity Fig. 85. — Displacement of Pedunculated Flap upon Pedicle. to take the place of the mucous membrane, the cut surface of the flap being covered with Thiersch grafts. The defects may also be repaired by folding pedunculated flaps upon themselves, one skin surface being turned into the defect. 3. The covering of a defect by pedunculated flaps taken from distant parts has its oldest prototype in the Italian procedure. It, like the Indian method, was employed at first only for rhinoplasty. This method first became well known through the writings of Taliacotius or Taglia- cozza (1597). The operation was perfected especially by vcn Graefe, and there- fore it was known for some time as the German method. Flaps of dif- ferent shapes are taken from the arm, forearm, or hand, and are sutured into the defects, the parts being immobilized until healing is com- plete. The pedicle of the flap may be cut, as a rule, in about ten days. In this way defects of the face may be repaired with flaps from the arm, of the hand and arm with flaps from the breast, of the foot and leg with flaps from the healthy extremity. 4. The covering of defects with nonpedunculated flaps taken from dis- tant parts, grafliiu/ or travsplantation of skin, was probably attempted by the ancient Indians. In spite of repeated unsuccessful attempts, it was tried again and again. Reverdin's work, 1869, in which he trans- planted small pieces of skin from 2 to 6 qmm. in diameter upon granu- lating surfaces, prepared the way for later studies and skin grafting as it is practiced to-day. Thiersch in 1886 perfected the method, obtain- ing permanent healing by transplanting upon surfaces from which the granulation tissue had been curetted away large broad strips of epi- FUNDAMENTAL RULES FOR PLASTIC OPERATIONS 133 denuis t'()iitss of the skin, the method described by Krause should be employed, (^ar-e- ful observance of asepsis and the dry operation are, according to Krause, the most important considerations next to the complete control of hicm- orrhage. The luemorrhage should be controlled by the ligation of the larger vessels, and by even compression with dry gauze. According to the experience of the author, the use of three per cent hydrogen peroxide solution for rapid conti'ol of the cai)illai'y luemoi-rhage does not injure the ti.ssues. The elements of the transplanted cutis degenerate rapidly, and the 138 GENERAL DISCUSSION OF PLASTIC OPERATIONS flaps must be taken with the greatest care to prevent more injury than that already produced by interference with its nutrition. Vigorous scrubbing, brushes and antiseptics are to be avoided in preparing the field of operation. The strip of skin, in the form of an elongated spindle 6 by 20 cm., should be taken from the thigh or arm, in children from the back, and the resulting defect closed by sutures after the edges have been under- cut. If, as frequently is the case in plastic operations upon the face (to cover simultaneously the cheek, temporal region, or adjacent parts of the neck), flaps the size of the hand and corresponding to the form of the defect are required, the resulting wound should be covered at once with epidermal strips. In preparing the cutis strips, Krause directed all the incisions against the cutis, so that the strip when free contained no fat. Von Esmarch removed the skin and a layer of subcutaneous fat, and then spread it out upon the hand with the fat upward, and cut away the fat with a pair of curved scissors. Hirschberg has demonstrated that flaps con- taining subcutaneous fat will heal, but, as a rule, they have no advan- tage. In parts of the face where the least contraction of the flap pro- duces distortion (about the eyelids) the author uses by preference flaps containing a thin layer of fat, as they become softer and more movable cutis than without fat. In making a cutis flap it should be remembered that after it is cut it shrinks and becomes smaller. If the wound to be grafted is not yet dry after the flap is cut, the latter should be folded so that the raw surfaces are in contact, further injury of the flap being prevented in this way. The flaps, when applied to the wound surface, become so tightly agglutinated by the fibrin layer that they appear to be glued together. Agglutination, which is pre- vented by the slightest hemorrhage, is an important factor in the healing process. The edges of the defect and flap should be closely and accu- rately approximated. Sutures as a rule can be dispensed with, and as they exert tension, are not to be advised. The dressings, as previously described in discussing the technic of epidermal grafting, may be employed. The flap appears cyanotic after a few days, and its epidermis be- comes separated. If some parts of the graft die, they dry under aseptic treatment, and are finally cast off by granulation tissue. If after ten days the greater part of the flap is reddish and warm, moist dressings may be applied to hasten the separation of the necrotic areas. Inflammation prevents complete healing. If, however, the flaps have become firmly attached after a few days, they withstand severe inflam- mations, as no exudate is formed beneath them. PLASTIC OPERATIONS WITH COMPOUND FLAPS 139 Use of Toes to Replace Fingers. — Concerning the healing of trans- planted pieces of skin, vidt Wound Healing. Nicoladoni s procedure of using the tip of a toe with a nail to cover the bony stump of an index finger which h;hl l)een partly torn away comes under the head of skin grafting. Epidermal strips have the advantage of surety and rapidity of heal- ing. Cutis strips, on the other hand, are more resistant, shrink less, and give better cosmetic results. On the face and parts of the body fre- quently exposed to trauma, such as the palm of the hand and the ante- rior surface of the leg, the cutis strips are to be preferred for grafting. Where the quick covering with skin of a granulating surface is desired, as after extensive burn, and Avhere shrinkage of the grafted area is of no great significance, or it does not occur, as on the forehead, epidermal strips should be employed. CHAPTER III PLASTIC OPERATIONS WITH COMPOUND FL.VPS, AND TRANSPLANTATION OF MUCOUS MEMBRANE, CARTILAGE, AND BONE The pedicle Avhich provides nourishment for and insures the via- bility of the pedunculated skin flaps permits also of the use of deeper lying tissues, such as mucous membrane, cartilage, and bone for the repair of defects. In the Dieffenbaoh procedure (1834), employed in a number of dif- ferent ways to repair the lips (cheiloplasty), the mucous membrane is transferred with the skin flap to form the red margin of the lip and its inner lining. If cnly a small area of mucous membrane is lost, a flap consisting of mucous membrane only is required. Compound Flaps. — Compound flaps are used most frequently to repair bony and cartilaginous defects. The studies of von Langenbeck con- cerning the value of the periosteum for plastic purposes resulted in the introduction of his operation for the repair of cleft palate (uranoplasty, 1861), which is used as originally devised by him even at the present time. Two pedunculated flaps, consisting of mucous membrane and peri- osteum, are freed from the palatal processes of the maxillre and united to cover the defect in the palate. The layer of bone formed in these cases is thin but sufficient. The skin-periosteal flaps taken from the fore- head to repair nasal defects (von Langenbeck 's periosteal rhinoplasty) are unreliable and insuflficient as far as the fornuition of bone is concerned, and have been replaced by the skin-periosteal-osteal flaps. As early as 140 GENERAL DISCUSSION OF PLASTIC OPERATIONS 1855 Langenbeck had thought that it might be of advantage to remove a thin layer of bone with the skin and periosteum in performing rhino- plasty, but he desisted " because resection of the external table would open the veins of the diploe and phlebitis, and suppurative meningitis might follow this injury." Konig in 1866 was the first who attempted to perform a rhinoplasty of this kind. The attempt was success- ful, and the foundation for a great number of operations was laid. The skin-periosteal-osteal flap or cortical bony flap (Konig) is formed in the following way: When the skin is cut it is not raised from the sub- jacent periosteum, but a chisel is inserted and a thin plate of the ex- ternal bony layer which remains attached to the periosteum is raised. The pedicle should contain no bone, as it would interfere with turning the flap. The entire flap, composed of skin, periosteum, and bone, is then twisted or displaced into the defect, which has previously been vivified; ossification occurs, and the defect is repaired. Skin sutures are suf- ficient to maintain the flap in position. If the piece of bone is separated from the periosteum by the chisel, it can be placed in the defect and cov- ered with the flap of skin and periosteum (vide Transplantation of Bone) . This procedure has been used extensively in a number of ways: for rhinoplasty, for covering defects in the skull (Konig and W. Mueller), for filling in and repair of pseudarthroses (W. LIueller and von Eisel- berg), and for the transplantation of small bones and of entire segments of bone. It is possible, e. g., to use a pedunculated flap of the forearm, in- cluding a piece of the ulna, to form a nose according to the Italian method ( Israel ) . The two distal phalanges of the finger may be replaced by those of the toe by a method introduced by Nicoladoni. In this opera- tion a quadrilateral flap, the base of which is directed forward, is raised, and the extensor tendons and the joint (the interphalangeal or meta- carpo-phalangeal of one or two toes depending upon the case) and the flexor tendon are divided. The skin upon the plantar surface remains attached and forms the pedicle. The toes are then attached to the vivified stump of the finger by skin, tendon, and bone sutures, and both extremi- ties are immobilized in plaster of Paris dressings to prevent tension upon the pedicle, which is divided in about two weeks. The following are examples of the different ways in which skin- periosteal-osteal flaps have been used in plastic surgery: Flaps from the sternum (Schimmelbusch) or clavicle (Konig) have been used to repair tracheal defects. Fritz Konig has used for the same purpose, with suc- cess, a compound flap, the cartilage being taken from the thyroid car- tilage. Osteoplastic operations resemble closely plastic operations with com- pound flaps. In these cases a layer of bone which retains its connection PLASTI*' OPERATIONS A\'ITII COMPOUND FLAPS 141 with llif sdl't piiils is ck'vatc'cl, and ai'ter tlir (■oiii|)lcli()ii of the operation it is replaced in the area which it formerly occupied (osteoplastic resection of the skull, Wauner; osteoplastic resection of the maxilla, von Langen- bi'ck; of the nose, Oilier and von Bruns; the external wall of the orbit, Kriinlein; the /.vf^oma for different operations upon the trigeminal nerve). Sometimes parts of neigliboring bones are retained in ami)U- tations and reseetieiis, and are disi)laeed with the soft tissues attached to them to cover the ends of sawn bcnes (Pirogotf's osteoplastic exarticu- lation of the foot, using part of the os calcis to cover the sawn surfaces (if the tibia and libula ; yen Mikulicz-Wladimirow's resection of the foot, using the anterior part of the foot in a similar way; Gritti's amputation of the tliigh, transplanting the sawn patella to the femur). TluM-e are a number of diCferent procedures which may be employed to repaii- small bony defects, being intermediate between the peduncu- lated skin-bone flaps and the direct transplantaticm of bone. In these a layer of bone is i-aised which remains connected witli the periosteum, the lattei- forming the pedicle, about which the layer of bone is twisted (for repair of saddle-nose, amputation of the lower extremity by Bier's method to obtain a more useful stump). The transplantation of mucous membrane is especially useful to re- place the conjunctiva palpebru' in the fonnaticm of lids (blephai'o[)lasty). The mucous membrane may be taken to the best advantage fi-om the lips and cheelcs. In blepharoplasty a peduncidated flap of skin is first transplanted, and after the flap has healed in position the nnuious mem- brane is grafted (vide p. 47). The same technic is employed in grafting mucous membrane as in grafting skin. Chips and plates of bone have been taken from the anterior surface or crest of the tibia to fill in a defect in the skull (Seydel), to fill in a sunken nasal bridge, and to repair a pseudarthrosis (Mangoldt). The purposes for which cartilage may be transplanted have been pre- viously mentioned. Transplantation of bone has been employed extensively; results are more certain when fresh, living material is used. Bone chips and frag- ments, longitudinally divided long bones, or resected pieces of the latter may be used. The metatarsal bones, the bones of the forearm and leg, have been longitudinally divided and used by Bardenheuer to repair defects in neighboring bones (Cramer), Resected pieces of bone from the patient or from an extremity which has been recently amputated, may be used to repair a defect in another bone. Bergmann transplanted a piece of the fibula 12 em. long into a de- fect in the tibia, following a resection for a sarcoma. The piece of the fibula was maintained in position by silver wire sutures. The soft tissues 142 GENERAL DISCUSSION OF PLASTIC OPERATIONS must all be removed from the bone, which is to be employed for transplan- tation, and the latter must be thoroughly cleaned and boiled. Asepsis and the control of ha-morrhage are most essential factors in the success of bone transplantation. The transplanted bone should be maintained in position by sutures whenever displacement is likely to occur. The advantages of the transplantation of bone as compared to the use of pedunculated skin-periosteal-osteal flaps are these: Larger frag- ments of bone may be used, and the large scars following the use of flaps — e. g., in the face — are avoided. If the transplantation is not success- ful, it may be tried again, or the more reliable skin-periosteal-osteal flap may be employed. PART II WOU:^D INFECTIOIN^S A^D SURGICAL INFECTIOUS DISEASES I. THE NATURE OF INFECTION; THE LOCAL AND GENERAL REACTION CHAPTER I THE NATURE OP INFECTION If materials from without which injure the tissues gain access to a wouiul, the latter is regarded as contaminated or infected. A wound infection may be caused by poisonous substances such as snake venom, as well as by bacteria, and therefore a purely toxic is differentiated from a purely bacterial infection. The bacterial are so much more frequent than the toxic infections that the term has practically been limited to the former, and when a wound, the field of operation, and the hands are spoken of as infected, the terra is employed in this sense. Toxic Wound Infections. — In toxic wound infections the poisons enter the circulation and produce a general toxic infection (e. g., snake venom ) . Bacterial Wound Infections. — Bacterial wound infections may be fol- lowed by general infections, but these are not pure general bacterial infec- tions, for toxins are produced by bacteria when they grow in the tissues, and are liberated when they die and are dissolved, and in these general in- fections the organism is flooded not only with the bacteria, but with their toxic products as Avell. Sometimes in the general bacterial infec- tions the most marked symptoms are produced by the presence and mul- tiplication of the bacteria in the blood stream and viscera, while in other cases they are due to the absorption of the toxins from the primary focus, few. if any, bacteria being found in the blood and viscera. Theoretically a general bacterial and a general toxic infection may be ermeable to the bacilli, the filtrate if injected into animals will produce the same symptoms as those produced by the bacteria, while the bacterial residue has no action. The filtrate therefore contains poison- ous materials which have been produced in the culture media. These poi- sonous secretion products of bacteria are called toxins. Their chemical nature is not fully understood. Apparently they do not belong to the albumins proper, although they are closely related to them and to the ferments. They are extremely sensitive to chemical influences, particu- larly .so to heat, and lose their toxic action immediately when heated to 80° C. and in a short time after being heated to 50° C. Their chief char- acteristic is their specificity, all toxins having a definite specific action corresponding to that of the bacteria by which they are secreted. The toxins of many bacteria (streptococci, staphylococci, bacillus pyoeyaneus, bacillus of tetanus) contain Ixxlies which dissolve (ha'molysins) or agglu- tinate (agglutinins) red corpuscles. Experiments have demonstrated that luemolysis and agglutination are due to different substances. The second variety of bacterial poisons are the bacterial protoplasmic poisons. They are the substances which are contained within the proto- plasm of the bacteria, and are liberated only when the bacteria die and are dissolved. Buchner named the albuminous-like poisons which ar(> ob- tained Avhen cultures are boiled or ground up, bacterial proteins. Their action when the bacterial protoplasm contains no true toxin (endotoxin) is not specific. They have a common action which, as a rule, is pyogenic (Oppenheimer). The action of the proper pyogenic bacteria or micro- organisms depends upon the toxins produced by them and endotoxins 146 NATURE OF INFECTION; LOCAL AND GENERAL REACTION which are freed when bacteriolysis occurs. The results of bacterial in- fection of a wound are twofold — local and general. CHAPTER II LOCAL REACTION The local reaction begins \vith the entrance of the bacteria into the tissues (invasion). It does not, however, follow immediately the inva- sion, as the bacteria must first become adapted to their new surround- ings, and must develop to such an extent that the bactericidal proper- ties of the tissues can no longer restrain their growth. The length of the period of incubation varies, depending upon the number and viru- lence of bacteria and the resistance of the organism. It is of only a few hours' duration when the bacteria are derived from a patient with a severe infection (e. g., general pyogenic infection, meningitis, perito- nitis, phlegmon). It is longer — according to Friedrichs's experiments at least six hours for the bacillus of malignant cedema — when, as is usually the case, the bacteria come from the outer world. Bacteria of a low grade of virulence frequently are unable to invade the tissues, as their growth is prevented by the bactericidal properties of the tissue fluids. Bacterial toxins destroy the tissues, but they also irritate them and incite a number of processes which are intended to defend the tissues against their invasion. The more active the defense the more violent the local reaction. The usual local reaction may be absent if a weakened organism is attacked by highly virulent bacteria, as in such a case as this a powerful defense would not be possible. In experimental work there is no local reaction when the organism has previously been im- munized against the bacteria in question; there being no necessity for defense, as the protective bodies which will not permit of the develop- ment and invasion of the bacteria are already present in large quantities. The local reaction is inflammatory in character and varies in char- acter and degree. It differs even with the same infection, and depends upon a number of factors, especially upon the virulence of the bacteria and the resistance of the tissues. In many cases the local reaction is char- acteristic, giving to the infection distinct clinical features. Strepto- cocci from the same source may produce a serous, a fibrinous, or a suppurative inflammation. The local reaction produced by pyogenic cocci, diphtheria and tubercle bacilli is very different. In a purely toxic infection the general symptoms are produced by the absorption of the toxins, and the local changes have nothing characteristic — e. g., tetanus. LOCAL REACTION 14< Inflammatory prceosses are charactL'rized by three fundamental chanij-es, not withstand in.ir their ditVerent eiiuieal pietures. The changes are not only incited by bacterial toxins, but also by mechanical, thenual, and chemical irritation. [At the present time the changes produced by mechanical, thermal, and chemical irritation are regarded as reparative ratluT than as inflammatory. J The three processes are: 1. Disturbance of circulation with exudation. 2. Degenerative changes. 3. Regenerative changes. 1. Disturbance of Circulation with Exudation. — The vascular changes maj' be most easily followed when the mesentery of a frog or rabbit is spread out upon a glass slide and observed under a microscope. In this way the mesentery is exposed to the desiccating influence of the air and the irritating substances in it, and inflammatory processes are incited. The vascular changes begin with an active (congestive) h>T)er»mia, as the irritation paralyzes the vasoconstrictors and the vessel walls become Fig. S8. — Sectiox of Ixfi.amed Omenti-m from AL\n-. (After Ziegler.) a, Normal trabe- culae in oineutiim; b, normal endothelium; c, small arterj'; /, detached endothelium; /, polynuclear cells; g, extra vasatcd red blood corpuscles. relaxed. The blood flows more rapidly through the ai-teries. capillaries, and veins. Soon, however, there is a marked slowing of the blood stream in the center of the inflammatory focus, and a passive hypenvmia suc- ceeds the active, as the injured vessel walls oifer more resistance, become 11 148 NATURE OF INFECTION; LOCAL AND GENERAL REACTION mcire permeable, and the surrounding tissues lose their tension. Often there is a transitory stagnation of the blood stream in the capillaries (stasis). Migration of Leucocytes. — A peripheral stasis of the leucocytes in the veins, and their accumulation in the capillaries precedes the exu- dation. As soon as the blood stream begins to slow, the leucocytes pass to the peripheral portion of the blood current, which ordinarily is com- posed of plasma containing no cells. The heavier red blood corpuscles remain in the center of the stream. Slowly the leucocytes roll along the vessel wall, until single cells or whole groups of them become at- tached. This occurs much more readily in the capillaries, where there is often stagnation of the blood stream. Then follows the emigration of the leucocytes, which has been described by Cohnheim. Just as an oil drop swimming upon water changes its form when small parts are sent out, and assumes its form again when these flow back, so the motile protoplasm of the leucocytes sends out narrow pseudopodia through the vessel wall where the cement lines of the endothelium, which under nor- mal conditions, and still more so when the vessel wall is injured, offer a point of exit. When the entire leucocyte has passed through the vessel wall, it begins to wander into the tissues. Cliemotaxis: Positive and Negative. — This active passage of the leu- cocyte from the vessel wall is due to the attractive action of the cause of the inflammation. This property of leucocytes and almost all motile cells of being attracted by definite chemical substances, particularly by most bacterial toxins and proteins, is called positive cliemotaxis {vide Leucocytes, p. 159). Some bacteria, such as the bacillus of anthrax and malignant oedema, repel the leucocytes, this phenomenon being called negative chemotaxis. Formation of the Exudate. — "While leucocytes wander into the inflam- matory focus from all sides and infiltrate the tissues, so that their struc- ture can no longer be recognized, an exudate is being poured out from the vessels which separates the tissues and fills the tissue spaces. The pouring out of the exudate, which is to be regarded as a product of secretion rather than of filtration (Heidenhain), is due to an alteration of the vessel wall, in consequence of which the secretory function of the endothelium is altered. The injured vessel wall becomes more per- meable than normal, so that materials which usually remain in the blood are no longer retained. The inflammatory exudate differs from lymph in that it contains greater numbers of cells and larger amounts of albumin. As a result of the exudate the hyperasmic area becomes tense and hard (inflammatory infiltrate) or presents the signs of oedema (in- flammatory oedema), as it pits when pressure is made with the finger. Important provisions for the protection of the tissues are combined LOCAL REACTION 149 with these changes. In the non-bacterial inflammations the liquefaction of the necrotic tissue which renders al)sorpti()n possible is the first pro- tective step. The cellular exudate forms the first line of defense against bacteria, as it contains bactericidal bodies which are ably supported in their action by the leucocytes (phagocytes). rolymorphonuclcar Leucocytes, Plasma Cells, etc. — The cells which emigrate from the vessels are mostly polymorphonuclear leucocytes with neutrophile granules, which, according to Ehrlich, are derived chiefly from the bone marrow. If the vessel wall is severely damaged, red cor- puscles which have escaped by diapedesis or rhexis, and other varieties of leucocytes, such as lymphocytes and eosinophilous leucocytes, the granules of which stain with acid dyes, are found. The lymphocytes are small, round, motile cells with large nuclei. They lie together in small groups (so-called small cell infiltration) and Ribbert is of the opinion that they form a small lymphatic focus, particularly in the neighbor- hood of the vessels, which increases as the inflammation progresses, and because they are intended to absorb noxious materials they remain for a long time. 2. Degenerative Changes. — The degeneration and necrosis within the inflammatory focus is partly due to the bacterial toxins, to mechani- cal, chemical, and thermal influences — all of which act upon the cells and fre(iuently cause their death. They are also partly due to circulatory and nutritional disturbances resulting from the pressure of the exudate, the stasis in the capillaries, and the thrombosis of inflamed veins and arteries {cidc Pyogenic Disease of the Vessels, p. 288). The necrotic tissues become liquefied or absorbed by the leucocytes or the ferments liberated by them when they die. Liquefaction and al)- sorption are rarely conq^lete, and the necrotic tissue is only separated from the healthy, rarely completely li(iuefied or absorbed. 3. Regenerative Changes. — The first signs of regeneratitm are seen early (after twelve hours). The protoplasm of the connective tissue cells and of the endothelial cells of the lymph and blood vessels increases in amoiuit, and numerous mitotic figures may be seen, indicating that the tissues are therefore proliferating actively. It is difficult to determine the origin of the large, round, mononuclear cells which stain heavily and characteristically with methylene blue. These have been called plasma cells by Unna, who regarded them as derivatives of connective tissue cells. According to Marschalko, Ribbert, and others, they are derived from large lymphocytes. The growth of tissue increases as the hypei-aMuia and exudate subside, resulting in the development of granulation tissue, which is composed of fibroblasts, leucocytes, lymphocytes, newly formed and old ground substance, and many newly formed blood vessels. Eventually the granu- 150 NATURE OF INFECTION; LOCAL AND GENERAL REACTION lation tissue fills in the defects resulting from the necrosis and lique- faction of the tissues. Therefore granulation tissue is always found in ulcers of the skin and mucous membrane, about sequestra in bone, in the walls of abscesses and fistulae, etc. The granulation tissue surround- ing dead tissue aids in separating the latter (demarcation), and as the inflammation subsides, produces a secretion rich in leucocytes, the fer- ments of which digest the necrotic tissue. The granulation tissue becomes transformed into scar tissue as wound repair progresses. Symptoms of Acute Inflammation. — The classical symptoms of acute inflammation, which were described by Galen, are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). The redness and the local elevation of temperature about the inflammatory focus are due to the active hypergemia, the swelling to the exudate, the pain to the action of bacterial toxins, and the other harmful agents upon the nerve end- ings. The fifth symptom, which is sometimes described as functio Isesa, the disturbed function of the part of the body involved, is due to the swelling and pain. Character of the Inflammation and Clinical Course. — The character of the inflammation is determined by its cause. Sometimes all the symp- toms are pronounced, sometimes they are but slightly developed; some- times hyperemia and exudation predominate (e. g., inflammations due to pyogenic bacteria) ; sometimes degeneration and necrosis (e. g., cau- terization, burns, and frostbites of the third degree, in putrefactive and severe pyogenic infections) ; and sometimes the proliferation of tissues (e. g., in syphilis, actinomycosis, and some forms of tuberculosis). The inflammations associated with hyperasmia and exudation have an acute clinical course, while those resulting in the formation of large amounts of new tissue develop gradually and are chronic. Intermediate forms are called subacute. The clinical course depends upon the viru- lence of the bacteria and the resistance of the tissues. An acute inflam- mation may become chronic, if the virulence of the bacteria diminishes; the reverse may happen if the virulence increases. The character of the exudate and the amount of local tissue degeneration characterize differ- ent forms of inflammation. The following forms may be distinguished: 1. In serous infammation a watery exudate containing large amounts of albumin and but relatively few cells is formed. It gives rise in mu- cous membranes to a serous discharge mixed with mucus ; in the cutis to the formation of vesicles with clear contents; in the subcutaneous tissue to an inflammatory oedema ; in the large body cavities, joints, and bursfe to characteristic serous exudates. Serous inflammation may be acute (erysipelas), or chronic (tuberculosis of serous cavities), depending upon the bacteria. Serous inflammations may be associated with the mildest LOCAL REACTION 151 (osteoiiiyi'litis ;ilhuiiiiiios;i) ov the scvci-cst infections oansod by pyoff(>nic cocci (sci'oinirulcnl, plilc.nnion). Frc(iiicntly there nvo ti'ansitions to the fibrinous oi- purulent types, tlie lil)i'in is j)reci[)itiite(l or the serous exu- date is rich in cells. 2. Fibri)ious inflammation is characterized by the precipitation of albuminous bodies dissolved in the exudate. Ferments which are appar- ently derived from dei;eneratinans (heart, liver, and kidneys) are also dui' partly to the action of toxins. LiTioHATUUE. — AschojJ. Elirlichs Seitenkcttcnfheorie und ihre Anwondung aiif die kiiiist lichen Iiniiiunisienmgsprozesse. Zeitschr. fiir allgein. Physiok, Bd. 1, 1902. — Bchriny. Allgeni. Therapie tier Infektionskrankheiten. Urban u. Schwarzenl)erg, IS':^0.— Buck ner. Ueber Inimunitat. Derea natiirliches Vorkoinmen. Miinch. nied. Wochenschr., 1891, p. 551. — Curschmann. Zur diagnost. Beurteilung der vom Bliiid- darm, etc., ausgehenden entziindl. Prozesse. Miinch. med. Wochenschr., 1901, p. 1907. — Friedbcryer. Die bakterizid. Sera. In Kolle-Wassermanns Handb. der path. Mikroorg., BiL 4, p. 452. — Friedrich. Die aseptische Vcrsorgung frischer Wunden. Chir.-Kongr. Verhandl., 1898, II, p.^4G. — Kiittner. Diagnost. Bkituntersuchungen boi chirurg. Eiterungen. Chir.-Kongr. Verhandl., 1902, I, p. 12G. — Lexer. Ziir Beluuul- lung akuter I'^ntziindungen niittelst Stauungshyperaniie. Miinch. med. Wochenschr., 190(), p. ()ij3. — M titichnikoff . Die Lehre von den Phagozyten und deren experimentelle Cirundlagen. In Kolle-Wassermanns Handb. der path. Mikroorg., Bd. 4, p. 332. — Moxter. Die Beziehungen der Leukozyten zu den bakterienauflosenden Substanzen tierischer Safte. Deutsche med. Wochenschr., 1899, p. 687. — Notzel. Ueber d. Bak- terienresorption frischer Wunden. Arch. f. klin. (!hir., Bd. 60, 1900, p. 25. — Oppen- heinur. Die Bakteriengifte. In Kolle-Wassermanns Handb. der path. Mikroorg., Bd. 1, p. 344.— Paltauf. Die Agglutination. Ibid., Bd. 4, p. 645.~-Rdnier. Die pjhrlichsche Seitenkettenthcorie untl ihre Bedeutung fi'ir die med. Wissenschaften. Wien, li)04. — Sachs. Die Hiimolysine vuid ihre Bedeutung fiir die Immunitiitslehre. Wiesbaden, 1902.— Schimnielbusch und Richer. Ueber Bakterienresorption frischer Wunden. Fortschr. der Med., Bd. 13, 1895. — A. Wassermanii. Weitere Mitteil. i'lber Seitenkettenimmunitat. Berl. klin. Wochenschr., 1898, p. 209;— Wesen der Infektion. In Kolle-Wassermanns Handb. der path. Mikroorg., Bd. 1, p. 223; — Antitoxische Sera. Ibid., Bd. 4, p. 452; — Hiimolysine, Cytotoxine und Priizipitine. v. Volkmanns Saininl. klin. Vortr. Natur Forscher, No. 331. — Wrede. Die Ausscheidung von Bak- terien durch den Schweiss. Chir.-Kongr. Verhandl.^ 1906. CHAPTER IV FEVER All the reactive processes which follow the absorption of bacteria and their toxins have for their object the control of the infection. The general reaction is expressed clinically by fever. 13 164 NATURE OF INFECTION; LOCAL AND GENERAL REACTION Symptoms of Fever. — The chief symptom of fever is an elevation of body temperature. The normal body temperature, when taken by the mouth is 98.6° F., in the rectum 99.6° F. In mild fevers the temperature reaches 101° F. and in severer ones 104° F., or even 1° to 1.5° higher. Disturbances of digestion (anorexia, vomiting) ; of the circulation (rapid and soft pulse) ; and of the respiration; and nervous symptoms (irrita- bility, headache, disturbance of consciousness, delirium) often accom- pany fever. These vary with the temperature, and are caused less by fever than by the bacteria which produce it. The elevation of temperature results from a disturbance of the equi- librium between heat production and heat loss. In the healthy indi- vidual as much heat is lost by radiation and conduction from the skin and by evaporation from the skin and lungs, as is produced, for example, by oxidation processes cccurring in the muscles. In fever the production of heat is increased, and the amount lost is not sufficient to maintain the equilibrium. The increased production of heat depends upon increased metabolism and oxidation processes, for in fever the amount of oxygen contained in the expired carbon dioxid (Liebermeister, von Leyden) is greater than that which is inhaled (Regnard, Zuntz), and because of the increased destruction of albumins the nitrogen excreted in the urine is increased. In a healthy individual increased metabolism (muscular effort) does not produce an elevation of temperature, because the ex- cessive heat is lost by radiation, conduction, or evaporation. In fever the processes which effect this are disturbed. The loss of heat does not keep pace with its production. There is interference with the loss of heat, so that in the beginning this may be less than normal, and thus there is produced a heat congestion (Traube). According to Krehl, it is most probable that the substances which produce fever incite abnormal decomposition processes. Thus there is produced an increase in the decomposition and oxidation of albumins which interferes with the loss of heat. It may be that the stimulus which excites heat loss is deficient, or that the mechanism (blood vessels, sweat glands, and breath) which effects it functionates poorly, or finally that the regulating center in the brain is at fault. A sudden rise of temperature (stadium incrementi) is often ac- companied by a feeling of chilliness or a rigor. The amount of heat lost is diminished, while the production of heat is increased in this stage. The capillaries of the skin are contracted by the action upon the vasomotor centers of the fever-producing substances. Reflex mus- cular twitchings may occur and give rise to the clinical picture of a chill. In the climax (fastigium) which follows after one to two hours, the skin is white, dry, and somewhat injected. The amount of heat lost is FEVER 105 relatively increased, but not eiion<:h is lost to ])rin<; about a rc^turii to the normal condition. The fall of the fever (stadium decrement!) is frequently accompanied by mai-kcd swcatiny- and sonictimes by symptoms of collapse. Heat is not foi-nu'd in such lar^c amounts, -while the loss of heat is elTeeted in a ntniibci" of ditTcrcnt ways. If, during- an infection, the orjj^anism be- comes weakened and its resistance decreases, the temperature falls; for example, if, as a result of cardiac weakness, sufficient heat is not pro- duced. Collapse, which frequently j)roves fatal, may then develop. Surgical Significance of Fever. — 1. Particular fever curves ^ive to many infections a characl(M"istic im{u-ess which is of o;reat diagnostic importance. 2. An elevation of temperature indicates some irregularity in Avound repair, the beginning of invasion by micro-organisms or the accunndation of intiannnatory products. Causes of Fever. — 'i'lie fact that the temperature rises Avith the developuKuit of an abscess or with the beginning of suppuration or putrefaction in a Avound, and that it subsides Avhen the pus is permitted to escape or the inflammation subsides, is proof that the substances pro- ducing the fever result from the inHanunation or are contained in the Avound secretion. At a time Avhen little Avas known about bacteria, and nothing Avas knoAvn about their action, experiments Avere made Avith putrefactive Avountl secretions and the decomposition products of ani- mals and plants (Billroth, AVeber, von Bergmann) to determine the cause of fever folloAvi ng Avound infections. Not only the decomposition products from suppurative and putrefac- tive foci, but a number of other substances Avhich produce an increased decomposition of albumins (Krehl) cause fever. All ferments (fibrin ferment, according to \'on Berguumn and Angerer), poisonous albumi- nous substances, the decomposition products of cells (haemoglobin), for- eign constituents of the blood ( cells and serum ) of man and animals, and especially the toxins of pathogenic bacteria cause fever. Relation of Fever to Absorption of Toxins. — Decline Due to Protec- tive Substances. — It has been demonstrated by experiments upon ani- mals and man and by clinical experience that the dit¥usion of the toxins of pathogenic bacteria in the body produces fever, and that the decline of the fever follows the development of protective substances in the blood. The fever in diphtheria subsides as soon as antitoxin is injected, Avhile after the crisis in pneumonia protective substances are present in the blood. Depending upon Avhether the antibodies are developed quickly or sloAA'ly, the fall of temperature is sudden (critical) or gradual (lytic). In continuous fevei', in Avhich the difference betAveen the maximum and minimum rises of tempcM'atiu'e taken morning and CA'cning is at most one degree, the poisonous products of the bacteria predominate over anti- 166 NATURE OF INFECTIOxN; LOCAL AND GENERAL REACTION bodies. In intermittent fever, in which there are intervals of days with- out fever, antibodies are formed intermittently, are then exhausted, and allow the newly formed toxins to act. The same holds true for remit- tent fever in which the fever falls in the morning. The different forms of fever curves in the different infections depend upon the bacteria producing the infection, the toxins which are formed in the tissues, and the products of decomposition (ferments in the exu- date, dead tissues which are dissolved) resulting from the inflammation. For this reason many diseases have typical fever curves, in which a high fever persists for a certain time and then falls ; in pneumonia and erysipelas, for example, in about one week the organism overcomes the infection by oxidizing the products of decomposition and by producing protective substances. The examination of the cells (medulla of bone, spleen, and lymph glands) of an organism which has formed bactericidal bodies in a num- ber of infections will reveal increased cellular activity, as indicated by relatively numerous karyokinetic figures (Pfeiffer, Marx, A. Wasser- mann, Freymuth), showing that an effort has been made in this way to overcome the infection. Fall of Fever after Incision of Ahscess, Amputations, etc. — The fall of temperature after the incision of a phlegmon or abscess or after the amputation of a suppurating extremity indicates that the toxins and products of decomposition are no longer being absorbed. If the fever rises again, it indicates that new tissue is being invaded or that the dis- charge of pus is prevented. If the infection is not controlled by incision or amputation the fever continues until death, the overwhelming infec- tion producing continuously new toxins before sufficient protective sub- stances are formed to prevent their fatal action {vide p. 156). Lotv Fever in Fatal Infections. — Fever may be absent or slight in fatal infections. Because of the virulence of the bacteria or the weak- ness of the organism (old people) there is no general reaction. In ani- mal experiments there is often no fever after the injection of large fatal doses of toxins, but subnormal temperature and collapse. Fever, there- fore, not only indicates the beginning and extension of severe infection, but indicates during its entire course the activity of those processes which combat infection. Some importance has justly been attributed to the harmful action which fever exerts upon bacteria. Many bacteria, particularly the gonococei, are killed when exposed to high temperature. The conditions in the culture tube, however, are not compai'able to those in the living body, for in tlii' foi-nicr the bacteria are exposed to the desiccating action of the air, and i'ov this reason this supposed action of fever is doubtful (A. AVassermann), FEVER 167 Action of Antipyretics. — 'I'lic iriorr one considers the value of the febrile reaction, which was claimed by Hippocrates, but which has been doubted more recently, the less one is inclinetl to prescribe chemical agents (antipyretics) to control the fever. One fears that they will inteifere with the production of protective substances, although Schiitze has demonstrated at least for typhoid fever that antibodies are formed even when the temperature is reduced by antipyrin. The surgeon should not, however, use antipyretics to reduce the fever, for next to the general appearance of the patient, it is the most important index of the condition of the wound or inthunmatory focus. Aseptic Fever. — A non-infectious or aseptic fever (Genzmer and von Volkmann) is distinguished from fever resulting from the absoi-ption of infectious substances, especially bacterial toxins. This fever occnrs after subcutaneous injuries, especially after fractures; with vascular sar- comas; when there is extravasation of large quantities of blood into the tissues ; and after injuries of certain parts of the brain. It does not occur constantly, however, and difil'ers clinically from the infectious fever in the absence of a chill and general febrile symptoms. The pulse is good and only slightly accelerated, and there is but little elevation of temperature (100° F., rarely higher). This fever is caused by the formation and absori)tion of pyrogenic substances from blood exudates and dead tissue. Earlier it was sug- gested by Alex. Schmidt, von Bergmann, and von Angerer that the fever was caused by the fibrin ferment. According to the later investi- gations of Schnitzler and Ewald, it is produced by the nucleins, albumi- noses, and allied substances. The elevation of temperature after injury of the brain is caused by a disturbance or irritation of certain parts of this organ (e. g., medial part of the corims striatum). It may be produced experimentally (heat puncture ) . A slight elevation of temperature without other symptoms of fever occurs frequently after operation- and open wounds (also after child- birth), although there is no irregularity in wound repair. This has been spoken of as aseptic fever, and the absorption of the decomposition products of injured tissue and of blood exudates has been regarded as the cause (von Volkmann). The demonstration, however, of bacteria in accidental- and operation-wounds which heal without inflannnation, likewise the demonstration of slightly virulent pathogenic bacteria upon hands which have been thoroughly sterilized, upon the sterilized skin of the patient, in the air, etc., indicate that bacteria are an important factor in so-called aseptic fever following operation- and accidental- wounds, even when the wound repair pursues an aseptic course. Used in this sense, Volkmann 's designation, aseptic fever, may still be retained. 168 NATURE OP INFECTION; LOCAL AND GENERAL REACTION A purely nervous fever, due to an irritation of the central nervous sys- tem (heat center), occurs in insanity and psychoses, particularly in pare- tic dementia and hysteria. Literature. — v. Bergmann und Angerer. Das Verhaltnis der Fermentintoxikation. Festschr. d. Wiirzburger Universitat, 1882. — Brunner. Wundinfektion und Wundbe- handlung, I, Frauenfeld, 1898. — Freymuth. Exp. Untersuch. iiber d. Beziehungen leichter Infekt. z. blutbikl. Apparat. Deutsche med. Wochenschr., 1903, p. 350. — Genzmer und Volkmann. Sept. u. asept. Wundfieber. v. Volkmanns Sammk klin. Vortr., No. 121.— Krehl. Das Fieber. Path. Physiol., Leipzig, 1904.— Adolf Schmidt. Lehrbuch der allgem. Path, und Ther. innerer Krankheiten. Berlin, 1903. — Schnitzler und Ewald. Beitrag zur Kenntnis des aseptischen Fiebers. Arch. f. klin. Chir., Bd. 53, 1896, p. 530. — Unverricht. Ueber das Fieber. v. Volkmanns Samml. klin. Vortr., Natur Forscher, No. 159, 1896. — A. Wassermann. Wesen der Infektion. In Kolle- Wassermanns Handb. der path. Mikroorg., Bd. 1, 1903, p. 223. II. WOUND INFECTIONS PRODUCED BY PYOGENIC AND PUTREFACTIVE BACTERIA AND THEIR RESULTS A number of different varieties of bacteria are found in wound infections. Those producing- suppurative infiannnalion are grouped as pyogenic bacteria. Closely allied to these, and often associated with them, are the putrefactive bacteria. A second large group includes those bacteria which produce specific diseases (cf. 2, Part III). The pyogenic bacteria are divided into those which produce suppura- tive inflammation (pyogenic cocci), and those which rarely produce pus, but more frequently other forms of inflanunation or specific diseases (pneumococci, gonococci, bacterium coli connnune, bacillus pyocyaneus, typhoid bacilli). No pyogenic bacteria are exclusively pyogenic, on the other hand they are all phlogogenous — that is, they produce inflamma- tion which, with some more frequently than with others, ends in sup- puration. CHAPTER I THE MOST IMPORTANT PYOGENIC BACTERLV The first microscopic demonstration of minute living matter in pus is ascribed to 0. "Weber (1863) and Rindfleisch (1866). Later von Reck- linghausen, AYaldeyer, and Klebs (1871), Orth (1872), Birch-Hirschfeld (1873) discovered micrococci in pya-mia, septicaemia, puerperal fever, and suppurative inflammation. In 1874 Billroth described another form, his cocco-bacteria septica. R. Koch was the first to make an accurate study of the pyogenic bac- teria, and his work on wound infections (1878) laid the foundation of modern bacteriology, and the isolation and cultivation of different varie- ties of bacteria began with the introduction by him of transparent, firm culture media (1881). Ogston (1880-82) described the microscopic appearance of cocci found in pus, and differentiated streptococci from 169 170 WOUND INFECTIONS PRODUCED BY BACTERIA staphylococci. In 1883 Becker, following Koch's directions, obtained in pure culture a yellow staphylococcus from a case of osteomyelitis, and Fehleisen a streptococcus which caused erysipelas. Pure cultures of a number of different varieties of cocci were obtained by Rosenbach (1884) and Passet (1885) and differentiated from one another, and their etio- logical significance in the inflammatory processes associated with them recognized. (a) STAPHYLOCOCCI (Spherical fission-fungi, occurriiig usually in grape-shaped colonies; from (rTa4>v\ri, meaning grape.) The staphylococcus pyogenes aureus was first obtained in pure cul- tures by Becker ; later by Rosenbach. The cocci occur mostly in groups, rarely singly or in pairs (Fig. 89). They stain readily with basic aniline dyes, and are not destained by Gram's method. They grow upon ordinary cul- ture media, appearing in gelatin after from thirty-six to forty-eight hours as small white points, in stab cultures as a grayish white deposit. On the third day the gelatin be- comes liquefied, and the colonies assume a yellowish color. The en- tire culture medium is liquefied in three weeks. Upon agar, after standing for twenty-four hours in the incubator, they appear as round white, later as golden yellow, colonies ; the culture medium is not liquefied. They develop similarly upon blood serum and potato. Bouillon is clouded. The cocci are very resistant, and withstand drying for some days. After remaining in cultures for over a year they are able to develop, and only after being exposed to a temperature of 80° C. for a quarter of an hour are they killed (von Lingelsheim). The yellow staphylococci are widely distributed. They may be found alone, or associated with other bacteria in all forms of suppuration or general infection in man, and they are able to develop after being encapsulated in bone for a number of years. They pass into the blood and frequently produce inflammatory foci in young bones; this is partly due to the peculiar way in which they grow, as they form clumps W'hich may occlude the capillaries. Fig. 89. THE MOST LMruUTAXT I'YOCiEXIC BACTERIA 171 They are found in the skin, the hair, and upon mucous membranes. A wide area of skin surrounding;- small pustules, furuncles, or a suppu- rating wound is infected with pyogenic cocci. They may be found upon a surgeon's hands who daily comes in contact with pus or infectious materials. They are found upon the mucous membranes of the upper respiratory passages, without giving rise to inflammation (Miller), occur- ring especially in the saliva, in the crypts of the tonsil, in the coating of the tongue, and upon the nasal mucous membranes. They can be transferred to the air in small particles of mucus, which are discharged in speaking, clearing the throat, coughing, and sneezing (Fluegge). Apparently they find favorable conditions for growth in the buccal cavity of man. They disappear in a few days when transferred to animals — e. g., to the buccal mucous membrane of the rabbit (Lexer). Usually, however, staphylococci found upon healthy mucous mem- branes are attenuated. They may be carried by the food without loss of virulence into the gastrointestinal canal, and in case of perforation or circulator}^ disturbances (contusion, invagination, or strangulation) cause peritonitis, or, usually associated with other bacteria, inflammaticm about the rectum (periproctitis). They are frequently found in the conjunctival sac and upon the vaginal mucous membrane. They are found upon objects surrounding man, and are especially numerous when one is unclean in the treatment of a suppurating focus or inflamed mucous membrane; being then found in the linen, in pocket handkerchiefs, and on all objects with which the patient comes in contact. They have been demonstrated in the dust of the street, in the air of hospitals, but not in the earth or in unconfined air (Passet). The staphylococcus aureus rarely occurs spontaneously in animals. They have been found in osteoarthritis in geese (Lucet), in osteomyelitis in cattle (Haas) and horses (Frohner) and in mastitis in cows. They differ in virulence, both in wound infections and in infection produced in animal experimentation. The virulence of cocci is increased by transmitting them through different animals. Rabbits and guinea pigs are susceptible ; mice and dogs, cows, horses, and goats are less so. Cutaneous inoculations are only successful when the cocci are highly virulent (after cultivation). Subcutaneous injec- tions are followed by the formation of encapsulated abscesses containing thick pus. Usually the inflanunatory process is not progressive. Fatal infections are produced only by the injections of cultures into the pleura, peritoneum, or blood vessels. Animals die after intravenous injections in from one to eight days, and suppurating foci are then found in the muscles, viscc^ra, and joints (in young animals foci in bones are found especially frequently, Rodet). If attenuated cultures are used, the 172 WOUND INFECTIONS PRODUCED BY BACTERIA animals run a temperature and are sick for a short time, often de- veloping- a chronic suppurative osteomyelitis of one or more bones (Lexer). It is important to determine the pathogenicity of the different staphy- lococci (e. g., those upon the skin of sterilized hands, in nonpurulent wound secretion, in the saliva and air). At the present time there is no method which can be relied upon. Animal experiments cannot be relied upon, as the susceptibility of animals and the virulence of the cocci vary. The serodiagnostic test of Kolle and Otto may prove of value in this connection (vide below). The toxins of staphylococci are of two kinds : The toxin (staphylo- toxin) demonstrable in culture filtrates and in inflammatory exudates produces local necrosis and suppuration and general toxic symptoms. It is destroyed when heated to 60° C. It is toxic for leucocytes (van de Velde) and dissolves red blood corpuscles, and must therefore contain a leucocidin as w^ell as a heemolysin (haemotoxin) (Neisser and Wechs- bcrg). The second is a protoplasmic toxin (endotoxin), which is bound to the bacterial cell, and is found only after the bacteriolysis of large quantities of staphylococci (von Lingelsheim). Staphylococci also form ferments which digest albumen and gelatin. Attempts at immunization have given no practical results, although some have succeeded in different ways in immunizing animals, and have obtained from them a serum which was active in normal animals (von Lingelsheim). Kolle and Otto have used the blood serum of rabbits which had been immunized with large quantities of dead cultures of staphylococci to differentiate the pathogenic from the saprophytic varieties. The serum of an immunized animal has the property, even in dilutions of 1 to 100, to agglutinate in a short time pathogenic bacteria. [Serums obtained by immunization with pathogenic strains have a much higher agglutinating power for these strains than for nonpathogenic varieties, and the con- verse is also true. — Ricketts' " Infection, Immunity, and Serum Ther- apy," p. 383.] Nonpathogenic varieties are not agglutinated by serum obtained by immunization Avith pathogenic varieties. Nevei-theless the testing of the agglutinating properties of human iserum is not used to determine whether the disease is produced by staphylococci or not, as the serum contains staphyloagglutinin not only in pure staphylococcic infec- tions, but also in infections in which they are secondary to some other va- riety of bacteria fBeitzke). The formation of antihfpmolysins has also been used for diagnostic purposes. According to Neisser and Weehsberg, an antitoxin is developed for the staphy]oha?molysin (staphylolysin). This antitoxin, which is called antiha-iiiclysin or aiitilysin, prevents the action of the lysin. Bnick, IMichaelis, and E. Schultze found that in THE MOST IMPORTANT PYOOENIC BACTlCllIA 173 .slaphylcHMK'cic inl'ci'l idiis llic iiiitilysiii (Miiitnil I'i('(|iicii1ly, but unl, nlwiiys, excot'ik'd ('(iiisidcijihlN' llial ol' tlic scniiii ol' ;i licjillliy man. The staphylococcus pyogenes albus was (irst cultivated l)y Uoscnbach. It differs from the aureus in that its cultures remain white. It is found more frecinently than the aureus as the cause of mild inflammations, combined with which it usually causes severe inflannnation. It is found almost constantly upon the skin, and frecjuently produces suppuration about stitch holes and mild wound complications. The staphylococcus albus may be demonstrated constantly in the skin of the hands {vide Hand Sterilization, Part I), and frequently upon accessible mucous mem- branes. Notwithstandinof the fact that it occurs much more rarely than the aureus in severe suppurative processes (excepting- the double infec- tion with both varieties), it should be remembered that it may produce severe inflanmiatory chanoes, even fatal general infections. In animal exi)eriments it does not differ from the aureus. The staphylococcus pyogenes citreus (Passet), characterized by its color, likewise the staphylococcus cereus albus and flavus, character- ized by the waxy appearance of their white or yellow^ colonies, are of much less importance. They are only rarely found in liinnan pus. (ITentschel found the staphylococcus citreus in a fatal infection follow- iu^ a furuncle of the lip in the pus. blood, and in the spleen. Jacobitz also found them in a general infection.) (b) STREPTOCOCCI {Streptococci are fisfdon-fungi occiirrituj in chains or pairs.) The streptococcus of erysipelas discovered by Fehleisen in 1881 and cultivated by him in 1883, and the streptococcus pyogenes cultivated by Rosenbach in 1884 are not to be regarded as specific for any diseased process, but as closely related. Classifications based upon pathological and clinical symptoms are unreliable, as any streptococcus independent of its origin may, under certain conditions, produce any form of inflam- mation which is peculiar to streptococcic infections. Mild suppuration or severe general infection may be produced by the streptococci of ery- sipelas, while other varieties of streptococci, althoiigh not derived from an erysipelatous focus, may produce erysipelas (Petruschky). The clini- cal picture does not depend upcm the variety of streptococci, but upon a number of different factors, among which the virulence of the bacteria and the susceptibility of the patient are the most important. The many transitions in the clinical forms of streptococcic infections are explained in this way. Depending upon the cultural differences upon definite culture media 174 WOUND INFECTIONS PRODUCED BY BACTERIA Fig. 90. (blood agar, litniiis-iiK'trose agar), Schottmueller and Eug. Fraenkel have differentiated three varieties of streptococci which are pathogenic for man. Of how much bacteriological and clinical importance this dis- tinction is, must be determined by later investigations. Streptococci are spherical or somewhat flattened, have no movement of their own, and are slightly larger than staphylococci. They always divide in the same direction, and the characteristic slightly tortuous chains of from eight to twenty cocci are formed in this way (Fig. 90). Diplococcic forms are found only in the tissues, inflammatory exu- dates, in the blood, especially in severe inflammatory processes, and these become transformed in cul- ture media into long chains. They stain with aniline dyes, and according to Gram's method. Streptococci may be most easily cultivated upon agar and blood se- rum. After twenty-four hours (in the incubator) small, round, some- what transparent, closely approximated colonies develop, which do not become much larger during later growth. Upon gelatin (at room tem- perature) they develop much more slowly; small, transparent drops de- veloping after a number of days ; a delicate white deposit forming along the tract in stab cultures. Gelatin is not liquefied. Bouillon is clouded by one variety of streptococci, while a flocculent deposit is formed by another at the bottom of the media. The streptococci become attenuated or die after a few days upon any kind of culture media, so that they must be transferred daily if their virulence is to be preserved. It is simpler to use Petruschky's method in maintaining virulence, in which two-days-old stab cultures are kept in an ice chest and the same virulence is maintained for months. Strepto- cocci are particularly resistant against drying. They can even be dried upon blotting paper for some time and still retain virulence (Pe- truschky). The cocci are destroyed in cultures which are heated for an hour at from 70° to 75° C. Streptococci are as widely distributed outside of the body as staphy- lococci. However, it is more difficult to demonstrate them on man, in the air of hospital wards and operating rooms, upon ob.jects, skin, and mu- cous membrane, as they are overgrown by other varieties of bacteria upon culture media. They are found in the same places as the staphylococci. THE MOST IMruRTAXT rY(J(;i:XIC liACTKRIA 175 The freqiK'ney of erysipelas and jjiierpcral sepsis in preantiseptic times indieates how easily virulent strej)toeoeei may be transferred to wounds or to the vaj^ina and uterus by unsterilized hands and in- struments. Their frecjuent occurrenee in the upper air passages upon healthy as well as upon slightly or severely infiamed nuicous membranes shows that they find favorable conditions for growth here. But their presence alone is not sufficient to produce pathological changes; other factors are necessary, such, for example, as an increase of virulence resulting from putrefactive processes or decrease in local resistance from chilling or some injury. Virulent streptococci are expelled, especially in catarrh, from the buccal and nasal cavity with forcibly expired air (in coughing and sneezing), or they are carried by the saliva and food into the stomach, where they are not always destroyed by the gastric juice. The develop- ment of streptococcic peritonitis following perforation of the gastro- intestinal tract due to subcutaneous rupture or ulceration, the finding of streptococci in the pus of appendiceal abscesses and in the exudate in the sac of a strangulated hernia demonstrate conclusively that strepto- cocci are carried by the food into the intestines. Streptococci are found in many different inflammatory processes, and are frequently associated with staphylococci. If the streptococci act alone, a serous exudate into the tissue is in the beginning the most marked feature of the inflammation. Erysipelas is usually a serous in- flammation. Frequently in the severe progressive phlegmon due to the streptococci, only a few insignificant purulent foci develop within the inflammatory oedema, necrosis of the connective tissues usually occurring rapidly and becoming extensive. jMild suppurative processes are rarely caused hy streptococci. Severe general symptoms develop much more frequently from small cutaneous wounds infected with streptococci than from similar infections with staphylococci. Streptococci may be found in all the inflanunatory processes which are produced by staphylococci. They are found much less frequently, however, in furuncles and osteomyelitis. JNIixed infection with the strep- tococcus, such as occurs in tuberculosis of the lungs, diphtheria, typhoid fever, and putrefactive inflammation, always adds to the gravity of the prognosis. The virulence of streptococci varies within wide limits in man as well as in susceptible animals. The difference in clinical pictures is largely dependent upon this fact, partly also upon the kind of infection and the individual resistance, Avhich may be reduced by disease (tubercu- losis, inHueuza, diphtheria). The clinical pictures of streptococcic infec- tions differ even in healthy individuals, as the inoculation experiments 176 WOUND INFECTIONS PRODUCED BY BACTERIA of Koch and Petruschky have demonstrated. Streptococci may be atten- uated by passage through another species ; for example, streptococci from a rabbit may be attenuated for this animal by passing them through a mouse (Knorr). Streptococci derived from man are therefore the most dangerous in human wound infections. This agrees with clinical experience. White mice and rabbits are the most susceptible of experimental ani- mals. The former succumb in from one to six days of a general infec- tion after subcutaneous or intraperitoneal injections of small amounts of streptococcic cultures. In rabbits the different grades of virulence of streptococci are indicated in the following way : In infection of the wound of the ear with slightly virulent cocci, an erysipelas of moderate severity develops ; while if highly virulent cocci are used a general infection without any local changes develops which proves fatal in from twenty- four to forty-eight hours. Different degrees of virulence may be pro- duced in streptococci of different origin by artificially increasing or decreasing their virulence. When an animal dies some days after the inoculation, streptococci may be cultivated from all the viscera and the blood or demonstrated micro- scopically. After intravenous injections metastatic foci of suppuration develop in many joints, more rarely in the viscera. Osteomyelitis de- velops in young animals after the use of attenuated cultures (Lanne- longue, Lexer). Guinea pigs are less susceptible than rabbits. Sheep, asses, and horses react to streptococcic infections. Spontaneous infections occur in these animals. Little is known of the toxins produced by streptococci. In experi- mental work the secretion products of streptococci, as well as their pro- toplasmic toxins, are active only when used in large amounts (von Lingelsheim, Aronson). The formation of toxins is favored when suit- able culture media are used (according to Marmorek, bouillon with the addition of leucin and glycocoll). [" G. F. Ruediger has shown that virulent streptococci produce a hemolytic toxin, when grown in various heated serums, and has proved that this hemolysin (streptocolysin) is a true toxin, possessing a haptophorous and toxophorous structure." — Ricketts' " Infection, Immunity, and Serum Therapy," p. 353.] The blood serum of an animal immunized against streptococci (rab- bit, mouse, ass, horse) protects other animals against infections which ordinarily prove fatal (Roger, Knorr, Marmorek, von Lingelsheim, and others). Streptococci from animals are not pathogenic (active) for man, and it is (juestionable whether immune sera from animals, even if the streptococci are taken from man, will be active. In the experiments of Koch and Petruschky prophylactic injections did not prevent the TUK MOST IMPORTANT PYOGRNIC liACTIORIA 177 development of erysipchis. Tlic I'avel serimi is triken from a horse which has beeu inociUated with forty-three strains of streptococci which were taken from man only and not i)assed thron^h other animals. Favorable action is to be expected in general infections only when the serum is used in the beginning; in severe and old infections the entlotoxin liberated by bacteriolysis causes a dangerous aggravation of the symptoms. The blood serum of immunized animals possesses also agglutinating properties which are most active against those cocci with the cultures of which the animal has been innmmized. Antilysins which neutralize the luemolysins are likewise present in innnune serum. Literature. — Hand and Textbooks. — Flilgge. DieMikroorganismen (Froschand Kruse). Leipzig, Vogel, 18U6. — C. Frdnkel. Bakterienkunde. Berlin, Ilinschwald. — Gilttther. Bakteri()k)gie. Leipzig, Thieme, 1002. — Heim. Bakteriok)gie. Stuttgart, Enke, 1898. — Kolle und Wassermann. Handb. d. pathogcnen Mikroorganisiiijjn. Jena, 1903-4. — Beitzke. Ueber Agglutination der Staphyk)k()kken durch incnschliche Sera. VerhanilL d. i)athok Gesellsch., September, 1904. Zentralbk f. allg. Pathok, B(L 15, Ergjinzungsheft, p. ir)4. — Brnck, Michadis und Schultze. Beitriige zur Serodiagnos- tik der Sta{)hyk)kokkenerkrankungen beim Menschen. Zeitschr. f. Hygiene u. Infek- tionskrankheiten, l^d. 50, 1905, j). 144. — Fehleiscn. Zur Aetiologie der Eiterung. Arch. f. klin. ('hir., Bd. 36, 1887, p. 966. — E. Fninkel. Ueber menschenpathogene Streptokokken. Mimchner med. Woch., 1905, p. 1868. — Frnhner u. Kdrnbach. Ein Beitrag zur primaren infekt. Osteomyelitis des Pferdes. Monatsh. f. prakt. Tierheil- kunde, lid. 14, 1903, p. 433. — Fromme. Ueber prophyl. u. therap. Anwendung des Antistrept. Serums. Miinch. med. Wochenschr., 1906, p. 20. — Hentschel. Pyaniie und Sepsis. Festschr. f. Benno Schmitt. Leipzig, l89C).—Jacohitz. Ein Fall von Sepsis, hervorgerufen durch Staphylococcus citreus. Miinchner mod. Woch., 1905, p. 2020. — Kerner. Exp. Beitrag zur Hiimolyse und zur Agglutination d. Strepto- kokken. Zentralbl. f. Bakteriol., Bd. 38, Orig., 1905, p. 223.— /voc/i und Pctrusrhkrj. Beobachtungen iiber Erysipelimpfungen am Menschen. Zeitschr. f. Hygiene, Bd. 23, 1896, p. 477.— Kolle und Otto. Die Differenzierung der Staphylokokken mittelst AgglutinaticMi. Ibid., Bd. 41, 1902, p. 369. — Lannelongue et Achard. Etude exp. des Osteomyelites a staph, et a. strept. Annales de I'lnst. Pasteur, 1891, No. 4, p. 209. — Lexer. Experimente iiber Osteomyelitis. Arch. f. klin. Chir., Bd. 53, 1897, p. 266; — Die Schleinihaut des Rachens als Eingangspforte pyogener Infcktionen. \\m\., Bd. 54, 1897, p. 73(). — -i\ Lingelsheini. Stre])tokokken. In Kolle-Wassernianns Handb. d. pat hog. Mikroorg., Bd. 3, 1!)03, p. 302;— Streptokokkenimmunitiit. Ibid., lid. 4, 1904, p. 1186. — Lubursch. Streptokokken als Krankheitserreger. Ergebn. d. allgem. Pathol. V. Lubarsch und Ostertag, January 3, 1896. — Marmorck. Die Arteinheit der fiir den Menschen pathogenen Streptokokken. Berl. klin. Wochenschr., 1',102, p. 299; — Das Streptokokkengift. Ibid., p. 253. — Fritz Meyer. Die klin. Anwendimg des Strejit.-Serums. Zentralbl. f. Bakt., Btl. 36, Refer., 1905, p. :i09.— Miller. Die Mikroorganismen der Mundhohle. Leipzig, 1892. — -v. Mikulicz. Die neuesten Bestre- bungen der aseptischen Wundbehandl. Chir.-Kongr. Verhandl., 1898, II, p. 1. — Nutvig. Bakt. Verhaltnisse in weibl. Genitalsekreton. Arch. f. Gyniikol., Bd. 76, 1905, p. 701. — Neisser und Li-pRtein. Die Staphylokokken. In Kolle- Wassermanns Handb. d. pathog. Mikroorg., Bd. 3, 1903, p. 105. — Neisser. Staphylokokkeninnnuni- tat. Ibid., Bd. 4, 1904, p. 1150. — A^mser and Wechsberg. Ueber das Staphylotoxin. Zeitschr. f. Hygiene, Bd. 36, 1901, p. 299. — Passet. Untersuchungen iiber die Aetiologie der eitrigen Phlegmone des Menschen. Berlin, 1885. — Petruschky. Untersuchungen 178 WOUND INFECTIONS PRODUCED BY BACTERIA iiber Infektion mit pyogenen Kokken. Zeitschr. f. Hygiene, Bd. 17, 1894, p. 59; — Entscheidungsversuche zur Frage der Spezifitiit der Erysipelstreptokokken. Ebenda, Bd. 23, 1896, p. 142; — Ueber die Konservierung virulenter Streptokokkenkulturen. Zentralbl. f. Bakteriolog., Bd. 17, 1895, p. 560.— Prosc/ier. Die Gewinnung von Antistaphylokokkenserum. Ibid., Bd. 37, Orig. 1904, p. 295. — Rodet. De la nature d'osteomyelite infectieuse. Comptes rendus de I'academie des sciences, 1884. — Roseiv- bach. Mikroorganismen bei den Wundinfektionskrankheiten des Menschen. Wies- baden, 1884. — Schottmiiller. Die Artunterscheidung der fiir den Menschen pathogenen Streptokokken durch Blutagar. Mlinchn. med. Woch., 1903, p. 849. — Tavel. Ex- perim. u. Klin, iiber das polyvalente Antistreptokokkenserum. Deutsche med. Woehen- schr., 1903, p. 950. (c) DIPLOCOCCUS PNEUMONIA The cliplococcus pnenmonise, diplococeiis or streptococcus lanceolatus, pneiimococcus was demonstrated by A. Fraenkel in 1886 to be the cause of croupous pneumonia in man, and his findings were later confirmed by Weichselbaum. The same micro-organism had been found in rabbits dying of a general fatal infection (so-called sputum-septicaemia) fol- lowing the injection of human saliva by Pasteur in 1881, and had been found by Rosenbach in 1884 and described as the micrococcus pyogenes tenuis. Gradually it has been recognized that the pneumococcus may be the cause of different inflammations following or occurring independent of pneumonia. The separate halves of the diplococcus are shaped like a lancet or candle flame. The pneumococcus is not motile. It possesses a capsule which is constantly present when the bacteria are found in the tis- sues, in the blood of man and ani- mals, and which may be present when the pneumococcus is grown on certain culture media (milk and serum). The capsule appears pale when the ordinary stains are em- ployed (aniline stains and Gram's method) (Fig. 91). It may be cultivated most easily upon slightlj^ alkaline culture me- dia at high temperatures. Upon agar and blood serum the cultures appear as small transparent drops resembling closely streptococcic colonies. Gelatin which is not liquefied is less suited for a culture medium (at 22° to 24° C.). Bouillon is somewhat clouded in the first few days. Fig. 91. THE MOST I.MPOllTAXT rVOGENIC BACTERIA 179 PiKMiiiiococci (lie I'iipidly u|)()ii all cultui'c inodia, and must tiiorcforo bo transplanted daily. When liansplaiitcd tlicy may undergo a number of changes; soiiu'linu's llic individual pncuiiiticocci become more round, sometimes more oval, tlie capsule may be \vantin hand, it is rapidly destroyed by dry- ^ ^'^ y ing (Kruse). Typhoid bacilli are excreted in the Vu.. 94. feces and urine; in the latter even dur- ing convalescence (Petruschky). They remain viable for a long time outside the body in damp places (e. g., the floor), so that the danger of infection is great. The bacilli may be easily transferred to the mouth by the infected fingers or in drinking water, during an epidemic, which comes from wells adjacent to privies or outhouses. The intestinal canal affords the infection atrium for the typhoid bacilli. They settle in the lymph follicles and cause inflammation, necro- sis, and ulceration. Nothing is known of the symptoms of wound infec- tions with typhoid bacilli. The bacilli do not remain confined to the lymph follicles in the in- testinal wall and mesenteric lymph nodes, which are soon involved. They early pass into the blood stream and become distributed in small foci in all the viscera and tissues, and during pregnancy may even be deposited in the foetus. They remain only temporarily in the blood, occurring in the greatest numbers during the eruptive stage, and therefore there may be some difficulty in demonstrating them in the blood, although it has frequently been done ( Castellani and Schottmueller, Burdach, and others). The bacilli are found most abundantly in the spleen, then in the bone marrow and periosteum ; they have also been demonstrated in the liver and gall bladder,^ in the kidney, the rose spots, and in the heart valves in endocarditis. Groups of bacilli may remain in the body for a long time without giving rise to symptoms ; for example, Buschke has * Infection of the mucous membrane of the gall bladder with tj^phoid bacilU is fre- quently followed by a chronic catarrhal inflammation, which is an etiological factor in gall-stone formation. 190 WOUND INFECTIONS PRODUCED BY BACTERIA found them in an osteal focus seven years after tyijlioid fever, Sultan six years after. Occasionally, but relatively infrequently, tliey cause inflammation and suppuration, which occurs most frequently during convalescence (post-typhoid inflammation). If the typhoid bacilli act alone the in- flanniiation usually pursues a mild and chronic course. The pus which is formed is thin, reddish yellow in color, and contains but few cells. The pyogenic action of typhoid bacilli has been proven by animal experimentation, and by finding them unassociated with other bacteria in difl^erent forms of post-typhoid suppurative inflammation, such as suppu- ration of marrow of bone and periosteal foci with abscesses of soft tis- sues, in suppuration of the subcutaneous tissues, and of muscle, in arthritis and in suppurative foci in the viscera, parotid gland, goiter, eye, testicle, epididymis, ovary, spleen, liver, in pleurisy, meningitis, and peritonitis. Quite frequently post-typhoid inflammations pursue a severe clinical course. In these cases pyogenic cocci and other micro-organisms (pneu- mococci, colon bacilli) are often the cause of the inflammation, the typhoid infection in the intestine providing the infection atrium or con- ditions favorable for the development of these bacteria. In these severe cases the typhoid bacilli have been found with other bacteria or the latter alone. It is possible, however, that in these cases the typhoid bacilli may have died in the abscesses or that the infection with pyogenic cocci was secondary. The entire course of the disease may be influenced by a mixed infection, and that a general bacterial infection with other bacteria may develop has been positively demonstrated by finding these bacteria in the blood. Guinea pigs and mice are the most susceptible of all the animals used for experimental purposes. They die in from one to two days after the injections of small amounts of typhoid cultures into the peri- toneal cavity. Death is due to the action of the toxins, as the bacilli are found in the blood only after the use of much larger amounts, and are then deposited in the viscera. After the injection of slightly virulent cultures the animal lives for some days, and only a few bacteria can then be found. The experimental production of the disease, as it occurs in man, by the feeding of cultures, has been successful to only a limited degree. The pyogenic action of the bacillus after injection into different tis- sues, joints, and body cavities of rabbits and dogs has been positively demonstrated (Orloff, Dmochowski and Janowslvi, Kruse). The virulence of typhoid bacilli decreases upon culture media, but may be raised by passing them through animals. The toxins are partly present in the culture media and partly freed by the death of the bacteria, both the culture filtrate freed of bacteria and the bacilli killed with chloroform vapor being active. The toxins TIIK MOST nirORTAXT I'VOCJEMC liACTIOKIA 191 have a special action upon the intestinal nmcoiis membrane (Sanarelli). In man sterile cultures injected in small amounts produce a rapid but transitory reaction (R. Pfeifit'er and Kolle). According to E. and P. Levy the culture filtrate contains a hannolytic substance, as it dissolves red blood corpuscles. A susceptible animal may be imnniiiizcd by one injection of a culture in which the bacilli have been killetl (Briefer, Kitasato, and A. AVasser- niann ) . Accordinii- to H. Pfeiflfer, the blood serum of an innnunized animal is not antitoxic, but bactericidal. It kills and dissolves typhoid bacilli in a short time, but iloes not neutralize the toxins; the serum should therefore be used (mly as a prophylactic measure. The blood serum of convalescent patients and individuals who have been inoculated with small amounts of a sterile culture have this bactericidal property (Pfeifit'er and Kolle). The lymph nodes, spleen, bone marrow, and thynuis iiland nmst be regarded as the principal sources of typhoid antibodies (Wassermann). Protective inoculation of soldiers with dead cultures has been performed with favorable results ((iafifky and Kolle). In order to lessen the unpleasant symptoms following inoculation, which are apparently due to the decomposition products of the bacteria and the culture media, Bassenge and jMayer prepared a filtrate from typhoid cultures which was freed of the decomposition products by shak- ing in sterile water. According to Pfeifit'er, the specific bactericidal properties of the serum of artificially immunized animals ma}^ be used to establish the identity of questionable typhoid bacilli. In this test the bacilli in question should be injected into the peritoneal cavity of an immunized guinea pig. If the animal remains alive the bacilli injected are typhoid, as the bacilli are killed by the serum. The solution of the bacteria may be followed under the microscope if some of the peritoneal fluid is with- drawn with a capillary tube, and a hanging drop prepared. This reac- tion is specific if the animal is immunized against typhoid, and therefore can be used to establish the identity of the typhoid bacillus. In vitro the typhoid immune serum, which within the body kills and dissolves typhoid bacilli, has another action. When a suspension of the ba- cilli are mixed with the serum upon a slide or in a small tube, they rapidly lose their motility and become agglutinated. This reaction depends upon substances which, because of their action, have been called specific agglu- tinins. The blood serum of many typhoid patients early shows this spe- cific agglutinating property (Widal and (Jruber). and this has been made use of in making a diagnosis of typhoid fever in the Widal or sero-diag- nostic test. A negative result does not, however, exclude typhoid, for this agglutinating property of serum develops late in many cases. 192 WOUND IXFECTIOXS PRODUCED BY BACTERIA Literature. — Bassenge iind Mayer. Zur Schutzimpfung gegen Typhus. Deutsche med. Wochenschr., 1905, p. 697. — Brieger, Kitasato und Wassermann. Ueber Im- munitat und Giftfestigung. Zeitschr. f. Hygiene, Bd. 12, 1892, p. 254. — Burdach. Der Xachweis v. TjqDhusbaz. a. Menschen. Zeitschr. f. Hygiene, Bd. 41, 1902. — Dmochowski u. Janowski. Experim. Untersuchungen iiber Mischinfektion bei Tj'phus u. iiber Eiterung bei Tj^Dhus. Beitr. z. path. Anat. Ziegler, Bd. 17, 1895, p. 221. — Eberth. Die Organismen in den Organen bei Typhus abdom. Virchows Archiv, Bd. 81, 1880, p. 58; — Xeue Untersuchungen iiber den Baz. des Abd.-TjToh. Virchows Arch., Bd. 83, 1881, p. 486; — Der Typhusbazillus u. die intestinale Infektion. v. Volkmanns Samml. klin. Vortrage, No. 226, 1883. — Gaffky. Aetiologie des Abdominaltyphus. Mitt, aus dem Gesundheitsamte, Berlin, 1884. — Gaffky und Kolle. Ueber Tjqshus- schutzimpfungen. Ivhn. Jahrb., Bd. 14, 1905. — Lentz. Immunitat bei Tj^Dhus. In Kolle-Wassermanns Handb. d. pathog. Mikroorg., Bd. 4, 1904, p. 894. — E. und P. Levy. Ueber das Hamolysin des Tjqahusbazillus. Zentralbl. f. Bakteriol., Bd. 30, 1901, p. 405. — Xeufeld. Tji^hus. In Kolle-Wassermanns Handb. d. pathog. Mikro- organismen, Bd. 2, 1903, p. 204. — R. Pfeiffer und Kolle. Spezif. Immunitatsreaktion des Typhusbazillus. Zeitschr. f. Hygiene, Bd. 21, 1896, p. 203 ;— Experim. Unter- suchimgen zur Frage der Schutzimpfung des Menschen gegen Typhus abd. Deutsche med. Wochenschr., 1896, p. 735. — SanarelU. Die Gifttheorie d. Abdominaltyphus. Zentralbl. f. Bakteriol., Bd. 16, 1894, p. 188.— A. Wassermann. Weitere Mitt, iiber Seitenkettenimmunitat (Ljinphdr., Knochenmark, Milz, Thymus als Bildungsstatten der Schutzstoffe). Berl. kUn. Wochenschr., 1898, p. 209.— Widal et Sigard. Etude sur le Serodiagnostic et sur la Reaction agglutinante chez les typhiques. Annales de ITnst. Pasteur, T. 11, 1897, p. 353. OTHER BACTERIA OCCASIONALLY PRODUCING PUS Besides the above described pj^ogenic bacteria, there are a number of other bacteria (influenza, pneumonia bacilli) which occasionally produce suppurative inflammation. These will be mentioned when the suppura- tive inflammations of the different tissues are described. The pyogenic action of the bacillus of tuberculosis, glanders, and of the actinomyees will be discussed in Part II, Chapter III, dealing with these diseases. CHAPTER II THE INFECTION ATRLV OF PYOGENIC BACTERIA A WOUND of the skin or mucous membrane affords most frequently the infection atrium for pyogenic bacteria. It is incorrect, however, to regard a wound as the only infection atrium, and to suppose that one exists in each infection. Pyogenic and other bacteria may under cer- tain conditions pass thi-ough intact skin and mucous membrane and pene- trate granulation tissue. THE IXFECTIOX ATRIA OF PYOGKNIC BACTERIA 193 Schimmelbusch's experiments in the production of furuncles demon- strate how bacteria may enter intact skin. The presence of the staphy- lococci upon the surface of the skin alone is not sufficient to produce an inflammation. A second factor is re(iuired, for the cocci must be Diechauieally rubbed or forced into roughened areas or fissures of the skin or into the points of exit of hairs or lanugo hair, much less fre- quently into the ducts of sweat glands. After the cocci have been rubbed into intact skin they may be demonstrated about the hair shaft. They multiply and pass into the hair follicle, and there produce the intlammation. From such a focus the cocci may pass into lymphatic vessels and nodes or invade the blood vessels, as the development of suppurative osteomyelitis in some distant parts following a furuncle demonstrates. Similar experiments with a number of pyogenic and other bacteria, such as anthrax (AYasmuth) and tubercle bacilli (Cornet) have been made. All these experiments show conclusively that bacteria may be rubbed into the hair follicle, the skin being intact, and that in this way severe, or even fatal infection (animal experiments with anthrax) may be .produced. An intact mucous membrane may be penetrated by bacteria (espe- cially by streptococci, pneumococci, less frequently by staphylococci, colon bacilli, etc). Only very virulent bacteria are able to do this, as experimental work upon the mucous membrane of the mouth cavity, pharynx, and intestines (Lexer, Bail) has shown. The bacteria pass into and multiply in the spaces produced by the continual and active mii:ration of leucocytes through the epithelium (Stohr's epithelial spaces) covering the lymphatic follicles (over tonsillar crypts, lingual, and pharyngeal tonsil, and Peyer's patches). The bacteria must, how- ever, be highly virulent before they can invade the tissues, as the wan- dering leucocytes have bactericidal properties (vide p. 157). Less virulent bacteria, as a rule, cause but little damage while they remain upon the mucous membranes, as they are prevented from pene- trating them by the secretion of the cells and the movement of the cilia. The constant presence of pathogenic bacteria upon the mucous membranes of the nasal, buccal, and pharyngeal cavities, of the respiratory passages and gastrointestinal tract, and the negative results of animal experi- ments (Buchbinder and others), which have shown that bacteria of ordinary virulence do not penetrate normal mucous membrane, dem- onstrate that this is so. If, however, the mucous membranes are injured (e. g., if the protective mechanism is interfered with) the harmless bac- teria will become virulent, will multiply rapidly, penetrate the mucous membranes, and produce inflammation of the deeper tissues. The pro- tective action of the mucous membranes mav be interfered with in a 194 WOUND INFECTIONS PRODUCED BY BACTERIA •2?i:^- ■l^ number of ways: for example, by destruction or paralysis of the cilia (trachea and bronchi), by diminution of the bactericidal substances (A. AVassermann), by circulatory disturbances resulting from local or gen- eral chilling, by disturbance of circulation in intestinal strangulation, by chronic inflammation, by chemical or mechanical irritation followed by separation and exfoliation of epithelium. The fact that wounds of the mucous membranes, especially of the nose, mouth, and pharynx, are rarely the beginning of severe inflam- mation, although constantly bathed, as it were, by bacteria, which when carried into operation-wounds by coughing and sneezing cause inflam- mation, appears to depend upon the bactericidal prop- erties of the secretion of the mucous membranes and the leucocytes which wan- der through them. The rich blood supply of mucous membranes, the continual movement of the saliva, and the attenuating effects of symbiotic saprophytes are important factors in this natural resistance. If mucous membranes become infected with high- ly virulent bacteria the in- flammation may extend to the submucous tissues, pro- ducing phlegmons, may at- tack the lymphatic vessels and nodes or reach the blood vessels. The rela- tions between acute angina and articular rheumatism, suppurative osteomyelitis and metastatic infection, between enteritis and gen- eral infection {vide Bacterium Coli Commune), are examples of the ex- tension of infection through mucous membranes which are often quoted. Uninjured granulation tissue is not permeable even to highly virulent bacteria and their toxins. Billroth showed that he could keep putre- factive substances and pus in contact Avith a large granulating wound upon a dog's back for some time without doing any harm. Noetzel has Mi^ .'i#"r/ It;.- - "t •> • ■ /i ■ "iV^ ^ ■ ■ •■ .»' • 'l^- ■ ;1: v.- ■*^' *-■■ "■.'(.'..- ' '.'-■ ■ <■• . X' * •■*^»'* **• " ' • V,;.' ,;^ .■^■.^: t -^ ^^./^-^^ ■:i:::::.:::0^^'^ f.,...-.^=-^?; .••■■' ■ iUT'' .•,-• .■-' .i;-#;^' «Sr.''--'->'r. Fig. 95. — Section of a Tonsillar Crypt of a Rab- bit Which Died of a General Bacterial Infec- tion Twenty-four Hours After Three Drops of a High Virulent Culture of Streptococci Were Rubbed into the Mucous Membrane Cov- ering the Tonsil. The streptococci have in- vaded the lymphoid tissue of the tonsil, passing through Stohr's spaces. THE INFECTION ATRIA OF PYOGENIC BACTERIA 195 demonstrated that j^'ramdatinu wounds of sheep, which are very sus- ceptihle to anthrax and tetanus, resist highly virulent cultures. The lessened susceptibility of granulation tissue to infection was known to the old surijreons, and they desired to obtain in their wounds (e. g., in plastic operations) good granulations as quickly as possible. The secre- tion of the granulation tissue removes the bacteria mechanically, and besides contains bactericidal substances (AfanasiefiP). The cells of the granulation tissue, like those of the epidermis, prevent the penetration of bacteria, but are not as resistant as the latter. They are easily torn, and if once the thin veil covering the surface of the granulation tissue is injured, the lymphatic vessels and blood vessels stand open to receive the bacteria. Therefore Noetzel was able to produce fatal anthrax or tetanus infections as soon as he injured and then infected the granulation tissue. The experiments above cited agree with clinical experience. The yellowish, dirty membrane consisting of secretion and colonies of bac- teria, which covers unhealthy granulation tissue, carries with it no added danger, for neither the bacteria nor their toxins are absorbed. If, how- ever, the granulating wound is injured by traction upon the wound edges during the removal of adherent dressings, by the use of a caustic or sharp spoon, severe inflammation (lymphangitis, erysipelas) may de- velop if virulent bacteria — for example, streptococci — are contained within the granulations. The skin att'ords most frequently infection atria for staphylococci and streptococci; the mucous membranes of the mouth and pharynx, nose, and accessory sinuses, the ear and respiratory passages for the streptococcus and pneumococcus ; of the upper part of the gastrointes- tinal canal for the streptococcus and staphylococcus; of the lower part of the intestine (likewise the bile passages) for the bacterium coli com- mune, more rarely for the streptococcus and staphylococcus. In the urinary passage, besides the gonorrheal infections, infections with the colon bacillus, streptococcus, staphylococcus, and bacillus pyocyaneus occur; in the female genital canal, besides gonorrhea, infections Avith the streptococcus alone or associated with other bacteria are most frequent. LiTEUATURE. — Afanasicff. Ueber die Bedeutung des Granulationsgewebes bei der Infektion von Wunden mit pathog. Mikroorganismen. Zieglers Beitr., Bd. 22, 1897, p. 11. — .V. Bail. Die Schleinihaut des Magendarintraktus als Eingangspforte pyog. Infektionen. Arch. f. klin. Chir., Bil. 62, 1900, p. 369. — Buchbindcr. Experim. Unter- suchungen am lebenden Tier- u. Menschendarm. Deutsche Zeitschr. f. Chir., Bd. 55, 1900, p. 458. — Helmherger und Martina. Experim. I'ntersuchimgen iiber die Durch- giingigkeit des Darmes f. Bakt. Deutsche Zeitschr. f. Chir., Bd. 7i, 1904, p. 527. — Jiirgeliiuas. Ueber die Durchgangigkeit des Granulationsgewebes f. pathog. Mikro- organismen. Zieglers Beitr., Bd. 29, 1901. — Lexer. Die Schleinihaut des Rachens als Eingangspforte pyog. Infektionen. Arch. f. klin. Chir., Bd. 54, 1897, p. 736. — Xiitzel. 196 WOUND INFECTIONS PRODUCED BY BACTERIA Ucber die Infektion granulierender Wunden. Chir.-Kongr. Verhandl., 1897, II, p. 272 and Arch. f. klin. Chir., Bd. 55, p. 543. — Schiniinelbusch. Ueber d. Ursachend. Furunkel. Arch. f. Ohrenheilkunde, 1889, Bd. 27, p. 252.^ — Wasmuth. Ueber die Durch- gangigkeit der Haut fiir Mikroben. Zentralbl. f. Bakteriol., Bd. 12, 1892, p. 824. — A. Wussermiuin. Infektion und Autoinfektion. Deutsche med. Wochenschr., 1902^ p. 117. CHAPTER III PYOGENIC INFECTIONS AND THEIR TREATMENT The invasion of the tissues follows closely the infection of the wound with pyogenic bacteria. Pyogenic, like all other bacteria, require a certain but short period, the so-called incubation period, before they actively invade the tissues. During this time they multiply, their viru- lence increases by growth upon the good culture media furnished by the tissues, and their own power is increased and the development of bac- tericidal substances in the wound secretion is retarded. After the invasion of a wound or of the uninjured mucous mem- brane or skin the bactericidal substances and protective mechanism are able to cope for the time being with the bacteria. The beginning strug- gle between the bacteria and the tissues with its victories and defeats pursues an acute, rarely a chronic course, which usually but not always ends in suppuration. If the bacteria are weak and few in number, they succumb to the bactericidal substances in the tissue fluids and the in- flammation is mild, ending without pus formation. No pus may be formed, but extensive necrosis may result when the bactericidal substances are too weak to resist the numerous and highly virulent bacteria. Be- tween the mild and virulent infections there is a variety which ends in pus farmation. When the struggle between the bacteria and tissues is about even, pus is formed. The invasion of new tissue indicates a vic- tory for the bacteria, while the subsidence of the inflammation and the encapsulation of the pus indicate that the bactericidal substances of the tissues have prevailed. An acute suppurative inflammation is there- fore characteristic of pyogenic infections, although other forms of inflam- mation, excepting the putrefactive forms, may be present {vide Inflam- mation). If bacteria and their toxins are absorbed the struggle is transferred to the whole body and becomes general. More forces are then at the disposal of the organism to combat the infection, which, however, are often denied when the infection is virulent or the general condition poor. A lymphogenous or hiematogenous infection, depending upon PYOGENIC INFECTIONS AND THEIR TREATMENT 197 wiiotlior it is carried l)y the lyriij)li (n- blood stream, is distinguished Iroiu au ectoy:en()us infection in which tlie bacteria gain access from the outer world, and an endogenous infection in which the bacteria have lain dor- nuuit for some time upon the mucous meml)ranes (e. g., of the intestine or l)ladd by alcohol at each change of the dressing, there is little danger of si)reading the infection. They afford much comfort to the patient. | Granulation tissue fills in the defect resulting from a large carbuncle in one week, and becomes covered with epithelium in from one to two weeks later. The scar then contracts (Figs. 97 and 99). The inflam- mation does not subside, neither does the fever fall, when small, insuf- ficient incisions are made. When thrombophlebitis of one of the larger veins develops, the vein Fig. 90. -'i'lii: Sami: (.'asi; I'lun \\'i:kks After (JPEUATION. 208 WOUND INFECTIONS PRODUCED BY BACTERIA should be opeiifd, after proximal ligation, and the suppurating thrombus removed. Frequently the incision is postponed too long. In furuncles or car- buncles of the face it is dangerous to delay, for here the large number of lymphatics and the frequent occurrence of thrombophlebitis of the facial vein may lead to fatal results through general infection or meningitis. General infection is prevented by an incision correctly made and proper after-treatment, although some believe that incision favors gen- eral infection. General infection may be easily produced by curet- ting out the pus, squeezing and irrigating the furuncle, and by any other form of mechanical irritation (vide General Rules for Treat- ment, p. 199). Successful treatment is more difficult in those cases in which a num- ber of furuncles develop upon different parts of the body (furunculo- sis) . In these cases the operative treatment must be combined v^^ith meas- ures which prevent the development of virulent staphylococci. Daily warm baths (with salt water, green soap, etc.) should be taken, the cloth- ing should be changed after each bath, new dressings applied to open furuncles and those w'hich have developed opened. Ointments and plas- ters favor the infection of adjacent areas. If the furunculosis is limited to one part of the body, one application of a five per cent formalin com- press, which may be allowed to remain for some hours, may be of great value. It is understood that diabetics should receive appropriate internal treatment. In severe cases heart stimulants can rarely be dispensed with. THE SUBCUTANEOUS ABSCESS Any inflammation developing in the deeper tissues may lead to an accumulation of pus in the cutis and subcutaneous tissues. Small ab- scesses following wounds are rarely limited to the sldn; they extend to or develop in the subcutaneous tissues. Abscesses due to the imperfect opening of a furuncle spread in this tissue, and circumscribed suppura- tion occurring wMth erysipelas, lymphangitis, and subcutaneous phleg- mon develops here. All deep-lying suppurating foci extending out- ward form collections of pus in the meshes of the loose connective tissue as soon as the subcutaneous tissue Is reached, as, for example, after rup- ture of suppurating foci of the body cavities, joints, bones, muscles, and all deep-lying abscesses. If subcutaneous ha^matomas following injuries become infected from an excoriation or w^ound, an abscess is formed. Lymphogenous and hasmatogenous infections of hematomas as well as the eetogenous may THE TYOGENIC INFECTIONS OF DIFFERENT TISSUES 201) occur. ]\Ietastatic abscesses in the subcutaneous tissues in all parts of the body, as well as metastatic abscesses of nuiscles, or«jans, and joints, may occur in general pyogenic infections, particularly after staphylo- FiG. 100. — The Interxal Layer of an Abscess ]\If;M ikanh: ( . 'mi, ,~rri .n « iRanui-ation Tissue. Newly formed capillaries lie within a cellular tissue composed of fibroblasts, leucocytes, lymphoc^-tes, and fine fibrillae. coccie infections. In rare cases after typhoid fever, the typhoid l)acilli are the cause of these general infections. 210 WOUND INFECTIONS PRODUCED BY BACTERIA The subcutaneous abscess is characterized by swelling, redness, and tension of the skin, pain, local elevation of temperature, and fluctuation in the center of a hard, infiltrated area. It is accompanied by a moderate, often continuous fever. The skin covering the center of the abscess becomes thin and bluish sooner or later and opens spontaneously if not incised. After the discharge of the pus the inflammation may subside and the abscess heal. The longer the pus remains in the tissues, the more extensive the granulation tissue which walls it off. This abscess membrane, composed externally of con- nective tissue bundles, internally of granulation tissue, harbors the pyo- genic bacteria, which in large cavities maintain a discharge of pus for a long time from the point of rupture (fistula). "When the bacteria and necrotic tissue have been discharged in this secretion, the opposing walls of the abscess grow together and healing occurs. As a rule, abscesses pursue a mild clinical course. If, however, the encapsulating membrane is ruptured by trauma, massage, or movements, the inflammation may extend and invade lymphatics or blood vessels. Abscesses heal rapidly when incised and subsequently tamponed or drained. They should never, however, be regarded too lightly. THE SUBCUTANEOUS PHLEGMON A progressive inflammation, which is most often superficial, of the subcutaneous or of the loose connective tissues filling anatomical spaces (e. g., of intermuscular connective tissue surrounding the oesophagus, of the mediastinum), is called a phlegmon. If the inflammation is caused by pyogenic bacteria, pus is formed; if by putrefactive bacteria, there is a tendency to gas formation and gangrene {vide Putrid Inflammation). A phlegmon of the finger or toe is called a panaritium or felon. Felons are classified as subepidermal, subcutaneous, synovial, articular, and osteal, depending upon the tissues involved. Phlegmon of the peri- osteum is synonymous with suppurative periostitis, phlegmon of bone marrow with suppurative osteomyelitis. A subcutaneous phlegmon may follow the pyogenic infection of a wound; the infection may occur through the blood stream in metastatic inflammation, or it may extend from deeper tissues. A subcutaneous phlegmon may extend downward and involve the fascia between the muscles, where an injury has prepared the way for the extension of the inflammation. Phlegmons present different clinical pictures, depending upon whether the serous or suppurative type of inflammation predominates and the extent of the necrosis. One differentiates a serous, a suppurative, and THE PYOCJEXIC INFECTIONS OF DIFFERENT TISSUES 211 necrotic phlei^mon, but tlio lines of se[)iU'arK)n ;ire not strictly drawn, because transitions are freijuent. The essential requirement in the development of a phlegmon is a bacterial invasion of the subcutaneous tissue. The cutis and the fascia which limit the inflammation are only involved secondarily. The bac- teria most frequently found in phlegmons are tlie staphylococci or strep- tococci. Often both are found; freipiently they are associated witli other pyogenic bacteria. Streptococci produce the severest forms of phlegmon, acting alone or combined with other bacteria. They are particularly virulent when they come from a streptococcic infection in another individual. Injuries during post-mortem examination of fresh cadavers with suppurative peri- tonitis, meningitis, or general infections are frequently the cause of the most malignant forms of phlegmon and wound infection. The painful swelling and redness of the skin, associated with an in- flammatory oedema of the surrounding tissues and severe general symp- toms, develop rapidly. The fever, which, as a rule, begins with a chill, rises rapidly and is in the beginning continuous. Later, when the gen- eral symptoms become pronounced, there is a decided morning remission. The neighboring lymph glands become swollen and painful early. Suppurative lymphadenitis, superficial lymphangitis, and thrombophle- bitis of the subcutaneous veins are often the results, but also frequently the cause of the phlegmon. Bacteria are frequently found in the blood when the bacteriological examination is correctly made {vide Blood Ex- amination in General Infections). A circumscribed phlegmon is differentiated from a diffuse phlegmon, depending upon the local course of the infection. The former subsides even after an acute onset, after a moderate extension. The virulence of the bacteria and their toxins is reduced bj" the resistance of the tissues and their juices. The phlegmon may run a subacute, often a chronic course, and one or several abscesses may form if a wall of granulation tissue develops which prevents the extension of the inflannnatitin. Trau- ma or rough handling (massage) may easily excite inflannnation again. The progressive phlegmon does not subside unless it is incised. It pursues an acute, even violent course, and often the subcutaneous tissue of a whole extremity or part of the trunk is involved, or the infection passes to the intermuscular connective tissue and spreads incessantly. These differences in clinical course depend partly upon the resistance of the body and the tissues involved. The diffuse phlegmon develops much more frequently in the sick and weak patient (diabetes, maras- mus) than in the healthy and strong, and also in tissues which have been damaged in severe injuries. Phlegmons, especially those which have been operated upon, fre- 212 WOUND INFECTIONS PRODUCED BY BACTERIA els. Deutsche Zeitschr. f. Chir., Bd. 78, 1905, \). 182. — Friedrich. Pachydermie im Anschluss an habituelles Gesichts- 220 WOUND INFECTIONS PRODUCED BY BACTERIA erysipel. Miinch. med. Wochenschr., 1897, p. 33. — Jordan. Ueber die Aetiologie des Erysii3els u. s. w. Miinch. med. Wochenschr., 1901, p. 1371. — Klemm. Ueber das Verhaltnis des Erysipels zu den Streptomykosen. Mitteil. aus den Grenzgeb., Bd. 8. — Koster. Behandlung des Erysipels mit Vaseline. Therapeut. Monatshefte, 1896. — Lenhartz. Erysipelas und Erysipeloid. In Nothnagels spez. Path. u. Ther. Wien, 1899. — V. Noorden. Ueber das Vorkommen von Streptokokken im Blute bei Erj^- sipelas. Miinch. med. Wochenschr., 1887. — Pfuhl. Ein Fall von Allgemeininfektion mit Streptokokken infolge Hauterysipel. Zeitschr. f. Hygiene und Infektionskrank- heiten, Bd. 12, 1892, p. 517. — Respinger. Untersuchungen liber die angebliche Kontagiositat des Erysipels. Beitr. z. klin. Chir., Bd. 30, 1901, p. 261. — Tillmanns. Erysipelas. Deutsche Chir. ERYSIPELOID There is a disease, the local symptoms of which resemble closely those of erysipelas. It was known earlier as chronic erysipelas, erythema mi- grans, and was called erysipeloid ^ by Rosenbach. It develops most fre- quently from small wounds of the fingers, but is occasionally seen upon the nose, cheeks, and neck. Onset and Clinical Course. — It begins with a mild burning and itch- ing of the skin without fever or any general reaction. The skin becomes somewhat swollen, painful, and discolored a deep bluish red. It extends slowly from the infection atrium, the older area becoming pale, toward the hand, from the base of a finger to the neighboring finger, but rarely as high as the middle of the hand. A lymphangitis of the arm which resists treatment is seen in ten per cent of the cases. The disease lasts usually one week. ]\Iany cases, however, namely, those which have not been treated, persist for three or four weeks. Erysipeloid has some relation to dead, decomposing animal matter. It attacks frequently cooks, butchers, tanners, fishmongers, men who open oysters, and merchants who come in contact with cheese or herring. Almost always some wound can be demonstrated which affords the infec- tion atrium. Organism Found in Erysipeloid. — A cladothrix-like micro-organism was obtained in pure cultures from a diseased area of skin by Rosenbach (1887) ; inoculation of a cutaneous wound with this micro-organism caused erysipeloid. The findings have been confirmed by the researches of Ohlemann (1904). It is difficult to classify this irregularly round microbe, which develops into threads in old cultures. Diagnosis. — It is impossible to mistake the disease when fully devel- oped. Erysipelas extends more rapidly and is almost always accom- 1 The author cannot accept the case reported by Tavcl, which presented fever, gen- eral reaction and severe local symptoms, as one of pure erysipeloid. He sees yearly 30 to 40 cases of erj\sipeloid among the 10 to 20,000 patients treated at the Royal Poly- clinic at Berlin. Apparently this case was one complicated by a pyogenic infection. THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 221 panied by fever. The redness assdeiated with lyiiipliangitis reticularis occurrinir upon the fin«i;ers has indistiiiet, never sharply defined boun- daries. Treatment. — 'llie best and simplest treatment consists of immobiliza- tion (papier niache splint) of the fingers, to which vaseline has been ai>plied, for two or three days. The redness rapidly fades, but if move- ments are made too early it recurs again in some areas. Resistant cases are rare. Literature. — Cordua. Zur Aetiologie des Erythema multiforme. Deutsche med. Wochenschr., 188.3. — Delbatico. Ueber das Erysipeloid. Deutsche Medizinalzeitung, 1898, No. 78. — Gilchrist. Erysipeloid (329 Fiille). Journ. of Cutaneous Diseases, 1904, November. — Ohlemann. Beitr. z. Kenntnis des Erysipeloids und dessen Aetiologie. I.-D. Gottingen, 1904. — -Roscnbach. Ueber das Erysipeloid. Chir.-Kongr. Verhandl., 1887, II, p. 75.— TawL Das Erysipeloid. Deutsche Zeitschr. f. Chir., Bd. 61, 1901, p. 528. (b) THE PYOGENIC INFECTIONS OF MUCOUS MEMBRANES The rich bacterial flora of the mucous membrane, which comprises not only harmless bacteria but pyogenic and putrefactive bacteria as well, may be easily increased during respiration or the taking of food. For this reason in many inflammations of mucous membranes mixed and secondary infections occur. The pyogenic infections can, in spite of the many transitions, be dif- ferentiated from the putrefactive forms, in which putrefactive bacteria are the deciding factors. Infection Atria. — Small injuries and large wounds, changes produced by diseases (diphtheria, gonorrhea, syphilis, tuberculosis, typhoid ulcers, cauterization, thrush, and ulcers due to dentition), or the anatomical re- lations of the nnieous membranes covering lymphatic structures afford the infection atria. A lymphogenous inflammation develops when the infection travels through the lymphatics from a neighboring focus; a hannatogeuous inflammation may occur in general pyogenic infections, as a result of which small embolic abscesses may develop in the intestinal and gastric mucous membrane. In certain diseases of the mucous membrane of the mouth cavity, which occur in chronic poisoning wdth mercury, phosphorus, lead, and arsenic, and begin with inflannnatory swelling and exfoliation of the mucous membrane, the bacteria of the mouth cavity are able to invade the tissues, as their resistance is greatly reduced. In this way the bac- teria participate secondarily in the severe ulcerating forms of inflamma- tion associated with necrosis or gangrene. Varieties. — The pyogenic bacteria found mo.st frequenth^ in inflam- mation of the nnicous membrane are the staphylococcus, streptococcus. 222 WOUND INFECTIONS PRODUCED BY BACTERIA gouococcus, pueumococcus, bacterium coli commune; to these may be added the bacilli of pneumonia and influenza. The superficial inflammations of mucous membranes produce a serous or suppurative catarrh (from Karappcwjto flow) or a fibrinous membrane (croupous inflammation). The mucous membrane becomes markedly hyperajmic and oedematous; in the larynx this oedema may be great enough to produce a dangerous stenosis. A serous, purulent, or purulo-hajmorrhagic exudate is then discharged upon the surface of the mucous membrane, the normal mucous secretion of which is altered. Often in the mouth and pharynx vesicles are formed with resulting exfoliation of the superficial epithelial layers (desquam- ative catarrh), and superficial ulcers (catarrhal ulcers) which heal by granulation tissue form. The lymphoid organs are always enlarged and may suppurate (tonsillar abscess, follicular abscess, intestinal ulcer). A fibrinous membrane is formed by the coagulation of the exudate, where the connective tissues are exposed after the destruction of the epithelium by inflammation or injury. The whitish yellow (if mixed with blood, brown) more or less firmly attached membrane shows a marked contrast to the reddened surrounding tissue. It resembles the pseudo- membrane of diphtheria, but the fibrinous network and necrosis of tissue never extends so deeply in croupous inflammation. This fibrinous (croup- ous ) inflammation which occurs in the upper air passages in a number of diseases (measles, scarlet fever, whooping cough, pneumonia, typhoid fever, etc.), and in which pyogenic bacteria participate (streptococci), is called diphtheroid to differentiate it from the inflammation produced by the bacillus of diphtheria. Similar fibrinous inflammations occur in the bladder, vagina, and intestine. Frequently they become secondarily infected with putrefactive bacteria and then gangrenous ulcers develop. Small, round, painful, yellowish areas, surrounded by a red zone, are produced by this fibrinous inflammation associated with necrosis of the epithelium. These occur frequently in the mouth and are called aphthae. Deep inflammations of mucous membranes develop from wounds, about penetrating foreign bodies, or extend from the inflamed surface of the membrane. They produce a marked inflammatory oedema and a phlegmon of the submucous tissues. The surface of the mucous membrane is involved in different degrees; it may present only a catarrhal inflammation, or may become necrotic. Pus collects in bony cavities lined by nuicous membrane, in hollow organs such as the gall bladder and appendix when the outlet is occluded by inflammatory swelling of the mucous membrane or by other causes (e. g., suppurative otitis media, empyema of the gall bladder, and pro- cessus ver)iiiformis). If secondary infection with putrefactive bacteria, THE PYOGENIC INFECTION'S OF DIFFERENT TISSUES 223 M'hich wjiiidcr in rroiit the iiioufli or iiilcst iiic, occui's the pus becomes foul siuelliiiu jiiul the iniieoiis iiieiiihr;iiie Ix'coiiies <;an^'i"enous. Ei-.ysijx'his of the mucous meiiihi'iine is an acute inlhunmatiori of the surface niemi)raue, combined, however, with a submucous and a deeper plileiiinon. Au accurate diafi'nosis can only be made when the infiairi- mation extemls to tlie skin, althoujih it may be suspected because of its violent coui'se with high fever and severe general symptoms. It occurs in the i)harynx, ncse, larynx, and upon the female genitalia, and recurs frc'cjuently where a chronic infhuinnation of the nnicous membrane favors the growth and invasion of the streptococci. Results of Inflammation. — The results of inflannnation of mucous membranes differ. Catarrhal intiammation and sui)erlicial ulcei"s heid by absorption of the intiammatory exudate and proliferation of the epi- thelium, leaving no trace of the inflannnation. A scar is found when a deep ulcer heals. Incomplete repair or the fretiuent recurrence of mild intiammation ])i'odnces a chronic intiammatory condition which re- sults either in thickening and induration with glandulai' hypertrophy and growth of the lymphoid tissue or atrophy of the nuicous membrane. Fever and general symptoms usually accompany the acute inflamma- tions of nuicous membranes. They may even be present in a very mild angina or enteritis. Their duration depends entirely upon the course of the local inflannnation. The extension of these pyogenic infections from the upper air pas- sages to the lung, and the different infections of the mucous membrane of the gastrointestinal tract are of much less importance to the surgeon than the suppurative phlegmonous forms of inflannnation, the second- ary diseases of the lymphatic glands, and the general infections with bacteria. The phlegmon of the mucous membrane carries with it many dangers. A suppurative inflamnuition of the floor of the mouth develops from a phlegmonous glossitis or suppurative periodontitis. It is accompanied by a marked infiltration of the tissues, extends between the muscle planes of the neck, and may cause an anlema of the glottis or a mediastinitis, which proves fatal. A phlegmon may spread under the mucous meml)rane of the mandible or cheek and produce a meningitis uidess controlled. The tissue of the tonsil is frequently the seat of small abscesses, which develop from the crypts, and the origin of phlegmons which extend to the peritonsillar tissues and soft palate. Phlegmons developing in the pharynx or oesoph- agus may gravitate in the loose tissues surrounding these structures to the mediastinum. Abscesses of the intestinal wall and submucous phleg- mons of the pylorus may rupture into the free peritoneal cavity and pro- duce a suppurative peritonitis; this occurs most frecjuently in the ap- 224 WOUND INFECTIONS PRODUCED BY BACTERIA pendix. Abscesses of the bladder may rupture externally and produce perivesicular suppuration, phlegmons of the urethral nuicous menibraiie (by ulceration, injury during catheterization) may spread to the scrotum and perineum. Periprocteal abscesses develop in the tissue surrounding the rectum. These rupture externally and leave frequently the resistant fistula? in ano. Where the submucous tissues are closely connected with bone, suppurative periostitis, osteomyelitis, and necrosis develop second- ary to the phlegmon. An inflammatory enlargement of the neighboring lymphatic nodes follows inflammation of a mucous membrane. The acute lymphadenitis occurring in the neck (submaxillarj' region in angina) is a well-known and striking example. The glandular enlargement disappears as the inflammation subsides. This enlargement persists if the inflammation recurs frequently or if there is a chronic inflammation of the mucous membrane. In such cases chronic irritation leads to a hyperplasia of the glandular tissue. The glands suppurate only in the more severe forms of suppurative catarrh, in phlegmons and erysipelas of the mucous membrane. The absorption of very virulent bacteria from diseased mucous mem- branes gives rise to metastatic inflammation or general infection. This may occur in superficial as well as in deep inflammations. It is well known that malignant and fatal general infections are produced by the streptococci, which enter the circulation from catarrhal, phlegmonous, and putrefactive inflammations of mucous membranes. In rare cases the colon bacillus may enter the blood during an enteritis. Metastatic in- flammations occur much more frequently than the general infections. Streptococcic, staphylococcic, pneumococcic, and other infections may de- velop after an acute angina ; inflammation of the accessory sinuses of the nose stands in intimate relation to suppurative arthritis, muscle abscess, metastatic phlegmon, and osteomyelitis. Treatment. — No agent or measure should be employed in the treat- ment of pyogenic inflammations of mucous membranes which favor the absorption of bacteria. Mechanical irritation, such as painting the pharynx, irrigating the nose, antrum of Highmore, the urethra, etc., wip- ing, tearing, or curetting away the fibrinous (croupous) membrane, for- merly extensively employed, does this. Antiseptics do not retard the development of the bacteria imbedded in the mucous secretion, neither do they destroy those hidden in the folds and pockets of the mucous membrane. On the other hand, if too strong they irritate the mucous membrane, destroy the surface epithelium, and in this way provide new infection atria. Besides, in washing the mouth small amounts of these antiseptics (e. g., potassium chlorate) may be swallowed and do harm. THE PYOUEMC INFECTIONS OF DIFFERENT TISSUES 225 The most important thiiii; in tlio treatment of acute inliannnations of mucous membranes is to remove mechanically the l)acteria contained in the secretion or resting up the surface of the mucous membrane. This is tlone by frequently washing' (ilependiuii' upon location, by yar.ules, mouth washes, weak irrigation) with lukewarm water, physiological salt solution or very dilute antiseptic solutions (e. sr., potassium permanganate, 0.5- 1.0:2,000; boric acid, 0.5:1,000; sublimate, 0.5-1.0:5,000; besides ace- tate of aluminum, menthol, thymol, salicylic acid, etc.). A two to ten per cent solution of hydrogen peroxide with the addition of salt solu- tion (for mouth wash and gargle) has become very popular. It has a deodorizing action and as the foam develops (free oxygen) it cleans the surface mechanically. The hygiene of the mouth cavity is very important in preventing the extension of the inflammation from its mucous membrane and adjacent areas. Less importance should be attached to tooth pastes, soaps, and tinctures, than to the much more important mechanical cleansing with toothbrushes and mouth Avashes. Phlegmons of the mucous membrane are treated according to general rules. Complications are treated according to their indications. The use of iodoform gauze is recommended for resistant ulcers, where these are accessible. AVhere this is impossible, they may be painted wath iodoform glycerin emulsion (von IMikulicz). Alcohol, camphor spirits, strong caustics, and the actual cautery may be used if necrosis and gan- grene develop. In all severe infections the general nutrition and conditions should be improved, for in this way the local resistance is increased. In chronic intiammation one per cent salt solution, mineral water, such as Eraser and Seltzer water, the latter warm or mixe'd with milk and used as a drink, may be employed for gargles and inhalation. One per cent tannin and alum solution, twxi to ten per cent silver nitrate and iodin glycerin solution may be applied with a brush or cotton swab. In hypertrophies cf the mucous membrane a concentrated solution of silver nitrate, tannin, etc., may be used. Enlarged palatal and pha- ryngeal tonsils should be removed by operation, as thej^ may give rise to recurrent inflammation. Literature. — Askanazy. Enteritis phlegmonosa. Zentralbl. f. allgem. Path., 1895, p. 313. — Feder. Die Desinfektion der Mundhohle. I.-D. Jena. lUOO. — Hasslauer. Die Bakterienflora der gesunden und kranken Nasenschleimhaut. Zentralbl. f. Bakt., Bd. 33. Origin., 1903. p. 47. — Heymann. Handb. der Larjnigologie vnid Khinologie. Wien, 1899. — Kraiis. Die Erkrankungen der Mundhohle iind der Speisenihre. In Nothnagels Handb. d. spez. Path. u. Ther., Bd. Ifi.— ?'. Mikulicz und Kilmmel. Die Krankheiten des Mundes. Jena, 1898. — Miller. Die Mikroorganismen der Miindhohle. Leipzig, 1892. — Stdhr. Ueber die Lyinphknotchen des Darmes. Arch. f. mikr. Anat., Bd. 33, 1889, p. 255. 226 AVOUND INFECTIONS PRODUCED BY BACTERIA (c) PYOGENIC INFECTIONS OF LYMPHATIC VESSELS AND NODES Bactericidal Action of Lymphatic Tissue. — Bacteria and their toxins are rapidly absorbed by tlie lymphatics from infected wounds and ulcers. The endothelium lining the lymphatic vessels may be injured by bac- teria and their toxins, leading to the formation of a thrombus such as occurs in thrombophlebitis, which will be described later. While in the lymphatic vessels and nodes the bacteria which have been carried by the Ij'mphatics are exposed to the bactericidal substances of the tissue fluids, and unless present in large numbers or very virulent they are destroyed. Under certain conditions the bacteria may pass through this lymphatic barrier and produce in this way a general infection. Absorption is accompanied by marked symptoms only when the bacteria are so numer- ous or so virulent that they are not destroyed by the tissue fluids, or when their endotoxins which are freed during bacteriolysis cause in- flammation. If the bacteria are numerous and highly virulent the tis- sues in which the lymphatics arise and those composing the walls of the lymphatic vessels and the lymph nodes react to the invasion, and an in- flammation develops which retards or prevents the deposition and multi- plication of the bacteria. Frequently the bacteria extend beyond the lymphatics and invade the surrounding tissues. Blood infections occur after lymphatic involvement only when the bactericidal properties of the lymph nodes have been so reduced that they no longer offer a barrier to the extension of the bacteria into the larger lymphatic vessels. The more virulent the bacteria the earlier the lymphatic vessels and nodes become inflamed. Lymphatic involvement may be exceedingly rapid after injuries received during post-mortem examinations or oper- ations, for the pus found in fresh cadavers and in very sick patients frequently contains the most virulent bacteria. Varieties. — Different varieties of pyogenic bacteria, especially staphy- lococci and streptococci, are the most frequent cause of acute, more rarely of chronic lymphangitis. Ljanphangitis develops from recent infected wounds, from suppurating wounds, ulcers, and granulating surfaces, from superficial and deep inflammatory foci and inflamed mucous mem- branes. The local symptoms of acute lymphangitis are most striking when the superficial lymphatics of the skin and subcutaneous tissues are in- volved. Lymphangitis occurs most frequently upon the extremities, espe- cially upon the arms, as Avounds of the hand, which provide the infection atrium, are very common. When infection occurs at the points of origin of the lymphatic vessels (e. g., about a wound or excoriation of the little THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 227 fing:or (II- a furuncle of the arm), there devek)ps a iiiaikcd redness of the skin, the b<»rcU'rs of whioh are always indistinct and extend in tlie direc- tion of the lymph stream. Sometimes the inthimmation, which is accom- panied by an itching and burning and a sensation of fullness, develops without any apparent cause, frecjuently after mechanical irritation of the small wound. The redness may be diffuse, mottled or netlike, corre- sponding to the form of the plexus of capillaries, ])ut in a few hours a number of red streaks develop from the reddened area. These grad- ually fuse, forming one or more streaks wliicli correspond to the main lymphatic trunk or trunks which empty into the painful swollen lymph nodes of the axillary fossa, lying along the axillary vessels. The streaks tleveloping in a lymphangitis of the foot extend toward the popliteal fossa or upon the anterior and medial surface of the thigh, where they end in the inguinal lymphatic nodes. In from one to two days the redness of the streaks becomes deeper and the lymphatic vessels impart the sensation of hard cords, which are painful when jialpated. The skin of the extremity involved becomes moderately swollen, painful, and tense. Inflannnation of the deep lymphatic vessels is indicated by a dull, distressing, rapidly increasing pain, and by swelling of the lymph nodes into which they empty. Frequently the deep lymphatics are involved alone or earlier than the superficial. The clinical course of lymphangitis is sometimes mild, at other times severe, depending upon the bacteria concerned, the character of the inflammation, and the complications. A superficial lymphangitis may subside in from one to two days, nothing remaining but a slight hyperemia and a sero-cellular infiltration of the adventitia and adjacent tissues, which rapidly disappear. The epithelium covering the area involved exfoliates. In this simple form of lymphangitis new streaks, indicating the involvement of other lymphatic vessels, may develop for several days, while the ones which have devel- oped earlier become pale and disappear. In other cases the old streaks become transformed on the second or third day into hard cords the size of the little finger. In these cases the walls of the lymphatic vessels .become hyperasmic, and an exudate is poured out into the tissues composing and surrounding them. The endo- thelial cells lining the vessels become swollen and are cast off, and thrombi of different lengths containing IjTnphocytes and endothelial cells are formed by the coagulation of the lymph. Thrombus formation usu- ally begins about the valves of the lymphatic vessels, and when the larger vessels are closed (thrombo-lymphangitis) a stasis of lymph develops. Involution is slow, requiring from one to two weeks, and while it is occurring the streaks become brown, then yellow, the cedematous swelling 228 WOUND INFECTIONS PRODUCED BY BACTERIA and the hard cords disappear, for as the hypergemia subsides the thrombi soften and become absorbed, the vessels become patent, the endothelium forms again, and the exudate is absorbed. The suppurative lymphangitis is the most severe form. The inflam- mation then spreads from the hard cords, invades surrounding tissues, and produces subcutaneous abscesses. The thrombi undergo septic soft- ening, and the vessel walls become necrotic. Abscesses develop about the lymphatic vessels, from which subcutaneous phlegmons may originate in the first or second week. One abscess develops from another after long intervals, and in this way the inflammation may extend over long periods. The same changes occur in the deep lymphatic vessels when inflamed, but only the suppurative form gives rise to distinct symptoms when the inflammatory exudate having become purulent reaches the skin. Complications. — Phlegmons and suppurative lymphadenitis are the most frequent complications of lymphangitis. Inflammation of the sub- cutaneous and deep veins accompanied by thrombosis may develop by direct extension of the inflammation, especially when suppurative, from the lymphatics to the veins immediately adjacent. Metastatic inflam- mation, especially of the lungs, is much less frequent in lymphangitis than in thrombophlebitis and suppurative lymphadenitis; still it is pos- sible for a part of a lymphatic thrombus to pass through a diseased gland, which no longer retains small emboli and bacteria, and to reach the heart. Frequently a mild or severe lymphangitis is the beginning of a gen- eral infection, and not infrequently the development of red streaks in the skin, so characteristic of lymphangitis, is the first indication of a beginning erysipelas. The severity of the clinical course usually depends upon the viru- lence of the bacteria and the resistance of the patient. Severe general infections not infrequently develop from wounds received during post- mortem examinations and operations. Severe forms of lymphangitis de- velop also in alcoholics, diabetics, and patients whose resistance has been reduced by some other infection. Many cases are very resistant to treatment. The inflammation accom- panied by thrombosis subsides slowly, and symptoms redevelop when some movement is made or injury received. The diagnosis of acute lymphangitis is rarely difficult. The inflam- mation about the point of infection might be mistaken for a subsiding erysipelas or erysipeloid, the redness of which has no longer sharp bound- aries. Lymphangitis of the superficial vessels might be mistaken for phlebitis, but the cords developing in the latter are much thicker; lymph- angitis of the deep vessels for an inflammation developing from bone. The latter mistake is most apt to be made when the lesion develops upon the inner side of the arm, in the popliteal fossa and Scarpa's triangle. THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 229 The trcatmoit deinaiicls absolute rest of the entire extremity, which should be obtained by a loosely applied splint, and cli'vation maintained as long as any red streaks are to be seen or any cords t(; be felt. IVIus- cular movements, rubbing and massage, which drive the lymph onward, carrying with it bacteria and particles of thrombi, favor the develop- ment of general infection and are to be avoided. An ointment usually contiols the pain. Abscesses should be incised when they form. (' ivddciu'd skill, soi'lcii in the center, fluctuate, and seem to be about ready to bi-eak tluou^h the skin. 1'he sintile nodes vvbicli are aggluti- nated suppurate. 'I'lie pus then breaks through the capsules of the separate glands and I'oruis a large lyini)liai)!iy nml contraction of their connective tLs-suf tralx'cuhv and capsule i^tibrous hyperphisia;. Ilypertrophied cervical ghiuds accompany eczema, rhagades of the nose and lip, and catarrh of the mucous membranes. They may become tuberculous. If the nodes are adjacent to a carcinoma and are indumted they may be regarded as carcinomatous. The treatment of chronic lymphadenitis usually depends upon the cause. Literature. — F. Fischer. Krankheiten der Lyniphgefasse, Lymphdriisen und Blutgofiisse. Deutsche Chir., 1901.— T/ior/i. Behundhius? der Leistenbubonen niit Injektion von HydrargjTum benzoicum oxydatum. Deutsche med. Wochenschr., 1897, therap. Beilage, p. 49. (d) THE PYOGENIC INFECTIONS OF BLOOD VESSELS A suppurative inflammation of the walls of arteries and veins devel- ops when an inflammation extends to the vessels from an adjacent focus or when the infection is carried by the blood. It occui-s, therefore, in areas adjoining and in foci of inflammation, in general and embolic in- fections. Arteritis purulenta begins as a i>eri- or as an endoarteritis, de- pending upon whether the bacteria enter the vessel from within or without. It is rarer than the corresponding inflammation of the veins, as the arterial walls are thicker and heavier. The pus of an acute or chronic abscess bathes for a long time the wall of a large artery which is separated from its surrounding tissue, and a periarteritis develops. This occurs often in the large, chronic abscesses of the neck and inguinal region, which have thrived upon treatment with poultices. Trauma is also a factor, for the suppuration is most marked where the arterial wall has been crushed during ligation (with infected ligatures), as in an injury, or where it has been pressed upon by a drainage tube, improperly placed. Endarteritis develops if an arterial thrombus laden with cocci suppurates, or if an infected embolus lodges in the artery. Bacteria may pass with the blood stream through the vasa vasorum and lodge in the media and adventitia. Thrombosis with necrosis and gangrene then follow the inflammatory changes in the vessel wall (as in influenza, typhoid fever). ]\Iild inflammations produce merely a cellular infiltration and thick- ening of one or all of the tunics of the vessel wall. Inflammatory changes in the intima (endarteritis productiva) may result in obliteration of the lumen of the vessel ; severe inflammation ending in suppuration destroys the vessel wall. 234 WOUND INFECTIONS PRODUCED BY BACTERIA If necrcsis of the suppurating infiltrated tissue occurs, the vessel wall becomes ereded and ulcerated. In the small arteries an obturating throm- bus, which is destroyed if necrosis occurs, frequently prevents hai^mor- rhage. Severe haemorrhage follows the rupture of the large branches and main trunks. This haemorrhage (secondary) is to be feared, espe- cially in large necrotic and gangrenous foci. It was the source of con- stant anxiety to the military surgeons of preantiseptic times in their amputations and disarticulations. If the vessel ruptures into an abscess cavity, a false aneurysm or a pulsating ha?matoma develops. The devel- opment of a true aneurysm frequently precedes rupture of the diseased vessel wall. If the remaining tunic at the point of ulceration (the intima, if the suppuration extends from without, the adventitia if from within) is forced outward or its entire circumference is widened before being rup- tured by the blood pressure, a spontaneous aneurysm is formed. If an infected embolus is the cause of this dilatation, the aneurysm is called embolo-mycotic. In order to prevent the dangerous arteritis of the large vessels in inflammatory foci, the surgeon should be careful in incising deep phlegmons and abscesses not to separate the connective tissue sheath of the large vessels. AVhere a ligated artery is exposed in a suppurating wound (e. g.-, a suppurating, therefore open ampu- tation-wound) it should be supported for at least a week by a tampon, so that the full force of the pulse beat is not expended upon the arte- rial wall. The development of an embolic aneurysm often indicates threatened rupture of the diseased arterial wall. For example, if a pulsating swell- ing, associated with severe local pain, develops within a few days in a patient suffering with endocarditis or general infection, and a few days before this sudden circulatory disturbances occurred in the extremity which made probable the diagnosis of embolism ; double ligation of the vessel should be made, as in hiemorrhage, above the diseased area in healthy non-inflamed tissue. Suppurative phlebitis (phlebitis puru- lenta) frequently begins as a periphlebitis associated with an inflamma- tion of the lymphatic vessels surrounding cr accompanying the large veins, or follows the extension of an acute suppurative inflammation from the cellular tissue surrounding the vein. If the inflammation de- velops from the lumen, thrombosis and infection through the blood stream precede it. In an inflamed area even the smallest veins are in- volved, for the inflannnatory slowing of the blood stream and stasis favor the formation of thrombi and the growth of bacteria. Mild inflamma- tions which do not end in suppuration produce, when subcutaneous veins are involved, painful hard cords of finger thickness which may be pal- pated under a reddened skin. The clinical picture resembles somewhat THF, PYOGENIC INFECTIONS OF DIFFERENT TISSUES 235 that of tliroiiiholyiiiphaimitis. These inflaiiiniations may subside com- pletely; the throiiil)us is tiieii ()r<;aiiized or absorbed, the lumen becomes closed or patent. This may occur even in large vessels. Frequently recur- ring inflammation of veins (occurring in the leg with varicose ulcers) pro- duces a chronic thickening of all the coats with a narrowing or oblitera- tion of the lumen (phlebitis chronica hyperplastica). If the organizing thrombus becomes partially calcified, vein stones or phleboliths are formed. Severe infiaiiniiations lead to a purulent infiiti-ation of the vein wall and surrounding tissues, and during the operation the yellowish, discolored, rigid, and thickened vein is found in sup])urating or (edematous tissue. Venous thrombcsis occurs constantly with suppurative phlebitis. The co- agulation is i)i'()duced by the bacterial toxins (Talke) which penetrate the intima, and by the infiammatory exudate which is poured out from the vasa vasorum (thrombophlebitis pui-ulenta). The converse is true, that phlebitis follows suppuration of a thromlms. After sn])purati< ii of the throml)us and destruction of the vein wall, tlie pus escapes from the lumen of the vessel into the surrounding tissues and produces an abscess, a progressive suppurative inflammation, or becomes mixed with the exu- date which is already present. Ha'morrhage rarely occurs, for the thrombus while softening has extended and has closed the vein proxi- mally and distally. The diagnosis of thrombophlebitis of subcutaneous veins is not difficult. It may be mistaken for a thrombolymphangitis. The diagnosis of inflammation of deep veins may be made by the pres- ence of oedema, by the palpation of hard, painful cords corresponding to the position of veins, severe pain, the presence of a local cause (such as varicose ulcer), and general symptoms. The following are the dangers which accompany thrombophlebitis: A)i extension of the inflammation along the vein. A suppurative meningitis may follow a furuncle of the lip, as the inflammation extends along the facial to the ophthalmic vein and to the cavernous sinus. A phlegmon of the scalp extends to the veins of the diploe and dura, while inflammation of the umbilical vein may be the cause of a fatal peritonitis in the newborn. A thrombophlebitis of the veins of the puerperal uterus extends along the spermatic and hypogastric veins to the common iliac and femoral veins and the inferior vena cava. The inflammation extends with the growth of the thrombus against the blood stream. The veins of the mesentery become inflamed in perityphlitis and severe enteritis, and the inflammation may extend to the portal vein. The second danger is the separation of eniboli ivhieh eontain hac- teria from suppurating thromhi. Thrombophlebitis may thus become the cause of a metastatic inflection. Any trauma or movement may separate or set loose an embolus in the small and lai'ge veins. As there ai'e venous thrombi which contain bacteria in every inflamed area, 236 WOUND INFECTIONS PRODUCED BY BACTERIA this danger must be kept in mind in the treatment of all pyogenic infections. The treatment of acute thrombophlebitis demands in the first place absolute rest of the extremity involved. This is obtained by immobilizing dressings and rest in bed, which should be continued as long as there are any signs of inflammation. Abscesses should be incised. If chills, a high remittent fever, general symptoms, and those of lung embolism lead to the suspicion that a demonstrable thrombus is suppurating and breaking down, ligation and resection of the vein above the thrombus (if possible resection of the diseased portion, or at least re- moval of the suppurating thrombus) prevents in many cases general infection. The inflamed subcutaneous veins of the arm and leg (Lee, "W. Muller) and the femoral vein (Kraussold) have been ligated with success. The internal jugular vein is ligated in thrombosis of the trans- verse sinus following suppurative otitis media (Zaufal), and the facial vein, when inflamed, secondary to carbuncle of the face. Trendelenburg records a case of general chronic puerperal infection which recovered after double ligation of the inflamed and thrombosed right hypogastric and spermatic veins. Literature. — v. Bungner. Spontanruptur der Art. femoralis. Arch. f. klin. Chir., Bd. 40, 1890, p. 312. — Fr. Fischer. Krankheiten der Lymphgefasse, Lymph- driisen und Blutgefasse. Deutsche Chir., 1901. — Frommer. Zur Kasuistik der Nach- blutungen. Arch. f. klin. Chir., Bd. 67, 1902, p. 439. — W. Muller. Zur operativen Behandlung infektioser und benigner Venenthrombosen. Arch. f. klin. Chir., Bd. 66, 1902, 13. 642. — Nasse. Mykot. Aneurysma der Art. femoralis. Deutsche med. Wochen- schr., 1898, Vereinsbeilage, p. 259. — Talke. Experim. Beitrag zur Kenntnis der in- fektiosen Thrombose. Beitr. z. klin. Chir., Bd. 36, 1902, p. 339. — Trendelenburg. Ueber die chir. Behandlung der puerperalen Pyamie. Miinch. med. Wochenschr., 1902, p. 513. (e) PYOGENIC INFECTIONS OF BONE Etiology. — Bone may be infected in three ways : 1. In compound fracture or in operations such as amputations, joint resections, and oste- otomies, in which the medullary cavity or the surface of the bone stripped of its periosteum is directly exposed to infection. 2. A suppurative in- flannnation of the surrounding soft tissue may extend to the bone, and it may become involved secondarily. 3. The infection may be carried through the blood by bacterial or infected emboli, which lodge in parts of the bone where anatomical conditions are favorable or where a locus minoris resistentice has been provided by some previous injury or circu- latory disturbance. The classification of suppurative inflammation of heme is based en- tirely, or almost entirely, upon the tissues involved. Inflammation of the periosteum is called periostitis; of the bone marrow, osteomyelitis; of the THE PYOGENIC INFECTIOxNS OF DIFFERENT TISSUES 237 cortex, osteitis. Usually when all the dilTere involved some collective term is required : myelitis being used in this sense. Any pyogenic organism may be the cause of osteomyelitis. In the ectogenous infec- tions, and those extending from inflammatory foci in the surrounding .soft tissues, the staph- ylococcus aureus and albus and the strep- tococcus, often associated with other bacteria (e. g., putrefactive), are most frequently found. In hipmatogenous osteomyelitis the staphylococcus pyogenes aureus is found with by far the greatest frequency; then follow next in order of fre(iuency mixed in- fections with the aureus and albus and the aureus and the streptococcus. The white staphylococcus and the streptococcus are more rarely found alone. The pneumococ- cus, typhoid bacillus, the gonococcus and bacillus of pneumonia are also found in os- teomyelitic foci, but cases of osteomyelitis caused by these bacteria are relatively rare when compared to those caused by the bac- teria above mentioned. Pathology. — The pathological changes eventually are the same whether the in- flammation attacks the bone from within or without, the order in which the tissues are involved l)eing merely reversed. If the inflammation develops from with- out, as occui-s most frequently after an in- jurv% or secondary to a phlegmon, a perios- titis develops first, the periosteum becoming swollen and reddened and raised from the bone by a layer of pus. The inflammation next extends along the vessels of the Haver- sian canals, and the cortex of the bone be- comes involved. In the short and flat bones an inflammation beginning in the periosteum frequently extends to the medulla. In a suppurative arthritis accompanied by a de- struction of the articular cartilage, the spongy bone of the epiphysis is involved, and in com- nt tissues of the bone are osteitis as well as osteo- FiG. 101.— SuppuRATivK Osteo- myelitis OF THE Tihia(Semi- DXAGRAMMATic). CI, Attach- ment of capsular lig:ament; 6, purulent focus in nictaphysis wliich has ruptured into the epiphysis; c, periosteum raised bj' pus; d, phlegmon of the medulla; e, separation of the epiphj^sis; /, extracaj)- sular rupture of pus; g, cap- sular ligament; h, rupture into joint. 238 WOUND INFECTIONS PRODUCED BY BACTERIA pound fractures in which the medulla is exposed infection, if it occurs, travels rapidly along the medullary cavity. In H.EMATOGENOUS INFECTIONS the mcdulla is usually primarily in- volved, occasionally the cortex and periosteum. When the infection begins in the medulla, it may travel in a number of different ways. The acute progressive in- fections of the medulla (medul- lary phlegmons) are frequently Fig. 102. — Tubular Sequestrum. Fig. 103. — Total Necrosis of the Humerus. Involucrum with sequestrum and cloacae. limited by the epiphyseal cartilages, but not infrequently the union between the metaphysis ^ and the epiphyseal cartilage is destroyed and the epiphysis becomes separated. 1 Metaphysis — a term used by Kocher to designate the spongy end of the diaph- ysis lying next to the epiphysis (Fig. 101). A suppurating focus situated in the metaphysis near the epiphyseal cartilage may produce: 1. A medullary phlegmon. 2. Extending along the epiphyseal cartilage, a separation of tlie epiphysis. 3. Passing THE PYOGENIC INFECTIONS OF DIFFERENT TIS.Sl ES 239 As the iiiliaiiiiiiiitiiiti extends rapidly outward alon^' tlie Haversian canals, the vessels oT wliieh become closed by tlironibi as a result of the intlanimation, a medullary phley:mon is usually accompanied by a sup- purative periostitis of the same extent. The periosteum is raised from the bone by a thick layer of pus, which finally ruptures throutrh it at a number of different points, where it becomes necrotic. The compact bone bathed in pus Avithout and within, deprived of nutrition by tlie separation of the periosteum and thrombosis of the medul- lary vessels and those in the Haversian canals, becomes ne- crotic (necrosis totalis). If only the inner layers of the shaft or the deeper spongy bone becomes necrotic, one speaks of a central necrosis in contradistinction to the ex- ternal or superficial necrosis, which occurs in periosteal or cortical suppuration. The bloodless white bone, killed by the suppurative in- tlannnation and permeated with l)acteria, excites and maintains in the living bone surround- ing it a reactive inflammation which may be rarefying or de- marcating as well as osteoplas- tic. Granulation tissue devel- ops at the boundary between the living and dead bone from the healthy marrow, the spon- gy bone, and the Haversian canals. This tissue gradually develops to such an extent that the space (demarcation pit) between the dead (sequestrum) and the healthy bone is completely filled. The sharp and jagged form of an old sequestrum penetrated by through the epiphyseal cartilage where pierced by canals for blood vessels an inflam- mation of the epiphysis. 4. Extending through the epiphysis a suppurative arthritis. 5. Passing along the epiphyseal cartilage and rupturing through the periosteum an intra- or extra-articular abscess, depending upon the insertion of the capsular liga- ment. Fi. 104. — ToT.\L Necrosis of the IIvmeki's .\.s Seen ix a Roextgex Hay Picture. 240 WOUND INFECTIONS PRODUCED BY BACTERIA canals and traversed by grooves is due to the digestive action of the granidation tissue and not to the pus (von Volkmann). It differs from the even symmetrical absorption or necrosis of fresh macerating bone. The total and central sequestra of the diaphysis are cylindrical or tubu- lar in shape, while cortical sequestra resemble a disk or chip. Weeks and months are required for a complete separation of a sequestrum, depending upon the extent of the necrosis. Often half a year is re- quired for the separation of a large sequestrum of the diaphysis. If superficial, the separated sequestrum may be discharged with the pus when it ruptures externally, or it may remain and be digested and absorbed by the granulation tissue. Only very small sequestra, most frequently those derived from spongy bone, can be destroyed in this way. During the separation and erosion of the sequestrum reparative proc- esses leading to the formation of new bone are going on. The perios- teum takes a very active, the medulla and surrounding intermuscular tissue a less active, part in this new bone formation. These reparative processes are most active in long hollow bones; least so in flat bones. Early, often within a week, the inner layer of the periosteum (cambium, germinal layer) begins to develop delicate layers of spongy bone (peri- ostitis ossificans). This proliferation continuing gradually produces in the course of months a bony shell, which in the beginning is thin, fragile, and porous, like pumice stone. Later it becomes thicker, shapeless, and sclerotic, surrounding the dead bone or sequestrum like a capsule. This newly formed bone, which is separated from the sequestrum by a thin layer of granulation tissue deficient at some points, and pus, is called the i nvolu ci-um (capsula sequestralis). CanalsoF different sizes (cloacEe) lined with granulation tissue through which is discharged the pus forming in the interior are found in the involucrum. The involucrum is deficient and weakened where the periosteum has become necrotic, and if weight is brought to bear upon the bone or it is manipulated roughly the involucrum may be fractured. If the involucrum is fractured union may not occur, a pseudarthrosis developing. AVhen the newly formed bone hardens the involucrum ceases to increase in size (von Volkmann). The spongy and compact bone may become so thickened and condensed as a result of the reactive inflamma- tion, that tRS~-surrounding~bon^HDecomes as hard as ivory (osteomyelitis ossificans, scleroticans, eburnatio). This ossifying or sclerotizing process may involve an area 5 cm. in width surrounding a suppurating focus or a sequestrum in spongy bone. This hard bone developing about a total sequestrum of the shaft may entirely fill up, or, as happens in the chronic sclerotizing forms of osteo- myelitis, entirely obliterate the medullary cavity. THE PYOGENIC INFECTIONS OK I)11'FI;RI-;NT TISSUES 241 Clinical Course. — The eliTiictil coiusc and i)ictur{' of suppurative osteo- myelitis (liilVr widely, the clitl'erenees (lepeudiui'- upon the vindence of the bacteria, the susceptibility of the tissues and of the patient, the loca- tion and predisjxisinsi' cause, such as trauma, exposure to cold, etc., the conii)lieations (suppurative arthritis and metastatic infections), the pre- dominance of necrotic or osteoplastic processes. The hieniatoiienous is the most important form of suppurative osteo- myelitis. 'I'he way in which this form of osteomyelitis develops has been made clear by a number of very conclusive pieces of experimental work. If a small amount of a virulent culture of staphylococcus pyoij^enes aureus is injected into the vein of a young rabbit or guinea pig, the Fig. 105. — Tiul-v of a Young Rabbit with a Total Sequestrum of the Diaphysis, Developing Three Months After an Intravenous Injection of an Attenuated Culture of Streptococci. (I natural size.) animal develops a fever and dies Avithin a few days, and a post-mortem examination reveals numerous abscesses in the viscera, muscles, bones, and joints. The smaller the amount of the culture injected the more marked the development of abscesses in the bones, the less marked their development in other parts of the body. The abscesses developing in the bones are most commonly situated in the broad metaphysis of the femur, the upper end of the tibia, and in the upper extremity of the humerus. The disease procured in animals experimentally is, like severe osteomyelitis occurring in man, a fatal general infection accompanied by the formation of metastatic foci developing especially in bones (Rodet, Colzi, Lannelongue and Achard, Lexer). Similar results may be obtained by the injection of the staphylococcus pyogenes albus, and the streptococcus pyogenes (Lannelongue and Achard, Lexer) and the bacterium coli commune (Ackermann). If old attenuated cultures of the yellow^ or white staphylococcus are injected the animal remains sick for a short time, but recovers. During the course of the sickness several hot painful swellings develop upon one or more legs, and as the swelling of the soft tissues subsides the thickening of the bones, which after two or thi-ee weeks present all the pathological changes of chronic suppurative osteomyelitis (osteomyelitis purulenta chronica), as it occurs in man, becomes more distinct. It is imi)Ossible to produce in animals by the intravenous injection of 242 WOUXD IXFECTIOXS PRODUCED BY BACTERIA a - staphylococci an acute progressive medullary phlegmon, unless an inflam- mation has been produced by the previous injection of some other organ- ism, e. g., a pyogenic bacillus which occurs frequently in rabbits (Lexer). Trauma has an actual influence in determining the location -of and contributing to infections in experimental animals. Extensive suppura- tion develops at the seat of fractures or where the bones have been injured after the intravenous injection of virulent cultures made at the same time or some days later (Ulhnann). Animal experiments have shown that pyo- genic bacteria, and of these most frequently the staphylococci, may be deposited by the blood stream in young growing bones pro- ducing .suppurating foci which are situated as in rnan in the metaphysis of the long,, hollow bones, and in parts of the bones the resistance of which has been reduced (locus MiNORis RESISTENTL5;) by some trauma, ex- posure to cold, etc. The micro-organisms may be absorbed from any inflammatory focus, no matter how small, or may be carried in emboli (infected emboli), or in groups (bacterial emboli), from the veins of the primary suppurating focus, which have become closed by thrombi. It may be impossible to demonstrate the pri- mary focus, but a suppurating focus in bone is proof positive that a primary focus exists or has existed in each case (Jordan). The absorption of bacteria, which may occur in any wound infection and bacterial invasion, leads to the development of a sup- purative osteomyelitis only when special con- ditions are provided. The bacteria, unless present in large numbers or continually in- vading the blood, are deposited in the bone marrow, spleen and liver (Wyssokowitch), Avhere they are exposed to the action of the bactericidal substances, which in the bone marrow are formed especially by tlie leuco- cytes. ITere they are either killed or so injured by bactericidal sub- stances that they can no longer multiply and invade the tissues (A. Fig. 103. — Femur of a Child Four Weeks Old, the Ves- sels OF Which Have Been Ixjected, as Seex ix a Roen'tgex Ray Picture (Periosteum axd Capsu- lar Ligaments Dissfxt- ED Away). a, Epiphyseal artorif's; h, mPlapliyscal ar- teries; c, doublf nutrient arteries. THE PYOGENIC IXFKCTIONS OF DIFFERENT TISSUES 243 Wassennann). In many inft'ctioiis the biuic marrow is more active than any other tissue in prodiiein<; the specific inunune bodies, and therefore the deposition of bacteria in it may be rejrarded in the lifjht of a protective measure, as the bone marrow destroys the bacteria and produces substances which are at the disposal of the orgranism in com- l)atin<; infections. E, Fraenkel, and earlier Weichselbaum, demonstrated in the bone marrow of patients dyinp: of pneumonia, felons, phlej;mons, and erysipe- las, the bacteria which had produced these lesions even when there had apparently been no blood infection. One must conclude, therefore, that bacteria are often deposited in the bone marrow even' when the local in- fection and the fjeneral reaction is not severe. If the pyogenic bacteria are present in the bone marrow, one of two conditions must be fulfilled before they can produce suppuration. The bacteria must either be virulent enough or present in large enough num- bers to resist the bactericidal substances, or the tissues must be so weak- ened by ti'auma or circulatory disturbances that they can no longer produce these substances in large enough amounts to restrain the growth of the bacteria (A. Wassermann). Osteomyelitis may also be produced by the displacement and lodg- ment of infected or bacterial emboli from the primary focus, which always contains veins which have been closed by thrombi or invaded by bacteria. Osteomyelitic foci which are intimately related to the arterial branches and are situated in the epiphyseal zone to which capillaries from all sides converge, and the foci in the short and flat bones (e. g., vertebra?, pelvis, phalanges) most frequently attacked by tuberculosis, must be regarded as of embolic origin ( Lexer V The vertebnp. pelvis, and phalanges, etc., are much less frequently the seat of suppurative than tuberculous lesions, and embolism (by infected or bacterial emboli) is apparently much less frequent in suppurative than in tuberculous osteomyelitis. Suppurative foci are more frequent in the metaphysis of long bones than in any other bones of the skeleton. The frequency of the lesions in the metaphysis cannot be satisfactorilv explained upon the supposi- tion that the bacteria are attracted by the bactericidal substances, for theoretically the diaphysis is as rich in these as the metaphysis; neither can it be explained satisfactorily by the lodgment of emboli, for other bones should then be attacked as frequently. The mechanical conditions provided in the epiphyseal zone of growing bones, in which there is a physiological hypera^mia with a slowing of the blood stream, and by the arrangement of the smaller vessels and the capillary loops with their branches which pass down into the primary medullary spaces of the epi- physeal cartilage (Langer), favor the deposition and retention of bae- >^ 244 WOUND INFECTIONS PRODUCED BY BACTERIA teria and explain the frequency of acute suppurative lesions in this part of the bone. The fact that staphylococci are retained in these vessels and cause suppurative osteomyelitis more frequently than any other variety of bacteria, must be ascribed to their peculiaritj^ of growth, occurring as they do in groups or clumps. If such a group gradually forms in these vessels, or if a group is carried from a primary focus, or if two or more clumps fuse, the small vessel is closed and the foundation for a suppu- rative osteomj^elitis is laid. The yellow staphylococci are found more frequently than the white in these lesions, as the former occur more frequently in the primary lesions in the skin, mucous membrane, etc. H^EMATOGENOUS SUPPURATIVE OSTEOMYELITIS MAY BE CAUSED: 1. By the deposition of highly virulent bacteria in the bone marrow. 2. By the lodgment of infected or bacterial emboli. 3. By the development or fusion of clumps of staphylococci in the finest capillaries. 4. The relation of trauma to osteomyelitis must also be considered. The relation between trauma (in the broadest sense, fractures, contu- sion, and cold) and osteomj^elitis is threefold: 1. Pyogenic bacteria which have gained access to the blood stream are apt to be deposited where the tissues are injured (locus minoris resistentiae ) . 2. The trauma may injure the tissues in which bacteria have already been deposited, and so reduce their natural resistance that the bacteria may multiply and invade the tissues. 3. The trauma may rupture the connective tissue or bony capsule which surrounds some old focus. The age at which the disease develops and the position of the focus differ. The greatest number of cases develop between the eighth and seventeenth years. The disease rarely develops after the twenty-fifth year. According to Haaga 59 per cent of the cases occur in the second decennium, 9 per cent in the third, 2.5 per cent in the fourth, and 2- per cent in the fifth. Animal experiments coincide with clinical experience as to the age in which osteomyelitis is most frequent. While young animals after intravenous injections of staphylococci develop suppurating foci in bone and some of the other tissues, older animals develop a suppurative ar- thritis, never intraosseal, and only rarely periosteal foci (Rodet, Lexer). This difference depends upon the greater vascularity of young grow- ing bone and the histological characteristics of the cellular marrow of young bone which differ markedly from those of the fatty marrow of adult bone. THE PYOGENIC IXFECTIOXS OF DIFFERENT TISSUES 245 The more frequent oeeurrence of tlie disease in country people is probably due to the fact that they are less cleanly than city people (Kuester). Osteomyelitis develops most frequently in the long hollow bones, and I in that part of the bone in which the changes associated with growth J are most active. According to different statistics the lower end of the f emur, the upper end of t jie tib ia, the upp er end of the humerus, and the lower end of the tibia must be regarded as the favorite sites for the development of suppurating foci. They are involved in order of fre- quency as given above. In the epiphysis of long hollow bones, in the short and flat bones where tuberculosis develops frequently, suppurative osteomyelitis rarely occurs. i\Iany different bones or different parts of the same bone may be involved simultaneously. Clinical Forms. — Clinically suppurative osteomyelitis may be divided into acute and chronic ft)rms with a number of complications. Classi- fication based upon the sequelte and bacterial forms may also be made. A sudden onset and severe course are characteristic of acute h.ema- TOGENOUS suPPURATi\^ OSTEOMYELITIS. Strong, previously healthy chil- dren or young adults suddenly present the symptoms of severe infection (chills and high fever) and complain of a severe localized pain. If an extremity is involved the pain may be severe enough to prevent any movement. At first the patient may be unable to indicate accurately the location of the pain, but it soon becomes localized in a part of the bone, usually close to a large joint. Often any external cause is wanting, often there is undoubted con- nection with a trauma; often a chronic suppuration, especially after a trauma becomes acute. In rare cases a suppurative osteomyelitis de- velops at the seat of a subcutaneous fracture, secondarj^ to an angina, which developed during the process of repair. The fever, accompanied by the severest general symptoms, is continu- ous. In the course of one or more days the aff'ected extremity swells and presents slight indistinct redness, soon also inflammatory oedema, ten- sion of the skin, fluctuation — in short, all the signs of a phlegmon of the soft tissues. The bone, if it can be palpated through the infiltrated tis- sues, appears to be thickened. The subcutaneous veins are prominent, the neighboring lymphatic glands enlarged and sensitive to pressure. Abnormal mobility of the epiphysis and slight dislocation indicate separation of the epiphysis, which occurs in from twelve to fifteen per cent of the cases (Garre. Reisz). This occurs, as a rule, at the end of the first week, rarely as early as the second day. The neighboring joints often become involved in the inflammation {vide Complications). 246 WOUND INFECTIONS PRODUCED BY BACTERIA A few days after the onset a serous infiltration of the soft tissues surrounding- the bone, particularly the intermuscular septa, is found if an operation is performed. The discolored periosteum, which may be perforated at different points, is raised from the bone by pus, and the white bone is surrounded completely or partially by it. AA^here the peri- osteum retains its connection with the soft tissues, it is able to regenerate. Upon closer inspection one sees pus discharged from the large canals of the metaphysis, which contain vessels, and small drops of fat floating upon the surface of the pus, which indicate that the latter has been discharged from the medulla. Pus is found in the beginning only in that part of the medulla adjacent to the epiphy- FiG. 107. — Foci of seal cartilage. The remaining marrow is deep red Staphylococci in . -, -, .-, -i •, j.j. j n • t, j. THE Neck of the ^^^ color, and through it are scattered yellowish spots Femur, Intracapsu- and streaks. Later it becomes transformed into a YE^lR^OLJcmLDl''^ yellowish green collection of pus. Microscopically groups of cocci are found in the pus. The bones more rarely involved are attacked in the severest multiple forms, which comprise about one fifth of the cases (Garre), in addition to the one usually affected. The bones become infected simultaneously from some primary focus or secondarily to some osteal focus (Garre). Sometimes the bones become involved simultaneously or in rapid succes- sion, sometimes after long intervals. Sometimes these cases pursue an acute, at other times a chronic course. Multiple osteomyelitis, like hematogenous osteomyelitis, is, as a rule, a general metastatic infection with pyogenic micro-organisms. It occurs in children, whose bone mar- row is especially susceptible to metastatic inflammation. An acute hEematogenous suppurative periostitis is most frequently associated with small suppurating foci in the cortex of flat bones and suppuration in the metaphysis of long, hollow bones. It occurs also in adults. Those cases of acute osteomyelitis in which the focus develops in the articular ends of bone have been placed in a special group, because the joints are so frequently involved (AV. Miiller). In this form, which has been observed in the very young up to the fifth year, small suppu- rating foci exist. They are situated like the tuberculous foci, where the vessels from the metaphysis or periosteum enter the epiphyseal cartilage, or in the femur, where the vessels from the ligamentum teres, in the knee from the crucial ligaments, enter and branch (Fig. 106). Foci are found in the periosteum, cortex and medulla. The carpal and tarsal bone may also be involved (Becker). In the hip joint foci are found in the upper angle of the Y-shaped epiphyseal cartilage. Staphylococci THE PYOGENIC INFECTIONS OK DIEF1:KENT TISSl'lOS 247 are found most fre(|nently in this form of osteomyelitis, the streptococcus and pneumococcns relatively fretjuently. Suppurative arthritis, or after extra capsul ar rupture para-artieular phlejimon, are the most prominent clinical features. When the operation is performed a focus is found, which should be thoroufjhly removed with a sharp spoon to prevent destruction of the epiphysis and its cartilage and to protect the joint from subsequent inflammation. Fig. ids. — Pneitmococcic Focus in the In- terx.\l m.\lleoltj.s, rupture through THE Epiphysis (Xine Months Old Child). Fig. 109. — Pneumoi mc , i. lOcus ix Lower Articul.\r End of ihe Fkmur of a Child Nine Months Old. P, Rupture through the epiphysis; K, capsule of joints. Osteomyelitis and periostitis serosa (albiiminosa of Oilier, non- purulenta of Schlange) is a rare form, which develops most frequently in the fenuir and is produced by the yellow and white staphylococcus and streptococcus. After a mild but acute onset it often pursues a chronic course and leads to the formation of large periosteal abscesses and sup- purating foci in bone and sequestra. A serous or mucoid exudate is found instead of pus, and it differs in this way from the suppurative form. This form has been classified by Schlange with acute osteo- myelitis because staphylococci have been demonstrated in the exudate. The inflammatory reaction is not so severe, however, as only a serous exudate is formed. According to Vollert and Garre it is possible that the pus, previously formed, may have undergone a mucoid degenera- tion. An exudate occurring in periostitis, which is surrounded by a thick resistant membrane, may resemble a cyst (periosteal ganglion, or if occurring (m the skull, it may be mistaken for a meningocele, Schrank). The superficial necrosis of bone and the demonstration of pyogenic bacteria make certain the diagnosis. Inflammation of the joints is the most important complication of acute suppurative osteomyelitis. The joints may become infected in 248 WOUXD INFECTIONS PRODUCED BY BACTERIA three ways. The rupture of a suppurating focus through the articular end, or of a medullary phlegmon through the epiphysis produces an acute suppurative arthritis. The arthritis may develop as a metastatic infection from a primary focus or from the bone primarily involved. It is then accompanied by a serous or purulent exudate. The third form of arthritis is the so-called sympathetic. A serous exudate, which appar- ently is produced by the toxins, de- velops, although the focus, acute or chronic, in the epiphysis is complete- ly encapsulated. This form of arthri- tis may present the clinical features of an intermittent hydrops. When the exudate is large, the capsule may become greatly distended and subluxation occur. Aspiration and immobilization of the joint, as a rule, control the ar- thritis, accompanied by the formation of large serous exudates. When, how- ever, the exudate is purulent, the joint must be incised and drained immediately in order to retain good function. Eesection of the joint must be considered when the epiphysis and articular cartilage are destroyed by the rupture of a medullar}^ phleg- mon (Fig. Ill) . Pathological changes in the articular cartilage produce ad- hesions and anchylosis (vide Diseases .zrot Joints). /^ — -/_-::v*i^ fjjA ' The most dangerous complica- tion is GENERAL INFECTION. If in a few days a fatal blood infection de- velops, in addition to the infection of one or more bones, it is impossil?Jc to say whether the general infection is secondary to the infection of the bone or whether the bone infection has occurred in the course of the gen- eral infection. In these cases no pus is found in the inflamed bones, but only hamorrhagie foci scattered throughout a hyperamic marrow (acute hajmorrhagic osteomyelitis). .P Ci. Fig. 110. — Slvkhe Osteomtelitis of THE Femur i.v a Child Nixe Weeks Old, Caused by Streptococci; Three Weeks After the Begin- NiXG OF the Disease. K, Center of ossification; H, suppurating focus; Ci, internal condyle; P, perforation; W, periosteal h»one formation; .S, seoues- 8' tmm:,' TFii", rvor.EXK" iXFi'icTioNS OF I )ii''Ki';Ri:.\ r Tissri:s 240 .Mi'tiisljil ic su|)|)iii';ilinii ill tlic serous cavities and jciints aiul puru- lent I'oei in the organs and muscles ^ives to this form ol' osteomyelitis the picture of a iicneral metastatic infection. As in multiple osteo- myelitis, (he metastases may develop simultane- ously from some })rimary focus or an osteal focus. Other complications depend upon the position of the bones involved. An empyema may develop from an osteomyelitis of the bones of the thorax or vertebrae. The severest eases, in which the symptoms of a general infection are most prominent, may end fatally within a week (the typhus of bone of French authors). As a rule, the fever and general symptoms subside as soon as the bone is opened and drained or the pus is discharged spontaneously. The mild subacute cases su])side spontaneously after a few Fig. in. — Suppurative days, as the infection is encapsulated. Acute osteomyelitis should always, however, be reg^arded as a gi'ave disease. Metastatic and general in- fection and complications of all sorts threaten the life of the ])atient, the destruction of the diseased bone, and the function of the joint. In the acute febrile stage and in the febrile relapses bacteria may be cultivated from the blood (Garre, Sanger, von Eiselberg, Canon, Lexer). The prognosis is bad, if the blood infection persists for some days after the focus has been opened and drained. Yet recovery has occurr(>d in cases in which the bacteria have persisted in the blood for weeks (Lexer). Diagnosis. — The acute violent onset with the symptoms of general infection and tlie symptoms of local inflammation are important in mak- ing the diagnosis of acute suppurative osteomyelitis. The diagnosis is not difficult if the local symptoms are found in bones, which are fre- 'quently involved, and if the inflammatory exudate in soft tissues can be 'traced to the bone and a direct wound infection or Ijanphangitie abscess can be excluded. Frequently a felon, a furuncle, an inflamed fissure or wound (e. g., scalp wound), an eczema, a scratch, a tonsillar abscess or an otitis media affords the infection atrium. Osteomyelitis is most frequently confused with deep lympba^gitis and lymphangitic al)scess, especially if these develop in i)arts, (poplitea fossa, Scarpa's triangle, and internal bicipital sulcus), which are fre- quently secondarily involved in osteomyelitis, and with large haema- Inflammation of the Elbow Joint Second- ary TO Osteomyelitis OF THE Ulna. Articu- lar cartilage of the fossa semilunaris destroyed and fibrillated. 250 WOUND IXFECTIONS PRODUCED BY BACTERIA togenous muscle abscesses. The incision Avhieh is necessary in the treat- ment makes the diiferential diagnosis possible. If the periosteum is firmly attached to the bone, the inflammation did not develop in the latter. The treatment of acute suppurative osteomyelitis should protect the patient from general infection and limit the necrosis of the bone. The earlier the focus is opened, so much the better will both indications be met. The incision should be made slowly, under general aneesthesia, through the intermuscular septa to the surface of the bone. If possible, artificial ischa?mia should be employed, so that nerves, tendons, and blood vessels may be avoided. The yellowish discolored periosteum, raised from the bone, should be incised ; the extent of the incision de- pending upon the extent of the suppuration. If the subperiosteal pus contains fat drops and is discharged from the bone the medullary cav- ity and the spongy tissue of the metaphysis should be opened. The compact bone should be removed by a chisel, and the entire suppurating focus exposed. The operator should avoid injuring the capsule of the joint, fracturing thin bone, and separating the loosened epiphysis. If the suppuration has extended to the epiphysis the articular cartilage should be spared. After the pus in the medulla and spongy bone has been removed by sponges or a sharp spoon the cavity in the bone and the wound should be tamponed with iodoform gauze. The general rules already given should be followed in apphnng the dressing, which should hold the fragments in apposition if the epiphysis has been separated, and in the after-treatment, which will be required for from three to five months. Frequently small sequestra are extruded while the bone cavity and the wound are closing by granulation tissue and the periosteum is form- ing new bone. Apparently after early operation the greater part of the remaining bone repairs and contributes to later growth. Incision of the abscess of the soft tissues without opening of the bone as well as drilling the latter at a number of different points is not enough. These methods of treatment do not provide for a fr|b discharge of pus from the bone. They favor and cause chronic suppuration, extensive necrosis, rupture into the joint, acute relapses, etc. The complete removal of the diseased part must be considered, if the epiphysis is necrotic, or if the shaft of a long bone is separated at both epiphyseal cartilages, is surrounded by pus, and no longer connected with living tissues. This occurs in the humerus, ulna, fibula, most frequently in the tibia and fibula of small children. In spite of such an extensive necrosis as above mentioned, the periosteum is able to form new bone, and is aided by isolated periosteal rests and the surrounding THE PYOGENIC LNFECTIONS OF DIFFERENT TISSUES 251 connective tissue. It is necessary to resect the infiltrated parts in flat bones (ilium, scapula, ribs). In the skull bones it is often necessary to trephine, in addition to chiseling away the diploe, in order to provide drainage for subdural abscesses. In the severest forms of osteomyelitis of the long hollow bones, ampu- tation or disarticulation may be necessary in order to overcome the gen- eral infection. This is of advantage only when the infection in the bone is not localized. Chronic suppurative osteomyelitis (osteomyelitis chronica puru- lenta) develops from the acute form and also occurs as an independent form. It follows open injuries of bone, periosteal suppuration, inflam- matory processes about bone (e.g., varicose ulcers), and ha^matogenous infections. If the acute stage of an osteomyelitis has subsided spontaneously after rupture and discharge of the pus, or if the pus has been dis- charged after incision of the soft tissues, the necrotic bone maintains an infiannnation, which in long, hollow bones may persist for a half year or longer. This inflannnation may separate or rarely digest the dead bone or produce osteo- plastic changes. During all this time there is no trouble to speak of, unless the neighboring joint becomes inflamed or the epiphysis separates. From time to time the fistula leading to the dead bone closes, and then the patient complains of throbbing pain in the bone, accompanied by fever, until the pus is discharged again. The bone is irregularly expanded, sometimes its entire circumference is involved, at other times only limited areas. When the patient comes to the physician an inflammatory infiltration with red- ness of the skin and deep fluctuation may be present. The opening of the fistula (if present) is surrounded by luxuriant granulations, and is not corroded, as in tuberculosis. AVhen the pus is discharged small sequestra may be extruded. A larger, pointed sequestrum, which the patient attempts to remove, may be caught in the fistula. Neighboring vessels are sometimes injured in this way. A severe, acute progressive suppuration of the bone, accompanied by a phlegmon of the soft tissues and high fever, foUoAvs, as a rule, an injury of the chronically inflamed bone. The cocci, which have re- P'lG. 112. — Centrai, Se- questrum IN THE Low- er Third of the Ra- dius OF Man Fifty Years OF Age. Tliein- volucnim .surrounding the tleaci bone is thick. Gradual enlargement of the bone for some j'ears. Never acute inflamma- tion and rupture. Few symptoms. 252 WOUND INFECTIONS PRODUCED BY BACTERIA niained in the granulation tissue or scar for years without doing any harm, pass through the ruptured protecting capsule, invade the tissues again, and are absorbed. The independent chronic forms have frequently a short, but not marked acute stage, which is often overlooked or forgotten. It occurs in the young as a febrile disease, associated with pain and swelling of one or more bones, which subside after a few days without the discharge of pus. After many years, even after full growth has been attained, pain develops in the area, which has always been somewhat expanded, but is now plainly thickened. This bony thickening, which may gradually become quite large, involves most frequently the ends (junction of metaphysis and epiphysis) of long bones, and not infre- quently is accompanied by arthritis (suppurative synovitis, after rup- ture of an osteal focus, or intermittent hydrops) and by abscess forma- tion in the soft tissues. Three principal forms which frequently pass over into each other may be differentiated: 1. The central sequestrum surrounded by a very thick involucrum with little or no suppuration (Fig. 112). 2. The bone abscess, which is found most frequently in the metaph- ysis. It varies in size from a pea to a hen's egg, is lined by a thick abscess membrane, and contains thick, sclerotic bone. The Ipacteria (both varieties of the staphylococcus) found in these abscesses may remain viable for twenty or thirty years. 3. The sclerotizing osteomyelitis (Garre), which has an acute or subacute onset, but does not lead to pus formation, is to be regarded as a less active form. The at times painful, gradually thickening bone, is transformed finally into a solid mass, which, as in syphilitic hyperos- toses, may encroach upon the marrow cavity. A large area or only the ends of the bone may be transformed into such a mass. Very small abscesses, foci of granulation tissue, and small central sequestra are frequently found within this sclerotic bony tissue. Acute exacerbations, which may follow trauma and other diseases, are the dangers of chronic suppurative osteomyelitis. Abscesses, inflam- mation and disturbance of the function of joints and different sequelag may develop even after long intervals. The diagnosis of the chronic form may be difficult if other signs do not indicate the nature of the changes, which may not be very distinct even in the Roentgen ray picture. The diagnosis of sarcoma, tubercu- losis, gumma, and bone cyst may be made, therefore in doubtful cases an exploratory incision should be made. The swelling which develops insidiously upon the ends of bones, near joints, and upon short bones, such as the clavicle, without the THE rVOGENlC LNFECTIONS OF Dll'EEKENT TLSSL'ES 253 sitrns of intlainniation and fistula formation, resembles myelogenous or periosteal sarcomas. At first they develop slowly, after a time more rapidly, and produce pain, functional and circulatory disturbances. The development of an inflammatory infiltration and reddening of the skin are the surest signs of the inflammatory nature of this chronic process. In rare cases (Koeher, Jordan) the swelling is composed mostly of granulation tissue, and the compact bone covering it is thinned, so that a microscopic or bacteriologic examination must be made before it is possible to diagnose the nature of the swelling. Thick masses of periosteal sear tissue, resulting from previous inflammation, may lead to the diagnosis of sarcoma (Xasse, W. ]\Iueller). When such a mass is exposed, small granulating and suppurating foci and se(iuestra will be found. Chronic epiphyseal foci, especially if they have produced a serous synovitis, may be mistaken for tuberculosis. The fistula.' following chronic osteomyelitis do not have the corroded borders which characterize the tuber- culous. The pus in the small osteal foci is thick and mucoid, not caseous, the sequestra jagged and irregular, not round, as in tuberculosis. The .swellings of the diaphysis. Avhich occur in the non-suppurative sclerotizing form, and are characterized by frequently recurring pain and a chronic course, remind one of syphilis, especially if there is no acute stage. ' Bone cysts resemble serous abscesses, which are encapsulated by thick connective tissue. The dem- onstration of bacteria makes a differential diagno- sis possible, if it cannot be made from other data. The treatment of chronic suppurative osteo- myelitis consists in the removal of the sequestrum, the exposure and evacuation of the suppurating focus. If the focus is centrally situated the bone must be chiseled away (ne- crotomy). One may figure upon a complete separation T)f even large sequestra and the development of a strone involucrum if six montlis have passed since the begin- ning of the disease. In exposing the focus the periosteum is incised the length of the swelling and reflected to either side. The expased wall of bone is then 113. — Necrosis of the Tibia with NriizRors Cloaca Exposed fob Sequestrotomy. 254 WOUND INFECTIONS PRODUCED BY BACTERIA removed with a chisel or gouge. When the sequestrum is removed the granulation tissue, pus, and abscess membrane are removed by sponges or the sharp spoon. The sharp borders of the bone are cut away with a straight chisel, and the cavity in the bone is then tamponed. Foci and sequestra about the epiphyseal cartilage must be followed if necessary into the epiphysis. The epiphyseal and articular cartilages and joint capsule should not be injured. Repair by the formation of granulation tissue is slow. Deep fistulas, which extend into the metaphysis, and which must be curetted fre- quently, often remain. The deep bone cavities near the articular ends, which cannot be smoothed off completely, because so near the joint, may be closed most easily in the following way : After healthy granulation tissue has devel- oped, a pedunculated skin flap is made and placed upon the vivified granulating surface, or during the operation the skin flaps are so fash- ioned that after the removal of the tampon they may be turned into the wound. They may be held in position ^ by dressings, small nails, or adhesive plaster. Osteoplastic necrotomy (Luecke, Oi- lier, Bier), in w^hich a piece of the in- volucrum, retaining a periosteal attach- ment, is used to fill in the cavity, has the disadvantage that dead spaces form be- neath the flap and pus is retained. The process of repair is not shortened. A number of attempts have been made to close these cavities with different kinds of plugs. The iodoform bone plug intro- duced by Mosetig-Moorhof, consisting of 60 parts of iodoform and 40 parts each of spermaceti and oil of sesame, has been the most successful. It does not act as a foreign body as other bone plugs do, and does not produce suppuration. It is gradually absorbed and replaced by con- nective tissue or newly formed bone, after the skin, which was inmiediately sutured, has been healed for some time. The most important sequelae are : Spon- taneous fracture or infraction at the point where the bone has been weakened by the inflammatory process. The fracture occurs most frequently in the demarcation zone, where Fig. 114. — Incision for Exposure AND Partiai^ Removal of the Tibia in Extensive Suppura- tive Osteomye;i>itis. THE PYOGENIC IXFECTTOXS OF DIFFEREXT TISSUES 255 the involucruiii is poorly developed or it is* weakened by an operation, in rare easi's al.so at the site of the secinestrum, which is not sntBciently supported by the involucruni. The fractnre may follow extensive suppuration. Necrotomy should be performed, and the fragments appi'oxi mated and retained in as good jxisition as possible. The repair of such a fracture is slow, ])seudarthrosis often cannot be prevented. Pathological dislocation oc- curs most freciuently at the hip joint; subluxation at the knee joint. They result from the destruction of the joint (de- struction-dislocation) or from distention of the capsule by effusions into the joints (dis- tention-dislocation ) . Separa- tion of the rim of the acetabu- lum, which then moves upon the ilium, may lead to the diagnosis of pathological dislo- cation. Bending may occur at the weak point of the involucruni if weight is borne upon the leg or as the result of muscu- lar contraction, e. g., this bend- ing may be forward in the lower end of the femur, dis- placement backward of the up- per end of the tibia from con- tracture of the flexor tendons. The most marked deformities follow separation of the epiphysis, with subsequent imperfect repair. These deformities are also partly due to irregular growths resulting from disease and destruction of the epiphyseal cartilage. Disturbances of growth consist of .shortening and lenulhening of the diseased and neighboring bones (Oilier, von Bergmann, Ilelferich). Shortening of the bone follows the destruction of the epiphyseal carti- lage, which does not regenerate. Foci in the diaphysis and nietaphysis may stimulate the zone in which growth is most active, and in-oduce a lengthening of the bone. Either of these changes, depending upon the Fig. 115. — Radioflexiox of the Hand Fol- lowing Destruction of the Lower Epiph- ysis OF the R.\dius by a Suppur.\tive Os- teomyelitis. 256 WOUND INFECTIONS PRODUCED BY BACTERIA position of the focus, may be produced experimentally (Lexer). These pathological changes occurring in the bones of the forearm and leg may give rise to a number of deformities (pes valgus, varus, nianus radioflexa, genu valgum, varum, etc.), for the plane of the joint is displaced and , deformities of the rapidly growing bones (healthy or diseased) result. Moreover, the healthy bones of an extremity may be increased in length as the result of the increased blood supply accompanying the inflammation. In inflammation of the bones of the leg, the femur may increase in length and the reverse ; in osteomyelitis of the bones of the forearm the humerus may become longer. In this way the short- ening of the diseased bone is compensated. According to Oilier, when a bone of an extremity becomes shortened, there is a compensatory lengthening of the bone ad- jacent to it. Contractures with fibrinous adhesions Fig. 116.— Marked Curvature of and anchylosis may follow the inflamma- THE Tibia Resulting from Short- . c A^ • ■ • • i ENiNG OF THE DISEASED FiBULA. ^lou of the jouits occumug lu thc coursc of an osteomyelitis. •Von Volkmann has designated as recurrent osteomyelitis the form which develops after an interval of years upon a completely healed osteomyelitis. The old area may be involved, or a bone which has been perfectly healthy. There is either the invasion by bacteria, which have remained latent about the old focus, or there is a new blood infection. It is possible to explain in this way the development of inflammatory changes in old csteomyelitic foci and in healthy bone. The scar tissue of the old focus may contain latent bacteria, or it may be the locus minoris resistentice, where the bacteria circulating in the blood are de- posited. When the inflammation occurs in bone not previously involved, one cannot exclude a focus which developed without symptoms in youth and remained latent. ' Bacteriology. — A classification of haematogenous suppurative osteo- myelitis based upon the bacterial forms cannot, as a rule, be made. The clinical difl'erenees between the inflammations produced by the dif- ferent bacteria are not striking enough to make this possible. Streptococci produce, according to our present knowledge, small cor- tical and metaphyseal foci with suppurative arthritis (especially in chil- dren) as well as medullary phlegmons with separation of the epiphysis and extensive necrosis. Streptococci also produce osteitis albuminosa. Till] I'YOeJENlC INFECTlOxNS OF DlFFIOltlONT TISSUES 257 abscess, clironic tliickciiin<,'', and inflaniination of tlie flat bones. The pus is thin, milky, discolored green, and is formed in hirge quantities. Mixed infections of staphylococci and streptococci produce severe local and genei'al symptoms. J'neumoeoceic osteomyelitis is more rare. The foci are situated in the ends of the bone neai- the joints, from which they produce suppurative arthritis. Tlu" pus i-esemblcs the stirptococcic pus. There develops in rare eases in children and adults during the course of pneumonia peri- osteal and cortical suppuration, and also suppurative inflammation of subcutaneous fi-actures (Lexer). A gonococcic osteomyelitis (in the humerus of an adult) has been observed once by Ullmann, A perichondritis of a rib has been observed by P^inger. The bacterium coli conunune has been found in some cases (Klemm, Blauclaire) associated with the typhoid bacillus and staphylococcus. Its l)resence is indicated by foul-smelling and discolored pus. Schlangenhaufer found the bacillus of pneumonia (Friedlaender) in an extensive osteomyelitis in an adult. There are also rare eases of acti- nomycosis in which the fungus has been found in an osteal focus (Wrede, Fig. 142, p. 369). Wyss found an anaerobic bacillus (Bacillus halo septicus) in the ichorous pus of an osteomyelitis of the tibia. Typhoid osteomyelitis (osteomyelitis typhosa) developing in the course of or subsequent to typhoid fever demands a separate considera- tion. It develops, as a rule, in from the fourth to the sixth week of the disease; sometimes after many years. It is caused by the typhoid bacil- lus, fre(iuently associated with the ordinary pyogenic bacteria, which pass from the intestinal ulcers into the blood and are finally deposited in the bones. Its onset is indicated by a rise of temperature and pain in the bone involved. Trauma is frequently the pre- disposing cause. The resulting abscess, which is often very large, contains, if there is no sec- ondary infection, a yellowish-brown, rust-col- ored fluid, the so-called typhoid pus, which may be sterile. It does not differ from ordinary pus Fig. 117.— Typhoid Focus •p I • £ i- -ii ii ; IN A Costal Carti- it secondarv nitectiou with the pyogenic cocci occurs. When the abscess ruptures, external suppurating fistula, which are maintained by small granulating and necrotic foci, are produced. These fistuUe, which are very resistant to treatment, remind one of tuberculous fistula'. Typhoid osteomyelitis develops most fre(iuently in the ribs. The foci are situated in the costal cartilages close to their articulation with the ribs or in the latter, in which are found small total sequestra sur- 258 WOUND INFECTIONS PRODUCED BY BACTERIA rounded by a thick granulation tissue and a thin involucrum. Cor- tical and central foci develop in the tibia; the involvement of other bones (pelvic and skull bones, clavicle, sternum, humerus, femur, ver- tebra^, spondjditis typhosa, Quincke) is rare. The osteomyelitis has an acute stage, and then pursues a chronic course. It is not rare for mul- tiple foci to develop. The inflammation remains localized and there is but little reactive bony growth. If the disease resembles acute sup- purative osteomyelitis there is either a mixed infection or infection with the staphylococcus or streptococcus alone (vide Secondary Osteo- myelitis). Ebermaier and Quincke made the important observation that typhoid bacilli are found as regularly, and almost in as large number, in the red bone marrow as in the spleen of patients dying of typhoid fever. They remain viable for a long time, as they have been found in osteal foci six to seven years after convalescence from typhoid fever (Sultan, Buschke, and others). According to Ponfick these bacteria produce slight but general alterations in the bony system, partly periosteal thick- ening, partly superficial caries. These findings make clear the relation existing between trauma and typhoid osteomyelitis. Pyogenic cocci may also pass through the diseased intestinal mucous membrane, enter the blood, and cause inflammation of bone even in adults, for the resistance of the bone marrow has been reduced by the typhoid infection. Suppurative inflammation of bone following infectious diseases is called secondary osteomyelitis. Before such an osteomyelitis develops, there must be a localization of the specific organisms in bone. In the metapneumonic osteomyelitis pneumococci and streptococci are found. Infection atria are provided in the course of infectious diseases for the ordinary pyogenic bacteria, and the resistance of the bone marrow is also probably reduced, and is therefore more susceptible to infection. This form of osteomyelitis de- velops in the course of or subsequent to typhoid fever, pneumonia, measles, scarlet fever, diphtheria, influenza, and smallpox. Phosphorus necrosis is also a secondary but not a pure suppurative osteomyelitis. Chronic phosphorus poisoning, which follows the inhala- tion of phosphorus fumes in the preparation of crystalline phosphorus and the manufacture of phosphorus matches, is associated with changes in the bones. Some post-mortem examinations have demonstrated an ossifying process (phosphorus periostitis and sclerosis), while clinical observations have demonstrated abnormal softness and fragility of the bones. Some patients have had multiple fractures (a case reported by Haeckel suf- fered thirteen fractures in sixteen years). The nature of these changes, especially those occurring in the jaws, is not exactly known. There THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 259 appears to be some direct relation to the phosphorus fumes which are inhaled. Continued feeding of small amounts of phosphorus produces in young animals an osteosclerosis (Wegner). On the other hand, a direct action ujxin exposed bony surfaces cannot be deiiioiisti-ated (von Stubenraueh), V \ ■ J^^ Fig. 118. — Phosphorus Necrosis of the Mandible After IIaeckel. Removed from a woman twenty-five years of age. At k, beginning line of demarcation, at Z a cloaca in the depths of which a cortical sequestrum may be seen. Osteophytes cover the surface of the bone. The most important changes occur in the mandible and maxilla, espe- cially in people who are engaged in the manufacture of matches. These changes were first described by Lorinser in 1845. The first changes, which sometimes consist of greater fragility of the jawbones, sometimes of thickening and sclerosis, develop without symp- toms and insidiously. The symptoms of the disease, which is to be re- garded as a secondary suppurative or sanious osteomyelitis, developing in bone already altered by phosphorus fumes, begin with an inflammation of the s:unis and periosteum. This inflammation is caused by the diflfer- ent pyogenic and putrefactive bacteria of the mouth cavity which gain access from carious teeth, small ulcers, and injuries to the gums and periosteum. Some of the teeth become loosened, yet there is no im- provement, as in the ordinary periostitis alveolaris, when they are extracted. Pain and swelling increase, the floor of the mouth and the 260 WOUND INFECTIONS PRODUCED BY BACTERIA cheeks become infiltrated. Later suppuration occurs, and fistulae are formed from which is discharged foul-smelling pus. Other teeth become loosened, the gums and the periosteum are raised from the bone by a layer of pus, and the surface of the bone is exposed. A large part of the bone involved may be destroyed by the chronic progressive inflam- mation; the entire mandible may become necrotic in from six to nine months. The remaining healthy periosteum forms a thick involucrum. The sequestrum, the edges of which become osteoporotic, separates slowly. In extensive necrosis two to three ,years are required for the separation of the sequestrum. Healing occurs after the sequestrum is extracted. In the meantime anchylosis of the jaw, disturbances of digestion, due to the swallowing of pus, poor nutrition, pain in the entire jaw, and other symptoms which are frequently accompanied by fever develop. The patient becomes w^eaker, and complications such as meningitis, general infection, and pneumonia may prove fatal. Death occurs in about one half of the cases. The mandible is involved about nine times more frequently than the maxilla, and the necrosis occurring in the former is much more extensive. The treatment is prophylactic and operative. The workrooms in match factories should be well ventilated; the mouth hygiene should be good ; employees should not be allowed to eat or drink in the workroom ; and the hands should be carefully washed after work. The teeth of the employees should be inspected frequently by a dentist, and no person employed who has bad teeth. By proper ventilation of the factory and proper care of the teeth of the employees, the largest match company in America, the Diamond Match Co., has practically eliminated the disease. The operative treatment consists of early and extensive subperiosteal resection of the diseased bone. After the periosteum and the osteophytes attached to it are sepa- rated, all the diseased bone is removed, the resection being carried into healthy tissues. Small partial resections of the alveolar process should not be made, but the middle piece, a half of the mandible, or the entire bone should be removed, depending upon the extent of the pathological changes, and the same treatment should be employed in necrosis of the maxilla (Riedel, ITaeckel). Suppuration ceases and repair follows after complete removal of the diseased bone. The periosteum regenerates bone so rapidly that good functional and cosmetic results are soon obtained, even after a total resection. Literature. — A. Becker (W. Miiller). Ueber einen ungewohnlichen Ausgang der akuten Osteomyelitis. Deutsche Zeitschr. f. Chir., Bd. 55, 1900, p. 577. — v. Bergmann. Ueber die pathol. Lilngszunahme der Knochen. PetersB. nied. Zeitschr., Bd. 20. — Braasch. Ueber pathoh Wachstum der Extreinitatenknochen im Gefolge akuter Osteomyelitis. I.-D. Berlin, 1897. — Dinochowski und Junowski. Ueber Eiterung THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 261 erregende Wirkiing des Typhusba^illus. Zieglers Beitr. z. path. Anat., Bd. 17, 1895, p. 221. — Endcrlcn. Histol. Untersuchungon bei experiin. erzeugter Osteomyelitis. Deutsche Zeitschr. f. Chir., Bd. 52, 18U9, p. 293. — Frunke. Uebcr einige chir. wiehtige Kt)in{)likationen und Nachkrankheiten der Influenza. Chir.-Kongr. Verliandl., 1899, II, p. 490. — Funkc. Beitr. zur Kenntnis der akuten Osteomyelitis. Arch. f. khn. Chir., Bd. 50, 18i)5, p. 4(52. — Gaiujolphe. Maladies des os, Paris, 1894. — Garrc. Ueber besondere Fornien und Folgezustiinde der akuten inf. Osteomyelitis. Beitr. z. klin. Chir., Bd. 10, 189:5, p. 241. — GcUiiskij. Fine Skelettdurehleuchtuiig l)ei einem Fall von Pyilmie. Fortsehr. auf d. Geb. d. Iltintgenstrahlen, Bd. 9. — Ilacckel. Die Phosphorne- krose. Arch. f. klin. Chir., Bd. 39, 1889, p. ry5'). — Ileljerich. Ueber die nach Nekrose an der Diaphyse tier langen Extremitiitenknochen auftretenden Storungen im Liingcn- wachstum derselben. Deutsche Zeitschr. f. Chir., Bd. 10, 1878, p. .324. — Ilidlmosir. Typhose Erkrankiuigen der Knochen und Gelenke. Sammelref. Zentralbl. f. Grrnz- gebiete, 1901, p. 417. — -Jordan. Die akute OsteomyeHtis. Beitr. z. klin. Chir., Bd. 10, 1893, p. 587; — Ueber atypische Formen der akuten Osteomyelitis. Did., Bd. 15, 1890, p. 457. — Koclier und Tavcl. Chirurgische Infektionskrankheiten, 1895. — Kiister. Ueber Friihoperationen bei Osteomyelitis. Chir.-Kongr. Verhandl., 1894, 11, p. 397. — Lexer. 1. Zur experim. Erzeugung osteomyelitischer Herde. Arch. f. klin. Chir., Bd. 48, 1894, p. 181; 2. Osteomyelitisexperimente mit einem spontan beim Kaninchen vorkommenden Eitererreger. Ibid., Bd. 52, 1896, p. 576; 3. E.xperi- mente iiber OsteomyeUtis. Ibid., Bd. 53, 1896, p. 260; 4. Die Aetiologie und die Mikroorganismen der akuten Osteomyelitis, v. Volkmanns Samml. klin. Vortr., N. F., 173, 1897; 5. Zur Kenntnis der Streptokokken- und Pneumokokkenosteomyelitis. Arch. f. klin. Chir., Bd. 57, 1898, p. 879; 6. Die Entstehung entziindlicher Knochenherde u. ihre Beziehung zu den Arterienverzweigungen der Knochen. Ibid., Bd. 71, 1903, p. 1 ; 7. Weitere Untersuchungen iiber Knochenarterien u. ihre Bedeutung f. Krankh. Vorgiinge. Ibid., Bd. 73, 1904, p. 481; 8. Untersuchungen iiber Knochenarterien u. s. w. Berlin, Hirschwald, 1904. — v. Mangoldt. Zur Behandlung der Knochenhohlen in der Tibia. Arch. f. klin. Chir., Bd. 69, 1903, p. 82.— v. Mosctig-Moorhof. Die Jo- doformknochen])lombe. Zentralbl. f. Chir., 1903, p. 433; — Erfahrungen mit der Jodoformknochenplombe. Deutsche Zeitschr. f. Chir., Bd. 71, 1904, p. 419. — Nasse. Chirurgische Krankheiten der unteren Extremitaten. Deutsche Chirurgie. — Oilier. Trait e experimental et clinique de la regeneration des os et de la production artificielle du tissue osseux. Paris, 1867. — Perez. Die Influenza in chirurgischer Beziehung. Deutsche Zeitschr. f. Chir., Bd. 63, 1902, p. 460. — Reiss. Klinische Beobachtungen iiber Osteomyelitis der langen Rohrenknochen, besonders in Bezug auf die Epiphysen- knorpelfuge und die begleitenden Gelenkaffektionen. Arbeiten aus v. Bergmanns Klinik Berlin, Bd. 15, 1901.— Regnaidt. De la longeur relative des os. Bull, et mem. de la societe anatom. de Paris, 1900, No. 5. — Rledel. Ueber Phosphornekrose. Chir.- Kongr. Verhandl., 1896, II, p. 485. — Rieffel et Mauclaire. Maladies des os. Traite de chirurgie, le Dentu et Delbet, Paris, 1896. — Rocseler. Beitr. zur Osteomyelitis mit besonderer Beriicksichtigimg der Therapie und der Heilerfolge. v. Volkmanns Samml. klin. Vortr., N. F., 243.— 5c/irt«2. Ueber Spondylitis typhosa. Arch. f. klin. Chir., Btl. 61, 1900, p. 103. — Schlagenhaufer. Osteomyelitis durch Bacillus pneumoniae. Zentral- bl. fvir Bakteriol., Bd. 31, 1902, p. 73. — Schlange. Ueber einige seltenere Knochen- affektionen. Arch. f. klin. Chir., Bd. 36, 1887, p. 97.— M. B. Schmidt. Akute eiterige Osteomyelitis. Ergebn. d. allg. Path. Lubarsch-Ostertag, January 5, Wiesbaden, 1900, p. 956. — Schrnnk. Ueber einen Fall von seriiser Osteomyelitis am Hinterhaupte, der eine Meningocele vortauschte. Berl. klin. Wochenschr., 1902, p. 780. — Schuchardt. Die Krankheiten tier Knochen u. Gelenke. Deutsche Chir., 1899. — Silbernuirk. Ueber die gewebl. Veriinderimgen nach Plombierung von Knochenhohlen. Deutsche Zeitschr. f. Chir., Bd. 75, 1904, p. 290. — v. Stubenrauch. Die Lehre von der Phosphornekrose. 18 262 WOUND INFECTIONS PRODUCED BY BACTERIA V. Volkmanns Samml. klin. Vortr., N. F., 303. — Trendel. Beitr. z. Kenntnis der akut. infekt. Osteomyelitis. Beitr. z. klin. Chir., Bd. 41, 1904, p. 607. — Ullmann. Osteomye- litis gonorrhoica. Wien. med. Presse, 1900. — v. Volkmann. Die Krankheiten der Bewegungsorgane, 1865. — Vollert. Ueber die sogen. Periostitis albuminosa. v. Volkmanns Samml. klin. Vortr., 352, 1890. — Wegner. Der Einfluss des Phosphors auf den Organismus. Virchows Arch., Bd. 55, 1872, p. 11. — Weichselbaum. Verander- ungen der Knochen bei den akuten Infektionskrankheiten. Verhandl. der Gesellsch. deutscher Naturforscher, 1894, Wien. — Wrede. Hamatogene Osteomyelitis durch Aktinomyces. Chir.-Kongr. Verhandl., 1906. — Wyss. Ueber einen neuen anaerob. path. Bac. Mitteil. a. d. Grenzgeb., Bd. 1904, p. 199. (f) PYOGENIC INFECTIONS OF JOINTS Etiology. — Primary infection of a joint follows gunshot, contused and punctured wounds, the penetration of foreign bodies (needle, nail, pieces of glass or steel), compound dislocations and fractures. Second- ary infection occurs when an adjacent phlegmon, erysipelas, acute and chronic suppurative osteomyelitis extends to a joint, or when a fistula, resulting from previous disease of the joint (e. g., tuberculous fistula), becomes infected. Bacteriology. — H^ematogenous arthritis develops when bacteria are deposited in the capillaries of the synovial membrane. This form of arthritis develops, as a rule, during the course of other infections, and an injury may be the predisposing cause. A multiple serous arthritis may develop in the course of an endocarditis caused by pyogenic bac- teria, which may resemble clinically and be confused with acute articular rheumatism. Suppurative arthritis accompanies especially acute suppu- rative osteomyelitis and the general pyogenic infections. Serous and suppurative arthritis occurs in the course of a number of infections which afford infection atria for the ordinary pyogenic cocci (diphtheria, scarlet fever, measles, smallpox), or for the specific micro-organisms of the disease alone or combined with other bacteria (typhoid fever, pneumonia, gonorrhea, erysipelas, epidemic cerebrospinal meningitis, influenza). Not only staphylococci and streptococci, but also the rarer forms of pyogenic bacteria, among these the bacillus of pneumonia and the men- ingococcus, are found in the different forms of arthritis. The staphy- lococci and streptococci produce particularly the severe, but are also found in the mild forms. Morbid Anatomy. — When one comes to the consideration of inflam- mation, the synovial membrane is the most important part of the joint. The lining of the joint capsule, the stratum synoviale, which differs from the stratum fibrosum external to it, extends to the edges of the articular cartilages. The free surface of the stratum synoviale is not covered with epithelium or endothelium, but by a thin layer of regularly arranged, THE I'YOCIENIC INFLECTIONS OF DIFFERENT TISSUES 263 epitholial-like connective tissue, whicli is provided with fine, threadlike or larger leatlike processes, the synovial villi, some of which contain fat. The synovial membrane and its villi are very vascular, and the capillaries penetrate into the fine, epithelial-like connective tissue. The synovial membrane is also provided with a well-developed lym- }>hatic plexus, which is not, however, in open communication with the cavity of the joint, as the lynii)luitic plexuses of the serous membranes are with the serous cavities. Clinical Forms. — The symptoms of inflammation follow infection. A small amount of the exudate is poured out into the tissue of the cap- sule, the greater amount into the cavity of the joint. It makes no dif- ference whether the liacteria have been carried into the loose connective ti.ssues of the synovial membrane by injury, have reached it through the l)lo()d, or whether an osteoniyelitic focus has ruptured into the joint and infected the entire surface of the membrane. AVe distinguish according to the character of the exudate three principal forms of synovitis (ar- thritis if not only the synovial membrane, but all the tis.sues of the joint are involved), the serous, fibrinous, and suppurative. There are a num- ber of transitional forms. Sometimes a fourth form, the ichorus syno- vitis (in open wounds), occurs when there is an infection with putre- factive bacteria. Serous and serofibrinous synovitis is a mild form. It develops after open injuries of the joints, secondary to encapsulated suppurating foci in the epiphysis, and to adjacent inflammation, in infectious diseases (pneumonia, typhoid fever, gonorrhea, etc.), and especially in "general infections. It develops acutely in one or more joints. The joint involved is pain- ful, tense, and becopies considerably swollen. The skin covering it may be hot and reddened. The function of the joint is interfered with, there is some fever, and the general symptoms vary. If there is a large amount of serous exudate, the joint capsule and the bursiP communicating with the joint become distended and promi- nent where anatomical relations permit (in the knee joint, at the sides of the ligamentum patellae and upper recess). Fluctuation is plainly made out, and the patella is raised from its normal position and floats. The normal contour of the joint is lost, and is replaced by that of the distended joint capsule {vide Tuberculous Hydrops). If, on the other hand, there is but a small amount of exudate, but con- siderable infiltration of the capsule and fibrinous masses are deposited upon the synovial membrane, tumorlike thickenings may be felt, espe- cially at the points of reflection of the capsule, which often creak when palpated or moved. These thickenings, together with an (edematous infil- tration of the peri- and para-articular tissues, render the outlines of the 264 WOUND INFECTIONS PRODUCED BY BACTERIA joint indistinct (particularly in the phlegmonous form of gonorrheal arthritis). As a rule, when serous synovitis is properly treated, the serous exu- date is absorbed and the inflammation subsides without leaving any articular changes. If the inflammation recurs, a chronic condition with hydrarthrosis and groAvth of villi, as in traumatic arthritis, may develop. Then, Avithout any pathological changes in the articular cartilages or bones, the distended capsule may permit of abnormal movements (flail joint) or the development of luxations and subluxations (for example, in t.yphoid fever, scarlet fever, and smallpox). If the tissues of the capsule become inflamed, they may shrink and produce permanent disturbances of motion. These will be still greater if there has been a large fibrinous exudate which produces adhesions (especially in gonorrheal arthritis). The serous exudate, a yellowish fluid somewhat clouded by pus cor- puscles, contains less mucin, but more albumin, than synovial fluid. The fibrinous exudate contains, besides small or large amounts of se- rous exudate, large amounts of fibrin, which occurs in acute infections in the form of flakes or membranes, loosely attached to the recesses, folds, and villi of the synovial membrane. In chronic inflammations these masses of fibrin become firmly attached to the hypertrophied synovial membrane and produce fibrinous, or if organized, fibrous, adhesions of the opposed surfaces. Treatment of Serous and Serofibrinous Synovitis. — In the acute cases immobilization of the joint, after the removal by puncture of the larger exudates, is often sufficient. In the recurrent and chronic forms, aspira- tion combined with irrigation with from one to two per cent carbolic or boric acid solution is to be recommended. Early massage and careful passive motion are required in those cases in which there is a tendency to stiffness. Besides, one may attempt to hasten the absorption of the inflam- matory infiltration of the capsule by an artificially induced hyperoemia (painting with tincture of iodin, treatment with hot-air apparatus, Bier's passive hyperemia). Suppurative Synovitis. — Suppurative inflammation of joints (empy- ema) may be superficial or deep, and involve the synovial membrane or all the structures of the joint (synovitis and arthritis (para-arthritis) acuta purulenta). The superficial suppurative joint inflammation (synovitis purulenta) — the catarrhal suppurative inflammation of joints of von Volkmann — is the mild form. The inflamed, reddened, and thickened folds of the syno- vial membrane secrete a profuse nuicopurulent exudate which often con- taioi) fibrin flakes. The inflammation involves only the inner layers of THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 205 the ciipsulc, ;ni(l if proper troatniont is institutod early tliei'(> may l)e a restitutio ad inte^rimi. If it persists foi' a loiial arthritis pursues a chronic course. The hydrops is the only form which may subside rap- idly, but it tends to recur. The suppurative and phleg- monous forms, on the other hand, are very re- sistant to treatment, al- though they only rarely result in abscess forma- tion. A After one or two 1^;. 120. — Boxy Anchylosis of the Knee Joint in ,1,1 • 1 THE Valgus Position Following a Gonorrheal months the pani and . * Arthritis. swelling subside; in the meantime the nniscles atroph.> and the contracture of the joint, which in the beginning was mostly reflex, is followed by anchylosis. 270 WOUND INFECTIONS PRODUCED BY BACTERIA The contraction of the infiltrated peri- and para-articular tissues, but still more the adhesions resulting from the organization of the fibrinous masses in the joint cavity, produce an anchylosis. In the beginning there may be but a partial or extensive fibrous anchylosis, but later when the articular cartilages are destroyed a bony anchylosis develops which is, as a rule, never complete, but there is no evidence upon section or in Rontgen pictures of any joint cavity (Fig. 120). The general condition is less affected by the infection than by the severe pain. The sequelae of gonorrheal arthritis are, besides anchylosis, contrac- tures and subluxations. The latter, due to a distention of the capsule and relaxation of the ligaments, may occur even after two weeks (Ben- necke). The acute onset and intense pain, which is aggravated by pressure and motion, are important in making a diagnosis of the exudative form of gonorrheal arthritis, and in differentiating it from other inflamma- tions. The swelling which develops in the phlegmonous forms is not sharply limited, sometimes it has a doughy feel and at other times fluc- tuates in certain areas. The skin covering the swelling is red and edematous. The fever, as a rule, is not high, and this often enables one to differentiate the phlegmonous form from suppurative arthritis due to the ordinary pyogenic bacteria. Often a bacteriological examina- tion of the aspirated fluid is necessary before a differential diagnosis can be made. Fewer joints are involved in gonorrheal arthritis than in articular rheumatism, and the pain is more intense. An existing gon- orrhea makes probable the diagnosis of gonorrheal arthritis. The rarer subacute and chronic forms cannot be easily differentiated from tuber- culous and syphilitic arthritis. 'The phlegmonous form in the chronic stage may resemble the tumor albus. The prognosis as to life is good if a severe and, as a rule, fatal endo- carditis does not develop. The prognosis as to function is best in the gonorrheal hydrops. The suppurative and phlegmonous forms, accom- panied by an infiltration of the soft tissues, are often followed by anchy- losis and joint changes. The disease may last from four weeks to many months. The duration depends upon the severity of the infection and the number of relapses. It may recur in a joint which has already been involved, so long as the gonorrhea persists. Absolute rest of the joint, which should be maintained as long as fever, pain, and swelling persist, is the most important part of the treat- ment. In most cases the inflammation will subside and contractures be prevented. Immobilizing dressings should be used for this purpose; in THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 271 inflaiiiinatioii of tlu' hip these may be eombiued with extension. If the exudate is lar^e, a.spiration with subseciuent eonipression may be neces- sary. The injection of Hve per cent earbtilic acid (up to 8 c.c.) has been used l)y Koenig. Incisions should be made only when abscesses develop and in the phlegmonous forms (particularly in mixed and secondary infections). If anchylosis develops, active and passive motion should be employed and the immobilizing dressing removed. The latter should be applied again if fever follows use of the joint. In bad cases an anaesthetic should be given when the adhesions are broken up and the contractures corrected. This procedure, which is often successful, is exceedingly painful, and cannot be satisfactorily performed unless an anaesthetic is administered. Bier's passive hypera^mia has a favorable influence in many cases. It controls the pain and permits of early movement. The toxins are diluted by the increased transudate and are gradually absorbed. In the lower extremity a resection of the joint may be required to correct the malposition. In the upper extremity (shoulder and elbow joints) soft tissues should be placed between the resected parts of the bone in order to obtain movement. In rare cases during the course of a croupous pneumonia one or many joints may become involved. This arthritis, which develops most frequently when the disease is at its height, is caused by the pneumo- coccus. The serofibrinous or suppurative catarrhal synovitis (arthritis) pursues an acute course, and if there are symptoms which indicate gen- eral infection, endocarditis, or suppuration in the serous cavities, the prognosis is bad. In favorable cases the synovitis subsides after immo- bilization, combined with puncture and aspiration if the exudate is serous, with incision if j)urulent. As a rule, there is restitutio ad inte- grum. Pneumococcic arthritis without a preceding pneumonia is rare in adults. It is more frequent in small children, developing secondarily to foci in the articular ends of bone {vide Osteomyelitis). Apparently an inflamed pharyngeal mucous membrane affords the infection atrium. Synovitis occurring during the course of t\'phoid fever, and caused bj' the typhoid bacilli, is rare. This form of arthritis develops during convalescence and pursues a benign course. The inflammation subsides after aspiration of the serous or seroha^morrhagic exudate and immobili- zation, if there is no mixed infection with staphylococci or streptococci which produce severe and destructive forms of suppuration. Literature. — Bennecke. Die gonorrhoische Gelenkentziindung. Berlin. 18P9. — Cave. Pneumococcic arthritis. The Lancet. 190L — Hartmann. Ueber die Behand- lung der akiiten primiir sjTiovialen Eiterungen der grossen Gelenke. Deutsche Zeitschr. f. Chir., Bd. 57, 1900, p. 231. — Heile. L'eber d. Zerstonmg d. hyalinen Gelenkund 272 WOUND IXFECTIOXS PRODUCED BY BACTERIA Epiphysenknorpels bei Tuberkiilose und Eiterung. Virchows Arch., Bd. 163, 1901, p. 265. — Hoffa. Die Pathogenese der arthritischen Muskelatrophien. Chir.-Kongr. Verhandl., 18'.I2, I, p. 93. — -Konig. Ueber gonorrhoische Gelenkentziindungen. Deutsche med. A\'ochenschr., 1896, p. 751. — Mauclaire. Des Arthrites suppurees. Paris, 1895. — Nasse. Die gonorrh. Entziindungen der Gelenke u. s. w. v. Volkmanns Samnil. klin. Vortr., N. F., 181, 1897. — Pfisterer. Ueber Pneumokokkengelenk- und Knocheneiterungen. I.-D. Berlin, 1902. — Predtetschensky. Akuter und chronischer Gelenkrheumatismus. Zentralbl. f. Grenzgeb., Bd. 5, 1902, p. 657. — Schuchardt. Die Krankheiten der Knochen und Gelenke. Stuttgart, 1899. — Witzel. Die Gelenk- und Ivnochenerkrankungen bei akuten infektiosen Erkrankungen. Bonn, 1890. (g) PYOGENIC DISEASES OF TENDON SHEATHS AND BURS^ Etiology. — Inflammation of tendon sheaths and bursas follows most frequently open injuries, penetrating foreign bodies, and the extension of inflammation from neighboring foci (suppurating wound of the skin, furuncle, subcutaneous phlegmon, erysipelas, etc.). Ha?matogenous in- fections are more rare. Staphylococci and streptococci are found most frequently in these inflammations; the latter especially in the severe forms. Other bacteria, such as the gonococcus, pneumococcus, bacterium coli commune, etc., are found but rarely. Pathology. — These inflammations have an acute onset, associated with fever. In the beginning the exudate is serous, but it rapidly becomes purulent. The extension of the inflammation depends upon the ana- tomical relations and the size of the tendon sheaths and bursse, and for this reason the clinical picture is often very characteristic. If the in- flammation is limited to the wall of the tendon sheath or bursa, it becomes covered with granulation tissue (pyogenic membrane). If a severe in- flammation produces after a few days a necrosis of the sheath or bursa, the inflammation extends rapidly and widely into the intermuscular and subcutaneous tissues. Then the clinical picture changes to that of a cir- cumscribed or progressive phlegmon. In the former the pus gradually ruptures through the skin, and fistulce are found which are resistant to treatment, while in the latter the inflammation extends far beyond the sheaths, the walls of which, as well as the tendons and their accessory bands, become necrotic. The tendon is affected early by the inflammation which extends along the synovial membrane, covering the tendon and lining the sheath. The connective tissue septa become filled with leucocytes in the first few days, and karyokinetic figures and an increase of the cells in the tendon indi- cate a reactive growth. Necrosis of the tendon begins in from three to five days. It becomes fibrillated and necrotic. If such a tendon is not removed it acts as a foreign body, like a sequestrum in bone, and a chronic suppurating fistula develops. A little of the tendon may sur- vive and become united with the cicatricial tissue, which develops from THE PYOGENIC INFECTIONS OF DIFFERENT Tl.SSl ES 273 the granulations after the necrotic tendon has been extruded. This cicatricial tissue interferes with the function of the part involved. Inflammation of a buksxV (bursitis acuta purulenta) is character- ized clinically by a rapidly developinsr, painful, circumscribed, fluc- tuatin«r swellinir, which develops in the position of a mucous bursa (e. g., bursa i)ra'patellai'is, olccrani). The skin covering the bursa becomes cedematous and reddened. The borders of the n'dncss an^ not sharply defined. The i>us either ruptures through the skin, producing a chronic fistula, or extends beneath the fascia covering the bursa and produces a large phlegmon. If the bur- sitis develops from a wound in the skin covering the bursa, lymphangitis and erysipelas often develop simultaneously. Inflammation of a tendon sheath (tendovaginitis acuta puru- lenta) (phlegmon of the tendon sheath, panaritium tendinosum) begins with a swelling which extends rapidly along the tendon sheath and is associated with loss of function of the part involved, pain upon pressure, and motion and some reddening of the skin. Fluctuation is first elicited, when there is a large collection of pus, particularly after the process is encapsulated, and shortly before it ruptures through the skin. The dangers and results of a suppurative bursitis lie in the exten- sion of the inflammation to a neighboring j(nnt. Those of a synoxntis. Fa.. 121. — Cicatricial CoxTRACTniE of the TnrMB Following a SrpprRATm: Inflamma- tion OF the Synovial Sheaths of the Flexor Tendons of the Thumb and Little Finger, the So-called V-Phlegmon. The inflammation followed a punctured wound of the little finger which was disarticulated because of osteomyelitis. leaving out of consideration a progressive phlegmon, lie in the disturb- ance of function produced by the destruction of the tendons and the contractures following the contraction of the cicatricial masses. A gen- eral pyogenic infection may follow a phlegmon which develops after rupture of the synovial sheath. The diagnosis is not difficult. The posi- tion of the acute inflammatory swelling indicates with certainty that either a bursa or a tendon sheath is involved. In the latter the inflam- mation extends along definite anatomical routes. An inflammation of the sheaths of the flexor tendons of the second, third, and fourth fingers extends only to the transverse furrow of the palm, as the sheaths end 274 WOUND INFECTIONS PRODUCED BY BACTERIA here. Inflammation of, the sheaths of the thumb and little finger extends to the wrist joint or even higher, for frequently the sheaths of these fingers communicate with the sheath which is common to the superficial and deep flexors. The treatment of acute suppurative btirsitis (bursitis acuta puru- lenta) consists of incision and the after-treatment which is employed in suppurative inflammation. In the treatment of tendovaginitis it should be especially kept in mind that the earlier the incision is made and the pus is allowed to escape the better will be the prognosis, both as regards the repair of the tendon and the later restoration of function, as early incision prevents the formation of broad adhesions between the tendon and its sheath. The incision should be made so that there will be the least possible cicatricial contraction. This always follows incisions made directly over the tendon which extend through the synovial sheath and its transverse connective tissue bundles. It may be avoided if small incisions are made. The incLsions should be made at the side of the tendon, and the transverse fibers of the sheath and the corresponding skin (transverse furrows in the fingers, in the wrist especially the lig. carpi volare) should be avoided. These small incisions frequently control the inflammation and permit of a complete restoration of function. When they do not provide for a free discharge of pus and control the phlegmon an incision must be made through the folds of the skin, the tendon sheaths, and the support- ing ligaments of the joints. Then the fate of the tendon, associated with complete loss of function, is sealed. If the inflammation is mild from the beginning, the extremity may be immobilized, elevated, and treated expectantly.. Sometimes in staphy- lococcic and gonorrheal infections the inflammation subsides or an ab- scess forms. Little is to be expected as regards restoration of function in the treat- ment of cicatricial contractures following phlegmonous tendovaginitis. The mechanical treatment, stretching of the scar, is naturally not suc- cessful, because of the anchylosis, the result of the accompanying ar- thritis. This treatment is rarely successful, even when the joints are not involved. An excessive stretching of the scar may be followed by an increased contraction. The finger may be straightened by excising the scar and skin grafting the defect, but there will be no return of motion. It is rare to obtain even a little motion, for when the scar is carefully dissected away from the tendon, new adhesions develop. Amputation is indicated if the life of the patient is threatened by general pj'ogenic infection or if the deformity, resulting from cicatricial contraction, interferes with work. THE PYOGENIC IXFECTIOXS OF DIFFERENT TISSUES 275 Acute gonorrheal bursitis and tendovaginitis should be especially mentioned. Frequently a serous, more rarely a suppurative bursitis or tendovajiinitis is associated with a tronorrheal arthritis. They are, as a rule, beniiin ; and subside spontaneously. Adhesions rarely form between the tendon and the sheath, and there is no disturbance of function. The bursa of the tendo Aehillis, the sheaths of the flexor and extensor tendons of the fingers, and the sheaths of the tendons passing behind the internal malleolus are most frecjuently involved (Xasse). The extremity ,sh(:uld be immobilized as long as the sj'mptoms of inflannnation persist. Large serous exudate should be aspirated, large purulent exudates incised, and active and passive motion should be be- gun at the proper time. Rapid healing and good function are obtained when proper treatment is instituted. Chronic changes with adhesions may follow this type of inflammation (Xasse). Literature. — v. Bergmann. Die Behandlung der akut progred. Phlegmone. Arbeiten aus der v. Bergmannschen Klinik, Bd. 15, 1901. — Jukohi und Goldmann. Tendovaginitis suppurativa gonorrhoica. Beitr. zur klin. Chir., Bd. 12, 1894, p. 827. — Xasse. Die gonorrh. Entziindungen der Geleuke, Sehnenscheiden und Schleimbeutel. V. Volkmanns Samml. klin. Vortr., X. F., 181, 1897. (h) THE PYOGENIC DISEASES OF MUSCLES AND THE SUBFASCIAL AND INTERMUSCULAR PHLEGMON Acute Suppurative Myositis {Myositis Acuta Puruh nta). — Acute sup- purative myositis, like every pyogenic infection, may develop in different ways. The interstitial tissue, as well as the contractile substance of the nuiscle, may be involved. AVe speak of an interstitial, which is as a rule suppurative, more rarely serous or serofibrinous, and of parenchymatous- degenerative myositis. Ectogenous infections follow most frequently wounds in which mus- cles have been crushed or lacerated (compound fractures, gunshot frac- tures with laceration and contusion oi nuiscles, bites by animals suffer- ing from hydrophobia, machine injuries, etc.). ]\Iixed infections with a number of pyogenic bacteria, also combined with putrefactive bacteria, are most frequent. If the cutaneous wound is small and its edges become quickly agglutinated, as in gunshot and stab wounds, and in fractures in which a sharp fragment pierces the skin, an inflammation of the injured muscle may not develop unless bacteria are carried into the wound by improper treatment, irrigation, and prob- ing of the wound. Inflammation, which is as a rule suppurative, may extend from adja- cent foci. A phlegmonous erysipelas, a subcutaneous phlegmon, tendo- vaginitis, lymphangitis, lymphadenitis, phlebitis, osteomyelitis, etc., may 276 WOUND INFECTIONS PRODUCED BY BACTERIA extend to the loose intermuscular connective tissues. After the fascia is destroyed the inflammation attacks the perimysium and the interstitial tissue. These are destroyed by suppuration, and the contractile substance of the muscle becomes necrotic. ' A hematogenous infection occurring in the course of a general pyo- genic infection may produce a circumscribed suppurative inflammation in one cr many muscles. The muscles may be attacked simultaneously or in succession. This form of myositis is most frequently caused by staphylococci and streptococci, more rarely by the pneumococcus and gonocoecus, colon and typhoid bacilli (following typhoid fever), and in- fluenza bacilli. A subcutaneous muscle injury (laceration, contusion with hematoma) may suppurate if there is inflammatory focus (felon, angina) from which the bacteria, which later are deposited in the injured tissue (locus minoris resistentie ) , may be absorbed. A beginning myositis is indicated by a painful swelling of the muscle, complete loss of function, and fever. The muscle involved becomes en- larged and hard, and its boundaries cannot be accurately determined be- cause of the tpdema of the surrounding structures, the subcutaneous tissue and skin. When the hard infiltrated area softens we have the symptoms of an abscess, which later ruptures through the skin. A progressive inflammation produces, after extending to the inter- stitial tissue, a destruction of the entire muscle, and then extends to the surrounding tissues. Permanent loss of function and contractures follow if a fatal general infection does not develop. The severest forms of interstitial myositis are followed by large defects in the muscle which are replaced by scar tissue. A circumscribed abscess develops if the interstitial pyogenic mem- brane encapsulates the pus, resulting from a destruction of the inflamed tissues. After the pus is evacuated by incision or discharged spontane- ously, scar tissue fills in the defect. This scar tissue does not inter- fere with the function of the muscle unless the abscess has been very large. Secondary myositis, developing from an adjacent suppurative osteo- myelitis or lymphadenitis, frequently pursues a mild course with only a serous exudate, and subsides spontaneously. The formation of scar tissue and degeneration of the contractile substance (myositis fibrosa), which interfere with the function of the muscle, are the usual results. In making a diagnosis it is important to note that the hard, painful swelling which develops suddenly and gradually softens, corresponds to the position of the muscle, and that the inflammation extends within the limits of the muscle. If the oedema of the surrounding tissues is marked, the development of a swelling which extends down to the bone is suggestive of myositis. A myositis may be mistaken most easily for an THE PYOGENIC INFECTIONS OF DIFFERENT TISSUES 277 iiiflainiiiatory swelling: associated uitli an intlaniinalion of the deep Ij^m- pliaties or a suppurative osteomyelitis. The ircatmcut consists of Iary:e incisions which should be made par- allel to the muscle fibei*s. The after-treatment is carried out accordinjj to rules ali-eady given {vide p. IDi)), disturbances of function due to scar tissuf may be overcome by operative measures. The distal tendon of the deirenerated muscle may be cut transvei-sely and united with the border of a healthy nuiscle, or with a pedunculated muscle flap taken from an adjacent umscle. Literature. — Ileinrich Lorenz. Die Muskelerkrankungcn. In Nothnagels spcz. Pathologic und Therapie, Bd. 11, Wicn, 18'.>8. Subfascial and intermuscular phlegmons, each of which may develop from the other, follow subcutaneous phlegmons, the rupture of suppu- rative intlannnation of tendons, uuiscles, joints, bones, and infection of the connective tissue surroundin"; the cesophagus. These phlegmons also develop in deep wounds and in the course of metastatic infections. They spread in the loose connective tissue, filling the intermuscular spaces, particularly along the connective tissue surrounding the large vessels (e. g., vascular sheath in the neck, axillary and popliteal fossa?). The brawny induration of the soft tissues, the reddening and oedema of the overlying skin, fever, pain, and loss of function are the most important symptoms. In favorable eases the indurated area softens and the pus is discharged. Frequently, however, dangerous complications fellow the rapid extension of the inflannnation. A phlegmon of the neck may extend to the mediastinum or cause a fatal (Pdema of the glottis. Large incisitms should be made early. The tissues surrounding the large vessels and tilling the intermuscular spaces must be exposed. If an original fecus (e. g., perforation of the (esophagus, suppurative osteo- myelitis or arthritis) exists, it should be found when possible. In the after-treatment, can* should be exercised to prevent the erosion of large vessels. Drainage tubes should be carefully placed; hard, re- sistant tubes shoidd not be used {vide Arteritis). LiTEUATURE.— A'. V. Bcrgmanii. Die Behamllung der akut progredienteii Phlegmone V. Bergnuuinsche Arbeiten, Bd. 15, 1901. Berlin, Hirschwald. Woody phlegmon (brawny induration) of Reelus is a peculiar in- flannnation, which involves most frequently the intermuscular and sub- cutaneous tissui'S of the neck. It pursues a chronic course, with little fever, a boardlike hardness, and almost painless swelling of the soft tissues. There is but little tendency to suppuration. Streptococci, staphylococci, pneumocoeci, and diphtheria bacilli have been found in the exudate, which is small in amount. Sometimes bae- 19 278 WOUND INFECTIONS PRODUCED BY BACTERIA teria are looked for in vain. Tliese inflammations develop most often from the mucous membrane of the floor of the mouth and pharynx. Apparently they are caused by attenuated forms of bacteria, and for this reason the tissues do not become necrotic and pus is not formed, or only in small amounts. If an incision is made early, because of the danger of oedema of the glottis or dysphagia, the surgeon finds a brawny indurated connective tissue, and often in the intermuscular spaces a cloudy, many times a purulent exudate, especially in the submaxillary region adjacent to swol- len and softened lymph nodes. This form of inflammation may be mis- taken for actinomycosis, as the boardlike infiltration is the most impor- tant characteristic of the latter. AA^arm, moist compresses are to be recommended to soften the infil- trated area. Quicker results are obtained by incision and exposure of the infiltrated intermuscular spaces. Even if pus is not found the bac- teria are removed with the wound secretion. Literature. — Jansson. Holzphlegmone. Hygieia, January 2, 1904. — Kusnetzoff. Ueber die Holzphlegmonen des Halses (Reclus). Arch. f. klin. Chir., Bd. 58, 1899, p. 455. (i) PYOGEmC INFECTIONS OF SEROUS CAVITIES AND DIFFERENT ORGANS Infection of the serous cavities and viscera may occur from without (ectogenous) or from within (endogenous). Ectogenous infections fol- low penetrating or perforating wounds (deep cuts, stab and gunshot wounds) ; endogenous infections follow traumatic or inflammatory per- foration of organs lined with mucous membrane (e. g., peritonitis follow- ing subcutaneous rupture of the intestine, pleuritis following traumatic rupture of a bronchiole in subcutaneous fracture of the ribs, meningitis after injury of the internal ear, or ethmoid cells in fracture of the base of the skull, etc.). Such an infection may occur through the lymphatics (lymphogenous) or by direct extension (e. g., pleurisy secondary to lung abscess, pneu- monia, osteomyelitis of a rib, peritonitis; meningitis secondary to osteo- myelitis of the cranial bones, thrombophlebitis of the sinuses, brain abscess; peritonitis secondary to pleuritis, the inflammation extending along the lymphatics of the diaphragm, phlegmon of the stomach, intes- tines, and abdominal wall ; brain abscess secondary to extradural suppu- ration or thrombophlebitis of the veins of the diploe ; abscess of the kid- ney (pyonephrosis) secondary to cystitis). Haematogenous infection may involve the viscera and serous cavities. In general pyogenic infections, accompanied by metastatic inflamma- tions, they become infected at the same time that other tissues do. In- GENERAL PYOGENIC INFECTIONS 279 fected emboli lodge in the lung and cause lung abscess; infection of the liver occurs through the portal vein. Three principal forms of inflamnmtion, which may be accompanied by different exudates, are to be differentiated in serous cavities: the cifcumscribcd, the acute progressive, and general inflammation. In the circuniscribed form the serous surfaces become adherent at the borders of the graiiulation tissue. In the acute progressive form the infiammation is not encapsulated, or only incompletely. An encapsulated focus may also rupture through the protecting granulation tissue; then an acute pro- gressive infiammation develops. The general form in which the entire surface of serous membranes is involved develops from the acute pro- gressive forms. Following pyogenic infections of the viscera, circumscribed foci, which are usually multiple, may develop, or the iiiflanmiation may be diffuse involving the entire viscus. The clinical course, diagnosis and treatment of these infections be- long to the province of special surgery. AVhen suppuration occurs in serous membranes a wide incision should be made, and free drainage established as soon as possible. In the skull and thorax the necessary preliminary operation must be performed (trephining, resection of rib). In the milder forms of infiammation puncture with aspiration may be sufficient (e. g., in pleurisy, lumbar puncture in meningitis). AVhen abscesses develop in the different viscera they should be incised; when possible, and the conditions found indi- cate such a procedure, the entire viscus should be extirpated (e. g., kid- ney, testicle, ovary, spleen). Literature. — Haegler. Ueber das freie serose Exsudat des Peritoneum als Friih- symptom einer Perforationsperitonitis. Zentralbl. f. Chir., 1904, p. 282. — Xoctzel. Die Prinzipien der Peritonitisbehandlung. Beitrage z. klin. Chir., Bd. 46, 1905, p. 514; —Die Behandhmg der append izitischen Abszesse. Il)id., Bd. 47, 1905, p. 826. — Peiser. Zur Pathologic der bakteriellen Peritonitis. Ibid., Bd. 45, 1905, p. 111. CHAPTER V GENERAL PYOGENIC INFECTIONS During the course of any local pyogenic infection micro-organisms and their toxins may be absorbed, and groups of bacteria may invade the l>Tiiphatic vessels and blood vessels and gain access to the blood. A general reaction follows the absorption of infectious materials, which 280 WOUND INFECTIONS PRODUCED BY BACTERIA varies in intensity, depending- upon the number and virulence of the bac- teria absorbed and the character of their toxins. This general reaction is characterized by fever and the symptoms which accompany it. The general reaction following a local infection is due to the absorp- tion of toxins, and is apparently of a protective nature. Bacteria are found in the blood quite frequently even in the mild general reactions, but the latter are very different from general pyogenic infections. In the general reaction following a local infection the bactericidal prop- erties of the blood and tissue fluids destroy the bacteria and neutralize the toxins, while in the general pyogenic infections the resistance of the organism is so reduced, or the bacteria are absorbed in such large num- bers and are so virulent, that they multiply rapidly and may be deposited in the different tissues and viscera producing metastatic foci. If the bacteria and their toxins prevail over the bactericidal properties of the blood and tissue fluids, a general pyogenic infection develops. There are two principal forms of general pyogenic infections, between which there are many transitions. The chief characteristic of one form is the development of multiple suppurating metastatic foci, of the other the multiplication of bacteria in the blood without the development of metastatic foci. I therefore differentiate : A general pyogenic infection with metastases in which there occur intermittent transitory infections of the blood (metastatic infection) and A general pyogenic infection without metastases in which there is a persistent (toxic and bacterial) infection of the blood. In the general infection characterized by metastases the infection is spread by way of the blood stream only, and foci of infection develop in different parts of the body. The infection may be produced in two ways: Either groups of bacteria (bacterial emboli) pass through the walls of the diseased vessels in the primary focus into the blood stream, or are carried by pieces of thrombi (infected emboli) which have been destroyed by suppuration into the circulation, producing where they are deposited metastatic foci of suppuration. Infarction frequently precedes the development of these foci. In some cases the bacteria and their toxins are not found constantly in the blood, occurring only when the bactericidal substances of the latter have been exhausted. This may happen daily or after long inter- vals, recurring regularly or irregularly. When the bactericidal sub- stances are formed again the bacteria are removed from the blood and deposited in large numbers in different parts of the body (bone marrow in children, joints, and large viscera) where they incite processes which combat the infection. Etiologically every hematogenous infection (hiipmatogenous osteomye- litis, arthritis, etc. ) must be regarded as a mild form of general pyogenic GENERAL PYOGENIC INFECTIONS 281 infection Avith victastascs, roj::ar(ll('ss of whether or not a primary infec- tion atrinni ean be found. (Minieally a siniile metastasis oeenrrin<2: in the cases above cited can only be reuai'tled as part of a general infection, when the blood infection persists and there are other symptoms indica- tive of a iivneral infection. The form without metastases is a ]iersistent ijeneral infection with bacteria and their toxins. Theoretically a general hactcrial infection (bacteria'mia) may be differentiated from a general toxic infection (toxa'mia), dei)ending npon whether the bacteria or their toxins pre- dominate in the blood. Such a distinction cannot, however, be made clinically. In general bacterial infections the l)aeteria which are absorbed from the primary focns rapidly multiply in the blood, for the organism is not able to ]>i'odnce enough protective substances to destroy the bacteria and neutralize the toxins (septicaemia as defined by bacteriologists). The resistance of the organism is so low relative to the virulence of the bacteria that there is no inflanniiatory reaction in the tissues ending in pus formation. In the general toxic infections (such as occur in tetanus and diph- theria) large ((uantities of toxins enter the circulation. This form of infection, which can scarcely be distinguished from the bacterial infec- tions except by negative blood cultures, occurs more frequently in in- fections with the unconunon pyogenic bacteria and in mixed infections, especially in mixed infections with putrefactive bacteria. There are a number of transitions between these two principal forms of general pyogenic infections. It is not necessary that each of these transitional forms be named, and besides, it is frequently difficult to apply a term wliich accurately describes the condition. The terms Avhich have been introduced into the nomenclature of the different forms of general infections have been variously interpreted by different authorities, and this has resulted in considerable confusion; for exanq)le, Gussenbauer and Brunner regard sepsis as synonymous with putrefaction, while Canon and Lenhartz re- gard it as synonymous with general pyogenic infection. Von Kahlden regards septicaemia as synonymous with toxannia (regardless of whether it is due to pyogenic or putrefactive bacteria). In order to avoid con- fusion and simplify matters. Lexer employs the term putrid infection and general putrid infection for local inflammatory process character- ized by putrefactive changes and the general symptoms following them. AYhile the terms pynemia, septica'mia, sapra'mia, etc., are not used in the German edition of this book, it seems best to explain the significance of these terms, which have become so firmly established in American medical literature. The general pyogenic infection icith metastases as 282 WOUND INFECTIONS PRODUCED BY BACTERIA used by Lexer is sjaionymous with ijyamia; general pyogenic infection without metastases with septicemia, and general putrid infection with saprcemia. (a) GENERAL PYOGENIC INFECTIONS WITH METASTASES (PYEMIA) Bacteria Most Commonly Found. — Any variety of pyogenic bacteria from any inflammatory focus is able to produce metastatic suppuration in the body. Staphylococci are found most frequently in these general infections, and next in order of frequency, streptococci, w^hich tend to produce suppuration of the joints and serous membranes, phlegmons, and erysipelas. Pneumococci, gonococci, colon and typhoid bacilli (after typhoid fever) are found less frequently than staphylococci and strep- tococci. Mixed infections with the staphylococci and streptococci are relatively common. Most Common Sources of Infection. — The bacteria may be absorbed from any inflammatory focus or may be carried from diseased vessels in the form of bacterial or infected emboli into the general circulation. The most common sources of infection are : 1. Infected wounds. 2. Local inflammatory^ processes. 3. Infected ulcers. Operation-wounds at the present time are rarely the source of general infection, although in pre- antiseptic times severe general infections were exceedingly common sec- ondary to infected operation-wounds. Infected wounds with recesses and pockets, the tissues of which are infiltrated with blood and necrotic (e. g., contused and lacerated wounds, large wounds of the soft tissues surrounding complicated compound fractures, bites inflicted by mad animals, deep wounds following explo- sions and machine injuries, and the inner surface of the uterus after delivery), are most freqviently followed by general infections. Putre- factive bacteria, which are often associated with pyogenic bacteria in infections of this character, increase the virulence of the latter and favor the development of general infections. Any local inflammatory process such as a furuncle, a phlegmon, an inflammation of a mucous membrane (especially an angina, an empyema of one of the accessory sinuses of the nose, otitis media), lymphangitis, thrombophlebitis, hematogenous endocarditis, arthritis, and suppurative osteomyelitis, may be the source of a general pyogenic infection. Ulcers of all sorts (tuberculous, typhoid, syphilitic, carcinomatous) may provide the infection atrium for a general infection. The So-called Cryptogenic Infections. — Although there are cases in which the primary focus cannot be found, it is certain that one exists or has existed in each case. In the cases of so-called cryptogenic infec- GENERAL rVUCiENlC LNFIXTIOXS 283 tion there may have been a slight inflammation of a mucous membrane which gave rise to but few symptoms, or a furuncle which has healed, and although the lesion may have healed entirely, bacteria may have been retained in the thrombosed veins of the area involved or the lym- phatic nodes Avhich di-ained it and later have eaused the general infection. Factors Favoring the Development of a General Infection. — All those factors which favor the absorption of bacteria and their toxins, or the setting loose of particles of thrombi or groups of bacteria in the lym- phatic vessels and veins favor the development of a general infection. The most common are injuries and mechanical irritation of the wounds, which even at the present time are frequently not avoided in the treat- ment. Trauma and other injuries, providing as they do the locus minoris resistentia', also determine the localization of Ineniatogenous infections. Lacerations, ha-matomas, and eireulatory disturbances so reduce the re- sistance of the tissues that they are no longer able to destroy, as the normal tissues do, the bacteria which are deposited by the blood stream. To cite an example of the lower resistance of tissues following an injury, a subcutaneous fracture, a subcutaneous or muscular haematoma becomes infected during the course of an angina and suppurates. Susceptibility of Different Tissues and Viscera. — The different tissues and viscera of the body nuist have some peculiar properties, concerning which but little is known, which determine the localization of ha*ma- togenous infections. For example, if a small culture of pyogenic bac- teria is injected into the cutaneous vein of an experimental animal, sup- purating foci develop first in the lungs, in which the grosser particles which have been injected are retained. Later foci develop in the joints or in young animals in the bone marrow, then in the periosteum and kidneys, less frefpiently in the liver and serous cavities. Only after the injection of large amounts of a culture do foci develop in other organs, especially in the muscles, and finally in the myocardium, subcutaneous tissues, etc. Mechanical conditions seem to play an important part in determining the localization of infections, for the bacteria, especially if carried in infected emboli, lodge most frequently in very vascular organs (lungs, bone marrow, synovial membranes, kidney, and liver). Bacteria seem also to be deposited in tissues and viscera (bone marrow and spleen) which form large amounts of bactericidal substances. They are retained, and if too many and too virulent bacteria are not deposited they are destroyed. Symptoms. — Clinically the symptoms of the general reaction (except- ing, of course, the so-called cryptogenic infections) which accompany an infected W'ound or a local inflammatory process precede the symptoms 284 WOUND INFECTIONS PRODUCED BY BACTERIA of the general infection. The fever accompanying the general reaction, which often begins with a chill and rises abruptly or gradually, is called absorption fever to differentiate it from the fever occurring in the gen- eral infections into which it often passes imperceptibly. This absorption fever should not be regarded, however, as indicative of a general in- fection unless there are other symptoms which usually occur in these cases. General infection with metastases is characterized by frequent chills, intermittent fever, severe general symptoms, and the development of metastases. The disease begins with a severe chill, and during the subsequent course of the infection chills may recur many times during the day or after long intervals. A high temperature (103°-104° F.) which rises abruptly accompanies each chill. The temperature drops suddenly from three to four degrees each day, especially in the morning, and rises later in the day, but this rise is not accompanied by a chill. The fever accompanying these infections is therefore usually of either an inter- mittent or remittent tj^pe. There are, however, frequent exceptions. Character of the Fever. — The fever becomes continuous if there is a rapid and continuous absorption of pyogenic substances from an exten- sive primary or secondary suppurating focus, or if the protective sub- stances are so reduced that the blood infection is frequently repeated or becomes permanent. These bactericidal substances, when formed in sufficient amounts, destroy the bacteria and neutralize the toxins so that the blood infection is, as a rule, transitory {vide Fig. 124). A remittent fever should not be regarded as indicative of a metas- tatic infection unless there are other symptoms. A simple absorption fever which is designated by Inany authors as ' ' septic fever ' ' or even " sepsis " may have a similar curve, as is frequently the case in inflam- mations caused by streptococci {vide Fig. 126). One should not conclude, as, for example, in erysipelas, that there is a toxic or bacterial blood infection, because there is a continuous ab- sorption fever, even if bacteria may be cultivated from the blood. So long as the other symptoms are wanting the fever is merely indicative of a long persisting reaction of the organism to the substances which are absorbed from the inflammatory focus. Different types of fever arc produced by different bacteria. These differences are so slight and depend upon so many factors that they have no clinical value. The general symptoms are malaise, pain in the extremities, rapid pulse and i-espiration, dry t(mgue, thirst, dry hot skin or profuse per- spiration, headache, stupor, delirium, anorexia, and vomiting. These symptoms are common to the infectious diseases. GENERAL I'VOCJEXIC INFECTIONS 285 Associated ■with these are symptoms which also occnr in preneral in- fections without metastases: severe diarrhcpa, which is caused by the excretion of the absorbed toxins or metastatic inflammation of the intes- tinal nuicous membrane due to emboli ; icterus, which may develop after a few days, probably due to the destruction of red corpuscles (hajmo- cytolysis) ; acute splenic swellint? which develops in this form of infec- tion and in other infectious diseases, sometimes produced by metastatic abscesses; alterations in the composition of the blood shown by a reduc- tion in the number of red blood corpuscles, and frequently by quite a marked leucocytosis {vide Blood Infection) ; and finally ulcerative endo- carditis, which, according to Lenhartz, develops in from one fourth to one fifth of all cases of general infection, especially in the form accom- panied by metastases. The ulcerative endocarditis develops most fre- quently upon the left side of the heart. If, as is frecjuently the case, the symptoms of lunu' involvement due to metastatic abscesses and inflammatory infiltration are most prominent, the patient becomes dyspn(eic, coug-hs and expectorates considerable foul- smelling material, which may dift'er quite a great deal in character. Fre- quently during the later course of the infection the physical findings of a pleurisy developing f n ni a focus situated in the periphery of the lung may be elicited. The development of an infarct of the lung is indicated by sudden dyspnoea, cardiac weakness, and bloody sputum. Involvement of the kidneys may not be accompanied by symptoms or may be indicated by the symptoms of a severe acute nephritis. Small foci resembling an infarct in shape develop in the cortex. Striated foci also develop in the medulla. The latter are caused by the bacteria which are filtered through the glomeruli into the uriniferous tubules. One after another of the joints, especially the larger ones, nia}" be- come affected. So]iietimcs the synovitis devt^lops acutely, sometinics sub- acutely. The exudate may be serous, serofibrinous, serohaniiorrhagic, or purulent. In severe cases the inflammation extends rapidly to the cap- sule and the articular cartilages, which are destroyed. Besides these joint metastases, there is often found (especially in general infections due to gonococci) inflammation of the tendon sheaths and bursa. Frequently small and large h^vmorrhages occur in the eye, the retina becomes necrotic; the crystalline lens becomes clouded or suppurates, iridocyclitis and panophthalmitis develop. The serous membranes, pia mater, pleura, pericardium, peritoneum, become infected through the blood or by extension of some focus in the brain, lung, myocardium, or abdominal viscera. In rare cases the tunica vaginalis testis becomes inflamed. As a rule, the inflammation is sec- ondary to some focus in the testicle or epididymis. IMuscle foci sometimes produce circumscribed abscesses, at other times 286 WOUXD INFECTIONS PRODUCED BY BACTERIA progressive phlegmons. These foci are especially numerous in staphy- lococcic infections, and often precede the development of subcutaneous abscesses. In chronic cases frequently sixty to one hundred subcutaneous and muscular abscesses develop and must be opened. The subcutaneous tissue may be the seat of progressive phlegmons, particularly if the in- fection is due to streptococci, while metastatic erysipelas, as well as a scarlet-fever-like erythema, small haemorrhages, herpes, and pustules may develop in the skin. The metastases stand in different relations to the primary focus. The metastases are spoken of as secondary, tertiary, etc., depending upon whether they have developed from the primary or a metastatic focus. An ulcerative endocarditis is very frequently the origin of such metastasas, A general infection with metastases may pursue an acute or chronic course. The acute forms prove fatal in a short time if the formation of metastases is not prevented by proper treatment of the wound which is in the infection atrium. The greater the number of metastatic foci, the greater are the dangers of a permanent blood infection. Bacteria and their toxins pass into the Ijlood from all these foci. Chronic Forms of Infection.— The chronic forms which are sometimes observed in staphylococcic infections may continue for weeks and months. In rare cases, if there is no severe infection of the viscera, recovery may occur even after a number of muscular and subcutaneous abscesses and suppurative arthritis have developed. Prognosis. — The prognosis is gravest in the acute cases with multi- ple metastases and pathological changes in the important viscera. Heal- ing may occur in the chronic cases with a limited number of metastases. Diagnosis. — The diagnosis in advanced cases is not difficult, espe- cially if the original inflammatory focus is still present. In the crypto- genic cases the pathological changes in the viscera often are most promi- nent and the disease may be mistaken for suppurative nephritis, cere- brospinal meningitis, or endocarditis occurring in the course of acute articular rheumatism. If the symptoms are not pronounced, acute mil- iary tuberculosis and typhoid fever must be considered. Blood Examination. — Examination of the metastatic foci and of the blood is mo.st imfjortant in making a diagnosis. Bacteria may be dem- onstrated in the blood in a large number of cases shortly after the chill with the methods which are emyjloyed at the present time. The finding of pyogenic bacteria excludes acute articular rheumatism, for in rheu- matism proper bacteria are never found (Lenhartz). Treatment.— The first indication in the treatment of general infec- tion with meta.stases is to prevent further infection of the blood. Often this is accomplished by thorough exposure of the primary focus accord- GENERAL PYOGENIC INFECTIONS 287 iiirations upon the lips and cheeks when a poorly nourished flap dies and becomes gan- grenous following infecticm with bacteria from the mouth cavity. Symptoms of Putrefactive Infections. — AVhen putrefactive inflamma- tion develops in a wound the temperature either rises abruptly with a chill or steadily, and the appearance of the wound becomes very char- acteristic within twenty-four hours. A foul, repellent odor arises from the dry wound surfaces. The loosely attached shreds of tissue and the skin edges for a varying distance have a bluish or black color. Twenty- four hours later small amounts of a brownish or greenish ichorous dis- charge are poured out from the deepest recesses of the wound, while the inflammatory redness and swelling, accompanied by an increasing pain, extend into the surrounding tissues. Soon the wound surfaces become discolored and moist, and the large shreds of necrotic tissue become liquefied or are cast off. When pressure is made upon the surrounding tissues, gas bubbles appear in the ichorous discharge. If the inflam- matory process subsides the inflammatory swelling and ichorous discharge gradually disappear, healthy granulation tissue develops around the gan- grenous area and healing occurs. In the worst cases a high continuous fever persists and the symptoms of general infection, which correspond exactly to those occurring in general pyogenic infections, develop ; death occurring in a few days, frequently at the end of the first day. Fre- quently streptococci, more rarely staphylococci or colon bacilli, are found in the circulating blood. Even the proteus vulgaris has been found in the blood in these cases (Krogius). In most cases, however, bacteria cannot be demonstrated in the blood, which is laden with toxic mate- rials as indicated by the severe changes occurring in it. If metastases develop, they have the same putrefactive character as the primary focus. Putrefactive Phlegmon. — If the putrefactive inflanunation extends, a ]dilegnion fonns which develops more rapidly, and is accompanied by severer local and general symptoms than the most malignant strepto- coccic infections. The names which have been applied to putrefactive phlegmons by different authors, acute suppurative (pdema ending in gangrene (Pirogoff), progressive gangrenous emphysema, emphysema- tous gangrene, fulminating gangrene (]Maissoneuve), gangrenous emphy- sema, gangrenous phlegmon, panphlegmon gangra^nosa (Fischer), etc., describe very well the clinical picture. Often within twenty-four hours an entire extremity becomes so cedematous and red that the painful swollen lymph nodes can no longer be palpated, and the red streaks indicative of lymphangitis, which is rarely absent, can no longer be 302 WOUND INFECTIONS PRODUCED BY BACTERIA seen. The inflammatory exudate is so great that the circumference of the extremity becomes three or more times as great as normal, and exerts so much pressure that the circulation is interfered with. The tense skin becomes pale and aua?sthetic, and large blebs with serohf^morrhagic con- tents form; bluish discolored areas develop and become transformed into black crusts, which are cast off as the gangrene extends. Fluc- tuation cannot be elicited anywhere in the enormously swollen extremity, but when the tissues are palpated an emphysematous crackling, which is characteristic of gas in the tissues, may be elicited. The fingers or toes are of a pale or bluish color and feel cold. When these infections develop from wounds they rarely remain confined to the subcutaneous tissues, but extend to the muscles and periosteum, and when a compound frac- ture becomes infected, the bone marrow is transformed into a decom- posing, putrefying mass (putrefactive osteomyelitis). Putrefactive arthritis is accompanied by great destruction, the capsule becomes necro- tic, the cartilages are separated and destroyed. Appearance of Tissues when Incised. — When incisions are made the frightful results of these infections are revealed. The incision passes through an cedematous or gangrenous cutis into an cedematous, grayish- green subcutaneous tissue from which a sanious discharge containing gas bubbles and shreds of fat and fascia pour out. The intermuscular con- nective tissues and muscles are in the same condition. Everywhere a gelatinous, discolored network of tissue is found from which an ichorous discharge and gas bubbles can be expressed. The periosteum is raised from the bone and separated into gangrenous shreds, while from the bone marrow decomposing matter is discharged from the seat of frac- ture or through large canals in the bone. The subcutaneous and deeper veins become thrombosed, the thrombi frequently undergoing septic sof- tening; the walls of the larger arteries have a grayish color and are about to rupture (gangrenous arteritis). Fatal haemorrhage may fol- low the erosion of an artery by the gangrenous process. Putrefactive Phlegmons following Urinary Extravasation, and the Escape of Fsecal Matter. — Putrefactive phlegmons develop in the scrotum, penis, and perineum following urinary extravasation. The urine is poured out into the tissues after injuries or inflammatory processes which destroy the integrity of the urinary passages, such as fractures of the pel- vic bones, periurethritis following urethral strictures, and injuries pro- duced while introducing catheters. A rapidly progressive swelling and redness, accompaTiied by severe pain and fever, indicate the beginning of the inflammation which leads to extensive gangrene of the muscles, fascia, and skin, if death from a general toxic infection does not occur before gangrene has time to develop. The greater the number of bac- teria in the urine such as occur in cystitis following hypertrophy of PT'TRi'lFACTIVl-: I.\Fi;( TlO.NS 'Mi till' })i"()stcito Jiiid uirtlujil stiiclui'i'. the more iJipid mikI scvitc llic iii- tlnininntioii will be. A siiiiil.ii- l)ut less rriuliiriil cliiiifiil i)i('liiff, as in this case pressure is not exerted as wiieti urine is extravasated, is produced by the discharge of fa'eal matter into the tissues, following, for example, gangrene of a strangulated intestinal loop in a hernia (faecal phlegmon and abscess). Necrotic and dying tissue affords the best culture media for putrefactive bacteria, and the development of putrefactive inflammation following the various forms of necrosis is not at all rare unless prophylactic meas- ures are instituted early. Bed sores about the sacrum and coccyx easily become infected from fweal matter. Gangrene, and in neglected cases jnitrefactive phlegmons and general infections, may then develop. A similar infection followed by similar results not infrequently develops in tuluMvulous flstula> about the perineum treated by quaclcs. Putrefaction in Senile and Arteriosclerotic Gangrene. — Senile gan- grene and arteriosclerotic gangrene of the fingers and toes readily pass from the condition of dry necrosis or nnnnmification into that of a moist putrefactive gangrene, which affords opportunities for the development of phlegmons. A gangrene due to freezing, embolism of the arteries of the extremities, nervous lesions, and carbolic-acid compresses may also give rise to putrefactive phlegmons. Pyogenic and putrefactive infec- tions develop mcst rapidly in diabetic gangrene. The resistance of the tissues is so reduced in diabetes that lymphangitis and phlegmons develop immediately after infection Avith putrefactive bacteria. Treatment. — Prophylaxis is the most essential factor in the treatment of putrefactive infections. The detached and contused tissues should be removed fi'om lacerated wounds, the edges of the Avound should be trimmed off, then the wound should be loosely tamponed and should be drained and treated by the open method. Secondary infection should be prevented by sterilizing the surrounding area and avoiding any use- less examinations oi- manipulatit iis. If gangrene has already developed, a dry aseptic dressing should be applied. Putrefactive processes rap- idly develop, especially in diabetic patients, when moist dressings are used. If the inflannnation has already develop<'d, the infected tissues should l)e freely exposed by opening the recesses and pockets of the wound and by incising freely the phlegmon or abscess. In the beginning a tampon of dry aseptic gauze should be used. Iodoform gauze is contra- indicated, as the iodoform is quickl.v decomposed in putrefactive proc- esses and may give rise to severe toxic symptoms. AYhen an extensive gangrene has developed in the wound, or there is a superficial gangrene of the skin, compresses of a three per cent solution of acetate of alumi- num, of boric acid or hydrogen peroxid solution may he used to hasten the separation of the dead tissue. A\'lien severe general symptoms de- 304 WOUND INFECTIONS PRODUCED BY BACTERIA velop amputation of the inflamed extremity should be considered, al- though only in rare cases is one able to prevent the dangers of general infection even by this radical procedure. (b) ALLIED PROCESSES Gas Phlegmon. — The gas phlegmon may be called a variety of gan- grenous phlegmon, which is characterized by the formation of large amounts of gas. The skin Ls raised from the subjacent tissue by large accumulations of gas, resembling an air cushion ; while after death there is a rapid, progressive formation of gas in the viscera (so-called foam organs). The more pronounced the gangrene, the less marked are the inflammatory symptoms. The bacillus aerogenes capsulatus and allied anaerobic bacteria (butyric acid bacilli) appear to be the most important causes of gas phlegmon (Welch and Flexner, Muscatello, Hitzmann and Lin- deuthal, Stolz, Koprac). The bacillus aerogenes capsulatus was found by Lenhartz in the blood during life in a puerperal infection which ended fatally. The proteus bacillus ( Graszberger, Widal, and Nobecourt) and the bacterium coli commune (Chiari, Klemm, Bunge, Tavel, and others) are occasionally found in gas phlegmons. ]\Iixed infections with pyogenic bacteria are also frequent. Malignant (Edema. — ]\Ialignant oedema is a term often applied to acute suppurative and putrefactive phlegmons; it should be used, how- ever, only to designate those rare, rapidly progressive phlegmons accom- panied by gas formation and gangrene of the skin and .subjacent tissues, which are caused by the bacillus of malignant oedema alone or associated with other bacteria. Even after a bacteriological examination it is fre- quently impossible to make a positive diagnosis because of the similarity of the bacteria (Ghon and Sachs) found in these analogous inflammatory proce.s.ses. The exudate before gangrene begins is serous in character and con- tains but few cells. This is due to the fact that the bacterial toxins exert a negative chemotaxis; the same occurring in gas phlegmons, in which there is no .secondary infection with pyogenic bacteria. The treatment of gas phlegmons and of malignant oedema ls the same as that of putrefactive phlegmons. Literature. — Albrecht. Ueber Infektionen mit gasbildenden Bakt. Arch. f. klin. Chir., Bd. 67, 1902, p. .514. — E. v. Bergmann. Zur Lehre von der putriden In- toxikation. Deutsche Zeitschr. f. Chir., Bd. 1, 1872, p. 37.3. — Brieger. Untersuchungen iiber Ptomaine, Berlin, 188.5-6. — Brumier. Wundinfektion und Wundbehandhing. Frauenfeld, 1898. — E. Friinkel. Ueber Gasphlegmonen, Schaumorgane und deren PUTREFACTIVE INFECTIONS 305 Erreger. Zeitschr. f. Hygiene, Bd. 40, 1902, p. 73. — Ghon und Sachs. Beitragezur Kenntnis der anaeroben Bakterien des Menschen. Zur Aetiologie des Gasbrandes. Zentralbl. f. Bakt., 1903, Bd. 34, Orig., p. 289 and Bd. 36, Orig., 1904, p. 178.— Kamen. Zur Aetiologie der Gasphlegnione, Ebenda, Bd. 35, 1904, p. 554. — Koprac. Ein Beitrag zur weiteren DifTerenzierung der Gangrene foudroyante. Arch. f. klin. Chir., Bd. 72, 1904, p. 111. — Lcnhartz. Die septischen Erkrankungen. Wien, 1903. — Panum. Das putride Gift, etc. Virchows Arch., Bd. 60, 1874, p. 301. — Pirognff. Grundziige der allgeineinen Kriegschinirgie. Leipzig, 1864. — Sandler. Ueber Gasgangran u. Schaum- organe. Mitteilung u. Sammelreferat. Zentralbl. f. allgem. Path., 1902, p. 471. — Stolz. — Die Gasphlegnione d. Menschen. Beitr. z. khn. Chir., Bd. 33, 1902, p. 72. — Westenhoefjcr. Weit. Beitrage z. Frage der Schaumorgane u. der Gangrene foudr. Virchows Archiv, Bd. 170, 1902. Noma ^ {Water Cancer, Gangrene of the Cheek). — Noma is closely allied to those putrefactive infections in which gangrene predominates. It involves most frequently the cheeks, more rarely the gums, palate, and lips. Similar infections occur about the anus and "vulva. Etiology. — The disease attacks almost exclusively weak and ema- ciated young children from two to twelve years of age, living in squalid, over-populated districts in cities; much more rarely adults. Measles and typhoid fever, sj'philis, mercurial stomatitis, diphtheria, dysentery, different forms of ulcerative stomatitis, malaria, poor hygienic condi- tions are predisposing and accessory causes which reduce the local and general resistance and prepare the tissues for the development of bac- teria. Noma is apparently a bacterial infection, but a specific organism has not as yet been demonstrated. As a rule, only isolated cases occur, and the possibility of direct transference from one patient to another can be excluded. Wherever a number of cases have developed in the same hospital or district, there has been a preceding epidemic of measles. Bacteria and Fungi found in Noma. — A number of different bac- teria and fungi have been found in noma. This is not to be wondered at when one considers the great variety and number of bacteria normally present in the mouth and found in putrefactive processes. Perthes dem- onstrated microscopically a streptothrix in the margin of the gangrenous area which sends out its terminal processes in the form of spirilla into the adjacent healthy tissues. lie was unable to produce the disease in animals with this streptothrix or to grow it in pure cultures. Freymuth and Petruschky found the diphtheria bacillus in two cases of noma ob- served by them. It is doubtful, however, whether the diphtheria bacillus should be regarded as the cause of these cases of noma, as they are found in the mouth of healthy individuals. It is a question whether noma is caused by any single variety of bacteria, or whether it is caused by a number of different varieties (Kolle and Hetsch). 1 From the Greek veneadat — to destroy. 306 WOUND INFECTIONS PRODUCED BY BACTERIA Clinical Course. — The specific process begins in an abrasion or an in- flamed area (ulcerative or mercurial stomatitis) in the mucous mem- brane of the cheek, near the angle of the mouth, occasion- ally in the mucous membrane of the palate, lips, or gums. Gangrene gradually develops from a vesicle with cloudy con- tents or a superficial ulcer, and extends both superficially and deeply. As the gangrene spreads the surrounding tissues become inflamed, indurated, and hard. A high fever develops and per- sists; the severity of the disease is indicated by the height of the fever and the mental disturbances. A swellinsr of the cheek Fig. 127. — Noma in a Chinaman Sixteen Years OF Age. (After photographs and communi- cation of Professor Perthes.) Tenth day of the disease. The dark area in cheek is the point at which perforation is about to oc- cur. which is not very painful de- velops, and soon there ap- pears upon the pallid skin a bluish-black discoloration cor- responding approximately to the area of mucous membrane Avhich is infiltrated. This bluish-black discoloration of the tissues is characteristic of noma. As the disease progresses the inflammatory reaction may become marked and the entire face and the side of the neck becomes swollen, but the gan- grenous process does not sub- Fui. 128. — Picture Taken on Sixteenth Day op THE Dlsease After Cauterization. Dcatli on twenty-.second day, tlic disease liaving extend- ed to the f)harynx and soft palate. PUTRi:i' A( Tl\l': IN 1' KCTIONS 307 side. ^VitlliIl the (irst wcrk tlic dark, ^antirenous tissues slouch out; the process exteuds aud destroys the cheek, the mucous meuibrane cover- ing the upper and k)wer jaws ; the teeth become loosened and drop out, and the surfaces of the maxilla and mandible become exposed. In the malignant cases the pansirene extends to the nose, the tongue, the phar- ynx, the palate, the li])s, and the other cheek. The amount of saliva is increased and a foul-smellin«i' discharge is poured into the mouth, which may be swallowed and aspii'ated, causiiii;' liastrointestinal dis- turl)ances, bronchoi)neiniionia, and gangrene of tlie luiiii'. rroijHOsis. — Death, which fre(|uently occurs at the end of the first week, ends the frightful suffering in seventy-five per cent of the cases. It is due to i)aralysis of the lieai't, resulting from a general toxic infection, exhaustion, or pneumonia. In rare cases the gangrene sul)sides after the ne- crotic tissues have sloughed out, and then it does not extend into the surrounding inflamed tis- sues; healthy gi-anulations form, the necrotic soft tissues and bone are separated and cast off, and healing occurs. Large de- fects of the cheek, lip, and nose, with cicatricial lockjaw and ec- troj)ion, remain after healing. Treat))) eiit. — The treatment consists of destruction of the gangrenous tissue with the Pa- quelin cauteiy. The entire thick- ness of the cheek in which the gangrene develops should be cauterized, and even the healthy tissue inmiediately adjacent to it. Trendelen])urg ri>connnends splitting the clu>ok in order to expose more thoroughly the diseased area. Attem])ts have been made to prevent the putrefactive decomposition of the gangrenous tissue by the use of caustics (zinc chlorid, acetic acid) and to control the inflammation by using a five per cent solution of hydrogen peroxid as a mouth wash freiiuenfly. If treatment is instituted early, procedures which are not mutilating may be successful. Every effort should be made to improve the general condition of the patient. It nuiy be necessary to perform plastic operations to close the defects. F'iG. 120. — Deformity 1'\)i, lowing a Nom.\ of THE l'\\CE, Wiiitii IIeai.eo. 308 WOUND INFECTIONS PRODUCED BY BACTERIA and to remove the masses of cicatricial tissue to cure the cicatricial lock- jaw. Literature. — v. Bergmann. Verletzungen und Erkrankungen der Mundhohle Handb. d. prakt. Chir., 2dJEdition. — Kolle und Hetsch. Noma. In KoUe-Wassermanns Handb. d. pathog. Mikroorg., Bd. 3, 1903, p. 904. — Krahn. Ein Beitrag zur Aetiologie der Noma. Mitteil. a. d. Grenzgeb., Bd. 6. — Perthes. Ueber Noma und ihren Erreger. Chir.-Kongr. Verhandl., 1899, II, p. 63. — v. Rankc. Zur patholog. Anatomie des nomatosen Brandes. Miinch. med. Wochenschr., 1903, p. 13. Hospital Gangrene {Wound PhagedcBna). — By hospital gangrene is understood a wound infection resulting in an acute progressive necrosis of the tissues with putrefactive decomposition of the same. The name cf hospital gangrene has been given to this form of infection, as in pre- antiseptic times it frequently occurred in epidemic form in civil and military hospitals. The infection was transferred from wound to wound by the lint and sponges (the materials used for dressing wounds in ear- lier times), the instruments, and the fingers of the operator or his assist- ants. It attacked recent and old, large and small wounds, and pursued a rapid and severe course, which often ended fatally. At the present time the surgeon occasionally sees a case of the milder form of hospital gangrene, which develops most frequently about the anus or the external genitalia. Operation- and accidental-wounds are but rarely attacked by this form of infection. Etiology. — Hospital gangrene is apparently of bacterial origin, but no specific bacterium has yet been found. Vincent and Matzenauer have demonstrated a bacillus in a number of cases, but have been unable to grow it in pure cultures. Nasse found in one case an amoeboid organism. If one reads the descriptions of hospital gangrene given by the older authors, one cannot help thinking that a number of different infections — putrefactive gangrene and phlegmon, perhaps even gas phlegmon, and infections with the diphtheria bacillus (wound diphtheria) — were grouped under this term. Clinical Course and Forms. — Depending upon the course, authors have differentiated a superficial and a deep form of hospital gangrene (Phagedasna superficialis et profunda, von Pitha, Konig) ; upon the gross appearance an ulcerative and a pulpy gangrene (Delpech). The symptoms begin after an incubation period of from two to three days with fever, pain, and changes in the appearance of the wound. In the ulcerative form which attacks especially granulating wounds, the wound surface becomes mottled with yellowish-brown areas, and small haemorrhages occur within the granulations. If the changes are mild and not progressive, one speaks of a diphtheritic form of hospital gangrene. In the ulcerative form the gangrene extends rapidly over the entire wound, transforming the tissues into a discolored, foul-smelling mass^ PUTREFACTlVi: IXFLXTKJXS 309 AVlu'ii tlio f^aiii^rciions tissues are cast off, ulcoi-s with sliarply cut otl,u:<'S I'oinaiii wliicli rapidly eoalosce. While the hii'iiiorrluij^ic mottled floor of the ulcer becoines gangrenous, the sharply cut, iiregular borders of the ulcer, surround(Hl hy ])ainful, iiiHained, and infiltrated skin, ex- tend. Th(^ chauiics ehai-aeteiisti(; of the pulpy form of gangrene may develop ill the floor of the ulcer, 'i'he floor of the wound then becomes diy and covei-ed with a thick, dii'ty, fil)i-inous meiiibraiie, wliich may be removed in shreds, leaving bleeding surfaces. After a sliort time an ichorous secretion is poured out, and the surface of the wound, as the result of putrefactive changes and the develoi)ment of gas within the tissues, becomes transformed into a grayish black or yellowish gray, firmly attached, semifluid mass (so-called pulp), which has been com- pared to decomposing brain matter. These changes, which may fre- quently be associated with considerable parenchymatous ha-morrhage ( haemorrhagie form), may develop in a single night in large, recent operation-wounds (for example, after an amputation). If the process remains superficial, the surface of the wound may gradually become clean, and covered with healthy granulation tissue, but the infection may recur at almost any time until healing is complete. In the more malignant forms, the process, which resembles closely a putrid phlegmon, extends deeply, involving the loose subcutaneous and intermuscular tissues and the connective tissues of the vascular sheaths. If the resistant fascia? are destroyed, large pieces of decomposing muscle are extruded. If the process still extends the periosteum is destroyed and the superficial layers of the bone become necrotic, the walls of the vessels ulcerate, and fatal htemorrhages may occur. Prognosis. — The dry forms of hospital gangrene may cause death within two days by rapid extension, accompanied by a general toxic infection. The mortality, depending upon the hygienic conditions and the simultaneoiis occurrence of other diseases (cholera, typhoid and dys- entery), differs. It varies, according to the statistics compiled by dif- ferent authors, from 6 to 80.6 per cent (Konig). Churacifr of the Fever. — The fever may be continuous or remittent, and may fall abruptly when the gangrene subsides, and after the use of the actual cautery or caustics. In rare cases it begins with chills. The general symptoms correspond to those developing in general pyogenic and putrefactive infections. Compli((iiio)is. — Erysipelas, metastatic suppuration, lymphangitis, lymphadenitis, and mixed infections with pyogenic bacteria are the most frequent complications. Diagnosis. — The diagnosis of hospital gangrene under conditions ex- isting at the present time is difficult. So few cases are seen that one does not have enough clinical experience to enable him to recognize the 21 310 WOUND INFECTIONS PRODUCED BY BACTERIA milder forms, and the severer forms of hospital gangrene are not seen at present. It is scarcely possible to differentiate wound diphtheria from the milder forms except by microscopic examination unless the infection develops in a wound upon a i)atient already suffering with diphtheria. Treatment: Prophylactic and Operative. — The present method of treating wounds, and improved hygiene in both civil and military hos- pitals prevent the development of the infection. Complete isolation cf patients suffering with hospital gangrene is not necessar3^ They should be separated from patients recently operated upon with clean wounds, but may be kept without danger in wards in which patients with pyogenic and other infections, erysipelas, etc., are isolated. The early and energetic use of caustics, concentrated zinc chlorid solution, and nitric acid, or at the present time the actual cautery, plays an important part in the treatment. Deep-lying gangrenous foci should be exposed by incisions and rendered accessible. If the hgemorrhage is severe, the principal artery supplying the part should be ligated at some distance from the gangrenous area, in healthy tissues at the point of election. Amputation is indicated when the general symptoms become severe, and may be the only measure which will save the life of the patient. Literature. — Delpech. Memoire sur la complication des plaies et des ulceres connues sous le nom de pourriture d'hopital. Paris, 1815. — v. Heine. Der Hospital- brand. Handlj. d. Chir. v. Pitha-Billroth, Bd. 1, 2. Abt., 1869--7 4.— Konig. Ueber Hospitalbrand. v. Volkmanns Samml. klin. Vortr., No. 40, 1872. — E. KiXster. Hos- pitalbrand. In Eulenburgs Realenzyklopiidie. — Matzenauer. Zur Kenntnis und Aetiologie des Hospitalbrandes. Arch. f. Dermat. u. Syphil., Bd. 5.5, 1901, p. 394.^ — Nasse. Ueber einen Amobenbefund bei Leberabszessen, Dysenterie und Nosokomial- gangran. Arch. f. klin. Chir., Bd. 43, 1892, p. 40. — Rosenhach. Der Hospitalbrand. Deutsche Chirurgie. Lief. 6, 1889. CHAPTER VII SUPPLEMENT TO THE TREATMENT OF ACUTE INFLAMMATION The recognition of the fact that local infections (pyogenic and putre- factive) could not be reached by drugs administered or applied exter- nally, resulted in the establishment of the fundamental principle of early incision to permit of the escape of infectious material, and the use of the tampon, which removed these materials by its capillarity. Bier in 1905 introduced still another method by which it may be pos- SUPPLEMENT TU THE TREATMENT OF ACUTE INFLAMMATION 311 sible to combat infections. In the Bier treatment an attempt is made to increase the natural resistance of the tissues by inducing a local passive lu'peraMnia, and to place the organism in a condition in which it can resist infection, and by avoiding large incisions, immobilizing dressings, and tampons, and by early motion to restore the function of the diseased extremity. But such a method, in which the greater part of the struggle against infection is left to the organism, can be employed with safety only when the infection is mild. It is doubtful whether the treatment will suffice in severe infections, for in these more than in any other the final results depend upon the resistance of the organism, which only rarely can be estimated in the beginning of an infection. Passive hypera-mia, according to Bier, is induced by the application to the extremity involved of a thin elastic constrictor 6 cm. in width. The constrictor is applied near the trunk over a few turns of a gauze bandage or about the neck under slight tension. The constrictor is fastened with a safety pin, or, according to Klapp, by cohesion of the ends of the con- strictor after having been placed in water. The constrictor may be applied at higher or lower levels several times during the day. A piece of rubber tubing may be iLsed above the shoulder and about the testicle, and an elastic bandage 3 cm. in width about the neck. The constrictor should not be applied tight enough to stop the circulation or even to weaken the pulse, the object be- ing merely to slow the blood stream and to cause a dilatation of the blood vessels. AVhen properly applied the extremity becomes hot and oedematous, and the pain in the inflammatory area rapidly subsides. If the constrictor is too tight the pain increases in severity. It is difficult to maintain the proper degree of hypera-mia, and the patient must be continually watched, especially if not very intelligent, as it may be necessary to remove and reapply or to read.just the constrictor several times during a treat- ment. ]\lany have difficulty in maintaining a warm hypenvmia with an acute eedema. If the constrictor exerts too great compression the nutritional disturbance resulting from the increased stasis injures the tissues and reduces their natural resistance. The constrictor in the beginning, applied daily, may be allowed to re- FiG. 130. — Band for PRoorciNG Pas- sive Htper.emia Applied to the Arm. (After Bier.) 312 WOUND IXFECTIOXS PRODUCED BY BACTERIA main ten hours, later as long as twenty-two hours. "When it is removed the extremity is elevated or suspended in order to lessen the oedema. Small punctures may be made into the inflamed area to assist in the treatment. Large incisions are employed only when there are severe circulator}^ disturbances in the inflamed area. Incisions are made when softening has occurred and there is an accumulation of pus. Tampons are not used, however, as the transudate which is poured out in such large amounts folloAving the passive hyperaemia keeps the wound open. Only deep wounds are drained. The pus is expressed each day when the dressings are changed. From the first day active and passive motion is begun ^even when there is an inflammation of tendon sheaths or a joint), the object being to obtain as good functional results as possible. For the same reason no immobilizing dressing is applied, the wound being merely covered with se\eral layers of gauze, which are maintained in position by a loosely applied roller bandage. The method has been recommended for the treatment of all kinds of acute inflammatory processes, especially of a pyogenic character, of the extremities, head, and testicle (lymphangitis, phlegmons of all kinds, felons, suppuration of bones and joints, gonorrheal arthritis, infected open accidental- and operation-wounds), and to hasten the separation of necrotic tissues, etc. Although the method has been enthusiastically re- ceived, there are some serious objections to it. In private practice it is not entirely practical, for the patient must be watched continually. According to Lexer's experience good results may be obtained in mild infections which do not progress rapidly, and are accompanied by little or no fever if the treatment is instituted during the first few days. These infections, hcnvever, subside completely or end in the formation of a small abscess, which rapidly heals when a small incision is made, just as frequently when an immobilizing dressing is applied and moist com- presses are used. Often, however, under this treatment, the inflammatory infiltrate increases in size (even in mild cases in which a hyperemia has been early induced), and there develops still more rapidly than when poultices, which are no longer used to-day, are employed an acute, rap- idly progressive phlegmon w^hich ruptures into and invades the healthy surroimding tissues. The local inflammation becomes worse and extends. Phlegmons of the tendon sheaths and suppurative arthritis heal with good functional results if the hyperaemia ls induced early. It is well known that good functional results have been obtained in these cases by the usual treatment, but good functional results are much more fre- quent when Bier's method is employed, and the clinical course is shorter than when early incisions and dry dressings are used, but the treatment must be continued until the inflammation has completely subsided in order to i^revent, with certainty, recurrences. SUPPLEMENT TO THE TREATMENT OF ACUTE INFLAMMATION 3L3 Tu some of the severe eases the local ami general condition has become worse even when the hyperiemia has been induced early. I am con- vinced that some of the bad results that I have seen follow this treat- ment could have been avoided if immediate, early incision combined with the use of a tampon had been employed. Some of the bad results which I have had may be briefly mentioned: (1) Rapid extension of the in- flammation with the formation of a large inflanunatory infiltration and abscesses; (2) rupture of the abscesses into healthy surrounding tissues; (3) general infection in a streptococcic arthritis of average severity upon which the treatment had a favorable influence for one week; (4) a fatal case in a child with a pneumoeoccic infection of the knee joint. In the last case two days after the hypertpmia was induced the temperature, which had been 101° F., rose to over 10-1° F. with symptoms of severe intoxication, and death rapidly followed. The most effective factor in the treatment is not the bacteriolysis produced by an accumulation of the protective substances, which may set free a large amount of endotoxins injuring the tissues and the organism ; not the dilution of the toxins by the oedema, nor the increased absorption which follows the removal of the constrictor ; but the mechani- cal flushing and washing of the inflamed and oedematous tissues by the greatly increased amounts of transudate. Recent large, open, accidental-wounds are cleansed very quickly and heal without infection if an hyperaeniia is induced. It may be used to advantage in the treatment of inflanunatory infiltrations before they have softened, when combined with large enough incisions to permit of the escape of the transudate. Passive hyperasmia acts favorably in severe cases, and a tampon can be dispensed with if large incisions, which per- mit of the escape of the infectious materials, are made before the hyper- aeniia is induced. If incisions are not made the liyperaMuia may do harm, for the transudate, like Schleich's solution when used in acute in- flannnations, may drive the bacteria and their toxins into healthy tissues and favor the extension of the inflammation. Therefore, in my opinion incisions should not be delayed until soften- ing has occurred, but should be made, especially when there is an acute febrile onset, before the hyperemia is induced. Cavities containing pus should be opened wide in order to permit of a free discharge of the pus and the transudate which follows the application of the constrictor. Haem- orrhage must naturally be controlled by a tampon before the hyperaeniia is induced, the transudate favoring the separation of the gauze. Expression of the pus by digital pressure, the avoidance of inmio- bilizing dressings, and early movement of the diseased extremity are not to be recommended. Passive hypera?mia is not to be recommended in the treatment of acute lymphangitis. 314 WOUND INFECTIONS PRODUCED BY BACTERIA Klapp has recommended for the treatment of small inflammatory foci, especially those occurring upon the trunk, an apparatus from which the air may be exhausted which resembles somewhat the dry cup formerly employed very extensively. Naturally the pressure exerted by the edges of the glass should be removed from the acutely inflamed area. Fig. l.Sl.-^SucTioN Apparatus for Ma.stitis. (After Klapp.) The suction glasses (Fig. 131), which are made in different forms and sizes, should be applied daily for about three quarters of an hour in all. After being in position for five minutes the glass should be removed for from one to three minutes and then reapplied. The appa- ratus should be boiled before using, and vaseline should be applied to Fig. 1.32. — Suction Apparatu.s for Felons. (After Klapp.) the skin where the rim comes in contact in order to prevent the glass from falling off. The vacuum should not be too low, and the glass should not be allowed to remain in position too long, as haemorrhages may occur into the tissues. Furuncles and carbuncles with necrotic centers, small inflammatory foci on the fingers, in the breast and lymph nodes, which have already SUPPLEMENT TO THE TREATMICNT OF ACUTE INFLAMMATION 315 softened and have been opened by a small incision, suppurating hieina- tomas — in short, all encapsulated foci not accompanied by fever and without a tendency to progress — may be quickly rid of pus and infectious materials by this suction treatment, witliout any added iujui-y to the tissues. Large incisions may b(^ avoided] in tliis ■\v;iy and the time re- quired for healing shortened. Beginning mild inflammations, so com- mon upon the hands of physicians, may be easily controlled. Cautious treatment with a suction apparatus is to be recommended for all cases of this character. According to my experience, however, it should not be recommended for the treatment of inflammatory infiltrations which Fig. 133. — Suction Glass for a Furuncle. (After Klapp.) have not softened and which are accompanied by fever and have a tend- ency to extend rapidly. An inflammation of this character, which after early incision and use of the dry tampon subsides in from one to two days with an immediate decline in the temperature, may extend and be associated with the formation of large amounts of pus and an extensive destruction of tissue when this treatment is employed. The local con- dition is aggravated and the time required for healing is lengthened, and even after the inflammation has subsided the induration persists and is more extensive than when early incisions, not combined with the suction treatment, are made. Literature. — Bestdmeyer. Erfahrimgen liber die Behandlung akut entziindl. Prozesse mit Stauungshyperiimie. Miinchn. med. Wochenschr., 1906, p. 46L — Bier. Behandlung akuter Eiterungen mit Stauungshyperiimie. Ibid., 1905, p. 201 ; — Die Hyperiimie als Ileilmittel. Leipzig, Vogel. — Klapp. Ueber die Behandlung entziindl. Erkrankungen mittelst Saugapparaten. Miinchn. med. Wochenschr., 1905, p. 740. — Lexer. Zur Behandlung akuter Entziindungen mittelst Stauungshj'perii- mie. Ibid., 1906, No. 14; — Die Behandlung der septischen Infektion. Zeitschr. f. arztl., Forthildung, 1906. — Rami. Ueber die Behandlung akuter Eiterungen mit Stauungshyp(>r;iniie. Wiener klin. Wochenschr., 1906, No. 4. — Wolf-Eisner. Die Biersche Stauungshy|ieramie vom Standpunkt der Endoxinlehre. Miinch. med. Wochenschr., 1906, p. 1102. — [Siehe auch tlie Diskussion iiber das Thema in den Chir.- Kongr.-Verhandl., 1906.] 316 WOUND INFECTIONS PRODUCED BY BACTERIA CHAPTER VIII SURGICAL, HEMATOLOGY Hematology, though but recently introduced into the fields of diag- nosis and prognosis, has given results of such great value that a very brief consideration of its more important branches as related to sur- gerj^ is here presented. A more systematic study of the various changes of the blood in many surgical conditions will not only lead to more acciu-ate diagnoses and methods of treatment, but will help to clear up many of the obscure problems in connection with the pathogenesis of disease. ]\Iuch has been written recently upon the value of blood ex- aminations. No one questions the great value of a positive blood cul- ture or other results equally decisive. Negative findings and those changes which are not so constant — e. g., the presence or absence of a leucocytosis — have led to widely different conclusions. This much is certain, however, that in the hands of competent men the examination of the blood, when correlated with the clinical symptoms, will lead to the identification of many puzzling conditions. For the technical methods involved, the reader is referred to works on laboratory diagnosis and hematology. BACTERIOLOGY OF THE BLOOD The bacteriological examination of the blood is frequently the means of identifying many puzzling septic conditions. ]\Iany descriptions given previously convey erroneous ideas as to the technic involved and as to the interpretation of the results. The statements frequently made that the demonstration of streptococci in the blood in cases of septic infections means a fatal issue, and that the presence of pneumococci and typhoid bacilli in the blood in cases of lobar pneumonia and typhoid fever respectively is to be regarded as a very bad prognostic sign are erroneous. These statements are usually based either upon insufficient data or upon results obtained by a crude technic. It can readily be understood how the demonstration of a bacteraemia by meth- ods wholly inadequate — imless the bacterium sought for is present in verj^ large numbers, as occurs frequently in overwhelming infections — will lead to the erroneous conclusion that invasion of the blood stream in septic infections means a fatal issue. Recent perfections in the technic of blood-culturing have demon- strated beyond reasonable doubt that most specific infections are in real- ity bacteremias. SURCJICAL H.EMATOLOGY 317 A study of the results of blood cultures is interesting. The earlier observations in typhoid fever, scarlet fever, and streptococcic infec- tions, in rheumatism, endocarditis, pneumonia, and other septic condi- tions show a low percentage of positive findings, while the more recent works show a very much higher percentage of positive results. In nearly every instance the difference in the results is due to improved methods. These include the use of larger quantities of blood for inocu- lation, and more particularly the use of more favorable culture media. In scarlet fever streptococca^mia has been demonstrated during life by Ilektoen, Jochmann, and others. Baginsky and Sommerfeld demonstrated streptococci in the blood of every one of eightj'-two cases of scarlet fever examined post mortem. Bertelsmann found numerous bacteria in the blood during urethral fever which followed the passage of sounds in cases of stricture. In most instances they rapidly disappeared, but in two cases the bac- teremia persisted. In a case of acute follicular tonsilitis Rosenow isolated the strepto- coccus pyogenes from the blood during the initial chill, but not subse- quently. In two cases of empyema which recovered, cultures from the pus and blood j'ielded streptococci pyogenes of high virulence in one case and pneumococci in the other. Five cases of puerperal sepsis out of eight examined contained strep- tococci in the blood. Two of the cases with the streptococca^mia and one in which the blood cultures were negative died; the rest made uneventfid recoveries. In lobar pneumonia, pneumococci have been demonstrated in the blood in a large percentage of cases by Badnel, Prochaska, Frankel, Rosenow, and others.^ Positive blood cultures have been obtained in a small percentage of cases by Cole, Libraan, Kohn, and Sello. Rosenow, Badnel, and Frankel attribute very little prognostic significance to the mere demonstration of pneumococci in the blood, finding them alike in the fatal and non- fatal cases, while Cole, Libman, Kohn, and Sello regard a pneumo- coccaMuia as a bad prognostic sign, because of their higher percentage of positive findings in the fatal cases. In this connection it should be stated that blood cultures in cases of post-operative pneumonia are, as a rule, negative unless the pneu- monia is of* the frank, outspoken, lobar type, when the pneumococcus is usually obtained in pure cultures. In typhoid fever tlie liacillus typhosus has been cultivated from the • The total number of cases Rosenow has examined thus far is 300 and the high percentage of positive findings above reported is maintained. 318 WOUND INFECTIONS PRODUCED BY BACTERIA blood in about eighty per cent of cases by Cole, Schotmiiller, Auerbach, and others. The highest percentages of positive cultures are obtained during the first week of the infection, often before the appearance of the agglu- tination reaction, thus making it a most valuable diagnostic procedure in the differentiation of septic conditions which resemble typhoid fever. In paratyphoid fever similar results have been obtained. Among other conditions in which a blood culture is often the means of making a correct diagnosis should be mentioned malignant endocarditis, gon- orrheal sepsis, cerebro-spinal fever, and other septic states of obscure character. A positive blood culture in any infection is final from a diagnostic viewpoint. On the other hand, a negative result is of doubtful value and does not prove the absence of mJcro-organisms in the blood. By a simple modification of the technic, Frankel and Kinsey {Jour. Am. Med. Assn., 1904, 759) changed their percentage of positive findings in pneumonia from twenty to eighty in the same epidemic. Similar re- sults have been obtained in typhoid fever. Anyone with an understanding of bacteriological principles can make a blood culture. It is a perfectly harmless procedure when prop- erly carried out. There is no danger of thrombosis. The following steps should be followed : 1. Preparation of the Arm. — Constrict the arm by means of an elastic rubber tube to the extent of producing venous stasis, care being exer- cised not to interfere with the arterial circulation. This is likely to happen in severe septic conditions when the pulse is of small volume and of low tension. Locate the median basilic or median cephalic vein. The point selected for the puncture should be near the median line, so as to avoid the external and internal cutaneous nerves. The former lies just beneath the outer end of the median cephalic vein, while the latter crosses the median basilic at its inner end. The skin should be sterilized with ninety-five per cent alcohol. The superficial epithelium should be rubbed off. If this is done thoroughly, there need be no fear of infecting the patient or of contaminating the culture media. The more elaborate methods for sterilization are un- necessary, and as they are time-consuming they are undesirable, espe- cially for routine work. 2. The Puncture and Withdrawal of the Blood. — The venous punc- ture is usually easy, provided a needle with a sharp point is used. Those fitting a glass syringe of the Luer type, having a capacity of not less than 10 c.c, are very satisfactory. For sterilizing the syringe and needle the autoclave is to be preferred. The syringe and needles should be boiled for at least one half hour in order to prevent con- STTRGICAL ILEMATOLOGY 310 tainination. Aft(M- the syriiigi' is (illcd llic constrictor slioiild be re- moved before withdrawing the needle. Abxlcrate pressure should be made over the site of the puncture with a dry sterile sponge until the blood clots. This may be done by the patient while the operator inocu- lates the media. The blood clot which forms is sufficient protection for the small, punctured wound. A small collodion dressing may be applied, but it is uiuiecessaiy. The minute ])lo()d clot exposed to the air protects the vein more securely against bactt-i-ial infection than when coveiH'd willi collodion. 3. The Inoculation of the Media. — The strictest precautions should be observed, for it is during this procedure that contamination is most apt to occur. The neetUe which has been passed through the skin is apt to carry with it a smaller or larger number of staphylococci, no matter what method of sterilization is used. It should therefore be removed and inocidation made through the sterile glass end of the syringe. The tubes or flasks containing the media should be held as nearly horizontal as possible during inoculation. The mouths should be flamed thoroughly and the cotton plugs replaced as soon as possible. The character of the media is of the greatest importance. Litnms milk and beef broth are the most favorable for routine work. The reaction of the latter should be one per cent acid to plienolphthalein or neutral to litnms. The broth slunild be made from meat and not from the extract of beef. It should be sterilized by fractional sterilization instead of by the autoclave. This is particularly important when a pneumocoecus infection is suspected. Dilution of the blood, while of lesser importance, should be taken note of. A convenient way to control this factor in routine w(n-k is to take four flasks, each containing 50 c.e. of the media, and add approxi- mately one, two, three, and four or more c.c. of blood to each flask, raspectively. The inoculfited media are then placed in the thermostat. At the end of twenty-four hours the cultures usually show the presence of a growth if the result is to be positive. Very exceptionally, positive results are obtained first aftei" three or four days have elapsed. EXAMINATION OF BLOOD FOR H^MATOZOA Attention to the microscopic examination of the blood for animal parasites in puzzling septic conditions will frequently lead to a correct diagnosis. Pernicious malaria without definite paroxysms and with an atypical course often resembles typhoid fever, meningitis, uru'mic coma, perni- 320 WOUND INFECTIONS PRODUCED BY BACTERIA cious ana?mia, tuberculosis, and dysentery. An examination of the blood will usually reveal the malarial organism. In tropical countries the spirillum of Obermeier, filaria sanguinis hominis and trypanosoma Gambiensi should be searched for. All of these occur in the peripheral blood, while the Leishman-Donovan bodies of tropical splenomegaly are usually obtained by splenic puncture, since they appear only exceptionally in the general circulation, LEUCOCYTOSIS The term leucocytosis has come to mean the presence in the blood of an increased number of white blood corpuscles of the same variety morphologically as those in normal blood. Usually the greatest in- crease is in the polymorphonuclear neutrophiles, and this is sometimes spoken of as a polymorphonuclear leucocytosis. A distinct diminution of leucocytes is often spoken of as a leuco- penia or hypoleucocytosis in contrast to hyperleucocytosis, indicating an excess of cells. Much experimental and clinical work has been done in recent years upon the significance and value of inflammatory and infectious leuco- cytosis. The work of Metschnikoff and bis school upon phagocytosis and allied subjects has taught us to look upon a leucocytosis in many in- fections not only as an expression of the intensity of the irritant, but as a positive means of defense. The investigations of Wright and Douglas, Ilektoen, Ruediger, Rosenow, Potter, Dittman, Bradley, and others have thrown much light upon the mechanism involved. They have shown that destruction of various bacteria in the test tube is a result of the combined action of the serum, " opsonin," and the living cell, the leucocyte. They have pointed out that opsonification, phago- cytosis, and intraphagocytic digestion probably play an important role in combating certain infections. If a leucocytosis were constantly present in the same disease and always absent in certain others, and if the maxim that " the higher the leucocytosis the more favorable the prognosis " were always true, there would be no occasion for the diverse opinions held by different ob- servers as to the value of leucocytosis as a prognostic sign. But since a high leucocytosis may be an expression of a severe infection and at the same time be an index of resistance, and because in overwhelming infections it often fails to appear from the beginning or later disap- pears, there is ample reason why authors differ as to its value. When we remember that a pathological leucocytosis may be inflam- matory or infectious, post-hjemorrhagic or toxic in nature or the result SUKUICAL IlyEMATOLOGY 321 of malignant disease, it is obvious that enumeration of the leucocytes can help us in the clia' jnniidicc with delayed coagulation the coagidatiun time should, vvlien ])()ssihh', be l)rouglit within live niinutes before an operation is performed. Early in typhoid iwev, delayed eoatiulntion may predispose to in- testinal lui'iiiorrliati-e, while in the later stages of this infection the coagulability of the blood may be so increased as to favor thrombosis. This tendency to rapid coagulation is believed to be due to the exces- sive (piantity of calcium salts in the blood of the convalescent typhoid, the result of the prolonged milk diet. Wright and Knapp suggest, in order to prevent thrombosis in this disease, the partial decalcification of the milk by the addition of sodium citrate as soon as the danger of haemorrhage is over. HAEMOGLOBIN AND ERYTHROCYTES A relatively greater diminution in the hti'moglobin than in the red cells occurs in the symptoinatic ano-'mias attending the chronic consti- tutional diseases, in chlorosis, infections, ha?morrhagic disordei's, and the various toxic states. Because the hemoglobin reduction in these conditions is greater than that of the red cells, the amount of hfemoglobin per red corpuscle is less than normal. This condition is known as a low color index. The color index is obtained by dividing the percentage of ha-moglobin by the percentage of red cells present. It is important in all cases of anaemia to determine this point, since the graver antemias and leu- kunnias have a normal or even a high color index; the low haemoglobin reading in these cases being due to the reduction in the number of red cells. Pallor of the skin is not necessarily due to anaemia. It may be due to a deficient cutaneous circulation, the result of valvular disease, myo- carditis, or vasomotor disturbances, and hence should never be used as an index of the ha-moglobin content of the blood. In the interpretation of ha'moglobin values it nnist be remembered that concentration of the blood may account for abnormally high fig- ures, while in dilute hydra'mic blood the reverse occurs, the gain or loss in either instance paralleling the fluctuations of the erythrocytes. Individuals with a low haemoglobin reading do not bear general ana'sthesia and the loss of blood incident to an operation well. Bier- freund, Mikulicz, and others believe that a hasmoglobin percentage below thirty or forty contraindicates a general anaesthetic. Numerous reports of successful operations under general anaesthesia in cases in which the hemoglobin percentages ranged betAveen fifteen and thirty have been made, but all agree that operations should be performed as a life-saving 324 WOUND INFECTIONS PRODUCED BY BACTERIA measure only when the haemoglobin is so low. Nowhere in the realm of surgery does the skill of the operator and ana?sthetist count for so much. Bergmann, Bauman, Aborti, and others have shown that iron is the most useful blood builder for patients deficient in heemoglobin, hence it should be given freely in secondary ana-mias. Arsenic stimulates indi- rectly the h^mogenic centers, and is therefore of greater value when the deficiency in haemoglobin is the result of a diminution in the num- ber of erythrocytes. It has little or no effect in exciting directly a haemoglobin increase. CRYOSCOPY The freezing point (expressed by the Greek delta, A) of normal blood ranges between —0.56° and —0.58° C, while normal urine freezes between —0.9° and —0.2° C. These fluids are no exception to the law that the greater the molecular concentration of liquids the lower the freezing point. Surgically, cryoscopy is used chiefly in determining the integrity of the kidneys. Koranyi showed that in diseases of the kidney with renal insuf- ficiency the A of the blood falls, while that of the urine correspond- ingly rises, the blood becoming surcharged with excrementitious mat- ter, which the crippled kidneys fail to discharge. Kiimmel, Lindeman, and others assert that a freezing point below — 0.58° or certainly —0.6° is a distinct contraindication to a nephrec- tomy, because they believe that when this figure is obtained both kid- neys are too extensively implicated to insure adequate elimination when one kidney is removed. This view has been revised because Tieken, Loeb and Adrian, Rovsing, and others have shown that unilateral le- sions may cause decided abnormalities of the A, while bilateral lesions may exist without any such change. Their studies have shown that cryoscopy alone is of doubtful value in determining the state of renal activity, because other factors modify the molecular concentration of the blood and urine, such as circulatory stasis, dependent upon cardio- vascular, hepatic diseases, abdominal neoplasms, and anaemia from any cause. A lowering of the A of the blood, while not accepted univer- sally as a contraindication to nephrectomy, should always make the sur- geon cautious. This question, as well as other clinical features of cryos- copy, has been extensively studied by Tieken, Ogsten, Casper and Rich- ter, and Rinker. Literature. — Badnel. Rev. de M6d., 1899, p. 70. — Baginsky and Sommerfeld. Arch. f. Kinderheilkunde, 1902.— CoZe. Bull. Johns Hopkins Hosp., 1901, XII, 203; 1903, XIII, Vid.—Hektoen. Jour. A. M. A., 1903, XL, 685; Jour. Infectious Dis., 1906, SURGICAL ILEMATOLOGY 325 III, l')6.—Jochmann. Zcit.schrift f. klin. Aled., 1905, LV, :il6.—Kinsnj. .lour. A. M. A., 1004, 7r,\).—Kohti. Dcutsfh. med. Wochenschrift, 18U7, XXIII, 180.— Li6woh. Jour. Med. Research, I'.IOl, I, 84. — I'rockaska. C'entralblatt f. inner. .Med.. l'.)00, XXI, 114.5. — Roscnow. Anier. Jour, of Obstetrics, 1!)U4, 702; Jour. Infectious Di.seases, 1904, 280; 1900, III, GS^i.—SrhotmiilUr. Deutsch. nied. Wochen.schrift, 1900, Aug. 9.—Sello. Ztschrft. f. klin. Med., 1898, XXXVI, 112.— Wright and Douglas. Proceedings of Roy. Sec, 1903, LXXII, 357; 1904, LXXXIII, 128. III. WOUND INFECTIONS OF DIFFERENT ORIGINS AND SURGICAL INFECTIOUS DISEASES CHAPTER I WOUND INFECTIONS CAUSED BY POISONS Poisoning by Insects, Snakes, etc. — Intoxications, varying in sever- ity, may follow the sting or bite of a number of different insects (bee, wasp, hornet, spider, gnat, flea, bedbug, and others). Besides the local inflammatory reaction which follows the sting or bite, there may be general symptoms, such as superficial respirations, rapid pulse, faint- ness, collapse, and vomiting. These general symptoms are most apt to develop when a man or animal has been attacked by a swarm of bees or wasps, and the lesions are distributed over a large part of the surface of the body. Usually the general and local symptoms subside rapidly, but the patient may feel weak and feeble for several days. Death has followed, however, a single sting by a bee or wasp. The sting, which is situated in the posterior end of the bodies of bees and wasps, together with the poison bladder, is frequently left in the wound, and should always be removed. The wound should be touched with a dilute solution of ammonia in order to neutralize the poison, which contains an acid (probably formic acid). The same method should be employed in the treatment of stings by the European scor- pion, which are very similar to stings inflicted by bees and wasps. The application of naphthalene has been recommended in the treatment of mosquito bitas (Voges). [" Poisonous snakes are widely distributed in all countries of the temperate, and especially of the torrid, zones. In the United States about seventeen species of rattlesnakes and ten species of copperheads and moccasins, viper.s, coral, and harlequin snakes, etc., are classed as poisonous; with them a Texan reptile known as the Gila monster is also classed. In South America, Central America, Africa, the West Indies, and Australia many venomous reptiles are found. In Europe the adder and viper are dreaded, while in India much attention has been paid to the Thanatophidia, the cobra having furnished the venom upon which 326 WOUND LNFECTIU.WS CAUSED 15 Y I'OlriUXS 327 the work of Fraser, Caliiiette, and others has been based." — Keen's " Surgery," Vol. I, pp. 539 and oiO.] [" The poison apparatus of snakes consists of a secretory gland on each side which conmninicates with a tubular fang by means of a duct. In the pa.ssive state the fangs are directed backward on the roof of the mouth, but when the animal strikes, their points are made to project forward and the poison is forced through the canals by mus- cular compression of the sac. The venom is a glandular secretion." — Ricketts, '' Infection, Inmiunity, and Serum Therapy," pp. 264 and 265.] Bites caused by poisonous snakes may be recognized by two small punctured wounds lying side by side, while a zigzag woiuid is produced by non-poisonous snakes. Action of l^^nake Venom. — Snake venom, like the toxins produced by bacteria, dissolves red blood corpuscles, and contains two toxic albu- minous bodies (toxalbumins) which produce a local and general re- action. [" The venoms of different snakes vary a great deal in their toxic properties. The most important constituents are those which attack the nervous system (neurotoxin), the blood corpuscles (hiemolysins and hiemagglutinins), and the endothelium of blood vessels causing ha?mor- rliages (h^emorrhagin, an endotheliotoxin). The neurotoxin caiLses death by paralysis of the cardiac and respiratory centers. The haemo- lysin appears to be of less importance as a cause of death. ' ' The venoms of the cobra, water moccasin, daboia, and some poison- ous sea snakes are essentially neurotoxic, although they have strong dis- solving powers for the erythrocytes of some animals. In studying the ha^molytic powers of the venoms of cobra, copperhead, and rattlesnake, Flexner and Noguchi found cobra venom to be the most ha^molytic. and that of the rattlesnake the least. They attribute the toxicity' of rattle- snake poison chit^tiy to the action of ha^morrhagin. The same authors studied the action of different venoms on the cells of various animals, and by absorption experiments found independent cytotoxins for the testis, liver, kidney, and blood. Xot only was there a distinct cyto- toxin fo-r each organ of an animal, but also for the same organ of dif- ferent animals, results which speak for a remarkable complexity of venom. Certain venoms contain a leucoc}i;ic toxin. Proteohjtic Ferments. — " That venoms contain proteoh-tie ferments is shown by their ability to digest gelatin and fibrin. This power may be related to the softening of the muscles which has been noted clinic- ally in eases of poisoning. The rapid decomposition of the body which follows death by snake-poisoning is as.sociated with a decrease in the bactericidal power of the blood, which, according to Flexner and No- 328 WUUXD IXFECTIOXS OF DIFFERENT ORIGINS giiclii, depends on fixation of the complement by the venom. ' ' — Ricketts, " Infection, Immunity, and Serum Therapy," px). 265 and 266.] Symptoms : Local and General. — The local symptoms consist of pain- ful swelling of the tissues surrounding the wound, which develops soon after the bite is received. The skin cohering the swollen tissues is not discolored at first, but petechia and suggillations soon develop. In a short time the swelling becomes very extensive, and within half an hour the extremity becomes twice its normal size. The lymphangitis and lymphadenitis which frequently develop are due to the absorption of the venom; suppurative phlegmonous inflammation to secondary infec- tion with pyogenic bacteria. Necrosis and gangrene of the cedematous tissue are frequently produced by a too long-continued and too great constriction of the extremity or by subsequent putrefactive infections. In a few hours after the injury the general symptoms, consisting of dizziness, faintness, fever, headache, small rapid pulse, dyspnoea, the feeling of anxiety, vomiting, diarrha'a, with or without blood, and col- lapse, develop. In the majority of cases these symptoms disappear in a few days (on an average of nine daj's, according to W. K. Miiller) and the patient recovers, although a marked weakness may persist for a long time. Death due to cardiac weakness or asphyxia occurs in from three to nine per cent of the cases. The coagulability of the blood is reduced in these fatal cases, and numerous hgemorrhages are found in the viscera and intestinal mucous membranes. Comparative Toxicity of Venoms. — The local and general symptoms following bites inflicted by the rattlesnake (America) and the cobra (Asia, Africa) are much more severe than those following bites inflicted by the viper, and end fatally more frequently. The mortality follow- ing bites inflicted by these two snakes is about twenty per cent. In India more than 20,000 people die each year as the result of snake bites. Immediate death may follow injury' of a vein, with direct injection of the venom into the circulation. The cases of ordinary severity end fatally in a few days, the patient becoming delirious and unconscious, and tetanic con\iilsions developing. In chronic cases death may follow the after-efl:'ects of the venom (cachexia, tendency to oedema, htemor- rhagic diathesis) after months or years. It is important to know that the venom in museum specimens never becomes inactive. Treatment: Local and General. — The laity have recognized for a long time that the symptoms following snake bites are due to absorption of venom, and have formulated two important rules to prevent or lessen the absorption of the poi.sonous material: (1) To immediately suck the wound, removing the venom, or to express it by digital pressure applied to the tissues aljout the wound; (2) to tie off the injured part (for example, an extremity) close to the bite as soon as possible, and in this WOUND IXFECTrOXS CAUSED BY POISONS 329 way prevent the absorption of the venom until some other treatment can be iiistitutod. It is daniiorous to suck a wound unless one has a special apparatus oi" some kind or can protect the lips, as fissures may l)ecome infected. Venom has no effect upon healthy mucous mem- l)raii('s, and even if inti'oduced into the stomach is rendered harmless. Tlu' layman has outlined the work for the physician, whose duty it is to excise the wound as soon as possible and to make large incisions into the inthuiied, and, if a constrictor has been applied, haii(lluiig dcr N'ergiftungeii. Haiulbuch der spez. Therapie innercr Krankheilen von Penzoldt und Stintzung, 1895, Bd. 2. — Lamb. Die Serumbehandlung der Schlangen- bisse. Lancet, Nov. 5, l'JU4. — Lcwin. Die Pfeilgifte. Histor. u. experim. I'nter- svichungen. Reiiner, Berlin, I'JOH. — TJ'. K. Midler. Die Verletzungen durch Schlangen- biss in Pommern. I.-D., Grcifswald, 1895. CHAPTER II IIYDKOPUOBIA (lYSSA, RABIES) Hydrophobia as it occurs in man is an acute wound infection which invarial)ly proves fatal. It is transmitted to man by the bite of a rabid animal, most frequently (ninety per cent) by the dog, or in its saliva, whit-h in some way is introduced into fresh wounds. Virus of Hydrophobia: Negri Bodies. — Nothing definite is known con- cerning the virus of hydrophobia. Negri in 1903 first described round bodies -1 to 10 fx in size in the nervous system of animals dying of the disease. These bodies are found within the large ganglion cells, and are especially numerous in the horn of Amnion and in the cells of the cerebellum. They are also found, but not in as large numbers, in the cells of the medulla oblongata, the spinal cord, and spinal gan- glia. Negri's findings have been confirmed by Volperino, Bertarelli, Schift'mann, ]\Iaresch, and others. These bodies may be regarded as the most characteristic findings in animals and men dying of liydro- I)hobia. Further investigation must decide whether Negri is correct in regarding them as protozoa and as the specific cause of the disease. Distribution of the Virus. — It has been demonstrated by animal ex- periments that the brain, spinal cord, and peripheral nerves contain the virus. It has even been demon.strated in the saliva of animals before they have sho^^•n symptoms of the disease. The virus apparently passes from the wound along injured nerve trunks (Babes, di Vestea-Zagari, AVyssokowitch, and others). [" Experimental work shows conclusively that the virus is conveyed to the central nervous system by means of the peripheral nerves, and that the infection is closely associated with the wounding of nerves. It has been shown that if wounding of nerves is entirely avoided, as in intraperitoneal injections into rabbits (^larx) the full virulent nervous tissue may be used for immunization." — Ricketts, " Infection, Immunity, and Serum Therapy," p. 517.] The infection develops most rapidly and mo.st frequently after the injection of small amounts of the brain or spinal cord of patients or animals dying of the disease into the subdural space. Infection does not follow 332 WOUND INFECTIONS OF DIFFERENT ORIGINS subcutaneous injections, and the results of intravascular injections are inconstant. This partly demonstrates that the virus is taken up by and extends along injured nerves. Susceptibility of Different Animals. — All warm-blooded animals are susceptible. The disease may be transmitted to man by the dog, wolf, cat, and fox. Direct infection from man to man is not known. Hydrophobia in Dogs. — In dogs the incubation varies from three to five weeks. The prodromal stage is characterized by restlessness, loss of appetite, nausea, and irritability. Then in a few days the symptoms characteristic of the second stage of the disease become pronounced. [" According to Bollinger the initial or prodromal stage lasts from one half to two or three days, and the stage of real madness, irritation, or maniacal stage lasts three to four days." — Tillman's " Text-book of Surgery," I, 398.] The virus may be transmitted to man and animals through the saliva before there are any symptoms of the disease. The bite of an animal which is apparently healthy may therefore carry with it the danger of infection. Two forms of hydrophobia may be distinguished in dogs — the raging and the paralytic. According to Pasteur, the raging form develops when the virus attacks chiefly the brain, and the paralytic form when it attacks chiefly the spinal cord. In the convulsive or maniacal form the disposi- tion of the dog changes suddenly. The animal becomes more irritable, attempts to bite other animals or surrounding objects, runs confusedly about, and utters long-drawn-out howls, emaciates rapidly, and shows a preference for indigestible things, such as wood, earth, and fgeces. A pharyngeal spasm develops at every attempt to drink, therefore the name hydrophobia, meaning " fear of water," has been given the dis- ease. The third stage (stage of paralysis) develops upon the third or fourth day. The hind legs first become paralyzed. The paralysis later extends to other muscles, and on from the third to the sixth day con- vulsions develop and death occurs. An animal which develops hydro- phobia never recovers. The paralytic form is still more rapid; the paralysis (particularly of the muscles of the extremities, mastication, and deglutition) develops earlier, as there is no stage of excitement. Hydrophobia in Man. — Hydrophobia in man is characterized by a long period of incubation, generally from twenty to sixty days. It va- ries from fifteen days to six months. A longer period of incubation than six months is extremely rare. Hydrophobia does not follow every bite by a rabid dog, as the clothes afford some protection against the infec- tious saliva. Only a small proportion of those bitten by rabid animals (according to Babes, not one third; according to others, still less) de- velop the disease. Hydrophobia follows less frequently bitas of pro- tected parts of the 'body, more often bites of the head and face. HYDRorilUBIA 333 Clinical Course. — The pnidromal stage begins with pain in the wound or scar, which radiates along the nerves supplying the sur- rounding area. Sometimes the scar becomes reddened, sometimes when the wound is not heaUxl the graiiuhitioiis are unlicalthy. Loss of appe- tite, headache, melancholia, restlessness, anxiety, sleeplessness, slight dysphagia and dyspnoea, sometimes early aversion to licpiids, in spite of great thirst, and slight temperature indicate the beginning of the disease. After a few hours or days, painful pharyngeal spasms develop at every attempt at drinking and eating. These pharyngeal spasms, which finally may be even provoked by the sight of a drinking glass, render the swallowing of food, even the swallowing of saliva impossible, and are tlie principal symptoms of the hydrophobic stage which is char- acterized by an increased reflex excital)ility. At this time the skin and sense organs are hypersensitive, and any irritation, such as stroking or blowing upon the skin, loud noises, strong light, etc., produces a dyspna'ic conditicm and clonic spasms of all the muscles. The pupils become dilated when the skin is irritated or the auditory nerve is stimu- lated (Schaffer). When this increased excitability extends from the spinal cord and medulla to the brain, the reflexes are abolished, the dilated pupil does not react, the urine is discharged involuntarily, and delirium develops. Sometimes extensive paralysis occurs (lumbar and cervical paraplegias) and sometimes the last or convulsive stage may begin with violent and persistent vomiting and be characterized by con- vulsions. The patient rapidly becomes exhausted, a high fever devel- ops, and death occurs, most fre(iuently between the second and fourth days of the disease. Consciousness may be retained until the end. Pathological Anatomy. — Inflammatory and degenerative changes have been described in the motor centers of the central nervous system, especially in the spinal cord (acute myelitis). These changes are most advanced in the segments which correspond to the nerves primarily in- volved (Schaffer). [Babes has described peculiar perivascular nodules in the medulla and spinal cord composed of lymphoid cells; van Ge- huchten, a proliferation of the endothelium surrounding the ganglion cells. Degenerative and atrophic changes occur in the latter.] Diagnosis. — Hydrophobia may be mistaken for head tetanus, as pharyngeal spasms occur in the latter also. Hysteria must be consid- ered in making a diagnosis. Treatment. — In the treatment of bites of rabid or supposedly rabid animals an attempt should be made to render the virus harmless as soon as possible. Excision of the wound, amputation of small parts, and open treatment of the wound are most efficacious. Cauterization of the wound is not safe, as the eschar prevents the discharge of wound secre- tion, and the retained virus develops beneath it. The same thing hap- 334 WOUND INFECTIONS OF DIFFERENT ORIGINS pens when the primary wound or the one following its excision is sutured. The edges of large and deep wounds, the tissues of which are contused and lacerated, should be trimmed off and a tampon which provides for the discharge of the secretion should be inserted. Because of the longer incubation period local treatment is of more value in man than in animals. Babes found that in order to prevent the development of the disease in animals, the wound must be cauter- ized with a Paquelin cautery not later than five minutes after infection. If the disease has developed, narcotics should be given to control the painful spasms. Plourly subcutaneous injections of curare (one fifth to one half grain) have been recommended (Penzoldt). Rectal and subcutaneous injections of physiological salt solution should be given to control the thirst. The disease has almost disappeared from Germany and England. The police regulations against stray and suspected animals are very rigid, and there are laws which provide for the muzzling of dogs. Ac- cording to M. Kirschner there were, on an average, only four deaths a year from hydrophobia in Prussia in the period between 1889 to 1899. In England there have been no deaths for several years. In America hydrophobia is still common. In Chicago from fifteen to twenty deaths occur each year. The long incubation period in man is taken advantage of in the Pasteur treatment, as an immunity may be established against the virus before the symptoms develop and the disease may be prevented. Pas- teur gave the name of street virus {virus de rue) to that obtained from the nervous system of dogs in which the disease develops spontaneously. When the street virus is injected subdurally into rabbits, they develop the disease after two or three weeks. "When this virus is passed through a number of rabbits the incubation period is reduced finally to six days. It is impossible to reduce the incubation period below six days, and the virus obtained from the nervous tissue of such an animal is extremely virulent. It is called the fixed virus (virus fixe). In the Pasteur method this virus is gradually attenuated by drying the spinal cord. The virus obtained after drying the cord for fourteen days is the weakest and is no longer active for rabbits. Dogs, which are more susceptible than man, may be rendered immune against highly virulent virus, if bouillon emulsions of a fourteen day old cord, then a thirteen, twelve, and so on are injected daily ; in other words, if the virulence of the virus injected is gradually increased each day. The Pasteur treatment is the only one, according to our present knowledge, which will prevent the development of the disease. It cannot be relied upon M^hen the incubation period is short (about two weeks), as is frequently the case in bites of the face and in those in- TETANUS: LOCKJAW 335 flictod ]\v wolves, or when treatiiuMit is institntod latft, so that only two or tlnre wei'ks t-hipse before the symptoms dcvcloi). However, if the injections are given in i-apid succession, an iiiiinuiiity against the strong- est virus may be established as early as the third day, and cures have repeatedly been made. Ten e.e. of the emulsion should be injected subcutaneously each time in the hypoehondrium. After the protective inoculations have been completed the blood contains protective sub- stances (Kraus and Kreisl). Mortality. — The mortality has been considerably reduced since peo- ple bitten by rabid or supposedly rabid dogs have been subjected to the Pasteur treatment. Pottevin estimates the mortality among 13,817 pa- tients treated in Paris as 0.5 per cent, while the mortality among patients not treated is not lower than 10 per cent. Hogyes gives the mortality of those who received treatment as 0.85 per cent, of those who did not as 11.14 per cent. In the dangerous wolf bites, 90 per cent of which are folloAved by the disease, the results following early treatment, a mortality of from 10 to 15 per cent are very favorable (Babes). Injections of blood serum obtained from immunized animals have also been made with succe.ss (Babes, Tizzoni, Schwarz). Literature. — Babes. Studien iiber die Wutkrankheit. Virchow's Arch., Bd. 110, 1887, p. 562; — Ueber die Behandlung von 300 von wiitenden Wolf en Gebissenen. Zeitschr. f. Hygiene, Bd. 47, 1904, p. 179; — Behandlung der Wutkrankheit des Menschen. Ln Handb. der spez. Therapie von Penzoldt u. Stintzing, 1903, Bd. 1; BerUireUi. Die Negrischen Korpercl>en im Xervensysteni der wutkranken Tiere, ihr diaguostischer Wert und ihre Bedeutung. Zentralljl. f. Bakteriol., Bd. 37. Abstract. CHAPTER III TETA^a'S : LOCKJAW NicOLAiER in 1884: produced fatal tetanus in mice, rabbits, and guinea pigs by infecting them with garden earth, in which he had dem- onstrated a bacillus with a somewhat rounded end. Rosenbach (1885) found a similar bacillus in the wound of a patient sick with tetanus. Kitasato (1889), using anaerobic culture media, was the first to obtain pure cultures of the bacillus and to produce with the cultures experi- mental tetanus. Bacillus of Tetanus. — The tetanus bacillus is a slender, slightly mo- tile organism which develops a terminal spore, and for this reason the bacillus with its spore resembles a drumstick. The bacillus fre(juently develops filamentous forms in cultures. It stains readily with the ordi- 336 WOUXD IXFECTIOXS OF DIFFERENT ORIGINS Fig. 134. — Tetanus Bacilli. uary stains and also by Gram's method. The bacillus is Avidely dis- tributed in thi' ground, and is found as far as 30 cm. below the sur- face, being carried probably to this dep>th in the dung of animals, in v.'liich it is frequently found. Ap- Tjarenth" the bacilli find conditions favorable for growth in the intes- tines of animals, but tetanus does not develop from the intestine, as / ^._^ V « ^ ^"^^ ^ ^ , feeding experiments have demon- ^ • ^-*^^-* ggi strated. Of the domestic animals, the horse, cow, and sheep develop the disease most frequently after in- jury (or after castration). Y ' ^ ^ «5v ^ai^ fe* / The bacilli are obligatory an- > S* * xs-i %■: ^^/^ aerobes, and grow best at 98.5° F. Yellow colonies having irregular off- shoots which grow out into the me- dium appear in gelatin and agar on the second day. Gelatin about stab cultures slowly liquetias and gas is formed. Bouillon is clouded. All cultures have a disgusting odor. Susceptibility of Different Animals. — Guinea pigs, mice, and rabbits are best suited for experimental purposes. Fatal tetanus is easily pro- duced in these animals by the injection of virulent cultures. Cultures become inactive when heated for five minutes at 149° F., and are ren- dered toxin free, as the toxins secreted by tetanus bacilli are destroyed by heat. The toxin-free cultures still contain viable spores, but are active only when injected in large amounts. The bacilli must there- fore be injected with their toxins to obtain results. If old cultures, rich in toxins, or foreign bodies to which bacilli are attached, are em- ployed, a fatal tetanus develops after an incubation period of from one to three daj's. As a rule, the bacilli do not extend beyond the wound, and only in rare cases have they been demonstrated in the vis- cera (von Oeftingen and Zumpe). Tetanus Toxins. — Filtered cultures, and bouillon cultures from which the bacilli have been removed, are active, as they contain the toxins which have been secreted by the bacilli. These are soluble in water and can be precipitated by sodium-ammonia sulphate (Buchner) or zinc chlorid (Brieger and Boer). Dry preparations of the toxins which are more useful for experimental purposes may be made from the precipitate. According to Ehrlich and ]\ladsen there are two toxins. They found in bouillon cultures tetanospamin, which has a strong affin- ity for nervous tissues and produces the muscular spasms, and teta- nolysin, which dissolves red blood corpuscles. TETANl'S: LOCKJAW 337 Tlie strength of the toxin is dependent upon the virulence of the bacilli. The virulence of the bacilli is remarkably increased by sym- biosis with other bacteria, especially by putrefactive processes in the wound (A. Schiitze). In order to demonstrate the bacilli in a wound the penetrating for- eign body or a particle of dirt should be transferred to an experimental animal. If bacilli are present, the symptoms of tetanus, which proves fatal after a few days, develop, and the spore-bearing bacilli can then be demonstrated microscopically iu the wound secretion and can be obtained in pure cultures. Tetanus a Wound Infection. — Tetanus is essentially a wound infec- tion, even if clinicians are accustomed to differentiate a traumatic teta- nus (with a demonstrable infection atrium) from a rheumatic or idio- pathic tetanus (without a demonstrable infection atrium). Any injury of the epithelium of the skin or mucous membrane, however insignificant, may be followed by tetanus. Frequently the wounds which are followed by the disease are those in which the tissues are lacerated and contami- nated with earth. It follows most frequently compound fractures, in- juries produced by the explosion of a bomb, or by penetrating foreign bodies (for example, a splinter of wood) ; more rarely gangrenous wounds, scratched acne pustules, insect bites, and the wound resulting from the separation of the cord in the newborn (tetanus neonatorum). It sometimes follows lesions of the inner surface of the uterus, as in puerperal tetanus, and injuries of the epithelium of the mucous mem- brane of the nose and pharynx (supposedly in idiopathic tetanus). CJiaracteristics of Wounds Favoring Development of Tetanus Ba- cillus. — It is remarkable, considering the wide distribution and resist- ance of the bacilli, which have remained virulent for eleven years on a splinter of wood, that the disease is so rare. As a rule, the infection of the wound with tetanus bacilli is not alone enough to cause the dis- ease. The bacillus demands special conditions for its development. Saprophytic organisms, usually found in wounds contaminated with earth or foreign bodies, favor the development of the bacilli, which, as a rule, are easily destroyed by the bactericidal substances in the tis- sue fluids. Severe injuries to the tissues (lacerations and contusions), which are followed by necrosis and putrefactive changes, also favor the growth of the bacilli. [" Necrotic tissue favors the proliferation of tetanus bacilli in two ways. In the first place, it seals up the wound to a certain extent, and thus provides the reiiuisite anaerobic condition; in the second place, it would seem to prevent phagocytosis of the bacilli in some obscure way. It has been suggested that the strong chemotactic relation which exists between necrotic material and leucocytes causes the latter to take up dead tissue rather than bacilli. That innocent 338 WOUND INFECTIONS OF DIFFERENT ORIGINS foreign material may favor the development of tetanus was shown by Vaillard and E-ouget. They demonstrated that tetanus would develop in the presence of an artificially produced ha?matoma or a subcutaneous fracture, while in the absence of such predisposing factors the bacilli were taken up by phagocytes." — Kicketts, " Infection, Immunity, and Serum Therapy," pp. 247 and 248.] Rational w^ound treatment (open treatment and drainage) often prevents the development of those con- ditions Avhich favor the growth of the bacilli and the later development of the disease. Epidemics of Tetanus. — Epidemics of tetanus have been observed in wars. These epidemics are easily explained, as all the important fac- tors (severe injuries, contamination of the wound with street dirt or earth) which favored the infection of the wound and growth of the bacilli were present. Post-operative tetanus, which often became endemic in earlier times, is only occasionally seen by the surgeon at the present time. In these cases the wounds are infected by soiled dressings, unclean instruments, etc. Tetanus has occasionally developed after gynecological operations (Koch, Phillips). Tetanus bacilli rarely extend beyond the primary wound. They have been demonstrated in the neighboring lymphatic nodes (Schnitzler), in the viscera (Creite), in the circulating blood (Hochsinger), and in the blood taken from cadavers (Hohlbeck). Incubation Period of Tetanus. — The incubation period in man varies from twenty-four hours to sixty days. As a rule, the disease develops between the eighth and fourteenth days. Tetanus has developed in four clays after an accidental infection with a pure culture of the bacilli. ["In the statistics of Rose, twenty per cent of the cases showed symp- toms in the first week, forty -five per cent in the second, and about thirty per cent in the third or fourth weeks." — Ricketts, " Infection, Im- munity, and Serum Therapy," p. 249.] A certain time is required for the development of the bacteria and their toxins before they are ab- sorbed and act upon the nervous tissues. Condition of Infected Wounds. — There are no changes in the wound which are characteristic of an infection with tetanus bacilli. The wound may be suppurating, granulating, or healed when the first symp- toms of the disease develop. Frequently foreign bodies on which the l)aci]li have gradually developed are found in the cicatrix. Symptoms and Clinical Cause. — The chief symptoms of tetanus are tetanic muscular contractions accompanied by clonic spasms of greater or less degree, recurring at varying intervals. The muscular contrac- tion is most pronounced in the muscles of mastication, and causes the painful " lock-jaw," the so-called trismus. More rarely the contrac- TETANUS: LOCKJAW 339 lion begins in the nniseles abont the wound and then extends, so that hiter alnu)st the entire nuiseuhiture is involved. A liiuh fever may be present from the l)i'uinninu\ oi- may (U'velop hiter durinii' Hk' last hours or days of the disease. Fever may be absent in the fatal eases as wrll as in the cases wliieh recover. Tetanus pursues an acute or chronic course, depending upon the severity of the symi:)toms. In the acute form, S})asms of tlie muscles of the neck and face de- velop soon after the trismus. Then the muscles of the back, abdominal wall, and extremities become involved in frequently recurring clonic spasms. Unless the local spasms begin in the muscles of the arms, the latter are either spared or but little involved. Contraction of the mus- cles of the face gives the patient a characteristic grinning expression (risiLS sardonicus) and a senile appearance (facies tetanica) due to the wrinkling of the skin of the forehead and cheeks. The painful muscular spasms, mostly tonic in character, may finally involve practically all the muscles of the body. These spasms, recur- ring at irregular intervals and lasting for different lengths of time, are often produced by the slightest irritation, such as touching the patient or by some noise, and so disturb him that sleep and the taking of food are rendered impossible. The attempt to sA\'allow may bring on a con- vulsion, as the reflex excitability is so increased. Bathed in sweat, with anxious expression and grinning mouth and with teeth pressed firmly against one another, the unfortunate patient awaits these frightful convulsions, which, if the extensor muscles of the back are involved, often force the head far back into the pillow (opis- thotonos). The discharge of fteces and urine may be rendered dif- ficult or impossible by the contraction of the sphincter muscles. If the nmscles of respiration are involved, death from suffocation may occur twenty-four hours after the trismus. Spasm of the glottis, cardiac pa- ralysis, and aspiration pneumonia may cause death. Shortly before death the temperature, which may be very high (109°-110° F.), falls. These excessivelj' high temperatures are partly due to muscular action. Prognosis. — Most frequently these acute cases terminate fatally within the first four days. Each day which the patient survives gives a better prognosis, for usually after a week the convulsions become less frequent and less severe, some groups of muscles lose their rigidity and are spared when subsequent spasms recur. The earlier the symptoms of tetanus develop after an injury, the more frequently the spasms recur and the more extensive the muscle groups involved, the graver the prognosis. ["In man, as in animals, it is found that the shorter the incubation period, the more severe the disease and the worse the prog- nosis. It is stated th.at of those ca.ses w^here the incubation period is 340 WOUND INFECTIONS OF DIFFERENT ORIGINS under ten days, not more than 3 to 4.5 per cent recover; when the incu- bation period is from eleven to fifteen days, 25 per cent recover; in those cases in which the incubation period is still longer, about half the patients attacked throw off the disease. Different authors give dif- ferent statistics, but these are the general results." — T. C. Allbutt, " System of Medicine," p. 773.] If acute symptoms do not develop again and if no complications, such as aspiration pneumonia, occur after improvement begins, the patient may slowly recover. Disappear- ance of the trismus and lessened excretion of sweat are indications of recovery, but both are unreliable. In chronic forms this severe clinical picture is not seen. The mus- cles of respiration are not involved, and but little fever, or none at all, accompanies the difficulty in swallowing, the trismus, and the rigidity of the muscles of the neck. These may be the only symptoms. Recov- ery may occur after a week, at latest after three months. Diagnosis. — The diagnosis, when the symptoms are pronounced, is easy. If, in the chronic forms, trismus is the only symptom at the beginning, all acute diseases of the mouth and pharynx which are associated with trismus and an elevation of temperature must be excluded. Varieties of Tetanus. — Tetanus in the newhorn (tetanus neonatorum) develops in from one to five days after the separation of the cord. The demonstration of bacilli in the pus discharged from the suppurating navel proves conclusively that the infection occurs here. The child pre- sents the ordinary symptoms of the disease. The way in which the crying child releases the nipple, which was eagerly grasped, is rather striking. In most cases death occurs on the third or fourth day. Puerperal Tetanus. — In puerperal tetanus (tetanus puerperalis) the infection is introduced by filthy midwivas, often in performing abor- tions. The uterine mucous membrane affords the infection atrium for the bacilli which have been demonstrated in these cases. This form of tetanus is severe and ends fatally. Head Tetanus. — Head tetanus (tetanus cephalicus) follows injuries in the area of di.sti'ibution of one of the cranial nerves. The disease has received a number of names, selected because of its principal symptoms. In the acute severe forms pharyngeal and laryngeal spasms, the result of increased reflex excitability, soon develop. These resemble the spasms occurring in hydrophobia, and for this reason the disease has been called tetanus JnjdropJiohicns by Rose. It is characterized by tetanic contractions of the muscles of mastication, combined with a paralysis of some of the muscles supplied by cranial nerves, particularly of those supplied by the facial nerve (therefore tetanus facialis according to Rose, or tetanus paralyticus according to Klemm). The rigidity then TETANUS: LOCKJAW 341 extends to the inuseles of the neck, trunk, and extremities. Death is ])ro(hieed by suli'oealion duruii^ a convulsion, or by cariliae paralysis. In tlie subacute antl ehronie eases the syniptoiiis are often mild, and may be limited to the region supplied by cranial nerves. According to l^runner. in some eases a tonic contraction of the muscles supplied by the facial nerve develops first upon the side of the injury, or, if the injury is in the median line, upon both sides; then follow inunediately spasms of the nuiscles of nuistication. In other cases, however, the nniseles supplied by the facial nerve l)ecome paralyzed first upon the side of the injury, and spasms of the muscles of mastication then de- velop. It is remarkable that the paralysis never involves the motor braneh of the lifth cranial nerve. I'aralysis of the third and fourth cranial nei'ves has been noted when the injury involved the eye. As a rule, fever does not accompany head tetanus. Apparently the toxin extends along the nerves, injures the nuclei, and produces paralysis in this way. Treatment. — In discussing the treatment of tetanus, serum therapy nuist be considered first. It is impossible to understand the action of antitetanic serum without a clear idea of the action of tetaiuis toxin, and therefore the mode of action of the latter will be briefly dis- cussed. After an incubation period varying Avitli the animal used, a fatal disease follows subcutaneous and intravenous injections of tetanus toxins. It has been determined by experimental work that the toxins are absorbed from the wound by the end organs of motor nerves, and that they pass along the axis cylinders to the central nervous system. The toxins also circulate in the blood, from which they disappear when the spasms begin (Blumenthal). In all probability these toxins are deposited in some part of the neuromuscular apparatus. It has been shown that the toxins act upon the central nervous system, especially upon the motor centers of the spinal cord and medulla oblongata. The excitability of these centers is increased in tetanus, and any stinmlus l)i't)vokes a violent reaction. The results of the following experiments prove concliLsively that the toxin does not act upon the muscles, the peripheral nerves, or brain (von Leyden and Blumenthal) : (1) When the motor nerves are cut or the animal is curarized, the tetanic mus- cular contraction ceases; (2) when the cerebrum is removed, tetanus can still be produced (Brunner) ; (3) tetanic contractions do not de- velop in muscles when the corresponding spinal segments are destroyed. Pathological Anatomy. — ]\Iicroscopic changes in the motor ganglion cells have been described by Goldscheider, Flatau, and others. These changes are not regarded by other investigators as peculiar to tetanus. A. AVjissermann and Takaki have shown that tetanus toxin has a strong 23 342 WOUND INFECTIONS OF DIFFERENT ORIGINS affinity for nervous tissue containing substances not found in other organs M^hich bind the tetanus toxins. If a mixture of tetanus toxins and brain tissue is injected into guinea pigs or rabbits the animals do not develop the disease, as the toxins have already been rendered inert by their union with the nervous tissue. [" It is held by certain authors that the toxin attacks only the nervous tissue in man ; in some of the lower animals, however, various organs, especially the liver, have an affinity for the toxin." — Ricketts, '' Infection, Immunity, and Serum Therapy," p. 250.] Absorption of Tetanus Toxin. — It has been demonstrated by the ex- periments of Meyer and Ransom, Tiberti, and others that the toxins pass along the peripheral (motor) nerves to the central nervous system. Local contractions which are not frequent in man, except in head teta- nus, occur in animals after subcutaneous (not after intravenous) injec- tions. These local contractions are due to the extension of the toxins along the nerves to the segments corresponding to the muscles about the wound (Stinzing and others). Tetanus Antitoxin. — If an animal has recovered from the disease it is immune against small doses of virulent toxins or larger doses of atten- uated toxins. By injecting gradually increasing doses of the toxins the immunity may be so raised that the animal can withstand the in- jections of pure tetanus toxins or of virulent bacilli. The animal has become immune, and, according to Behring and Kitasato, its blood serum has the power to neutralize tetanus toxin, to protect other ani- mals against tetanus, and to cure them when the disease has already developed. The bacilli are not killed by the antitoxin, but they are no longer active, as their toxin is rendered harmless. The blood serum of immunized horses (antitoxin) affords a certain protection to man when used in the treatment of tetanus. According to our present knowledge, a concentrated antitoxin is able to neutralize the tetanus toxin circulating in the blood, and if the organism is not flooded with large quantities of the toxin, one may hope by repeated injections not only to neutralize the toxin in the blood, but also to render harmless the toxins continually absorbed from the wound, before they can act upon the ganglion cells in the spinal cord and medulla. As soon as the toxin becomes united with the gan- glion cells, the antitoxin circulating in the blood no longer has any effect, as it either reaches the spinal cord in too small amounts or is unable to break up the chemical union between the toxin and the gan- glion cell. Attempts have been made to bring the serum into direct con- tact with the central nervous system and the centers upon which the toxins act. Jacob has injected the serum into the subdural space, Kocher into the ventricles of the brain. Experimental work indicates TETANUS: UXJKJAW 343 that direct injection is of some value. No definite conclusions can be drawn from clinical experience. Antitoxin should be injected as soon as possible after the first symp- toms of the disease develop (according to von Behring within the first thirty hours), and a subcutaneous or intravenous injection of a certain amount should be made daily. T^npleasant symptoms follow the intra- venous injections of some sera, and for that reason von Behring recom- mends that suljcutaneous injections should be made, preferably in the area surrounding the wound. In tetanus puerperalis the serum should be injected into the vagina, in tetanus neonatorum into the abdominal cavity. Calmette recommends that the dried serum be sprinkled on the wound. Kiister has exposed the nerves supplying the region of the wound and has injected the serum into them. This treatment has ap- parently been successful in some cases. [Antitetanic serums are not standardized by American manufac- turers, and it is impossible to control accurately the dosage. Not less than 10 c.c. should be given for prophylactic purposes, and this dose should be repeated. It is impossible to set any definite limits for the amounts which should be used for curative purposes. As previously mentioned the curative action of the serum cannot be relied upon. It is most useful as a prophylactic, and should be given in all cases in which there is a possibility that tetanus may develop.] Technic for Injection of Serutn into the Lateral Ventricle and the Spinal Subdural Space. — In Kocher's method of injecting into the lateral ventricle a small trephine opening is made in the skull from 1 to 1^ inches lateral to the bregma, the point at which the sagittal and coronal sutures meet. A long needle is then passed 2 or 2-| inches into the brain substance in a vertical direction. "When fluid flows from the needle, the serum is injected slowly. Tavel makes the opening 1 j inches from the median line and 1^ anterior to the coronal .sutures. He then passes the needle toward the foramen magnum. The lateral ventricle may also be reached from the frontal region, from just above and a little to the inner side of the frontal eminence (von Bergmann), from the lateral surface of the skull (Keen), and from the occipital region (Beck). It is best to make a skin periosteal flap in exposing the area in which the opening is to be made. The flap can then be sutured in position and subsequent injections made through it (Tavel). The danger of infec- tion is lessened by this procedure. The technic employed in Quincke's lumbar puncture is used in mak- ing spinal injections. The patient is placed upon his left side and a needle is passed between the spines of the third and fourth lumbar verte- l)rie, and is forced forward somewhat upward and inward. After con- siderable cerebro-spinal fluid has escaped, the serum is injected slowly^ 344 WOUND INFECTIONS OF DIFFERENT ORIGINS Results of Serum Treatment. — It is difficult to judge of the value of the serum treatment in mild cases, as a large proportion of these recover spontaneously. On the other hand, in the severe cases, which usually develop within a week after the injury, the serum has no cura- tive action, although it has been demonstrated that it passes through the body, as it has been found in the urine (von Leyden). As the serum treatment cannot be relied upon when the disease has developed, it is tlie duty of the attending physician to try any treat- ment which may possibly cure the disease or at least alleviate the suffering. Treatment of the Wound. — Toxins are being continually absorbed from the wound, and this should be prevented. When the position and form of the wound permits, as in the fingers or toes, an amputation or a thorough excision should be performed. In extensive and compli- cated injuries of the extremities, particularly in compound fractures, amputation is indicated as soon as the. first symptoms develop. Only in the mildest cases should this indication be disregarded. All necrotic tissue and blood clots should be removed from the large wounds of the trunk, and the undermined soft tissues should be opened widely in order to prevent putrefaction, which, according to experimental work, increases the virulence of the bacilli. The aseptic, open treatment of the wound is an important preventive measure, as it permits of the free access of air which prevents the growth of anaerobic bacilli. Foreign bodies, lying in the wound or encapsulated in the scar, should be re- moved, as large numbers of bacilli are usually attached to them. Cauterization of the wound, which is frequently recommended by physicians, does harm, as the eschar which forms prevents the discharge of wound secretion. If the wound is contaminated with street dust, manure, or earth, or has been received in localities where tetanus is of frequent occurrence, a prophylactic injection of serum should be given, and if practicable the wound should be excised. In spite of such proph- ylactic injections, tetanus may develop and end fatally, even if the majority of cases handled in this way recover (Suter). The remaining treatment is purely symptomatic. Narcotics should be given to control the spasms, especially the dangerous spasms of the muscles of respiration. Large doses of morphin and chloral act best. In feeding the patient, the dangers of aspiration pneumonia should be kept in mind. Rectal feeding is indicated as long as the trismus and pharyngeal spasms persist. Any external irritation will cause convulsions and the patient must be placed in quiet surroundings. Morphin should be given before the dressings are changed or the pa- tient is catheterized. Stimulants should be given as the heart becomes weak. DIPHTHERIA 345 LiTKKATURK. — )'. nikringund KitastUo. Uebcrdas Ziistandekommon der Dii)hthcrie iiM.l (liT Totaiiusiiiummitiit bci TuTcn. Deutsche nicd. Wuchonschr., \S09, p. llUi. — Biryrll and Levi/. Ueber dcu llinfluss des Curare bei Tetanus. Therapie der (Jegeiuvart, li)U4, p. 39(3. — lirunncr. Kupttetanus. lieitr. z. klin. Chir., Bd. 9, 10 u. 12. — Calmette. Sur I'ubsorption de I'antitoxin tetanique par les plaies. Academie des sciences, Mai, VMY.i. — Crcite. Zum Nachweis von Tetanusbazillen in Organen des Menschen. Cen- tralbl. f. Bakteriol., Bd. 37, Orig., 1904, p. 312. — Hohlbeck. Vorkomrnen des Tetanus- bazillus ausserhaib der Infektionsstelle beim Menschen. Deutsche med. Wochenschr., 1903, p. 172. — Kitasato. Ueber den Tetanusbazillus. Zeitschr. f. Hygiene, Bd. 7, 1889, p. 22."). — E. Koch. Tetanus nach Bauchoperat. Deutsche Zeitschr. f. Chir., Bd. 48, 1898, p. 417. — Kruse, in Die Mikroorgani.smen von Fliigge, 1896, Bd. 2. — Ku.^er. Eiu Fall von ortl. Tetanus. Antitoxineinspritzungen in die Xervenstamme. Heilung. Chir.-Kongr. Verhaudl., iOO.">, II, p. 1(31. — Lexer. Zur Tetanusbehandlung. Therapie. d. Gegenwart, 1901, Juni. — v. Leijden und Blumenthal. Der Tetanus. Spez. Path. u. Ther. von Xothnagel, V. Bd., 1900. — v. Lingelslieim. Tetanus. In Kolle-Wassermanns' Handb. d. pathog. Mikroorganismen, Bd. 2, 1903, p. 566, with Lit. — Marx. Ueber die Tetanusgift neutralisierende Eigenschaft des Gehirnes. Zeitschr. f. Hygiene u. Inf., Bd. 40, 1902, p. 231. — Meyer und Random. Untersuch. iiber d. Tetanus. Arch. f. experim. Pathol., Bd. 49, 1903, Part 6. — Xeumann. Der Kopftetanus. Kritisches Sanimelreferat. Centralbl. f. Grenzgeb., Bd. 5, 1902, p. 503. — Xicolaier. Ueber infektiosen Tetanus. Deutsche med. Wochenschr., 1884, p. 842. — Philips. Tetanus as a Complication of Ovariotomy. The Lancet, 1892. p. 139. — Ro.^e. Trismus und Tetanus. Deutsche Chir. — Rosenbach. Zur Aetiologie des Wundstarrkrampfes. Arch. f. klin. Chir., Bd. 34, 1886, p. 306. — Steuer. Sammelreferat iiber die Therapie des Tetanus. Centralbl. f. Grenzgeb., 1900, Bd. 3. — Stinzing. Beitrag zur Lehre des Tetanus trau- maticus. Grenzgeb. d. Med. u. Chir., 1898, Bd. 3 und Mimch. med. Wochenschr., 1898, p. 1265. — Suter. Zur Serumbehandlung des Starrkrampfes, insbes. iiber Tetanuser- krankungen trotz prophylaktischer Serumtherapie. Arch. f. klin. Chir., Bd. 75, 1905, p. 113. — -Tiberti. Ueber den Transpert des Tetanusgiftes zu den Riickenmarkszentren durch die Xervenfasern. Centralbl. f. Bakteriol., Bd. 38, Orig., 1905, p. 413. — v. Torock. Experim. Beitrage zur Therapie des Tetanus. Zeitschr. f. Heilkunde, 1900, Bd. 21. CHAPTER IV DIPHTHERIA The so-called diphtheritic inflammation of the skin and mucous membranes is a fibrinous inflammation associated with extensive necro- sis. This particular form of inflammation, sometimes superficial and sometimes deep, is not caused by diphtheria bacilli only. Typhoid and dy.sentery bacilli, streptococci and chemicals (ammonia) produce simi- hir chan«ies in nuicous membranes. Diphtheria bacilli are the cause of the epidemic infectious disease called diphtheria in which the mucous membranes, especially those of the upper part of the respiratory and alimentary tracts, are inflamed. Streptococci and staphylococci are fre- quently associated with the diphtheria bacilli in the.se cases, or they alone may produce a fibrinous inflammation and necrosis of the mucous 346 WOUND INFECTIONS OF DIFFERENT ORIGINS Fig. 135. — Diphtheria Bacilli. membranes, such as frequently occur in scarlet fever (diphtheroid scar- latina ) . Bacillus of Diphtheria. — Diphtheria bacilli, which were first ob- tained in pure cultures by Loffler (1884), are to be regarded as the cause of epidemic diphtheria, and occa- sionally of wound diphtheria. They are slender, often somewhat curved, rods, usually lying irregularly scat- tered, frequently in clusters. The bacilli are not motile, are about as long as the tubercle bacillus and _ _ slightly broader. Often one end is \ Vi?^ ^ *" r ^ -. '7 thickened, but they do not form -..— ^.-r. *i^ '■• / gpores. They are found in the mem- branes covering mucous surfaces, in pneumonic foci in patients dying of diphtheria, and have also been demonstrated in the adjacent lymph nodes, in the blood of cadavers, in the pus from submucous phlegmons, and in metastatic abscesses and in wounds. They stain with Loffler 's alkaline m ethyl ene-blue solution, Ziehl's carbol-fuchsin, and with Gram's method. They grow best upon Loffler 's solidified blood serum, also upon glycerin-agar, with free access of air. Pinhead size, whitish gray, opaque colonies appear after twenty-four hours. The borders of the colonies, when viewed under a glass, are irregular and slightly granular, and may readily be distinguished from the small and transparent col- onies of streptococci growing near by. In bouillon they form small granules, which become attached to the test tube. For diagnostic purposes a piece of the membrane should be re- moved with sterile forceps, washed in sterile water to remove the bac- teria of the mouth, and a number of stroke cultures made upon slant media. After ten hours at the earliest, grayish yellow streaks appear upon the surface, from which microscopic preparations may be made. The bacilli should be stained according to Gram's method. Animal experiments should also be made to prevent mistaking them for the non-pathogenic pseudo-diphtheria bacilli, similar in appearance and found in the mouth. Guinea pigs are best suited for experimental purposes; usually 0.5 c.c. of a twenty-four-hour old bouillon culture will kill these animals. Rabbits, sheep, young dogs, cattle, horses, hens, pigeons, and cats are susceptible; mice and rats are not. After subcutaneous injections of DIPHTHERIA 347 cultui'rs, animals die in twenty-four hours or in from one to two weeks, tlepencliu},' upon the virulenee of the baeteria and the number injected. (Edema about the point of injection, pleural exudates, and fatty de<:eneration of the viscera are found when a post-mortem examination is made. Paralyses have been observed. Infections of the mucous mem- brane produce an inflammation associated with necrosis. Subcutaneous injections of filtered bacteria-free cultures produce the same results, as they contain the poisonous metabolic product (tox- ins) of the bacilli. Diphtheria bacilli are therefore, like tetanus bacilli, toxic bacteria. The infection is primarily a local one, and the general symptoms are i>roduced by the absorption of the toxins. Only rarely do the bacilli pass beyond the primary focus of infection. According to the investigations of Brieger and C. Frankel, diph- theria toxin should be regarded as a toxalbumin ; but when pure it does not respond to the tests employed for either albumins or peptones ( Brieger and Boer). Optically, it is inactive and cannot be placed in any of the groups known to organic chemistry (Beck). Diphtheria Antitoxin. — The blood serum of experimental animals immunized against diphtheria protects other animals from infection and cures those in which the symptoms have already developed (von Behring and Wernicke). It contains an antitoxin. Diphtheria bacilli, like tetanus bacilli, are not killed by the antitoxin, but their toxins are neutralized and the bacilli gradually disappear from the body. The blood serum of patients who have recovered from the disease has for a short time the power of immiuiizing animals (Klemensiewicz and Es- cherich, Abel). The serum used in the treatment of the disease is obtained almost exclusively from horses (von Behring^ (vide Treatment). Modes of Infection and Susceptibility. — Infection in man follows direct or indirect transference of the bacilli from a patient. Direct infection may follow kissing, coughing, and sneezing. Infection may be carried by any object, especially eating utensils and handkerchiefs which have come in contact Avith the patient's mouth or the secretions from his mouth and nose. Diphtheria bacilli may cause a febrile angina without a membrane. Convalescent patients, and even healthy people who have been about diphtheria patients, harbor bacilli in their mouths, and so it is possil)le for the disease to be transferred by people who are not sick. The patient s excreta are especially dangerous, as the bacilli remain viable from three to four months in the dried condition ; for example, in the expectorated and dried membrane. All people are not, however, susceptible to the disease. Children from two to four yeare of age are most, adults least, susceptible. Among adults immune persons are found whose blood serum has a pro- 348 WOUND INFECTIONS OF DIFFERENT ORIGINS tective action, although they have never had the disease (Abel, Wasser- mann). Diseases of the mucous membranes, chronic catarrh and an- gina, such as occur in measles and scarlet fever, favor the development of diphtheria. An immunity, which lasts for a short time, follows the disease. It is doubtful whether' the disease is transferred from animals to man. DIPHTHERIA OF MUCOUS MEMBRANES Loffler's bacillus, usually associated with other bacteria, produces an inflammation which involves most frequently first the mucous mem- brane covering the tonsils, the pillars of the fauces, and the pharynx; and which then may extend to the mucous membranes of the nose, larynx, trachea, and finer bronchi, and the middle ear. Much more rarely the inflammation involves primarily the mucous membrane of the larynx and nose. Primary inflammation of the mucous membrane of the vagina and secondary involvement of the oesophageal and gastric mucous membranes occur, but are very rare. Onset. — The disease begins with general and local symptoms. Often it develops suddenly with high fever, delirium, etc. ; often slowly with prostration, chilly feelings, and loss of appetite. The first local symp- toms naturally depend upon the location of the infection. Diphtheria of the pharynx begins with pain upon swallowing; of the larynx, with hoarseness, coughing, and dyspnoea; of the nose, with a profuse, puru- lent, hgemorrhagic discharge. At first the infected mucous membrane is swollen, glistening, and reddish. Soon small, whitish, slightly raised patches appear (in pha- ryngeal diphtheria these appear upon the tonsils first). At first these patches may be easily removed, as they are composed of fibrin only, which is deposited upon the sloughing epithelium. These patches grad- ually extend and become thicker as an exudate is poured out, so that, for example, in pharyngeal diphtheria after a few days the tonsils, the pillars of the fauces, the uvula, and the entire pharyngeal wall become covered with a whitish or grayish yellow membrane. The inflamma- tion may extend deeper and involve the connective tissues of the mu- cous membrane, then these become inflltrated and necrotic. Pseudo-membrane. — In the beginning of the disease and in mild cases the pseudo-membrane is but loosely attached to the surface of the epi- thelium. When removed only the epithelial cells are taken with it, and healing without sear formation may occur if a new membrane does not form. In advanced and severe cases the connective tissues of the mu- cous membrane are also involved, and the membrane is often removed with difficulty, and when removed leaves bleeding surfaces. It is no DIPHTHERIA 349 longer correct to distinguish in epidemic diphtheria between croupous and diphtheritic changes or between croup ^ and diphtheria,- for they are only dift'erent phases of the same local pathological processes. As a rule, tlie pseudo-membrane is more closely attached to squamous than to ciliated epithelium, as in the former there is no basal membrane to prevent its attachment to the underlying connective tissues. After spontaneous separation of the pseudo-membrane, the mucous membrane almost always heals without a scar. On the other hand, when the pseudo-membrane is forcibly removed, another membrane usually forms and the necrosis extends deeper. Scars form in the ton- sils only when the tissues of the same undergo extensive necrosis. Separation of Pseudo-membrane. — The .separation of the menlbrane occurs nuK'h more rapidly in adults than in children. In the former it may begin after the first day, while in the latter after the first week (Rumpf). Extension the Result of Secondary Infection. — The inflammation rarely extends to the cartilages of the larynx anil the bones of the nose. The extension in the severer cases is due to secondary infections with other bacteria (putrefactive or pyogenic). The fibrinous necrotic areas then undergo putrefactive changes or a gangrene of the entire mucous membrane develops. An extensive cicatricial stenosis of the larynx may follow these secondary infections. In diphtheria infections there is an inflammatory oedema of the subnnieous tissues, which occasionally ends in suppuration (abscess, phlegmon). Pyogenic bacteria are important factors in abscess forma- tion, but diphtheria bacilli alone have been found in the pus (Tavel). The adjacent lymphatic nodes are always swollen and inflamed. Frequently they contain small grayish white necrotic foci, but abscesses rarely develop. According to Frosch, bacilli may be nnich more fre<|uently demon- strated in the blood and viscera than was formerly considered to be the case. Histology of Lesions. — Microscopically (Fig. 13C)) there is found in freshly inflamed areas a layer of fibrin, the fibers of which are arranged in meshes Avhich cover the degenerating epithelium. The meshes of this fibrin layer contain degenerated epithelial cells and leucocytes. Its ' A fibrinous inflaiiimatioii, which is not due to Loffler's bacillus, occurs in the pharjTix and larynx in a number of different infectious diseases, such as the acute exanthemata, t>^)hoid fever, whooping cough, and pneiunonia. This is called secon- dary croup, or better, diphtheroid. -The term diphtheritis is used by many to designate the local changes which occur in epidemic diphtheria. There is, however, at the present time, no uniformity of opinion concerning the use of this term. 350 WOUND INFECTIONS OF DIFFERE.Vt ORIGINS liner fibers extend down to the inflamed and infiltrated tissues. Older membranes are stratified, the oldest and most superficial layers con- sisting of layers of epithelial cells and fibrin, and containing large numbers of saprophytes. Then follows a fine-meshed and then a more recent coarse -meshed layer of fibrin. The bacilli are usually found in the first layer, while the coarse-meshed layer is firmly attached to the inflamed and in- filtrated connective tis- sue. Clinical Course and Severity of the Disease. — The clinical course of the disease is usually so acute that recovery or death occurs Mdthin a week. The severity of the disease depends upon the character of the epi- demic, the position and extension of the inflam- mation, and upon mixed infections. Laryngeal is much more dangerous than pharyngeal diphtheria, and the prognosis is very luifavorable if secondary infection with other bacteria, especially streptococci, occurs. Prog-nosis. — The mortality is especially high in children. Almost all children in the first year of life die. The mortality decreases as age advances. Causes of Death. — There are a number of causes of death, depend- ing upon the local course of the disease, the general toxic infections, and complications. The inflammation of the mucous membrane alone is frequently the cause of death in j'Oung children, as the membrane, the profuse secre- tion, and the resulting oedema produce a rapidly developing stenosis of the larj'nx. Suffocation may be prevented by tracheotomy. Tra- cheotomy has a favorable influence upon the course of the disease only when it is performed early, before a marked asphyxia has developed, and when the disefi.se remains limitf^l to the larynx. If the inflamma- tion extends to the bronchi, tracheotomy will not save the patient, for the fibrinous masses fill the bronchi and their branches, and suffoca- e f ^ Fig. 1.36. — Section Through the Uvula, from a Case OF Phartxgeal Diphtheria. (After Ziegler.) a. Normal epithelium; h, submucous connective tissue; c, fibrin with a netlike arrangement ; d, fibrin infiltrated ■with round cells Ij^ing upon necrotic connective tissue; e, blood vessels; /, a hsemorrhagic focus; g, groups of micrococci. DIPHTHERIA 351 tioii occurs, even if occasionally lar<^-e masses of the membrane are couylied iii*. Tlie general toxic infection causes chaniifs in the nerves supplying the heart or in the heart muscle. Death often follows a few days after the development of the disease, often (hiring convalescence, from pa- ralysis of the vagus, fatty degeneration of the heart muscle, or paralysis of the cardiac ganglia. Complications. — A number of complications which are not fatal are caused by the to.xins, such as diseases of the kidneys (albuminuria and acute nephritis) and the diphtheritic paralysis, which apparently is an ascending neuritis with subsequent central degeneration (Baginsky, J\ainy). An early paralysis of the soft palate developing in severe cas&s is differentiated from a late paralysis developing usually in the second and third week, which recovers slowly but spontaneously. The musclas of the palate and pharynx with disturbance of speech and swallowing, the extrinsic muscles of the eye, and the muscles of accommodation are most frequently paralyzed ; the muscles of the face, vocal cords, dia- phragm, trunk, and extremities more rarely. Hemiplegia may be cau.sed by cerebral hemorrhage or embolism. Broncho-pnet'monia, due to aspiration or extension of the inflam- matory process to the lungs, and mixed infections, particularly with streptococci, are to be regarded as serious complications. Not only the local changes, necrosis of the epithelium, and phlegmonous inflamma- tion, but also the general symptoms, become more severe in poly- infections. Then, usually, the clinical picture of a general putrefactive infection rapidly develops. The inflamed mucous surface becomes cov- ered with a dirty, blackish membrane, and a foul-smelling secretion is di.scharged. There may be some fever or the temperature may be sub- normal, the patient rapidly fails, the heart becomes weak, htemor- rhages occur into the skin, the joints become inflamed, endocarditis and nephritis may develop (putrid diphtheria). The toxins secreted by putrefactive ))acteria and streptococci are important factors in these cases, as the frequent demonstration of streptococci in the blood and the not infrequent ineffieieney of the antitoxin show. Such cases almost always end fatally within a few days. Diagnosis. — The diagnosis of dii)htheria is not difficult in acute cases when the pathological changes in the mucous membranes are visible. It may be mistaken for a follicular angina. In laryngeal diphtheria without "pharyngeal nvolvement, the examination of the expectorated membrane and the laryngoscopic findings exclude other forms of in- flannnation. In ad dts it may be confu-sed with syphilis of the tonsil. In all cases diphtheria bacilli should be demonstrated by cultural methods. If the fharj'nx is wiped with a small piece of sterile gauze 352 WOUXD INFECTIONS OF DIFFERENT ORIGINS or with an applicator, and a number of stroke cultures ' ' made, a definite diagnosis can be made, after a little practice, in t- • i /e hours. Treatment. — It is most important in treating the local conclitf»,-i that chemical or mechanical irritation which might favor the extension of the inflammation and the absorption of toxins be avoided. In fact, the great number of agents (caustics, antiseptics, emetics for mechanical removal of the membrane) which have been recommended in the treat- ment indicate of how little value they have been. On the other hand, salt solution, frequently inhaled, and mild anti- septic gargles have a very favorable action upon the inflamed mucous surface and favor the separation of the membrane. Antitoxin is of the greatest importance in the general treatment. [The value of antitoxin, both for prophylactic and curative pur- poses, has been demonstrated. The amoimt used for curative purposes depends upon the virulence of the infection and the time at which the patient is seen. The average dose recommended by the United States Pharmacopoeia is 3,000 units. The Chicago Health Department advises that from 3,000 to 8,000 units be given in ordinary cases. From 1,000 to 1,500 units should be given when the patient is first seen, and the injection may be repeated if there is no improvement within twenty- four hours. In the severe cases, 8,000, 10.000, and 14:,000 units have been given, and the patients have not suffered from such quantities. The serum may be injected under the skin of the thorax, thigh, or back. The earlier the serum is injected the better the results will be.] Prophylactic injections of from 200 to 500 units are to be recom- mended in epidemics. Results of Antitoxin Treatment. — In most cases a marked improve- ment is noted soon after the injection. The inflammation extends no farther, the membrane becomes loosened, the s^nnptoms of stenosis sub- side, the swelling of the mucous membrane disappears, the general con- dition improves, and the fever falls. The mortality has been greatly reduced since the serum treatment has been employed. Antitoxin has caused a reduction of more than fifty per cent in the mortality (Ricketts) ; from forty -one per cent to eight or nine per cent (Baginsky). After several days eruptions which resemble those of urticaria and measles, also swelling of the joints, frequently follow the injections. In the severe forms, in which gangrene and secondary streptococcic infections develop — the so-called putrid diphtheria — antitoxin frequently gives no results. The remaining treatment should attempt to control the symptoms and complications (cardiac weakness, paralysis, nephritis, phlegmons, cicatricial larj'ngeal stenosis) as they develop. DIl'llTHEllIA 353 DIPHTHERIA OF THE SKIN Not iiirr<'(|uciitly the edges of tracheotomy wounds become f?an- frrenous. Later these wounds suppurat(> and liealthy granuhition tis- sue develops. Sometimes, however, the gangrene extends to adjacent and (U-eper tissues; tlie trachea and both sterno-cleido-mastoid muscles may then become exposed and large defects in the anterior wall of the trachea may develop. This acute progressive gangrene of wountls may be caused by diph- theria bacilli. When these bacilli gain access to a wound they produce a coagulation necrosis of its surfaces and a severe inHannnation of the surrounding tissues. The surface of the wound first becomes covered Avitli a dirty, grayish red, firmly adherent membrane, and later the tis- sues become necrotic and gangrenous. The necrosis and gangrene may extend beneath the edges of the wound. General symptoms, if present, are the same as those accompanying diphtheria of nuicous membranes; even paralysis has been observed (Billroth). According to Billroth, wound diphtheria was of fairly fre- quent occurrence in pre-antiseptic times in hospitals for children; and in severe epidemics all possible forms of accidental- and operation- wounds were attacked. It is rarely seen at the present time, except in tracheotomy wounds in patients sick with diphtheria. The bacteriological investigations of Brunner and others have shown, however, that the earlier observations as to the diphtheritic nature of these infections were correct. It has also been demonstrated that diphtheria bacilli may produce a diph- theritic inflammation without general symptoms, an inflammation with a fibrinous membrane (Schottmiiller and others), or, associated with pyogenic bacteria, suppuration (Brunner, Tavel, and others). The diagnosis of mild forms of wound diphtheria is very difficult. A grayish white or yellowish membrane fre(|uently develops upon granulation tissue which has been infected with streptococci, staphylo- cocci, the bacillus pyocyaneus, etc., and it is often difficult to differen- tiate between tbese infections and those due to diphtheria bacilli. The more severe infections resemble noma and hospital gangrene, which are rarely seen at the present time. A bacteriological examination is impor- tant in all cases and will determine the diagnosis. In the local treatment of wound diphtheria — general treatment is re((uired in only the severest cases — all agnnits which injure the wound surfaces should be avoided, and the separation of the diseased tissue and the foi-mation of healthy granulations should be favored by the use of moist dressings. It is important to i)revent the development of diphtheria in trache- 354 AVOUND INFECTIONS OF DIFFERENT ORIGINS otomy wounds. After the tube is introduced, the wound should be lightly packed with iodoform gauze to protect the fresh surfaces from infection from the trachea imtil healthy granulation tissue forms. The first indication in the treatment of diphtheria patients — who, because of the dangers of transmitting the infection, should always be kept in isolation wards — is to render harmless the toxins secreted by the bacilli. It is to the lasting credit of von Behring that he has given us not only the fundamental principles of immunity against infectious dis- eases, but also a serum which cures diphtheria. Literature. — Baguhsky. Diphtherie und diphtheritischer Krupp. Wien, 1898, Nothnagel's Handb., Bd. 2, and Deutsche Klinik, Bd. 2, 1903.— M. Beck. Diph- therie. In Kolle-Wassermann's Handb. d. pathog. Mikroorgan., Bd. 2, 1903, p. 754. — V. Behring. Die experimentelle Begriindung der antitoxischen Diphtheriethe- rapie. Deutsche Klinik, Bd. 1, 1903, p. 73; Diphtherie. Bibl. v. Coler, Bd. 2.~Brun- ner. Ueber Wunddiphtheritis. Berhn. klin. Wochenschr., 1893, p. 515; Eine weitere Beobachtung von Wunddij^hth. Ibid., 1894, p. 310; Wundinfektion u. Wundbe- handl., Frauenfeld, 1898, II, p. 130.^ — Cohn. Erfahrungen iiber Serumbehandl. d. Diphtherie. Mitteil. aus den Grenzgebieten, Bd. 13, 1905. — Ehrlich. Ueber die Konstitution des Diphtheriegiftes. Deutsche med. Wochenschr., 1898, p. 597. — Eross. Ueber d. Mortalitat d. Diphtherie. Jahrb. f. Kinderheilk., III. Folge, Bd. 10, 1905, p. 595. — Freymuth und Petruschky. Vulvitis gangrsenosa mit Diphtheriebazillenbe- fund. Deutsche med. Wochenschr., 1898, p. 232. — Gottstein. Die Periodizitat der Diphtherie u. ihre Ursachen. Berlin, 1903. — Giinther. Bakteriologie. Leipzig, 1902. — Heim. Bakteriologie. Stuttgart, 1898. — Kronlein. Ueber die Resultate der Diph- theriebehandlung mit besonderer Beriicksichtigung der Serumtherapie. Chir.-Kongress, Verhandl., 1898, I.-S., 105. — Kruse, in Die Mikroorganismen von Fliigge, Bd. 2, Leipzig, 1896. — Nowack. Blutbefunde bei an Diphtherie verstorbenen Kindern. Centralbl. f. Bakteriol., Bd. 19, 1896, p. 982. — Rumpf. Diphtherie. Handb. d. praktischen Medizin, Stuttgart, 1901, Bd. 5. — Rainy. On the Action of Diphth. Toxin on the Spinal Sticto- chrome Cells. Journ. of Path, and Bact., 1900, p. 612. — Schottmiiller. Wunddiphtherie u. s. w. Deutsche med. Wochenschr., 1895, p. 272. — Tavel. Ueber Wunddiphtherie. Deutsche Zeitschr. f. Chir., Bd. 60, 1901, p. 460; Diphtherie. In Kocher's chirurg. Enzyklopadie. — Wielaml. Das Diphtherieheilserum. Jahrb. f. Kinderheilk., Nr. 7, Bd. 7, 1904, p. 527. — Wright und Emerson. Ueber das Vorkommen des Bak. diphth. ausserhalb des Korpers. Centralbl. f. Bakteriol., Bd. 16, 1894, p. 412. CHAPTER V ANTHRAX Davaine in 1863 recognized that bacteria were the cause of the dis- ease, and originated the name bacillus anthracis. The bacilli culti- vated and described by Koch in 1876 are slender, cylindrical, non-motile rods from 6 to 10 p. in length. They are often united in tissues and culture media to form long chains. ANTHRAX 355 Fi(i. 137. — Antiihax Hacilli. The Bacillus of Anthrax. — Tlic bacilli slain willi aniline dyos, lia-nio- toxylin, ami l)\- (iijiin's Mictliod. A capsule sni'i'onnds the bacillus when ji'i-owiuii' in the body, but it is diriicult to obtain it in cuHure media. If prc'sent, the capsule appears in stained {)i'ei)aralion as a narrow, clear /one about the bacillus, ('lear oval s])aces, which correspond to the spoi'cs, are seen in bacilli in stained preparation. Often each member of a lon^' chain contains a. spor(\ which is set free when the bacillus de track, like the bars of a feather. Effects of Symbiosis with Other Bacteria. — The bacilli rapidly die in mixed cultures with the bacillus pyocyaneus. The latter produces a fermentlike substance (pyocyanase) which dissolves anthrax bacilli (Ennnerich). Streptococci and staphylococci are antagonistic, espe- cially so in the body. Anthrax in Experimental Animals. — White mice, guinea pigs, and rabbits are best suited for experimental purposes. These animals die in from one to three days after the infection of small cutaneous wounds with spore-free and spore-containing bacilli. Large numbers of bacilli 356 WOUND IXFECTIOXS OF DIFFERENT ORIGINS are found in the blood vessels of the ^ascera. According to Schimmel- busch's experiments, the absorption of the bacilli is so rapid that in mice the amputation of the tail, a wound of Avhich has been infected, does not prevent death, even if performed as early as ten minutes after the infection. After a half hour, bacilli may be demonstrated in the viscera. Animals die rapidly of a general infection after bacilli are rubbed into an intact skin (Wasmuth). Intestinal ulcers and fatal general infections follow feeding experiments with spore-containing bacilli. Spore-free bacilli are killed by the gastric juice and cause no symptoms. Infections of the respiratory tract follow the inhalation of infected dust (Buchner, Enderlen). Neither toxins nor endotoxins have been demonstrated. The toxic albuminous substances found in the blood and viscera by Hoffa and others are not to be regarded as specific anthrax toxins, but as toxic decomposition products (Sobernheim). Occurrence of Anthrax Bacilli Outside of the Body. — Anthrax spores are discharged upon the surface of the ground in the excreta of dis- eased animals. They remain viable in damp places for a long time (two to three years), and are widely distributed in all possible ways by animals and man, rains, floods, etc., over meadows and pasture lands. Grazing animals (cow, sheep, horses) ingest the spores with their food, and for this reason almost always develop the intestinal form of an- thrax. Primary anthrax of the lung does not occur in these animals; anthrax of the skin but rarely. Other animals (rats, dogs, and pigs) are immune. Immunization of Susceptible Animals. — Susceptible animals may be immunized by the injection of attenuated cultures (Pasteur's protective inoculation). The blood serum of immunized animals has protective and curative properties, especially if, as Sobernheim demonstrated, the serum and attenuated cultures of the bacilli are injected simultaneously (mixed active and passive immunization). The serum treatment in man was first successfully employed by Sclavo and Mendez. [The b&st known serums are those of Sclavo, prepared from the goat and ass, and those of Mendez and Deutsch. The properties on which the value of the serums depends are unknown. Sobernheim is very positive in stating that the bactericidal power of the animal's serum is not in- creased by immunization or infection, and the existence of an anti- toxin is not recognized. As in some other instances, immunization may cause an increase in the opsonins which would render the serum effective by its power to cause increased phagocytosis. The method of Sobernheim, that of mixed active and passive im- munization, seems to be successful as a prophylactic measure. The vaccine consists of a mixture of antiserum and bacilli. Immune and ANTHRAX 357 even noniial soriiins may at tiiiu'S a<,'y;lutinate the anthrax bacillus, but the reaction is inconstant, ajid the ability of an inniiuue serum to cause agglutination is no index of its protective power. Agglutination is somewhat difficult of determination because of the tendency of the bacillus to grow in tiie form of chains.] Modes of Infection in External Anthrax. — Only the external anthrax infections, Mhich are the most fre([uent of all the forms, are of surgical interest. The lesions characteristic of external anthrax follow infec- tions of wounds or develop in the intact skin, apparently from the hair follicles. Naturally, people who, in their employment, come in contact with animals dead of the disease or with the excreta of sick animals, develop this disease most frequently. The uncovered parts of the body are usually attacked. In W. Koch's statistics, comprising 1,077 cases, the head and face were involved 490 times, the upper extremities, espe- cially the hands, 370 times. Apparently the infection is frequently transferred by the hands to the face and other parts of the body, where insignificant wounds, scratches, rhagades, and excoriations provide the infection atria. It is certain that infection follows the use of hides of animals dead of anthrax (caps, pelts, sandals, etc.). The infection may be transmitted by the bites of fleas, or at least transferred by infected fingers when bites are scratched. Internal Anthrax. — Pulmonary Anthrax. — Infections of the lung may follow the inhalation of dust containing spores. Pulmonary an- thrax, which is most common in workers in paper factories, who handle and assort rags, appears usually as a double pneumonia and pleurisy and rims an acute course with symptoms of severe general infection, ending fatally in a few days (woolsorter's disease). Intestinal AntJirax. — The second form of intg^-nal anthrax, the in- testinal, is rarer than the pulmonary. In this form hiemorrhagie foci, which later become gangrenous, develop, mostly in the intestines. In- testinal anthrax may follow the use of infected food (milk, flesh, and viscera of diseased animals) or the contact of infected fingers with the mucous membranes of the mouth. The symptoms are severe, bloody diarrhoea, peritonitis, and collapse. A general infection rapidly de- velops and death occurs. Both of these forms of internal anthrax may accompany an exter- nal infection, the two forms developing sinuiltaneously or one being secondary to the other, the infection being carried by emboli (W. Koch). External Anthrax. — Clinically there are two forms of external an- thrax — the carbuncle and the oedema. They develop most frequently in the skin, occasionally in the mucous membranes of the nose and mouth cavity. 24 358 WOUND INFECTIONS OF DIFFERENT ORIGINS Anthrax Carbuncle. — The anthrax carbuncle develops in the begin- ning from a small reddened, itching area, in which there forms within one, two, or more days a small bluish red vesicle filled with a sero- hgemorrhagic exudate (anthrax pustule, malignant pustule). There develops very soon, especially if the vesicle is pinched or scratched, a discolored crust, which appears as if sunken in the inflammatory infil- tration surrounding it. The gangrenous crust may become as large as a quarter of a dollar or even larger (Fig. 138). Small vesicles with Fig. 138. — Anthrax Carbuncle. serohsemorrhagic contents, from which dark crusts develop, form upon the inflamed, oedematous area. Frequently anthrax bacilli may be demonstrated microscopically and culturally in the exudate which seeps out from beneath the crust, or by injection into mice. If the contents of the vesicles are purulent in character, a secondary infection with pyogenic bacteria has occurred. Anthrax CEdema. — Anthrax oedema most often accompanies anthrax carbuncle of the face. The cheek and neck may be involved when a pustule develops about the mouth, as the cedema tends to spread rapidly and to involve large areas. It is not sharply defined against the healthy skin as the pustule is. Frequently the skin covering the oedematous and swollen area is markedly reddened, and when this occurs the lesion has been spoken of as anthrax erysipelas. Gangrenous crusts develop from the blebs forming in the inflamed area, and large areas of skin become necrotic. Lymphangitis and Lymphadenitis. — The lymphatic vessels and nodes soon become involved in both forms of external anthrax and appear as painful swollen cords and nodules. Frequently the lymphatics re- tain and destroy the bacteria and prevent the extension of the inflam- mation. If virulent bacteria pass through the lymphatics or pass di- rectly into the blood from fresh wounds, they reach and are deposited in the viscera, especially the spleen and liver, where they develop rap- idly and in great numbers. They have been found in the severest fatal cases in the blood, and it is certain that they enter the blood stream ANTHRAX 359 (liirinp: the course of an infoction, but it is much more rlifficult to dem- onstrate them than the ordinary pyogenic bacteria in the circulating blood. It is doubtful, however, whether the bacilli multiply in the blood of man as they do in the blood of animals. They may pass through the placenta and the foetus may become infected. After death, not only anthrax bacilli, but also different forms of pyogenic bacteria have been cultivated from the blood. The anthrax jMistule provides the infection atrium for these secondary infections, which may produce local suppuration and abscesses along the lymphatic vessels and in the lymph nodes. Fever. — According to K. Miiller, local external anthrax is accom- panied by fever in only twenty-five per cent of the casas. The fever may become quite high, but as a rule it falls either rapidly or gradu- ally after a few days, if the infection is properly treated. In the severe cases with general infection, characterized by diarrhcea, delirium, and stupor, the fever persists until death, which occurs within a week. Abscesses along the lymphatic vessels and suppuration of the lymph nodes may follow secondary infection with pyogenic bacteria. These secondary infections follow some injury of the pustule, such as scratch- ing or separating the crust. Bacteria then gain access to the lymphatic vessels and a rise in temperature follows this new infection. A gen- eral anthrax infection without symptoms of a primary localization (skin, lung, or intestines) is extremely rare. Diagnosis. — The diagnosis of the external forms of anthrax is not difficult, as the appearance of the local lesions is very characteristic. The diagnosis is made certain by finding the bacilli in the secretion of the bleb, and in that discharged from beneath the crust ; by inocu- lation of mice and cultural tests. The bacilli, as a rule, are found only during the first week of the disease, as they are later destroyed by the tissue fluids and the antagonistic pyogenic bacteria. In the pneumonic and intestinal forms the bacilli may be found in the sputum and faeces. Prognosis. — The prognosis varies, depending upon the position of the primary pustule or cedema. Anthrax of the head, face, and neck is the most dangerous, and from twenty -three to twenty-six per cent of these cases terminate fatally. Aspiration pneumonia and oedema of the glottis may easily follow the swelling of the neck. According to Nas- sarow's statistics, the mortality in anthrax of the upper extremity is fourteen per cent, of the lower extremitj' five per cent. The mortality in internal anthrax is of course much higher (fifty to eighty per cent). It should be remembered that virulent bacilli may be absorbed and a general infection develop from external anthrax, notwithstanding the fact that only one fifth of the cases end fatally and that the disease remains localized much more frequently in man than in animals. As 360 WOUND INFECTIONS OF DIFFERENT ORIGINS a rule the bacilli are destroyed iii a short time by the bactericidal sub- stances in the tissue fluids. Tt^eatment. — In the treatment of external anthrax everything should be avoided which favors the absorption of bacteria. This is most apt to follow scratching, incision and excision of the carbuncle and infected lymph nodes, but may occur after any manipulation, such as cauteri- zation, the frequent injection of antiseptic solutions, the continuous application and changing of moist dressings. Even extensive car- buncles and aVdema heal spontaneously, and any such procedures are absolutely unnecessary and often are to blame for the poor results which follow in these cases. In the severest cases, in which a general infection rapidly develops, an operation is no longer of any value. The chief indication, therefore, is not to injure the infected tissues, as any interference may be followed by an infection of the blood. It is sufficient to cover the inflamed area with a layer of gauze, thickly covered with salve, to prevent rubbing by the bandages. An immo- bilizing dressing should then be applied and the extremity elevated or suspended. The inflammation and the fever subside under this treat- ment, and the crust becomes loosened spontaneously during the second week. It is a mistake to attempt to loosen the crust with tissue forceps, for the granulation tissue is injured in this way and infection atria are provided for pyogenic bacteria. Lymphangitis and abscesses may then develop. The immobilizing dressing should be allowed to remain until the swelling of the lymph nodes subsides and should not be changed too frequently. Abscesses caused by secondary infections should be incised. Defects of the lips and eyelids resulting from necrosis of the skin should be repaired by plastic operation after the disease has subsided. How important rest of the infected tissue is in prevention of a general infection may be illustrated by the results of two diff'erent experiments made upon mice, which are very susceptible to the disease. Friedrich amputated the tail of a mouse and placed the stump in a bouillon culture of virulent bacilli. He so fixed the animal that the stump Avould be suspended for some hours in the culture and still not be exposed to any mechanical irritation. Absorption with general in- fection did not follow, and the animal survived. In the other experi- ment Schimmelbusch amputated the tail and then rubbed a few drops of a virulent culture into the wound Mdth a knife, and a general infec- tion developed immediately. PropJiijlaxis. — In the prophylaxis, the transmission of the disease by infected animals should be prevented. Dead animals, together with their hides, should be buried in deep pits or burned in furnaces. No GLANDERS 361 ]);irt of the (lead niiiiiinl sliould Ix' used for fotmnoroial pnri)os('S. Es- pecial care should he exercised in disinfect iii<;' tli<^ stal)ies. l*(!oj)lo exposed to inrection should be clean and observe the usual pfecautions wliicli are taken against infectious diseases. The serum treatment may be tried in the severer cases {vide i)p. 35G and ;{r)7). LiTKiiATUKE. — Burow. Heber die Bok;im]>fuTig ties Milzbrandes uarh der Methode Sobeniheim. Berlin, tierarztl. Wochenschr., 11)0;5, No. 35. — Conrdili. Zur Frage der ToxinhiUluiig bei den Milzbrandbukterien. Zeitsehr. f. Hygiene, Bd. 31, lcSi)9, ]). 287. — Fricdricli. Bedeutung des innergeweblichen Dnickes fiir das Ziistandekoninien der Wundinfektion. Arch. f. klin. Chir., Bd. 59, 1889, p. 458.-11'. Koch. Milzbrand und Rausehbrand. Deutsche Chir., 1S8(). — Luharsch. Milzbrand bei Menschen und Tieren. Ergebn. d. ])ath. Anat. von Lubarsch und Ostertag 5. Jahrg., 1898. — K. Midler. Der iiussere Milzbrand des Menschen. Deutsche med. Wochenschrift, 1894, p. 515. — Xicoluier. Zoonosen. Im Handb. d. prakt. Med. von Ebstein und Schwalbe. — Sobern- heiin. Experini. Untersuchungen zur Frage der aktiven und i)assiven Milzbrandimmu- nitJit. Zeitsehr. f. Hygiene, Bd. 25, 1897, p. 301 ; Weitere Mitteilungen iiber aktive und passive Milzbrandinnnunitat. Berl. klin. Wochenschr., 1899, p. 273; Milzbrand. In KoUc-Wasserinann's Handb. d. i)at'hog. Mikroorganisnien. Bd. 2, 1903, p. 1, and Inununitiit bei Milzbrand. Ibid., Bd. 4, 1904, p. 793. CHAPTER VI GI.ANDERS Glanders Bacilli. — The bacilli of glanders (Loftier and Schiitz) are slender, small, non-motile rods which do not form spores. They stain best with alkaline, aniline dyes. They do not stain by Gram's method; this is important in making a diagnosis. It is rather difficult to stain the bacilli in tissues. Sections should be stained in an alkaline meth- ylene-blue or borax methylene-blne solution, and then destained for some minutes in the solution recommended by Loffler (10 c.c. distilled water, 2 drops of concentrated sulphuric acid, 1 drop of a five per cent solution of oxalic acid). Cnllnrc Mrdia and Glanders in xinima]!i. — The bacilli grow best upon glycerin-agar, but also grow well u})on blood serum. Their growth upon gelatin is extremely slow. The virulence of the bacilli diminishes rapidly upon culture media, but may be considerably increased by pass- ing them through animals. Guinea pigs are most susceptible, and die within a few weeks after subcutaneous injections of virulent bacilli. An ulcer develops at the point of injection and the adjacent lymphatic nodes suppurate. Inflammatory and suppurating foci develop in the body, glanders nodes in the viscera, particularly in the lungs, spleen, 362 WOUND INFECTIONS OF DIFFERENT ORIGINS and testicles. Suppurative arthritis and ulcers of the nasal mucous membrane complete the clinical picture. Man appears not to be very susceptible to the disease. In the cases in man, which are not frequent, the infection is transferred in the mucus from the mouth or nose or in the pus discharged from ulcers of diseased animals. Endemics of glanders occur in horses, donkeys, and mules. The infection develops most frequently in the nasal mucous membrane, where nodules, not sharply defined against the healthy sur- rounding tissue, develop. These nodules are due to cellular infiltra- tion, and soon break down to form ulcers. Large quantities of mucus, which is as infectious as the pus discharged from the ulcers in glan- ders of the skin, are secreted by the diseased mucous membranes. The disease develops, excepting the rare cases of laboratory infection, almost only in people who come in direct contact with diseased animals. Infection Atria. — Frequently small wounds of the skin of the hands and face provide the infection atria. Babes and Cornil have demon- strated, however, that bacilli when rubbed into uninjured skin pene- trate the hair follicles and may cause a general infection. More rarely in man are the conjunctiva and the mucous membranes of the lip and nose, which are frequently the seat of rhagades and small wounds, primarily infected. Infection of the genital organs and transmission by coitus have been known (Strube). Character of Local Changes. — Small cellular nodules, which later become necrotic and form ulcers, develop in the mucous membrane when infected. The infection may extend and involve the lower parts of the respiratory tract. If the skin is infected, small cutaneous and subcutaneous nodular infiltrations, which resemble a carbuncle, de- velop. These are associated with the symptoms of acute inflammation, the epidermis is raised by an exudate and a glanders pustule forms or the area becomes gangrenous, and phagedenic ulcers with undermined edges and dirty floors develop. If the nodules of granulation tissue, which are often accompanied by an erysipelatous inflammation of the skin, extend into the subcutaneous tissue, abscesses develop from which is discharged a thin, foul-smelling pus. Clinical Forms. — Acute Glanders — Metastatic Foci. — These local changes are accompanied by a fever, which not infrequently begins without a chill and general symptoms. The adjacent lymphatic nodes become painful and swollen and suppurate (glanders bubo), and nodules form along the course of the lymphatic vessels from which ulcers and abscesses develop. The bacilli of glanders are carried to different parts of the body by the blood, in which they may be found during life. Many metastatic foci develop in the form of inflammatory nodules, nodular infiltrations, and abscesses. These metastatic foci are produced GLANDERS 363 by infected oinboli, for often many thrombi, loaded with bacilli, are found in the vt'ins of the primary focus. In rare cases suppurative arthi'ilis and osteomyelitis (osteomyelitis malleosa, Virchow) develop, Frc(|uentiy metastatic abscesses develop in the subcutaneous tissues, and esi)ecially in the nniscles, whik' in the viscera, especially in the lunji', nodules composed of round cells, which later suppurate and j^ive rise to the sym})toms of bronchitis and pneumonia, form. Pustules i-esemblin<;' those of pemphigus and snudlpox develop in the skin sec- ondary to the lodgment of bacterial and infected emboli ; ulcers likewise develop in the mucous membranes of the respiratory passages, nose, j)harynx, and larynx. The skin covering the abscesses and infiltrated areas is reddened. Tlw borders of this redness are sharply defined as in erysipelas, but do not extend. The general symptoms are fever, delirium, coma, vomiting, anil tliarrluca. These, in acute glanders, grow progressively worse and persist until death, which occurs in two or three weeks. Death is due either to a general bacterial infection or exhaustion. Subacute and Chronic Forms. — The subacute and chronic forms may persist for many months or years. Recovery occurs in about one half of the cases, if the acute form does not develop. The local process gradually extends with but few general symptoms, producing large defects in the skin, the infiltration of the skin occurring in the form of large nodules, wormlike or wreathlike strands (the name " worm " has been applied to the chronic forms), from which gradually develop irregular ulcers, fused with each other. If these ulcers have sharp borders and a reniform shape, due to cicatrization upon one side only, so characteristic of the ulcerating gumma, the disease may be mistaken for syphilis, especially if the ulcers are situated upon the lips, the palate, at the entrance to or upon the mucous membrane of the nose. In the chronic form of glanders, metastatic suppurating foci develop only exceptionally, and are then single and occur after long, irregular intervals. Diagnosis. — The diagnosis of glanders is most difficult in the chronic forms. The acute forms, especially in the beginning or in casi>s without a demonstrable primary focus, may be confused with typhoid fever, articular rheumatism, or general pyogenic infections. Often the inef- ficiency of the mercury or potassium iodid treatment of certain lesions of the skin first suggests glanders. It may be mistaken for actinomy- cosis or tuberculosis, and for that reason the name lupus malleosus has been applied to that form of skin glanders which resembles lupus. Intraperitoneal injections of pus from a suspected focus into a guinea pig may be employed as suggested by Straus in order to make a positive diagnosis. In two or three days after intraperitoneal injec- 364 WOUND INFECTIONS OF DIFFERENT ORIGINS tions of glanders bacilli the testicles become infiltrated and swollen, and a suppurative inflammation of the tunica vaginalis develops, if the animal does not die of a mixed infection. Of course cultures should be made and smears examined in doubtful cases. JIalleiii for Diagnostic Purposes. — ]\Iallein, a sterile cultural ex- tract (Kalning, Preusse), is of doubtful value for diagnostic purposes. [" Although it causes a rise in temperature in normal animals when given in considerable doses, the reaction produced in infected animals is so much more intense, and occurs with so much smaller doses that it is generally considered as specific in nature. Some doubt, however, has been thrown on the specificity of the reaction from the facts reported by various observers that toxic substances from other organisms, as tu- berculin and preparations from the pneumobacillus of Friedlander, the bacillus pyocyaneus, etc., cause similar phenomena in animals suffering from glanders. Wladimiroff asserts, however, that the reaction caused by these substances differs from that of mallein." — Kicketts, " Infec- tion, Immunity, and Serum Therapy," p. 457.] Bonome is the only one who has reported a febrile reaction after an injection of mallein into a patient sick with chronic glanders. Zieler obtained in two cases neither a general nor a local reaction worth mentioning. Apparently mallein has not the diagnostic significance in man that it has in horses. Treatment. — As a rule, treatment is powerless in the severe acute forms of glanders. In these cases there is always a general infection, which cannot be prevented by either sparing or destroying the pri- mary focus. Amputation may prevent the general infection-, if per- formed as soon as the diagnosis is made. In the mild forms im- provement follows excision of the accessible ulcers and nodules and incision of the abscesses. Sometimes the disease subsides under this treatment and the patient recovers. But all measures, such as curet- ting with a sharp spoon and rubbing the lesions with gauze saturated with antiseptic solution, which favor the extension of the bacteria to the lymphatic vessels and blood vessels, should be avoided. The resistance and nutrition of the body should be increased and the heart stimu- lated. Different indications should be met as the}' arise. AceordiDg to Golds, inunctions of mercury ointment act favorably. He tried this treatment in two severe cases which recovered. Other authors have not seen any improvement, even in the mild chronic cases, and the inefficiency of the mercm-y treatment has led many to change from a diagnosis of syphilis to a diagnosis of chronic glanders. Literature. — Bollinger, in v. Ziemssen's Handb. d. spez. Path. u. Ther., Bd. 3. — Bonome. La Riforma med., 1894 (Malleinwirkung). — Buschke. Ueber chronischen Rfjtz der menschlichen Haut. Arch. f. Derm. u. Syph., Bd. 36, 1896, p. 323.— Mr^c/i. Zur Symptomatologie und Pathologie des Rotzes beim Menschen. Beitr. z. klin. Chir., Al'i'IXU.MYCOrilS 3G5 Bd. 17, 1806, p. 1. — KriiKc, in Die Mikroorganismen von Flvigge, Bel. 2, 1896. — Kuhne. Uebcr Farbung der Bazillen in Malloiisknotcn. Fortschritte der Med., 1888. — Georg Mnijcr. Zur Kenntnis des Rotzbazillus und des RotzkmHchen.s. Centralbl. f. Bakteriol., Bil. JS, 1900, p. 673. — -Preuase. Berl. ticiarztl. Wochcnschr., 1898 (Malleinimpfungen). — Strube. Ueber Rotzkrankheit beim Mensehen. Arch. f. klin. Chir., Bd. 61, 1900, p. 376. — Virchow. Die krankhaften Geschwiilste. Rotz iind ^\'urnl, Bd. 2, p. 543. — Wladimirojf. Rotz. In KoUe-Wasserniann's Handb. der pathog. Mikroorganismen, Bd. 2, 1903, p. 707;— Innnunitilt bei Rotz. Ibid., Bd. 4, 1904, p. 1020.— Zi'e^er. Ueber chron. Rotz beim Menschen, nebst Bemerkungen iiber seine Diagnose u. medizinalpolizei- liche Bedeutung, den Wert des Malleins. Zeitschr. f. Hygiene, Bd. 45, 1903, p. 309. CHAPTER YII ACTINOMYCOSIS The ray fnn<::iis -was fir.st seen by von Langenboek (1845) in the granular pus of a gravitation absces.s, secondary to caries of the ver- tebra\ Its microscopic apjiearance was later described by James Israel (1878). A year before this, Bollinger had found a similar fungus in the granulation tumors occurring upon the jaws of cattle. Ponfick demonstrated that "^•''" ■^'' - the di-sease in man and animals was produced by the same fungus. 0. Israel in 188-1 was the tir.st to obtain pure cultures. Fig. 130(1. — Section Through a Fully Develoted Colony. (.\fter Bostroin.) a, Point at which central filamentous mas-s break.s through (he external layer of clubs; b, germinal laver surrounded bv clubs. Fig. 1396. — Section Through .\ Degen- erated Colony. (After Bostrom.) The Ray Fung-us. — Morpliohxjij. — There are found in actinomycotic tumors or in the pus discharged from them light yellow granules, vary- 366 WOUND INFECTIONS OF DIFFERENT ORIGINS ing in size from a grain of sand to the head of a pin, rarely larger. Each granule represents a colony of micro-organisms. According to Bostrom, the colony consists of an external layer of radially arranged clubs, the central ends of which become continuous with central fila- mentous masses (mycelia). There are two zones within the central mass. In the peripheral zone (germinal layer) the filaments are arranged in a radiating manner and run outward in a wavy or spiral course. In the central zone, which is less dense, the fibers interlace and break through the surrounding layer of clubs at one point and grow into the tissues. The isolated filaments are branched and have a wavy outline, differ- ing in these ways from the ordinary bacteria. Bacilluslike cells and coccuslike bodies may develop from the solid filament. These may become free and, according to Bostrom, are to be regarded as spores. Entire colonies may develop from single elements of the filamentous mass, from the spores as well as from the fragments of filaments, but not from the clubs. The filaments grow rapidly and produce the disease, Fig. 140. — Actinomyces. (After Sclilegel.) (1) Branched filament with terminal enlarge- ments; (2) long branched filament broken up into bacilluslike structures of different lengths, which are held together by the sheath of the fungus; (3) the division of the filament is still more advanced, indicating the transition of the bacilluslike structure into bodies resembling cocci. while the clubs are to be regarded as degeneration forms, incapable of further development. Swelling of the end of the filament is the first in- dication of the formation of clubs. [According to Wright, the radially arranged clubs, which give to the organism the name of " ray fungus," are a manifestation of parasitic existence.] They are found in the At'TIXOMYCOSIS 367 deeper parts of cultures, but are not found in youn<;- colonies. In did colonies they form a very thick layer or are calcilicd. Growth upon Di/fcrciit CuUure Media. — The ray fungus grows upon all media, but somewhat slowly. According to Bostrom, failures are fre(iuent when old colonies of contaminated material are used, and a number of tubes shouhl tlui'cfoi'c be i)rcpai'ed. The growth becomes visible during the first day in the form of small dewdroplike points from which develop, within two weeks, snuill yellowish ivd granules. Granules form in bouillon without clouding the media. ]\Iany varieties of the fungus, such as those studied by Bostriim, grow best under aerobic conditions, Avhile others, such as those investigated by J. Israel and Wolff, grow best under anaerobic conditions. Methods of Stauii)ig. — The filaments stain with aniline dyes and by Gram's method. A colony may be doubly stained, using gentian violet for the filaments and picrocarmine and eosin for the clubs. In staining secti(ms. Gram's method may be combined with carmine or the clubs may be heavilj^ stained with eosin and the tissues with ha?motoxylin. Experimental Inoculation and Botanical Classification. — It is dif- ficult to transmit the disease to animals by inoculating them even with pure cultures. J. Israel and IM. Wolf produced, by making intraperi- toneal injections of cultures into rabbits and guinea pigs, small granu- lation tumors which contained the fungus. There is a wide difference of opinion among authorities as to the exact botanical classification of the fungus. [" By some investigators ray fungi are considered as an independent family midway between the hyphomycetes and the schizomycetes (bactei'ia) ; others place them under the hyphomycetes in the group of the streptothrix ; while still others consider them as pleomorphous bacteria, placing them in the group cladothrix. Petruschky recognizes actinomyces, streptothrix, cladothrix, and leptothrix as genera in the family trichomyces, the latter belonging to the order hyphomyces. Biological variations which have been encountered have led to the recognition of several species of actinomyces, among which are a number of non-pathogenic forms. Wright limits the term actinomyces to those strains which produce colonies of club-shaped organisms in animal tissues." — Ricketts, " In- fection, Immunity, and Serum Therapy," pp. 459 and 460.] Occurrence and Distribution of the Fungus. — The ray fungus occurs upon grains and straw. Parts of grain and parts of straw to w^hich the ray fungus was adherent have been found in the inflanunatory swellings produced by the fungus in animals and man. Berestnew could demonstrate fungi, after careful search, upon dried plants, hay, straw, and grains. Liebmann has shown that after inoculating earth with ray fungi, the latter may be found in different parts of planted and WOUND IXFECTIOXS OF DIFFEREXT ORIGINS germinating vegetables and grains (beans, rye, Ijarley). Modes of Infection. — The infeetion in man as well as in animals is transmitted most frequently, as Bostrom has demonstrated, upon particles of grain. These penetrate the skin, or, in people who are accustomed to chew grain or who accidentally swallow it, pass into the mucous membrane of the mouth cavity, pharynx, oesophagus, respira- tory tract, and intestine. The infection may be transmitted by other foreign bodies (e. g., splinters of wood) to which fungi are attached. Where the characteristic inflammation is not at first superficial, but develops in the deeper tissues, it is probable that some for- eign body has carried the fungus. Grains provided with barbs (vide Fig. 141) are apparently able to penetrate deeply into the tissues. The ray fungus may also pass directly into the tissues. Clinical findings indicate that actinomj'cosis of the jaw and cheek fre- quently develops from carious teeth (Israel, Partsch). Partsch has found ray fungi in the ca-v-ities of carious teeth, and in one case the fungus had passed down to the end of the root canal. There is no doubt that in- fection may occur in this way. Other cases in which the syujptoms of actinomycosis de- velop, after a fracture of the mandible, after acute periostitis following extraction of teeth, indicate that the Avound or inflam- matory focus was secondarily infected Avith the fungus. In these cases the micro-organ- isms had apparently been saprophytic for some time. Action of the Ray Fungus and Character of the Lesions. — Th(- ray fungus produces in the tissues a chronic, progressive inflamma- tion. Its colonies are surrounded by a wide area of granulation and connective tissues, ACTI.NO.MVCOSIS 369 wliic'h are undermined by the fungi. Not infre(iuently in man it produces tumorlike growths, which in cattle were considered for a long time to be of a sarcomatous nature. The proliferation of the cellular elements is far greater than the exudation and degeneration, which are most marked in other forms of intiannuatiou. The inflam- matory new growth is, as von Esmarch has aptly described it, of board- like hardness, and is shari)ly delimited from the surrounding healthy tissue. It is adherent to the deeper structures and fused with the skin, if the inflammatory process has already extended to the surface. The granulation tissue undergoes fatty changes and becomes liquefied. Small suppurating foci, the skin covering which becomes bluish red in color, develop as the process extends to the surface. Finally these rup- ture through the skin, and fistulae are formed from which is discharged pus, which contains the characteristic sulphur-yellow granules (colonies of ray fungi) and necrotic granulation tissue. These fistuke are chronic and become longer and more branched as new foci develop, which dis- charge into them. An acute process accom- panied by fever and associated with the for- mation of phlegmons and abscesses is never caiLsed by ray fungi alone. In such cases there is a sec- ondary infection with pyogenic bacteria. When the foci are large and extensive, the general condition of the patient rapidly deteriorates and a cachexia, which may prove fatal, may develop. According to our present knowledge the lymphatic vessels and nodes are not involved in actinomycosis except in rare cases. The infec- tion nvAY be carried by tlie l)lood, however, whi'U the ray fungus invades a vein in the primary focus in which a thromluis is developing. Then metastatic foci may develop in any tissue or viscus, even occasionally Fig. 142.— H.EMATOGExoui? Osteomyelitis of the Femuk Caused by the Ray Fungus. k 370 WOUND INFECTIONS OF DIFFERENT ORIGINS in the bones (Fig. 142, Wrede). The clinical course of a general in- fection with the ray fungus, which is always fatal, is similar to that of the chronic pyogenic infections with metastases. Actinomycosis in Man. — Depending upon the point at which the infection occurs, actinomycosis in man may be divided into four groups : (1) Actinomycosis of the mouth cavity, (2) of the lungs, (3) of the intestines, (4) of the skin. Actinomycosis of the Mouth, Face, and Head. — Infections of the face and cheek are placed in the first group. They either develop in the mucous membrane of the cheek directly, or extend from the mucous Fig. 143. — Actinomycosis of the Face and Neck. (From Bevan's Surgical Clinic.) membranes of the upper and lower jaws and from carious teeth. In the former case there may be only a slight infiltration of the gum. An- chylosis of the jaw, an early and important symptom of the disease, de- ACTINOMYCOSIS 371 volops af? tho inflammation in the cheek extends, and the miLscles of mastication become involved in the intianmiatoiy mass. The muscles of mastication are not involved in the small, rapidly softening foci which form about the opening of Stenson's duct (Schlange) and de- velop in the middle of the cheek anterior to the masseter muscle. Fre- ((uently a cordlike, indurated process, extending beneath the mucous membrane of the cheek to the alveolar process or a carious tooth, may be felt. This indicates the way in which the inflammation has traveled. The inflammatory swelling, firmly connected with the underlying bones, extends from the cheek to the submaxillary and temporal regions. The temporal region is also involved when the iuflannnation extends upward along the internal surface of the ramus of the mandible. Actinomy- cosis of the maxilla may extend to the orbital and nasal cavities, or may rupture through the base of the skull and produce a fatal menin- gitis or encephalitis. The process may extend from the jaw or pharynx to the prevertebral tissues, with secondary destruc- tion of the vertebra?. Gravitation abscesses then pa.ss along the anterior surface of the vertebra? and an abscess may de- velop in the abdominal i> cavity, secondary to a focus in the mouth or pharynx. Only rarely do central foci develop in the jaw' secondary to a focus in an alveolus. The point of infection in cervical actinomycosis is most frequently in the pharynx, if the disease has not extended from a focus about the jaw. The tonsils and retropharyngeal tissues are most frequently in- volved first; occasionally the point of infection is in the mucous mem- brane of the oesophagus or larynx. The transverse, bluish red, indu- rated folds in the skin in which small subcutaneous abscesses develop are very characteristic of actinomycosis of the neck (Fig. 144). The formation of chronic fistula? and the discharge of colonies of ray fungi Fig. 144. -ACTIXOMYCOSIS OF THE NkCK. (After Illich.) 372 WOUND INFECTIONS OF DIFFERENT ORIGINS make the diagnosis certain. The swelling may become so extensive as to render movements of the neck impossible and to interfere with swallowing and breathing. Actinomycosis of the tongue, occurring in the form of a nodular infil- tration, is rare. This may be easily mistaken for a gumma, and if softened, for the ordinary abscess ; occasionally for a carcinomatous induration of the floor of the mouth. Actinomycosis of the Lungs. — Primary actinomycosis may develop in any part of the lungs; most frequently, however, in the lower lobes. This form generally follows aspiration of the ray fimgus from the mucous membranes of the mouth or pharynx. Israel's demonstration of a piece of a tooth in a pneumonic focus is very significant from an etiological viewpoint. Most frequently a broncho-pneumonic focus de- velops; occasionally a superficial catarrhal inflammation. A wide area of the lung surrounding a focus becomes indurated. There is a tend- ency for this area to become necrotic and to undergo cicatricial con- traction. The peculiarity of actinomycosis of the lung, in the early stages resembling tuberculosis, is its tendency to spread to neighboring tissues and not to remain limited to the lungs. The part of the lung involved undergoes considerable cicatricial contraction. AVhen the in- flammation reaches the pleura a serous pleuritis develops or the two leaves of the pleura become united and transformed into a thick cica- tricial mass. Suppurating foci, which later rupture externally, develop in this newly formed tissue. A number of fiistulse then discharge upon the surface of the chest, or a hard, tumorlike swelling, which later rup- tures through the skin, develops over the ribs. The inflammation may extend to the pericardium, or an abscess may rupture through the dia- phragm at its point of attachment to the vertebrae and extend to the abdominal cavity or pelvis. Abscesses of the spleen and liver or peri- tonitis may be caused in this way. A secondary actinomycosis of the lungs develops when an abdominal form extends to the thorax or when emboli, which may be easily carried into the pulmonary veins from the primary focus, lodge in the lung. Ray fungi may be found in the sputum in all forms of actinomycosis of the lungs. If not found, the disease should not, however, be excluded. Actinomycosis of the Intestines. — Intestinal actinomycosis begins most frequently in the caecum, and in the parts of the small and large intestine immediately adjacent to it. Other parts of the gastro-intes- tinal tract (stomach, small intestine, sigmoid flexure, and rectum) are but rarely primarily involved. The symptoms of intestinal actinomy- cosis develop slowly and are often obscure. Intestinal actinomycosis often resembles acute appendicitis because of fever, local pain, and the position of the induration. If the process extends through the intes- I ACTINOMYCOSIS 373 tinal wall to snrronnding tissues, adhesive peritonitis and larjj:e indu- rated masses, rtsenihliny tiunoi's, may develop. The neerotie tissue and abscesses, in which are sometimes i'oiuid particles of For complete alistrar-ts of oases of systcinif hlastorayccsis, see Transactions of Sixth International Congress of Dermatology, 1907. BLASTOMYCOSIS 377 lodeniia." (Jilclirist mimI Stokes, in July, 1896, iiindc a rcjioi't of tliis ease, and ajzain more i'ully in 18!)8. Six months al'tci" (jilelirist's duni- onstration oi thi' sections, Busse i)ul)iislied an ai-tiele reporting his ease, and ajiain with Busehke in a more extended study with a report in 1895 and 1899. In 1896 Curtis reported his study of a case of what he termed " saccharomycose humaine." Then followed I'eports of eases tei-med " blastomycetic dermatitis," the term adopted by (lilchrist, hy the following gentlemen : In 1898 Wells, llessler, Hyde, llektoen, and Bevan, with a further study of the organism from the latter case by llektoen in 1899; in 1899 Owens, Eisendrath and Ready, and ^NTurpliy and llektoen; in 1900 Anthony and Ilerzog, Coates, Bakhvin, Braytou (three cases in April, 1900, July, 1901, and February, 1902) ; Mont- gomery (Frank Hugh) (case rei)orted before the American Dermato- logieal Association), with a further report, with two additional cases by Montgomery and Ricketts in January, 1901 ; in 1901 Dyer, Stel- wagon, Harris, etc., since which time cases have multiplied until a large number has been recorded. From early in 1903 until the present time cutaneous blastomycosis has not been reported to any extent from Chicago; not that observations have been wanting, for new cases are constantly' coming under observation. Notwithstanding the fact that in the second recorded case of blasto- mycosis (that of Busse) a general infection occurred, much doubt has existed concerning general infection ; this doubt, however, has been dispelled by subsecjueut observations. The first recorded general infection was that of Busse in 1894, the second that of IMontgomery and Walker in April, 1902. Further re- ports of eases, with study more or less complete, frequently including autopsy records, have been recorded by Ormsby and ]\Iiller in i\ larch, 1903; by Cleary in ^lay, 1904; by Eisendrath and Ormsby in October, 1905, with additional clinical findings and autops}' report in the same case by LeCount and Meyer in INIarch, 1907, and Bassoe in December, 1905 ; in 1906 by Irons and Graham and llektoen and Christenson (two cases) ; in 1907, by Baum and Stober (demonstrated before the Chicago Dermatological Society) ; by Garvj' (paper read before branch of Chi- cago ^Medical Society) and ]\Iontgomery (Frank Hugh), this case Avas demonstrated by Dr. Montgomery before the Chicago Dermatological Society in April, 1905. In addition to these, we have seen three cases not recorded. Blastomyeetes were first demonstrated in the sputum, in the case of Eisendrath and Ormsby in 1905, and in fecal matter from the same case in 1906 as recorded by LeCount and Meyer. Geographical Distribution. — In the United States, Chicago is appar- ently the center of infection, as the majority of cases, both of cutaneous 378 WOUXD IXFECTIONS OF DIFFERENT ORIGINS and systemic blastomycosis, have been recorded there. In addition, cases have been noted in Indiana, AVisconsin, Nebraska, Texas, Massachusetts, Kentucky, Colorado, Utah, ^Maryland, New York, I\Iichigan, jMinnesota, and Iowa. Among the foreign countries may be mentioned Canada, England, Germany. France, Scotland, Japan, India, Italy, and South America. Organs and Tissues Involved. — In the victims of the disorder coming to the post-mortem table, blastomycetes have been demonstrated in the following organs: larjTix, trachea, lungs, pleura, myocardium, liver, spleen, pancreas, kid- neys, adrenals, lymph glands, bones, joints, sub- cutaneous and cutaneous tissues, brain, spinal cord, and colon. The organisms have been demonstrated in sputum and in fecal matter.^ Clinical Symptoms in Cutaneous Cases. — The age of the patient has varied from twelve to seventy-four years. Le- sions have occurred over practically^ the entire cu- taneous surface, the face having been the site of election in a great num- ber of cases; the region about the cheeks and eye- lids is frequently at- tacked. The size of the lesions has varied from a small beginning pap- ulo-pustule to large patches several inches in diameter. In the case used for illustration (Figs. 145, 146, and 147) nine patches ex- FiG. 145. — CrxAxzous Blastomycosis Sno'mNG Deli- cate Scar Tissue ix the Centek with Active Ad- VAXcixG Border. » Since the above was \vTitten, blastomycetes have been found in the prostate gland and in the urine. BLASTOMYCOSIS 379 isted, some of which covered an area of several inches. The lesion begins as a small papule, or papulo-pustule, which spreads peripherally, event- ually forming a patch of varying dimensions. A patch the size of a silver (piarter presents the following characteristics: It is surrounded by a bluish retl areola in which the small miliary abscesses characteristic of the disorder are found. The areola gradu- FiG. 146. — Cutaneous Blastomycosis Showing Circular Patch with Papillomatous Elevations Covering the Surface. ally slopes from the elevated patch to the normal surrounding skin, and is about one fourth of an inch in width. The main part of the lesion is elevated about an eighth of an inch, and the top of the patch is more or less flat, papillomatous or verrucous, crust-covered, or dis- charging, or superficially ulcerated. Pus may be squeezed from between the papillomatous projections, as in verrucous tuberculosis. The mil- iary abscesses in the sloping border of the patch are characteristic, and vary from minute, scarcely visible points to lesions the size of a pin's head, and from which a glairy, muco-purulent material can be obtained, from which the organisms may be recovered in pure cul- ture. In parts of the patch which have undergone involution a super- ficial scar is left, which is usually soft and smooth, but may be irregu- lar and corded. The scar, however, is not, as a rule, disfiguring except 380 WOUND INFECTIONS OF DIFFERENT ORIGINS when near the eyes, in which ease more or less extensive ectropion occurs. The course of the disease is, as a rule, chronic in the cutaneous cases, periods of activity and spreading alternating with periods of apparent Fig. 147. — Cutaneous Blastomycosis Showing Patch on Dorsum of Foot. quiet. The patches may be in close proximity or separated by quite a distance, as, for example, when the patch exists on the face near the eye, with another on the wrist; or again, one patch on the face and an- other on the leg near the knee, or at the same time on the face, arms, legs, etc., various sized patches and in varying degrees of activity may be found. Often in the scar of an apparently healed area the small abscesses containing the organism are noted, which may light up into activity at any time. As INIontgomery states: "A single patch may at one time present all the stages of the disorder, showing at the same time several of the following featni'es: the advancing border, new le- sions forming on old scars, verrucous or cauliflower lesions in various stages of development or disappearance, a base in places dry and firm BLASTOMYCOSIS 381 and ill others soft and infilti-ated ^vith niiioo-pns, a scar tissue in part thick and irregular and in part smooth, soft, supple, and non-attached to the deeper tissue." Cutaneous lesions occurring' in systeniic eases arc described under that headiiii;'. Clinical Symptoms in Generalized Cases. — Tlie observations recorded in this chapter were made from material collected chieHy about Chi- capo, with reference also to findings recorded in literature from other parts of this country as well as abroad, but no effort has been made to incorporate all the recoi-ded cases, as that would be beyond the scope of this article. In collecting data for descril)iiig the clinical symptoms and patho- logical findings of systemic or generalized cases, fifteen recorded and Fig. 148. — Cutaneous Lesioxs in a Patient the Subject of Generalized Blastomycosis. (Courtesy of the Jour, of Cut. Dis.) unrecorded cases are considered. In twelve of the patients the disease proved fatal. One has appai-eiitly i-ecovcccd (Gar\'y) and two others are either Avell or lU'arly so at the last rei)ort. Three of tlu' ea.ses the writer has studied carefully, and thi'ough the courtesy of his colleagues has observed and to some extent investigated six others. Of these nine 382 WOUND INFECTIONS OF DIFFERENT ORIGINS only one is living. It is readily seen, therefore, that when systemic involvement occurs it assumes a grave character. Some of the cases have proved rapidly fatal. The symptoms include those arising from infection of practically all of the organs of the body, but apparently the symptoms presented clinically are not proportionate to the marked findings demonstrated at the post-mortem table. For example, in the case of Ormsby and Miller, only mild physical findings referable to the lungs were noted before death, and the patient had only a moderate cough with scanty expectoration, yet the lungs were completely infiltrated with the tuber- cles and abscesses peculiar to the disorder. The kidneys, too, were infected, but urinary findings during life were negative. Some general symptoms, however, have been more or less constant. An irregular temperature has been the rule, ranging from 98^° to 103° F. One subject, however, had constantly a subnormal temperature, 96° to 98° F. (Cleary). Emaciation has been constant, and in some cases extreme. Weakness, with prostration and different grades of ancemia have occurred. Albumin with casts showing nephritis has been noted. This was present to a high degree in the case of Cleary. Cough with sanguineo-purulent expectoration has been present in several cases in which blastomycetes have been demonstrated (Eisendrath and Ormsby, Bassoe, Irons and Graham, and others). The yulse and respiration have been proportionate to the temperature in most cases. However, as emaciation increased, a feeble, rapid pulse was the rule. Pain oc- curred in the chest in one case, and severe pain in the back in another. OEdema of the extremities, as well as of the face, has been noted. One almost constant accompaniment has been the formation of multiple subcutaneous and cutaneous abscesses and nodules, which later have developed into ulcers, their distribution at times involving almost the entire body. The ulcers in these cases result from the breaking down of the subcutaneous abscesses, and at times cover large areas by sub- sequent burrowing and destruction of tissue. The ulcers are irregular in outline, ill-conditioned, discharging, or crust-covered, at times hav- ing fistulous connections with deeper structures. Occasionally metas- tatic abscesses have been sufficiently large to hold within their walls as much as a liter of pus. The pus in all these has been a product of the blastomycetes, as no other germ has been discovered, while these organisms have been obtained in pure culture. Diarrhoea, with the organism in the fecal matter, was noted by LeCount and Meyer in the case of Eisendrath and Ormsby. Spondylitis has occurred several times. In one case several vertebrae were destroyed with a corresponding amount of spinal cord. In addition to the vertebrae, some of the ribs, the tibia, and the cranial bones have been involved. Suppurative ar- BLASTOMYCOSIS 383 thritis has occurred in several cases, large (iiiantities of pns having been found in the joints. Blastomycotic laryngitis has developed in two cases, in one of which the organisms were demonstrated in the ulcers in the larynx (Ormsby and Miller). In one case lesions were demon- strated in the brain. The lymphatic glands have been exceptionally free, but in several cases involvement of these organs has been noted. The general picture, then, has been that of constitutional involve- ment, somewhat similar to tuberculosis, for which disorder it has been at times mistaken. Once (Walker and Montgomery) the diagnosis, both clinical and by autopsy, was made of tuberculosis, but on later investi- gation blastomycetes were demonstrated both in the skin and internal organs, with no tubercle bacilli. Miliary tubercles or nodules of blasto- mycosis strongly suggest those of tuberculosis. To sum up, the clinical picture is nearly as follows : Evidence of general infection, exhibited by irregular temperature, loss of appetite, general weakness, emaciation, cough, with sanguineo-purulent or pos- sibly only frothy expectoration, rapid, feeble pulse, acceleration of the respiration, at times albumin in the urine, multiple subcutaneous nod- ules and abscesses resulting in superficial irregular ulcers, abnormal physical findings in the lungs, such as dullness, bronchophony, bronchial breathing, various rales, etc., redema of the extremities, and various grades of anaemia. A combination of generally distributed, subcutane- ous nodules, abscesses, and cutaneous ulcers, with evidence of consti- tutional disease, shoidd always suggest generalized blastomycosis. Cutaneous Histopathology. — The original description given by Gil- christ in his ease, the first one recorded, has had few essential addi- tions during the many years that have since elapsed, and his findings have been corroborated by practically all observers. The resemblance in the histological architecture between many of these cases and some forms of cutaneous tuberculosis is striking. The epidermal hyper- trophy, the cellular infiltration in the corium, the partial or complete destruction of collagen and elastin in areas most markedly afl:'ected, the presence of many giant-cells, the formation of tubercles or pseudo- tubercles — all are found in both disorders. The striking and char- acteristic miliary abscesses in both the epidermis and corium, showing marked evidences of inflammatory action and containing the organisms peculiar to blastomycosis, mark the special difference. In blastomycosis the chief pathological changes occur in the epi- dermis and the upper portion of the corium. The stratum ^Malpighii is hypertrophied, sending prolongations in various directions into the corium. In this layer miliary abscesses of various sizes occur. They contain chiefly polymorpho-nuclear leucocytes, fragments of epithelial 384 WOI'XD IXFECTIOXS OF DIFFERENT ORIGINS cells in varioiLS stages of degeneration, parts of nuclei and other de- tritiLs, Avitli one or several of the causative organisms, the latter usually in pairs. The abscesses vary in size from those only sufficiently large to contain a few leucocytes with one organism, to those sufficiently large to he easily seen with the naked eye. The wall of the abscess consists of more or less flattened epithelial cells. Occasionally the abscesses contain in addition giant-cells, and at times a few plasma-cells. The rest of the rete is oedematous, its cells being swollen; the leucocytes are distributed irregularly about and between the cells. Hypertrophy Fig. 14!). — Mi' i ■ i iim lor.p.APii. CrxAXEors Sectiox (High Power) Showixo Giant-Cell, CoxTAiNixo ( JRGAXISM.S OF BLASTOMYCOSIS. (Courtesy of the Journal oj the American Medical A.ssocifUion.) of the rete facanthosis) is often so marked as to suggest an epithelio- matous change, but with careful study the basal layer is always found intact. The surface of the epidermis is irregular, and is covered with epithelial cell debris, fibrin, pus- and blood-cells. The eorium is the seat of a cellular infiltration. In the more acutely inflamed areas miliary abscesses occur similai' to those in the epidermis. Those in the center contain one or several organisms surrounded with leucocytes, which in turn are surrounded by connective tissue and plasma-cells, with many giant-cells interspersed. The giant-cells often BLASTOMYCOSIS 3S5 contain the ortranism sinlasiiia-cel]s are in excess. In some sections ]ai-,i:e numbers of classical plasma-cells are noted. Hyaline degenera- tion is described in these cells by Ricketts. General Pathology. — The findings recorded here, both gross and microscopic, are collected from the eight cases now recorded, with autopsy reports. In view of these findings, the striking and characteristic changes consist in the presence of nodules or tubercles and abscesses in the soft tis.sues, and caries in the bones. The organism of blastomycosis is mark- edly pyogenic. The nodules and ab- scesses vary greatly in :iize, location, and number in different cases, but are always present. The character- istic composition of these lesions in all areas consists, primarily, of the organism of blastomycosis in vary- ing numbers, leucocytes (polymor- pho-nuclear chiefly, but also mono- nuclear) and giant-cells ; secondarily, of plasma- and mast-cells, cellular and other detritus, pigment, red l)lood cells, etc., the latter being more or less abundant, depending on the location and acuity of the process. The abscesses vary in size from those which are microscopic to some suf- ficiently large to hold one half liter of pus. They may occur in all the organs of the body, as well as in the bones and joints, and are es- pecially characteristic in the subcu- taneous tissue, where at times fistula^ and large excavations are produced. These abscesses have also been noted in the glands, both abdominal and thoracic, behind the a?sophagus and in the bones (vertebrae, ribs, tibia, etc.). Fig. 1.50. — Cut Section of the Spleen Showing Are.\s of Bl.\sto.mycotic IxFii,TR.\TioN. (Photograp}i courtesy of the Journal of Cutaneous Diseases.) 386 WOUND INFECTIONS OF DIFFERENT ORIGINS A typical blastomycotic nodule has in its center an area of necrosis, with blastomycetes, leucocytes, and cellular detritus surrounded by giant-cells. It may contain also connective tissue, plasma-, and mast- cells. In some cases great destruction of tissue has occurred in certain of the internal organs. The lungs in all cases have been the seat of marked changes. The nodules and abscesses may infiltrate almost the entire organ. The presence of large numbers of blastomycetes with giant- cells and leucocytes is characteristic. Giant-cells always contain from one to several organisms. Plasma- and mast-cells, much pigment, and granular detritus are also found, and in some areas newly formed con- nective tissue. In one case a lung was almost completely destroyed. It contained an enormous number of organisms in various stages of development. The process in most cases is a blastomycotic broncho- pneumonia. Blastomycotic nodules or tubercles are found in the pleura, in peri- bronchial lymph glands, and in the myocardium. In the abdominal cavity the spleen has been the seat of most de- structive changes, consisting of nodules, areas of necrosis containing granular detritus, and large numbers of the parasites. Here giant- cells have not been conspicuous. The liver, kidneys, adrenals, pancreas, lymph-glands, and colon have all been the seat of similar changes to a less degree, except in one case where the adrenals (Cleary) were exten- sively invaded. Like the spleen, the adrenals contained no giant-cells. The destructive process has been marked in the spinal column in several cases. In one case several vertebra were destroyed, with a corresponding length of the spinal cord. The necrotic areas in the bones contain the organism in large numbers, leucocytes, an occasional giant-cell, and a fibrinous exudate. Amyloid degeneration is not constant, but has occurred in several cases and may be extensive. It has been found in the liver, kidneys, adrenals, spleen, retroperitoneal, mesenteric, and mediastinal lymph- glands, and colon. Summary of Gross Pathological Findings. — Blastomycotic subcuta- neous abscesses, nodules, sinuses, ulcers, and scars, covering practically all parts of the body. Blastomycotic laryngitis and broncho-pneumonia. Blastomycosis of the pleura, subpleural and retropharyngeal tissue, the peribronchial lymph-nodes, the liver, spleen, kidneys, adrenals, colon, various bones (tibia, ribs, vertebrse), the external surface of the spinal dura mater, the spinal cord, the cerebellum, various joints (elbow, knee, ankle, etc.), chronic parenchymatous nephritis, atrophy of the heart, etc. In addition to the above, blastomycotic areas have been demonstrated microscopically in the myocardium, pancreas, BLASTOMYCOSIS 387 and vai'ioiis lymph fjlands, mid niiiyloid dc'^'cnoration in tho orrrans previously iiienlioncd. Description of the Organism in Tissue. — The biological position of this oi'uanisni luis not been positively settled. In tissue its method of repi'oduetion is by genniiation. It is made up of a capsule (at times an adventitious capsule in addition), a clear zone, granules, and at times a vacuole. The size varies from 5 to 15 fi, but we have many times noted organisms as large as 30 fi. Taken as a M'hole, the organism is round or oval or some- what irregular, sur- rounded by a homoge- neous, doubly contoured, refractile capsule, im- mediately within which is a clear zone, while the center contains gran- ules of various sizes and shapes, and sometimes a vacuole. These proto- plasmic granules are at times basophilic, demon- strated by their taking the red part of Unna's polychrome methylene blue stain. While endogenous spore-formation is not proven in these organ- isms, one may often see ruptured capsules, and in the immediate neigh- borhood small granules similar to those within the capsule. At times when numbers of organ- isms are present, crescentic-shaped capsules partly filled may be seen. The organism is well seen in fresh pus or tissue mounted in a ten per cent solution of potassium hydrate, and may be easily stained with any of the common aniline dyes. Cultural Characteristics. — In common with other fungi, blastomy- eetes present multiform cultural appearances, depending upon the media used and the temperature at which they are grown. Ordinarily they grow well on glycerin- and glucose-agar, blood-serum-agar, and in broth. Fig. 151. — Smear from Tubercle-like Le.sion in the Spleen, Mounted in One Per Cent Pota.ssium Hydrate in Glycerin, Showing the Organism, of Blastomycosis ( X 1000). (Microphotograph, courtesy of the Jour, of Cut. Dis.) 388 WOUND INFECTIONS OF DIFFERENT ORIGINS As a rule, a moist, pasty growth occurs on glycerin-agar at room tem- perature, with only moderate aerial hyphie, while more aerial hypliie form on glucose-agar and agar-agar at the same temperature. Cultures begin to develop in from two to fourteen daj's, subcultures usually in from two to five days. Mycelial formation is more abundant during the first few weeks, but later budding -forms oc- cur. In the incubator the growth is more moist and pasty, and budding- forms are more numer- ous early. These latter facts have recently been again demonstrated by Hamburger. Otis and Evans, studying the growth of the organism isolated from a case of systemic blastomycosis reported by Ormsby and Miller, noted that in thirty hours, after a hanging drop culture was made in bouillon, the cells started processes which grew 60 fj. in length dur- ing the following twenty- four hours, the mycelia being homogeneous and possessing a very thin cell wall ; later protoplasmic granules and pinkish vacuoles appeared. After several days a subdivision of the mycelia into segments of varying lengths occurred. After a hanging drop culture in glycerin-agar had developed for about a month, there appeared an end- cell that budded, and in the course of several days a group of these cells was noted. It may be that the organisms develop in tissue by bud- ding only; on media by segmental mycelial formation with lateral eo- nidia, and later by a certain number of budding forms, the latter differ- ing, however, in some particulars, from the forms seen in fresh tissue and pus. Animal Experiments. — Both local and general infections have been produced experimentally in mice and guinea pigs. The latter are Fig. 152. — Growth of the Organism of Blastomycosis ON Glycerin-agar Twenty-one Days Old, from a Miliary Abscess in the Spleen, Showing Moist, Pasty, and Wrinkled Growth. (Photograph, cour- tesy of the Jour, of Cut. Dis.) BLASTOMYCOSIS 389 rather resistant to infection, but a general infection may be produced and tlie organism later recovered from practical!}^ all the viscera when large doses of the organism in culture are injected. The lungs, liver, spleen, kidneys, testicles, diaphragm, etc., have been the seat of tuber- cles peculiar to the disorder in which the causative organism has been demonstrated and recovered in pure culture. The histological picture presented in these various organs has been similar to that found in Fig. 153. — Sme.\r fro.m Giis spore-formation. It varies in size from 15 to 30 /x in diameter and contains sporules, sometimes as many as a hundred in a single capsule, which escape upon rupture of the capsule and develop into adult forms. Prickles or long spines are described covering the capsule. On media the organism grows as a mold fungus. Like blastomycosis, it produces lesions in skin and in internal organs resembling tuberculosis. The cutaneous lesions are granulomatous and may appear as papulo- pustules, ulcers, tumors, etc. Cutaneous lesions may precede the gen- eral infection, or be secondary, as in blastomycosis. The cases, as a rule, have been fatal. The majority of the cases have been reported from California. Since a more extended .study has been made of the generalized cases of blastomycosis, the early differences thought to exist between the two di.sorders have been reconciled. At present the only constant difference is found in the mode of reproduction of the two organisms in tissue, the one by budding, the other by endogenous spore- formation. On media, too, many differences may be pointed out, but these differences are no greater than those obser^^ed between different cultures of undoubted blastomycetes. It is maintained by D. W. Mont- BLASTOMYCOSIS 391 gomen' that potassium iodic! has little or no effect either in the cure of or inhibition of the progress of coccidioidal disease, while there is no question as to its value in blastomycosis. It seems, therefore, that with so many points of resemblance, and with so few differences, the two diseases should be classed as members of the same group. It is justi- fiable to assume that climatic differences play a part. One patient suf- fering from generalized bla-stomycosis made a complete recovery on going to California, but large doses of potassium i«xlid were admin- istered for a long period before leaving Chicago (Garvy). Diagnosis. — Tuberculosis is the disease which is most apt to be con- fused with systemic blastomycosis. In one case, rectjrded several years ago, the diagnosis of tuberculosis was made both clinicaUy and at au- topsy. It has been the aim diu'ing the developmental period of the stud- ies of the disease to positively exclude the presence of the bacillus of tuberculosis. In two cases, in the study of which the writer was inter- ested, tuberculin injections were made with negative results. Guinea pigs were inoculated with pus from cutaneous and subcutaneous le- sions, and also with tissue and tubercles from internal organs, always with negative results as far as tubercle bacilli were concerned. Large numbers of smeai-s from various areas, as well as sections of tissue from the same areas, were examined for tubercle bacilli with negative results. The only parasite found microscopically, experimentally, and culturally wa.s the organism of blastomycosis. In any case of doubtful general tuberculosis the sputum, as well as piLs from the cutaneous or subcutaneous lesions, should be examined for blastomycetes. The cutaneous cases have been mistaken most often for verrucoos tuberculosis, less often .for syphilis, and occasionally for epithelioma. The chief points of difference between blastomycosis and verrucous tuberculosis are: In blastomfiiosis .the edge of the patch is more in- flammatory and contains the characteristic miliary abscesses, from which the organisms can be readily removed, examined in a ten per cent solution of potassium hydrate, and be readily seen. There are apt to be several patches, and these develop with great rapidity. In verrucous tuberculosis the site of election is often the dorsum of the hand alone, while in blastomycosis, if this region be involved, other areas also, such as the face near the eyelid, are likely to be affected. In case of doubt a histological section reveals the true nature of the process. Miliary- abscesses in the epidermis and the corium, containing leucocytes and ])lastomycetes, make the diagnosis positive. Cultural experiments also may be made. The smooth, supple scar of blasto- mycosis is characteristic. The late lesions of syphilis are the only ones that could possibly be 392 WOUND INFECTIONS OF DIFFERENT ORIGINS confused with the lesions of blastomycosis. The circiuate lesions of lues, made up of indi^ddual tubercles and characteristic ulcer- and scar-for- mation, differ from the regular, circular, or oval patches of blastomy- cosis with characteristic edges, miliary abscesses, etc. The latter may persist for long periods in the same area, while a lesion of syphilis is apt to heal and advance to new areas. The microscope should be used to establish the diagnosis when there is doubt. Induration, a hard, pearly border, and the absence of the miliary abscesses in the margin, are sufficient to differentiate an epithelioma from a blastomycotic lesion. Technic of Examining for Blastomycosis in a Given Case. — The bor- der is cleansed; then with a clean, sterile needle a droplet of sero-pus is removed from one of the miliary abscesses and placed on a clean slide. This is then covered with a drop of a ten per cent solution of potassium hydrate, a clean cover slip placed over the drop, which is examined after five minutes with a one sixth or one seventh objective. The double-contoured and usually budding organism of blastomycosis may be plainly recognized when present. Prognosis. — Practically all cases of the purely cutaneous type recover in time under proper treatment. Recurrences, however, are common. Twelve of the fifteen patients with undoubted general blastomycosis have died. Only one has apparently entirely recovered. In all gener- alized cases, therefore, the prognosis is grave. Treatment. — The chief remedial agent emploj^ed successfully is po- tassium iodid, first advised by Dr. Bevan. This drug nearly always produces marked results, and in many cases has entirely cured the dis- ease. Doses as large as 600 grains per diem are often required. It should be given in large dilution. It may be gradually increased, as in syphilis, or large doses in large dilution may be given early. It should be administered until the last vestige of the disease disappears or while renewed activity occurs after its withdrawal. Radiotherapy is of value in completely eradicating small resistant areas. More recently Dr. Bevan has advised a trial of copper sulphate in one-quarter grain doses three times daily, with a one per cent solution applied as a wet dressing locally, with good results. In the grave, systemic cases, potas- sium iodid has exerted only inhibitory effects, except in one case, where it apparently had much to do with the recovery of the patient. It is interesting to note that this patient recovered under large doses of potassium iodid and a change of residence to California. In cutaneous cases a surgical procedure is not indicated unless the entire lesion can be excised. Recovery has followed complete excision in a number of local cases. The large abscesses and other lesions occur- ring in the generalized cases require surgical interference. TrBERCrLOSIS 393 LiTEUATUUE. — Gilclirist, T. C. Johns II()i)kin,s IIosp. Rep., 1896, Vol. I. — (lilchrid-Slokvs. Bui. of Johns Hopkins IIosp., 18%, A'ol. VII. — Basse, Otto. Cent, f. Bakt. luul Panisifcnk., IS'.tt, X\'I, p. 17.'). — Biisse-BiiscliLr. Viirhow's Archiv, 1895, Vol. CXL, p. 23; VerluuKll. der Deutschen Derniatologischen Gesellschaft, Schester Congress, 1899, p. ISl.—Curlis. Ann. de I'lnstit. Pasteur, 1896, Vol. X, p. 449. — Wells, II. G. N. Y. Med. Jour., March 2G, 1898.— //p.ssZer, Robert. Ind. Med. Jour., 1898, \o\. XMI, p. 48. — Hyde, Hektoen, and Bevan. Brit. Jour. Dermatology, 1898, Vol. XI. — Hektoen. Journ. Experimental Medicine, 1899, Vol. IV, Nos. 3 and 4. — Oivens, Eiseiulnith, anil Ready. Annals of Surgery, 1899, Vol. XXX. — Murphy- Ilektoen. Journ. A. M. A., 1899, Vol. XXXIII, p. 1383. — Anthomj-IIerzog. Journ. Cut. and Cicn.-Urin. Dis., Jan., 1900, 1. — Coates, W. E. Medicine, Feb., 1900.— Baldwin, L. B. Jour. A. M. A., 1900, Vol. XXXIV, p. 292.— Brayton, A. W. Ind. .Med. Jour., April, 1900, and July, 1901; Jour. A. M. A., Feb. 1st, 1902. —Montgomery, "Ricketts." Jour. C. and G. U. Dis., Jan., 1901, Vol. XIX, p. 26.— Dyer, Isadore, Jour. C. and G. U. Dis., Jan., 1901.— Stelwagon, H. W. Am. Jour, of Med. Sci., 1901. Vol. CXXI, p. 176.— Harris, F. G. Am. Jour, of Med. Sci., 1901, Vol. CXXI, p. 501.— Ormsby and Miller. Jour. Cutan. Dis., March, 1903. — Cleary, J. H. Trans. Chicago Path. Soc, Vol. XI, No. 5, May 9, 1904, antl Medicine, Nov., 1904:.— Else ndrath and Ormsby. Jour. A. M. A., Oct., 1905. — LeCount and Meyer. Jour. Infect. Dis., 1907. Vol. IV, Xo. 2.—Bassoe, Peter. Jour. Infect. Dis., 1906, LLL, p. 91; Trans. Chic. Path. Soc, Vol. VI, No. 10, p. 380. — Irons, E. E., and Graham, E. A. Jour. Infect. Dis., 1906, Vol. Ill, No. A.—Christetisen and Hektoen. Jour. A. M. A., July 28, 1906, Vol. XLVII, No. 4. — Baum and Stober. Demonstration of sections, Chicago Derm. Soc, April, I901.—Garvy, A. C. Demonstration before a branch of Chicago Med. Soc, May, 1907. — Montgomery, Frank Hugh. Case demonstration before Chicago Derm. Soc, April, 1905. Jour. Cut. Dis., 1907, Vol. XXV. — Hjjde and Montgomery. Jour. A. M.A., June 7, 1902, p. 14S6, Vol. XXXVIII, No. 23.— Ricketts, Howard T. Jour. Med. Res., Vol. VI, No. 3.— Evans, F. J. Jour. A. M. A., June 27, 1903, Vol. XL, No. 26.— Hamburger, W. W. Jour. Infect. Dis., Vol. IV, No. 2, 1907.— 0//s, F. J., and Evans. Jour. A. M. A., Oct. 31, 1903, Vol. XLI, No. 18.— Eastman, J. R., and Keene, T. V. Annals of Surgery, Vol. XL, No. 5, Nov., 1904. — Wernicke (quoted by Gilchrist, T. C). —Rixjord, Emmeti, M.D., and T. C. Gilchrist, M.R.C.S. (Eng.), L.S.A. (Lond.), Johns Hopkins Hosp. Reports, 1896, I, 209.— OphiUs, W. Jour. Exper. Med., Vol. VI, Nos. 4, 5, 6.—Ophids, W., and Moffett, H. C. Philadelphia Med. Jour., June, 1900. Ophids. W. Jour. A. M. A., Oct. 28, 1905, Vol. XLV, No. IS.— Montgomery, D. W., Rykjogel, H. A. L., and Morrow, H., J.C.D., Vol. XXI, p. 5, 1903.— Bemn, A. D. Jour. A. M. A., Nov. 11, 1905. CHAPTEE X TUBERCULOSIS The oro-anism now known as the tubercle bacillus was proven by R. Koch in 1882 to be the cause of tuberculosis. The discovery of this organism made clear a number of pathological changes affecting dif- ferent tissues and viscera, and made possible the grouping of a num- ber of diseases Avhich formerly had been considered to be separate and distinct. Undoubted clinical examples have convinced us that 394 WOUND INFECTIONS OF DIFFERENT ORIGINS bovine tuberculosis may be transferred to man, in spite of the fact that Koch (1901) was unable to infect cattle and pigs with bacilli of human origin and expressed his belief that the converse — i. e., that the bacillus causing bovine tuberculosis was not pathogenic for man — was true. IMore recent investigations, such as those of Kossel, "Weber, and Heusz, have shown that there are slight morphologic and cultural dif- ferences between the human and bovine types, that there are also some differences in pathogenicity, but that they are very closely related. Bovine bacilli are more virulent for most mammals than are human bacilli. Cattle are not susceptible to the latter, while pigs and goats develop, after subcutaneous injections, a chronic, progressive form of tu- berculosis. Rabbits are less susceptible to the human than to the bovine type. There is no marked difference in pathogenicity for guinea pigs. Von Dungern has shown that the same results follow inoculation and feeding experiments performed upon anthropoid apes with these two types of bacilli. The practical question is whether, after determining the differ- ences between these two types of bacilli, the precautions taken against the transmission of bovine tuberculosis to man are superfluous. Later investigations have shown that they are not. Of course, the human type is found most frequently in tuberculosis as it occurs in man, but the bovine type is found also, especially in children. The latter type is found not only in the primary tuberculosis of the intestines and mesen- teric lymph nodes, but also in the peritonitis which follows, in the vis- cera, in the miliary forms, and even in some cases in tuberculosis of cervical Ijnnph nodes, of the joints, and of the skin following injuries. It may be easily seen that the bovine bacilli are highly significant as an etiological fac- '' tor in human tuberculosis. Bacillus of Tuberculosis. — Tubercle ba- ' _^i I cilli are non-motile, often slightly curved, '- ' "^ ^'' slender rods from 1.5 to 4 ju in length. / They occur singly or in groups and clusters in the tissues, and, according to ^ the present view, do not form spores. -— ' In animals under certain conditions, Fig. 154. — Tuhkhclk Bacilli in ,1 , • j i 1 j Fresh Sputum. ^^^^ ^"^^^^ O^^* ^"^0 longer or shorter branching threads, resembling acti- nomyces somewhat. Friedrich and Nosske observed this method of growth after intra-arterial injections of virulent cultures. Besistance of the Bacilli. — The great resistance of tubercle bacilli explains the different modes of infection, in spite of the fact that they TUBERCULOSIS 395 do not grow outside of the body. They are not injured by drying or cold, and withstand 212° F. of dry heat for some hours. In the sputum they are not killed by chemical agents, as they are surrounded by mucus. IMoist heat at a temperature of 203° F. kills them in from one to two minutes. In sputum they are killed by boiling for five minutes. Cultitrcs. — It is difficult to obtain tubercle bacilli in pure culture, for if the material is contaminated the other micro-organisms develop much more rapidly and overgrow them. Pure cultures are most easily obtained by transferring fresh tissues or a slightly caseated focus from an infected guinea pig to blood serum or glycerin-agar. There then develop after two or three weeks if the tubes are kept at a temperature of 98.5° to 100.5° F. with free access of air, small, white, dry scales, which later become confluent to form a membrane. Other growths upon ordinary agar and bouillon may be obtained by transplanting this pure culture. Experimental Animals. — The guinea pig is best suited for experi- mental purposes, as it develops the disease most rapidly and in its severest form. An animal dies in from ten to twenty days of a general tuberculosis if a small amount of tissue containing bacilli or a pure culture is injected into the peritoneal cavity; after some weeks, fol- lowing subcutaneous injections, localized nodules and ulcers having developed in the meantime. Rabbits are less susceptible and die of a general tuberculosis only after intra-venous or intra-peritoneal injec- ti(ms. Tuberculosis of the intestines, mesenteric lymph nodes, tonsils, and cervical lymph nodes have followed the feeding of pure cultures; tuberculosis of the lungs, the inhalation of powdered cultures; and tuberculosis of bones and joints (W. Miiller, Friedrich), the injection of bacilli into the arterial system (femoral artery, aorta). Methods of Staining. — There are a number of different methods for staining tubercle bacilli. It is one of a group of " acid-fast " bacilli, and does not readily give up the stain which it takes. Counter stains may be used and the bacillus may be readily differentiated from the surrounding tissues and associated micro-organisms. They stain not only by Gram's method, but also Avith aniline dyes, if an alkali, aniline oil, or carbolic acid is added and the stains are allowed to act for some time. Other micro-organisms and cells, present in smears or tissues, may be destained with alcohol or acids. Examination of cultures, exudates, tuberculous de])ris, and sputum are made in the following way : Thin, even smears of the material to be examined are made upon cover glasses. The cover glasses are then passed through a flame two or three times until the smear is dry. Ziehl's carbol-fuehsin is then dropped upon the cover glass until the 396 WOUND INFECTIONS OF DIFFERENT ORIGINS smear is thoroughly covered. The cover glass is then gently warmed until steam arises; the specimen is allowed to remain in the hot stain two or three minutes, and is then washed in w^ater. The other bacteria and cells are then destained by placing the cover glass for a short time in twenty -five per cent nitric acid, or, better, a three per cent solution in hydrochloric acid in alcohol. After washing in water the smear is counterstained with a dilute aqueous or alkaline solution of methylene blue. This solution is then removed with blotting paper and the prepa- ration is again washed with water. Balsam may be applied to a well- dried cover glass and a permanent preparation made. Staining of Bacilli in Tissues. — Ehrlich's mixture of a saturated aqueous aniline solution with an alcoholic solution of fuchsin or gen- tian, in which the sections should remain from twelve to twenty-four hours, and Ziehl's solution are to be recotiimended for staining the bacilli in tissues. After washing they should be destained in a three per cent solution of hydrochloric acid in alcohol, or in a twenty-five per cent solution of nitric acid and placed in sixty per cent alcohol. They should then be washed in water a number of times to remove the acid, and counterstained with methylene blue or Bismarck brown. Differences between the Bacilli of Tuberculosis and of Leprosy and Smegma Bacilli. — For the method of difi:'erentiating the bacilli of tuber- culosis and leprosy, vide page 448. The tubercle bacillus may be mis- taken for the smegma bacillus (e.g., in examinations of the urine). Cornet recommends Weichselbaum 's method for differentiating between tubercle and smegma bacilli. Stain with carbol-fuchsin, then, without destaining, use a concentrated solution of methylene blue in absolute alcohol. The tubercle bacilli remain red, the smegma bacilli become blue. Animal inoculation is, of course, the surest and most satisfactory method of differentiating between the two. The difference in virulence of tubercle bacilli from difi'erent sources and during cultivation (decrease of virulence when growing upon me- dia, and increase wben passed through animals) depends upon the dif- ference in the toxin-content of the bacilli (von Behring). Toxins. — According to von Behring, toxins are found in the culture media and in the protoplasm of the bacilli. The latter (endotoxins) pro- duce, when dead bacilli are injected into animals, inflammation, sup- puration, and, when a thick emulsion is injected intravenously, tuber- culouslike changes in the tissues (Koch, Masur, Kockel, and others). Different toxic substances are found in the residue, which contains bacilli, obtained by the filtration of cultures. Koch prepared his tuber- culin by making a glycerin extract of this residue. Von Behring ana- lyzed this residue into separate substances, the end product of which, tuberculosin, he regards as the active and specific toxic base. TUBERCULOSIS 397 Immunization of Animals — Tuberculin-R. — Kooh with his tul)prcu- liii was tho lirst to allcinpt to iiiiniunize animals against tuberculosis and to cure animals already diseased. Tuberculous guinea pigs treated with tuberculin remained alive longer than control animals which were not treated (Pfuhl, Kitasato), but the animals never recovered, as Koch in the beginning thought possible. Tuberculin has not proven to be of any great value as a therapeutic measure. The changes in the local condition and the general reaction which follow its injection in tubercu- lous subjects make it very valuable for diagnostic purposes, although dangerous exacerbations and collapse may follow its use. It is used for diagnostic purposes, especially in cattle. When finally no reaction fol- lows the use of tuberculin, because of imnuinization against it, the tu- berculous process may extend or develop anew. The immunity which is established against tuberculin has no effect whatever upon the develop- ment and growth of the bacilli. In order to produce an immunity against the bacilli, Koch prepared his Tuberculin-R. [Tuberculin-K. is made in the following way: " Dried masses of the organism are ground up in an agate mortar. After suspension in distilled Avater and cen- trifugation, the emulsion consists of two layers. The overlying, opa- lescent, whitish fluid is designated as ' T. 0.' (Tuberculin-Obers). After the removal of the fluid from the precipitate the latter was again dried and ground, suspended in water and centrifugated as before, and the process repeated until none of the sediment remained. The different fractions of fluid, except the ' T. 0.' were combined to con- stitute ' T, R. ' (Tuberculin-Rest), which is really an emulsion of minute fragments of bacilli." — Ricketts, " Infection, Immunity, and Serum Therapy," p. 413.] The pyogenic substances are removed by precipitation and then the tuberculin is rapidly absorbed and no ab- scesses form. A. Wasserman and Bruck attempt to explain the occurrence or absence of the tuberculin reaction in the following way : According to their investigations, antituberculin is formed in tuberculous foci (local immunity), and the tuberculin injected into the body is attracted to the tuberculous foci by these antibodies. The complement is bound when the tuberculin unites Avith its antibody and there is a local accu- nuilation of ferments which liquefy the tissues and produce softening of the diseased foci. There is no local reaction, likewise no general re- action, when, as a result of tuberculin treatment, antibodies are found in the blood; then the latter become bound to the tuberculin in the cir- culating blood, and the tuberculin is prevented from reaching the tuber- culous foci. Von Behring (1902) successfully imnnniized cattle with the human type of bacillus, not dangerous for cattle, against bovine tuber- culosis. Just as Jenner succeeded in innnunizing man against small- 398 WOUND INFECTIONS OF DIFFERENT ORIGINS pox by inoculating him with cowpox, so von Behring was able to inoculate cattle with, the human bacillus and render them immune against infec- tion with bovine tuberculosis (therefore, Jennerization). The results obtained by \on Behring have been confirmed by Baumgarten. Modes of Infection. — Infection may follow the inhalation of dust or particles laden with bacilli, the ingestion of infected food, or the inoculation of wounds or ulcers. The disease has been transferred from a diseased mother to the fcetus. Whether the disease develops or not after the bacilli have been in- troduced depends upon the number and virulence of the bacilli and the resistance of the patient. Pulmonary tuberculosis is the most common form of the disease in man. It may follow directly the inhalation of the bacilli or may be secondary to a tuberculosis of lymph-nodes. Normally the upper re- spiratory passages are protected from infection by their mucous secre- tion, and for this reason are much more rarely involved than the lower. The sputum of a tuberculous patient carries with it the greatest dangers of infection in this form of tuberculosis. Bacilli are also found in the secretion of tuberculous ulcers, and are discharged into the outer world in the fa-ces and urine of tuberculous patients, but infection from these sources is not as common as that from the sputum. The sputum, unless proper precautions are taken, later dries upon the floor or pocket hand- kerchiefs, is pulverized and mixed with the air. Attempts have been made to educate the public not to spit upon the floors of large assembly halls, but into spittoons containing water, in order to prevent the dan- gers of infection (Cornet). The air about tuberculous patients may be infective, as small drops of fluid which contain bacilli are discharged when the patient coughs. The possibility of infection by the inhalation of both dried and moist tuberculous sputum has been demonstrated ex- perimentally (Cornet, Fliigge). Tuberculosis of the gastro-intestinal tract may follow the ingestion of infected food and drink and the swallowing of tuberculous sputum. The pernicious habit some mothers have of licking the artificial nipple used upon the nursing bottle, and of chewing the bread before giving it to the child is a source of danger in this form of tuberculosis. The milk of cows suffering from a general tuberculosis or a tuberculosis of the udder is rich in bacilli, and may cause an intestinal tuberculosis. There is also danger of infection from eating meat from tuberculous cattle which is imperfectly cooked, and butter made from milk contain- ing the bacilli. Roger and Garnier have demonstrated that the milk of a nursing mother may contain bacilli even when there is no disease of the breast, and, besides, the excreta of a tuberculous mother are always the source of grave danger to the child. TUBERCULOSIS 399 Fiii.'illy, lulx'i'clc l);i('illi iiiny be dcposilfd ii])on recent and old wounds, iijinyivnous jh'cms, and ulccis. liacilli may gain access to wounds of tlie hands during operations, post-mortem examinations, the shiughtering of diseased cattie, or the milking of cows with tuberculous udders, and they may be carried on the hands to other parts of the body. Small wounds of the skin (scratches) or ulcers (ulcus cruris) may become infected in this way. Infection may follow an injury pro- duced by an instrument or foreign body to which bacilli were attached. Occasionally infection may follow a fall, but this is rare, as the dust of the street, uidess it contains fresh tuberculous sputum, is free from tubercle bacilli (Cornet). Secondary infection of a wound, because improperly treated (use of court plaster moistened with sputum, washing out and bandaging with infected handkerchiefs), is much more frequent. Tuberculosis of circumcisitm wounds, following attempts by a tuberculous rabl)i to control haemorrhage b}' sucking the bleeding surfaces, ])el()ngs to this chuss of infections. Transmission of tuberculosis from the mother to the foetus is pos- sible (placental infection). Friedmann's experiments show that tuber- cle bacilli may pa.ss wdth the spermatozoa into the o\'Tim (conceptional and germinal transmission). Tuberculosis should be supposed to be of congenital origin only when it develops in the newborn, as older children living with tuberculous parents have been exposed since birth to infection. Experience shows that the children of tuberculous pa- tients are more susceptible to tuberculosis than the children of non- tuberculous patients (hereditary predisposition), and also that those whose nutrition is not good or who have been weakened by previous disease are especially susceptible (acquired predisposition). Histology of the Tubercle. — When tubercle bacilli are deposited in tissues they multiply slowly and incite a number of tissue changes. These begin wdth a degeneration of surrounding connective tissues and cells. This degeneration is then followed by a proliferation of the healthy connective tissue cells and the immigration of leucocytes into the area involved. Small grayi.sh, cellular nodules, to which the name of tubercle has been given, are formed. Virchow (1852) suggested that the term tubercle, w^hich before had had a general application, be applied only to this pathological change. The tubercles, which rarely become lai-ger than a millet seed, conqiose the tuberculous granulation tissue which is produced by the proliferation of tissues in which the bacilli are deposited, and by the immigration of leucocytes. Occasion- ally tuberculous granulation tissue develops without tubercle formation. The changes occurring in tlie tubercles and the tuberculous granu- lation tissue determine the course and the sequela^ of the disease. According to Baumgarten's investigations, the connective tissues 400 WOUND INFECTIONS OF DIFFERENT ORIGINS and the endothelial cells of the blood and lymph vessels, sometimes the epithelial cells, react to the stimulus of the tubercle bacilli and their toxins by dividing mitotically. In about one week in animal experi- ments there is an accumulation of large cells (epithelioid cells) which resemble epithelial cells and develop mostly from fibroblasts. Leuco- cj'tes in different numbers wander from the neighboring vessels into the inflamed area (Fig. 155). If leucocytes are present in such large Fig. 155.— Section through a Tubercle. Upon the margin of the tubercle lymjahoid cells ma}'' be seen; in the center epithelioid cells and a giant cell. numbers that almost nothing can be seen of the large epithelioid cells, one speaks of a small-cell or lymphoid tubercle, in contradistinction to a large-cell or epithelioid tubercle, in which the large cells resembling epithelial cells predominate. Tlie old connective tissue fibrils, separated by the cellular infiltratitm, form the supporting structure, the reticu- lum of the tubercle. In the center of the tubercle there are frequently found one or more multinuclear giant-cells (Langhans' type) in which the nuclei have a polar or peripheral arrangement. Groups of bacilli may be found within the cytoplasm of these cells. It is supposed that the bacilli stimulate nuclear division in these cells, and that the failure of cell division is due to the injury of the cytoplasm. [" Metschnikoff and others take a different view of the formation of giant-cells, con- TlUilORCl LO.SIS 401 sidering: that they represent individual epithelioid cells which have fused to form a multinuclear mass." — Ricketts, " lufivtion, Immunity, and Serum Therapy."] Regressive Changes in the Tubercle. — The fully developed tubercle, ■\vhieli is gray, translucent, and may be as large as a millet seed, begins sooner or later, inider the toxic action of the bacilli, to degenerate in the center. Round cells, fibroblasts, and giant-celLs gradually degen- crati' mitil the entire tubercle is transformed into a hyaline (coagu- lation necrosis of Weigert), finally into a granular, fatty mass, in which the bacilli gradually die. The caseated tubercle is oparjue and yellowish- white. A fibrous capsule is formed by the proliferation of the sur- rounding connective tissue which may replace entirely or partly the degenerated mass (fibro-caseous tubercle). The tubercle or groups of tubercles may undergo a number of re- gressive changes. The tubercle imbedded in the tuberculous granula- tion tissue has upon section the appearance of a spongy, semitrans- parcnt, grayish red (if caseation occurs, yellowish) mass. Ulcers and fistuhe follow regressive changes in tubercles situated near the surface of the body, in the skin, or mucous membrane. Large caseous (if the co-nnective tissue proliferates, fibro-caseous) nodules follow the degen- eration of tubercles situated in the deeper tissues or viscera. If the Fig. 15(1. — I'l hkkcui-oi's (Jiant Cells Containing a I-'f.w 'I'lJiKiuLK Hacilli. tubercles become softened and liquefied, large cavities with contents resembling pus (cavities in the lung, abscesses in lymph nodes) are formed. The extension of the tuberculous process and the development of tuberculous (cold) abscesses follow the deposition of bacilli in sur- rounding tissues and the development of new nodules. Gravity and the anatomical arrangement of the loose, fascial planes are important in determining the direction in which the disease extends and tuber- culous pus burrows (gravitation abscess). In ulcers of the skin and mucous uuMubi'anes the tubercles lie exposed in the ])ale, flabby, glassy, or yellowish gi-anulations; tliey cover the synovial membrane in tuber- culous arthritis, and are found in the walls of tuberculous abscesses (Fig. 157). 402 WOUND INFECTIONS OF DIFFERENT ORIGINS Fig. 157. — Tuberculous Abscess Membrane. The pathological changes, formation of granulation tissue, caseation, suppuration, or encapsulation, vary in the different forms of tuber- culosis. The virulence of the bacilli and the resistance of the tissues determine whether the tuberculous foci will cic- atrize, caseate, or sup- purate. The first form, which Konig has called the dry tuberculous granulation tissue, is much more benign than the caseating form. This difference in clinical course seems to depend upon whether small or large amounts of toxins are formed. In tuber- culosis of the serous cavi- ties and joints, the pathological processes are still more complicated, as a serofibrinous exudate is formed. Secondary Infection. — If a tuberculous focus becomes infected with pyogenic bacteria, through the blood or a fistula, an acute inflammation develops and a purulent exudate is formed as the result of the second- ary pyogenic infection. Tuberculous Pus. — Tuberculous pus, the result of liquefaction of caseous material, differs from that formed in suppurative inflammations caused by pyogenic bacteria. As the caseous material liquefies, it be- comes mixed with a serous or serofibrinous exudate. Tuberculous pus is watery, white or light green in color, and contains masses of caseous material, strings and flakes of fibrin. On the other hand, pus formed in suppurative inflammations is thick and creamy, as the solid par- ticles are evenly distributed throughout its substance. Pus corpuscles in tuberculous lesions early undergo fatty degeneration and disinte- grate (Tavel), so that but few are found when the pus is examined microscopically. Tubercle bacilli are not numerous, and it may be impossible to demonstrate them by microscopical examination. Often it is necessary to resort to animal inoculations to determine the character of pus removed from doubtful lesions. The liquefaction of tuberculous nodules and infiltrations is due to the action of poly- morpho-nuclear leucocytes, and not to that of tubercle bacilli or pyogenic bacteria. "When the leucocytes disintegrate ferments are set free, which digest and liquefy the necrotic, caseous material (Friedrich MuUer). TUliERCUl.OSlS 403 A lociil, limited tuberculosis is dirreiviilialed fi'oni a n-(>neral miliary tul)ereul(>sis, wliieli develops i'roiii llie former. The majority of the lesious developing in localized, limiicd tuberculosis are treated sur- gically. LOCAL SURGICAL TUBERCULOSIS The foci may develop in the infection atria or in the parts wliere the bacilli are deposited by the l)lo()d and lymph streams. (a) TUBERCULOSIS OF THE SKIN The Anatomical Tubercle. — The so-called " anatomical tubercle " may develop upon the hands of individuals who work with tuberculous materials from man or cattle, following an injury of the skin. A small, firm, reddish brown nodule, which may become as large as a pea, develops at the point of injury after some weeks. It is covered with a cornified, fissured epidermis, and often, after lasting for some time, disappears spontaneously. The " anatomical tubercle " is the most benign form of tuberculosis of the skin. It does not ulcerate, and only rarely is it followed by involvement of glands about the elbow. ^Nlixed infections occur frequently. Verrucous Tuberculosis of the Skin. — According to Riehl and Pal- tauf, verrucous tuberculosis of the skin (tuberculosis cutis verrucosa) is a form of tuberculosis which also follows injuries of the skin. The fiat, slightly elevated, usually rouiid, infiltrated area has a bluish red border and an irregularly warty surface. It pursues a chronic course, and the infiltrated area, without ulcerating, becomes as large as a silver dollar or may finally involve the dorsum of the hand and a part of the forearm. The hands are most frequently attacked, especially in such people as butchers and those who come in contact with materials from tuberculous cattle. A case in von Bergmann's clinic followed an injury of the dorsum of the hand with a milk pail. The epitrochlear and axillary lymph nodes may be involved after the skin lesion has persisted for some time. Tuberculous ulcers of the skin, excepting those developing in lupus exulcerans, are most often secondary to a tuberculosis of the nuicous membranes of the mouth, rectum, and genitalia. The process as a rule extends from the mucous membrane to the skin. These ulcers usually develop in the terminal stages of some of the other forms of the disease from small miliary nodules which form in the skin. The ulcers are characterized by flat, irregular, undermined borders, and by pale, translucent, yellowish, soft granulations which may be easily wiped away with little hamiorrhage with gauze. It has already been mentioned that the wounds following circum- 404 WOUND INFECTIONS OF DIFFERENT ORIGINS cision in yonng Jewish children may be infected, as a result of the sucking of the wound by a tuberculous rabbi. Small nodules then develop in the prepuce, which later ulcerate and lead to the formation of chronic ulcers. After some weeks the inguinal lymph nodes become involved; general glandular and miliary tuberculosis have been ob- served. Lupus. — Tuberculosis of the skin develops most frequently in the form of small brownish red macules or slightly elevated nodules, which are sometimes hard. The nodules may be of pin- head size or may become as large as a pea. The color of the nodule dis- appears but little when pressure is made ; this is an important diagnostic sign. They develop in all layers of the cutis, fre- quentty also in the sub- cutaneous fat, and corre- spond to the miliary tubercles or to a number of the same. They may be single or multiple, and the area of skin involved may be very circumscribed or extensive. The face is most fre- quently affected in this form of cutaneous tuber- culosis, the so-called lupus. In 100 cases the disease attacked the face 76 times, and of the 76 cases the nose was affected in 38. The skin of the extremities is attacked relatively frequently. The development of lupus nodules has been observed after inoculation of the skin with tubercle bacilli — e. g., after the use of saliva in tattooing. There are a number of eases in which the ectogenous infection of an already dis- eased area of skin (eczema) has been demonstrated. According to Cornet it is not essential that the skin be injured, for tubercle bacilli, like staphylococci, may be forced into the hair follicles and deeper tissues by rubbing (e. g., wiping the nose with an infected handker- chief). Of course the bacilli may be carried in the patient's sputum, and the skin about the mouth may become infected from it. The skin surrounding a tuberculous fistula or covering a caseated lymph node ^1. Fig. 158. -Lttptts Exulcerans and Exfoliativtjs Faciei. TUBERCULOSIS 405 or a tnborcnlons focus in a bono, may Ijocomo seoondarily involved. Tubt'irlcs may tlovolo]) at tbc nuico-ciitaneous mariil(i)i('()us Healing of Tuberculmi!^ Foci. — A tu1>erculous focus in bone may heal spontaneously. The bacilli are then overcome by the resistance of the tissues, and the focus is either encapsulated or replaced by newly formed coiuiective tissue. As would be expected, spontaneous healing occurs most frecpiently in small, circumscril)ed foci in which there is no sequestrum formation. Virulent bacilli may remain in the encapsulated or healed foci, from which recurrences develop when the capsule is destroyed or the resistance of the tissues lowered by trauma. The spontaneous healing of tuberculosis of the spine demonstrates that even the larger sequestra may become encap- sulated. 28 Fig. 171. — Tuberculous Caries of the Rim of THE Acetabulum. 1. Perforation inward into the pelvis. 2. Epipliyseal cartilage. 3. Base of the cuneiform seciuestruin corresponding to the lower branch of the nutrient artery. 4. Displacement of the acetabular rim upward. Preparation from a child twelve years of age. 422 WOUND INFECTIONS OF DIFFERENT ORIGINS Rupture of a Focus into a Jolut or Soft Tissues. — An osteal focus may rupture into a neighboring joint or into the soft tissues. If the focus ruptures into a joint a tuberculous arthritis develops, the clinical Fig. 172a. — Tuberculosis of the Right Shoulder Joint. Photographed from in front. 1. Very large, completely sepa- rated sequestrum. 2. Head of humerus deprived of cartilage and carious. 3. , Tuberculum majus. 5. Diaphysis. Fig. 172b. — Resected Head of the Hu- merus. Natural size (after Krause). Preparation made by sawing head of the humerus in frontal plane. 1. Cuneiform sequestrum which extends to the articu- lar surface, the cartilage of which has been destroyed. 2. Extensive caseous infiltration of the head, secondary infec- tion extending from the sequestrum into the tuberculum majus (4) and the di- aphysis (5). Fig. 173. — Tuberculosis of the Diaphysis of the Tibia of an I^ight Year Old Girl. The foci have been exposed by chiseling away a thick laj'er of bone. Slight expansion of the bone. Sclerotic bone surrounds the foci. course of which depends upon the character of the primary focus (Konig). If there is a tendency to the formation of scar tissue and healing, the tuberculous process extends but little in the soft tissues. TUBERCULOSIS 423 ir, oil tli(> other hand, \hovv is a tendency to caseation and suppuration, tuberculous or cold abscesses rorni. These abscesses (gravitation ab- scesses) follow the force of gravity, but may burrow against it. Large and very extensive cold abscesses may develop from exceedingly small foci. When the foci lie directly beneath the sUin, chronic fistuhe and ulcei's form after the rupture of the absces.s. Clinical Course. — 'Phe clinical picture of tuberculosis in dif- ferent bones varies. The articular ends of long hollow bones are most frequently involved. Round or cuneiform foci (foci of granu- ^ " /' lation tissue and pus with or without sequestra) . form which may rui)ture into the joint or into Fig. 174. — Tuberculous Osteitis of THE First and Second Phalanges OF THE Index Finger with Ab- scess Formation. Subcutaneous abssces.ses are also present upon the dorsum of the hand. tlie i)ara-articular soft tissues; foci in the cortex, beneath the periosteum, or within the me- dulla of the diaphysis are much less frequent. Diffuse tuberculosis of the epiphysis and diaphysis of large bones is rare and most frequently follows a severe form of tubei-- culosis arthritis. In the short, hollow bones, the changes arc most pronounced in the diaphysis. The cortical layer of bone is destroyed from within, and as the process reaches the surface the periosteum is stinuilated to the production of Fig. 175. — Tuberculous Osteitis of the Proxi- mal Ph.\lanx of the Index Finger. Flask- like expansion of the finger caused by sonae ex- pansion of tlie bone and the development of masses of jjiramilation tissue. 424 WOUND INFECTIONS OF DIFFERENT ORIGINS new bone, replacing partially the cortical bone, which is being de- stroyed. The entire diaphysis may be filled with caseous material or may contain one large sequestrum. The old name spina ventosa is frequently applied to tuberculosis of the phalanges, metacarpal, and metatarsal bones. Tuberculous osteitis of the phalanges gives to the fingers a peculiar, bottle-shaped form, which may also be produced by a tuberculous periostitis. Tuberculosis of the vertebrge is very common; they are the most frequently attacked of all the short bones. Frequently multiple foci develop upon the an- terior surface of the body of a vertebra be- neath the anterior longitudinal ligament or within the bone. These foci soften, and the diseased bone is then crushed by the weight of the super- imposed vertebra?. The spine of the diseased vertebra becomes prominent, and an an- gular kyphosis or gib- bus develops. If a number of vertebras are diseased, the ]sj- phosis will be rounded instead of angular. Spontaneous healing of inaccessible foci oc- curs frequently. The well-known deformity '* humpback " is the result of a healing of a tuberculous spondy- litis in malposition. As the tuberculosis heals there is a periosteal formation of bone upon the anterior surface of the vertebra?. Cravitation abscesses frequently develop in the course of tuberculous spondylitis. The retropharyngeal and psoas abscesses are the best-known examples. Tuberculosis of the lamina? is much rarer than that of the bodies of the vertebra? (being most frequent in the atlas and axis) , Fig. 176. — Tuberculous Caries of the Twelfth Thor- acic, First and Second Lumbar Vertebr.e; Marked Formation of Osteophytes upon the Anterior Sur- face OF the Sacrum. Left half of the pelvis removed. TUBERCULOSIS 425 Tiihi'i-fMilosis of tlu' cjiri);!! ;m(l Ijirsiil hones is fi'cqncnlly followed by sevei'e tul)ei'euU>ii.s nrtlifit is. The rihs ;ire most fre(|iu'iitly involved of any of tiie tiat hones. Su- perlieial, suhi)eriosteal foci, whieh may become very extensive, and lai'^-er osteal foei with sequestra develop. The frontal and parietal are the skull bones most frequently attacked. The foci of granulation tis- sue and se(|uestra may perforate the bone and extend to the dura; the dura will be exposed Avhen an abscess of the scalp is incised, and the granulation tissue and sequestra removed. Tuberculosis develops fre- quently ill the outer part of the orbital process of the superior maxilla and in the malar bone, where it articulates with the latter. It may also tlevelop in the scapula, clavicle, sternum, and ilium. Symptoms. — Clinically, as a rule, the first symptoms of tuberculosis of ])()ne eousist of pain and swelling. These develop as soon as the focus within the bone reaches the periosteum and soft tissue. Suppura- tion in the soft tissues and rupture into a joint give rise to definite symptoms (see below). The tuberculous abscess in the soft tissues develops slowly and the skin covering it does not present any of the signs of infiannnation (cold abscess). There is but a slight elevation of temperature in uncomplicated tuberculosis of bone ; frequently there is no fever at all. High fever indicates a secondary infection with pyo- genic bacteria, which frequently occurs when a suppurating fistula com- nnmicates with the abscess cavity, or it indicates the beginning of a miliary tuberculosis. Diagnosis. — I'sually the diagnosis of tuberculosis of bone is not dif- ficult. Tuberculosis of the vertebra^ skull and facial bones, phalanges, and a number of other bones presents a very definite clinical picture. The slow development of the abscess following the inflammation of bone, the absence of local as well as general symptoms of acute inflam- mation, the distention of the skin, the rupture of the abscess with sub- se(iuent development of chronic fistulas and ulcers with flabby, yellow granulations and undermined edges, and finally the swelling of ad.jacent lymph nodes leave no doubt as to the nature of the pathological process. Besides, tuberculosis develops most frequently in the bones of weak individuals, in whom there are already evidences of some other form of tuberculosis, such as tuberculosis of the lungs, lymph nodes, joints, skin, or mucous membrane. Sometimes it is difficult to make a differential diagnosis between tuberculous and suppurative osteomyelitis, especially when the foci pro- duced by the latter are small, are situated in the articular ends of the bone, and pursue a subacute or chronic course. Expansion of the bone speaks against tuberculosis. Only in the rare cases of primary tuber- culosis of the shaft of long bones does the cortical laver of bone become 426 WOUND INFECTIONS OF DIFFERENT ORIGINS expanded to resemble clinically spina ventosa, already described in tuberculosis of short, hollow bones. If there are no characteristic ab- scesses, fistula?, or ulcers, it may be impossible to make an accurate differential diagnosis before operation. The caseous pus and the round, small sequestra of tuberculosis are very different from the thick, creamy pus, and the irregular, notched sequestra resulting from pyogenic in- fection. In doubtful cases the demonstration of cocci in the pus, or of tubercle bacilli in the granulation tissue determines the diagnosis. The diagnosis of tuberculosis may sometimes be made with the X-ray if cuneiform sequestra are present. Treatment.- — The most important indication in the treatment of tuberculosis of bone is to remove accessible foci, especially if they sup- purate. This can be done when the epiphyseal focus has ruptured externally, when the inflammation involves the bones of the skull and face, ribs, etc. Large epiphyseal foci should be operated upon as soon as possible in order to protect the joint from the disease. The operation should also be performed as early as possible in tuberculosis of the short, hollow bones. If the disease is allowed to progress, the form of the fingers and toes is destroyed and changes occur which interfere with their function. The early operation should be perfonned when- ever the focus can be demonstrated and is accessible. All operations upon the extremities should be performed under Esmarch's artificial isch^emia. Frequently removal of the focus with a sharp spoon, after an incision has been made down to the bone and the periosteum has been reflected to either side, is sufficient. In other cases it will be necessary to use a chisel to remove a sequestrum which is not completely separated, or to expose and remove the contents of the medullary cavity, as in the treatment of suppurating osteomyelitis. If the latter is necessary, the epiphyseal cartilages should always be spared when possible (Fig. 173). The resulting cavities should be tamponed with iodoform gauze or filled with iodoform-giycerin einulsion after the skin sutures have been inserted. Resection of the diseased parts of flat bones (ribs, scapula, and ilium) gives the best results. Resection of the joint is indicated if the focus in the bone has ruptured into the joint and produced severe destructive lesions; amputation is occasionally in- dicated in the infiltrating, progressive form of tuberculous osteitis. The treatment depends upon the bone involved (e. g., vertebra). [In the treatment of all forms of tuberculosis great stress should be laid upon the necessity of improving the general condition and raising the resistance of the patient. Out-of-door life, good food, plenty of sun- shine, and rest are as essential as surgical treatment.] The treatment of tuberculous abscesses developing from osteal foci differs, depending upon the position of the latter. TUBERCULOSIS 427 In small abscesses with a subjacent, osteal focus, the following treat- ment is to be recommended: incision, removal of the abscess membrane, and insertion of a tampon of iodoform gauze. If the abscess is very- large, a taiiii)()n should not be inserted, but the incision should be su- tured and iodoform-glycerin emulsion then injected between the stitches into the cavity (Billroth). This treatment cannot be employed when the abscess has opened spontaneously or is acutely inflamed, for in those cases the dangers associated with a phlegmon require free incision and open treatment. It is difficult to cure abscesses by incision when there is an inacces- sible osteal focus. A psoas abscess is a good example of a lesion of this character. In these cases the osteal focus keeps up a continuous secretion, and after evacuation of the contents of the abscess a fistula forms which it is often difficult to protect from secondary pyogenic in- fections. Thase secondary infections aggravate both the local and gen- eral condition, and therefore incision of gravitation abscesses should be attempted only after the treatment by aspiration has been tried with- out success. Large syringes and canuhc should be used in aspirating cold ab- scesses, for the pus contains numerous fragments of tissue and flakes of fibrin. If these occlude the canula an attempt should be made to remove them with a wire or fine probe. The canula should be inserted oblicjuely through the skin and soft tissues, so that the edges of the wound will agglutinate rapidly when the canula is removed. The for- mation of a fistula may be prevented in this w^ay. For the same reason it is recommended that a small incision be made before the insertion of very large canulaj (Henle). Iodoform-glycerin emulsion should be injected after the removal of the pus (von Mosetig-Moorhof, Billroth, von Mikulicz). The results following the use of this emulsion are better than those following the use of iodoform-ether, carbolic acid, and zinc chlorid solutions, and it is generally employed. A ten per cent emulsion of iodoform in glycerin is employed. The emulsion should be thoroughly shaken before being used, and should be made fresh frequently (at least once a week). According to the experience of von Bergmann's clinic, it is not neces- sary to sterilize this emulsion. The activity of the emulsion seems to be reduced by sterilization, and besides iodin, which is harmful, is set free in the process. This emulsion may be injected into a large abscess cavity through the canula used for aspirating the pus. Fifty c.c. (in small children 10 c.c.) may be injected into such a cavity. If the abscess membrane has been removed and there are raw surfaces, only from 10 to 20 c.c. (in children a corresponding smaller amount) should be injected, unless 428 WOUND INFECTIONS OF DIFFERENT ORIGINS free escape is provided betM-een the stitch-holes, because of the dangers of poisoning following absorption. The injections should be repeated after intervals of from two to four weeks. Frequently abscesses heal under this treatment. The emulsion also has a favorable action upon the osteal focus. Careful asepsis should be practiced while the injections are being made in order to prevent secondary infection. If the latter occurs the abscess should be incised immediately and treated by the open method. Fistulas fol- lowing the rupture of gravitation abscesses frequently heal when iodo- form-glycerin emulsion is injected and the granulation tissue lining the fistula is repeatedly curetted away. The value of the emulsion depends upon the irritation produced by the iodoform which remains in contact with the tissues for some time. As a result of this irritation a healthy granulation tissue, which tends to contract and in which new tubercles cannot develop, forms, while the old tuberculous granulation tissue is destroyed. Iodoform, which is decomposed in the tissues, undoubtedly has some influence upon the bacteria, but this is little. A word of warning should be spoken against the use of excessive amounts of the emulsion. Severe, even fatal, iodoform intoxication has been observed after the injection of the emulsion into abscess cavities and joints. Many patients are very susceptible to iodoform, and the use of even small amounts of the emulsion may be followed by a gen- eral reaction associated with high fever and the symptoms of intoxi- cation. Naturally the emulsion should not be used when the patient gives a history of susceptibility to iodoform. Sometimes after the in- jection there are an increased pulse rate and an elevation of tempera- ture associated with an acute, transitory nephritis with hemoglobinuria, which has been regarded as due to the glycerin (Henle). (g) TUBERCULOSIS OF JOINTS (TUBERCULOUS ARTHRITIS) Tuberculosis of joints follows ha?matogenous infections, the rupture of a primary osteal focus into a joint; more rarely, a tuberculosis of adjacent tendon-sheaths. It is possible for infection to be carried through lymphatic vessels from diseased lymphatic nodes situated near a joint. Tuberculous arthritis is rarely a primary infection, as there is a focus in some other part — for example, in the lung, bronchial or mesenteric lymph nodes, mucous membrane or skin (Konig). Trauma has the same relation as an etiological factor to tuberculous arthriti.^ that it has to tul^erculous osteitis. In the majority of cases of tuberculous arthritis the disease begins in the articular end of one of the bones entering into the formation of the joint, and the synovial membrane becomes- involved secondarily. TUBERCULOSIS 429 Primary synovial ttibcrculosis is, however, more frecinent than was formerly considered to be the case. [jMiiller's statistics, pnblished from Kiinii^'s clinic, show that in 2)^2 cases of tnherculons ai'thi'itis, the dis- ease began in bone in 158, in the synovial membrane in 46, and that in 28 cases the origin could not be determined.] According to Konig a number of the osteal foci nuist be regarded as secondary to a synovial tuberculosis. The disease develops most fretjuently in the first two decades of life. The knee, hip, and elbow joints are most frecpiently involved, and in the order of freciuency as given. The joints may be involved in acute general miliary tuberculosis. Pathological Anatomy of Different Forms. — The formation of tuber- culous granulation tissue, in which are imbedded numerous miliary tubercles, a chronic reactive intiannnation of the synovial membrane, and the production of an exudate follow the deposition and multipli- cation of the tubercle bacilli in the synovial membrane of the joint. It makes no difference whether the bacilli are carried into the synovial membrane by the blood or whether they pass into the membrane after a primary osteal focus has ruptured into the cavity of the joint. The clinical coiu'se of the disease is determined by the character of the granulation tissue and the exudate, and by the secondary changes in the cartilages and bone. The tuberculous granulation tissue, which appears first upon the synovial membrane and later extends to the articular cartilages at the line of attachment of the membrane, may tend to cicatrize (the fibrous, dry, granulating form) or to degenerate and disintegrate (soft, slough- ing form). In the first form the synovial membrane, in the inner layers of which are foimd many tubercles, is considerably thickened and its free surface is ])artially or completely covered with pale, grayish red tuber- culous granulation tissue which only occasionally caseates or suppurates. In the beginning of the disease there is generally a serous or a sero- fibrinous exudate. In the caseating form of tuberculous arthritis the synovial mem- brane is covered with and partly transformed into soft, spongy granu- lation tissue, while the para-articular tissues are oedematous. Cir- cumscribed caseous foci and abscesses frequently form within this granulation tissue, which may rupture into the cavity of the joint, and a tuberculous suppuration, such as freciuently follows the rupture of primary osteal foci into the joint, develops in this waj'. If the process gradually extends through the synovial membrane, foci of granula- tion tissues and abscesses develop in the para-synovial tissues, which may later rupture through the skin and lead to the formation of fistula?. 430 WOUND INFECTIONS OF DIFFERENT ORIGINS Suppurative Tuberculous Synovitis. — Another and rare form of suppurative tuberculous arthritis, which has been observed especially in children (in the knee' and hip joint), develops rapidly after the miliary tubercles form. The synovial membrane, which is but little thickened, contains considerable numbers of miliary tubercles, and its surface is covered with an abscess membrane which can be easily removed (Syno- vitis suppurativa tuberculosa, Konig). Nodular Fortn of Tuberculous Arthritis and Villous Arthritis. — Often circumscribed masses of granulation tissue, accompanied by a ^* „„n^^ serofibrinous exudate, develop within the joints. The masses, which may become as large as a pigeon egg, are grayish red in color and are at- tached to the fibrous layer of the synovial membrane by a pedi- cle (nodular form of tuberculous arthritis, tuberculous fibroma, Konig) . These masses show no particular tendency to caseate and contain but few tubercle bacilli. In other cases villous- like growths, which branch like a tree, develop in the syno- vial membrane and thick, fibrinous masses are deposited upon the membrane or in the joint as the result of the chronic inflammation (villous tuberculous arthritis) (Fig. 177). An attempt has been made to explain the development of the rare lipoma arborescens (Johannes Miiller), which is most frequently asso- ciated with synovial tuberculosis of the knee joint, as due to the growth of the synovial villi resulting from the chronic inflammation. Similar growths are found in other diseases of the joints, such as chronic rheuma- tism, arthritis deformans, and syphilis. Of course tuberculosis may de- velop in a joint which already contains a lipoma arborescens (Krause). Fig. 177. — Proliferation of the Synovial Villi in Tuber cULOSis OF THE Knee Joint. (After Konig.) TUBERCULOSIS 431 The contents of the joint in the beginning of the disease or in iiiiM forms of the disease are serous in character (hydrops articuhiris ttiber- culosus serosus, Konig), the fluid being yellowish and clear or some- what clouded. White flakes in the exudate indicate the presence of fibrin (hydrops fibrinosus, Konig). Fibrinous masses, which may form a soft, white membrane, may be found in the joint cavity, most fre- ([uently in the recesses of the joint and along the line of reflection of the capsule. Frequently these fibrinous masses lead to the formation of vi-ilouslike structures and free-bodies. Kice Bodies. — The so-called rice bodies, corpora oryzoidea, which may fill the greater part of the diseased joint, are round and compressed, resembling seed- corn in shape. They are soft and white and are covered with an exceedingly slippery exudate. Often similar structures are at- tached to the synovial mem- brane by a pedicle; frequently they are free in the joint, but a connective-tissue center indi- cates that the pedicle has been destroyed and that the bodies which are free in the joint were formerly attached. These bodies should always be re- garded as the product of tuber- culous inflammation, for they, like the exudate, contain tu- bercle bacilli ; it may be only a few, but when injected into animals they produce tubercu- losis. Origin of Rice Bodies. — Ac- cording to Kimig, Landow, and Riese the pedunculated and free rice bodies develop from deposits of fibrin ; according to Schuehardt, Oarre, and Gold- man thev are to be regarded Fio. 17S. — Tuberculosis of the Knee Joint (Resection Preparatiox). Tlie articular cartilages covering the corresponding surfaces of the external condyles of the femur and tibia are destroyed. Small depressions may be seen in the articular cartilage covering the external condyle which is still retained. The edges of the cartilage are infiltrated with tu- berculous granulation tissue. Between the cartilage and the defect fungous masses may be seen. as the degeneration products of diseased synovial membrane (fibrinoid necrosis). The separation of the fibrinous or degenerated layers of the synovial membrane and 432 WOUND INFECTIONS OF DIFFERENT ORIGINS tlu^ foi-in of the free-bodies are i)robabl.y due to the movements of the i joint. \ A purulent tuberculous exudate is rare, and is found only in tlie severe forms of joint tuberculosis. The destruction which the joint undergoes is not limited to the liga- ments and articular flbro-cartilages, which are infiltrated with tuber- culous granulation tissues, but also extends to the articular cartilages and the subjacent bone. The articular cartilage is never the seat of primary tuberculosis, I although it may be attacked and destroyed when primary osteal or ' articular foci extend to it. Tuberculous granulation tissue extends from the synovial membrane to the articular cartilage and produces in it small holes, funnel-shaped depressions, and large defects which may extend down to the bone. According to Konig, these changes are due in the first place to the action of the organized fibrinous masses. The same thing is observed in hffimo- philiae joints. The destruction of the articular cartilage may follow the development of an osteal focus, the base of a sequestrum projecting into the joint and being worn off by the movement of the latter. Another specific process observed in primary tuberculous synovitis is the transformation of the yellow marrow of the spongy tissue of the epiphysis into simple granulation tis- sue without tubercles (osteitis granu- losa. Fig. 179). As the result of the extension of the inflammation the bony trabecula3 undergo lacunar re- sorption and are destroyed by osteo- clasts and the bone becomes soft and porous. Masses of granulation tissue extend into and through the articu- lar cartilage and project as fungous growths into the joint cavity. The articular cartilage is perforated like a sieve (von Volkmann). In other eases the granulation tissue separates the articular cartilage from the bone. The articular cartilage then ai)pears as a hump upon the bone; in the head of the femur as a liood. Tjater tlie thinned cartilage is broken Fig. 179. — Coronal Section or the Lower End of a Femur, which was Amputated because of Extensive Tuberculosis of the Knee Joint. The spongy tissue of the opiphj'sis has been transformed into simp'e granula- tion tissue without tubercles (osteitis granulosa). The articular cartilages are raised from the bone by this tissue. tubp:rculosis 433 Fig. 180. — Section of the Femur Involved in Tuberculosis of the Knee Joint. The articu- lar cartilage is raised and separated from the bone; the roughened, granulating bony surface may be seen below it. (After Konig). down or becomes stratified (Fig. 180). Tubercles develop only wben the granulation tissue of this form of osteitis extends into the joint. The tissue may then undergo caseation and pui-iform soft- ening; tlie bone, necrosis and caries (joint caries). The ai-tieular cartihiges and bone are destroyed by suppuration or by the pres- sure of masses of tuberculous granuhition tissue. Caries Sicca.- — There is a special form of tuberculous arthritis (caries sicca, von Volkmann) in Avhich the sec- ondary changes in the ar- ticular cartilages and bone develop without exudation. In this form of arthritis a thin layer of tuberculoui:> granidation tissue, which tends to cicatrize, forms and slowly destroys the cartilage and bone. An entire epiphysis may be destroyed while the granulation tissue is transformed into cicatricial masses. This form of tuberculosis is seen most frequently in the shoulder and hip joints. Reactive Changes. — The reactive changes occurring in the surround- ing tissues also belong to the anatomical picture of joint tuberculosis. These changes affect the connective tissues and periosteum. All the soft tissues, the joint capsule, the ligaments, tendon-sheaths, likewise the subcutaneous connective tissue, are transformed by the chronic hyperplastic inflammation into firm cicatricial masses which, because of the atrophy of the fat and accompanying oedema, often acquire lar- daceous and gelatinous characteristics. The same inflammatory irritation, after persisting for a long time, produces changes in the bone. Especially in the suppurative form a large number of osteophytes may develop about the joint involved as a result of an ossifying periostitis. Spo)itaueous Healing. — Tuberculous granulations may cicatrize and become ti'ansformed into scar tissue in which the tubercles are de- stroyed (U' encapsulated. Larger foci of granulation tissue and caseous masses may also be encapsulated by this tissue. The peri-articular tis- sues may also contract and the movement of the joint become linuted as the result of healing or apparent healing. This spontaneous healing 434 WOUND INFECTIONS OF DIFFERENT ORIGINS is of great importance from a therapeutic viewpoint, and treatment should be instituted which favors it. If the cartilage and bone are but partially destroyed, if the infil- tration of the bone is not extensive, and if there is no suppuration, spontaneous healing of the tuberculous process may occur. Adhesions which may become ossified then develop between the opposing surfaces, and fibrous or bony anchylosis develops. Concerning anomalies in posi- tion following healing, vide below. Clinical Course and Symptoms. — The symptoms and the sequelae of the various forms of tuberculous arthritis differ, and the clinical course of the disease has protean characteristics, but the symptoms of tuber- culosis of some joints are pronounced and characteristic. Usually the onset of tuberculous arthritis is gradual and the course chronic. According to Eovsing, in small children, especially in nurs- lings, suppurative tuberculous arthritis begins acutely with high fever. This form of the disease develops most frequently in the knee joint. The prodromata of tuberculous arthritis are weakness and a prone- ness to fatigue of the extremity involved. If there is an osteal focus the patient will have noticed for a long time a radiating pain, which finally locates in the joint when the arthritis develops. Frequently ex- ertion or slight trauma, such as movements of or bearing weight upon the joint, or pressure upon the head of the femur if the hip is involved, produces an exacerbation of the disease accompanied by some fever and severe pain. The first objective symptoms are a moderate amount of swelling due to exudation into the joint, thickening of the capsule, cedema of the para-articular tissues, and fixation of the extremity in characteristic positions (coxitis, abduction and outward rotation, goni- tis, flexion, etc.). In the beginning the diseased joint is fixed to prevent pain, which follows every movement. The patient attempts to hold the diseased joint in the position which is the least painful (Konig). This is espe- cially pronounced in the lower extremity, when the patient continues to walk after the disease has developed. The position assumed is that in which the capacity of the joint is greatest (Bonnet's experiments upon cadavers), and is partly the result of reflex muscular contraction. In the beginning of the diseases the abnormal position may be easily corrected under ansesthesia. Konig distinguishes the following forms of tuberculous arthritis: tuberculous hydrops, granulating tuberculous arthritis (fungus articuli, tumor albus), suppurative tuberculous arthritis. 1. Tuberculous Hydrops. — This form of the disease is seen most frequently in adults. It develops in the knee joint, but also in the ankle and elbow joints. The symptoms usually develop gradually and there TUBERCULOSIS 435 is no particular reaction, althouyli at times the onset is acute. The joint becomes filled with a serous exudate, the capsule becomes dis- tended, and tiuctuation may be elicited. As a rule, there are no other distinct evidences of tuberculosis {vide Fig. 181). The movements of the joint ai-e resti'icted as the articular structures are distended and painful. Contractures i-arely develop. Flakes of fibrin in the tluid removed by aspiration often indicate the tuberculous na- ture of the process. A definite diagnosis can be made, if there are no other symptoms of tuberculosis, only by a mi- croscopical demonstration of the bacilli or the positive re- sults following inoculation of aninuils with the fiuid. It is often difficult to differentiate between this form of arthritis and the arthritis due to trauma, floating bodies, syphilis, chronic gonor- rhea, and that accompanying supi)urative osteomyelitis. The exudate may gradually disappear and spontaneous healing may occur. Recurrences are frequent. Very often the serous exudate is merely the first stage in the development of a fungous tuberculous arthritis, the exudate gradually disappearing and fungous masses de- veloping. The diagnosis is not so difficult when there are large amounts of fibrin in the exudate (hydrops fibrinosus), for then peculiar grat- ing sensations may be elicited when the soft swellings in the capsule, which fluctuate but little, are palpated. These grating sensations are caused by the displacement of fibrinous masses, villi and rice bodies upon each other. Similar deposits and villous growths may be present in other diseases of joints (hiemophiliac joints, chronic rheumatism, arthritis deformans), and for this reason the tuberculous nature of the process may long be concealed. 2. The granulating form of tuhercnlous artlirifis (fungus) is the most frequent. Joints which are superficial gradually a-ssume a char- acteristic shape, when the granulation tissue develops in the joint and the para-synovial tissues become swollen. Such joints become spindle- FiG. ISl — Tuberculous Hydrops of the Right Knee. 436 WOUND INFECTIONS OF DIFFERENT ORIGINS shaped, as their outlines are destroyed by the distention of the capsule and the swelling of the para-articular tissues. This becomes more pro- nounced as the disease progresses, for the muscles above and below the swelling become atrophic (Figs. 182-184). The soft masses of granulation tissue often impart to the palpating finger the sensation of pseudo-fluctuation. Often the swelling is hard Fig. 182. — Tuberculosis of the Left Knee (Granulating Form, Fungus). and resistant, as the para-synovial tissues have been transformed into cicatricial tissue and the skin adherent to the indurated tissues is tense, shining, and anaemic (tumor albus). If the granulation tissue tends to cicatrize, complete healing may occur, but the joint will be anchy- losed, and, if not properly treated, in malposition. The contractures developing when proper treatment is not instituted are due to the short- ening of the muscles, which are no longer used, and to cicatricial eon- traction of the capsule and of the surrounding tissues. If the granula- TUBERCULOSIS 437 lion tissue ojiscates and suppiirak-s, absccssos and fistula' develop and there is an evening rise of teini)ei'ature. The greater the destruetion of the joint the more marked the con- ti-actures, as the ai'tieular ends of the bones, after having been destroyed, become displaced. For example, dislocation of the hip follows destruction of the head of the fenuir or of the upper and posterior part of the acetabulum (Fig. 171), genu, valgum and varum destruction of the bones Fig. 1S3. — Tubkrculosis of the Elbow Joint (Granulating Form with Abscess Formation). forming the knee joint. Pathological dislocations and subluxations may follow the distention and weakening of the ligaments by the granula- tion tissue and exudate as well as the destruction of the bones. Volk- mann has called the former distention-, the latter destruction-dislocations. They may de- velop gradually or after some insignificant injury. Diagnosis. — A beginning fungous tubercu- losis of a joint may be most easily confused with an osteal sarcoma (periosteal as well as myeloid) which develops into a joint. Some- times it is necessary to watch the case for some time before a diagnosis can be made ; often, Roentgen-ray pictures and exploratory incision are necessary. Arthritis occur- ring in haemophilia and associ- ated with periosteal gumma re- sembles clinically this fungous form of tuberculous arthritis. 3. Suppurative tuborulous arthritis (cold abscess of joints) f,o.Ts4.— Tuberculosis of the Ankle Joint is nuich rarer than the preceding (Granulating Form with Fistul.e). 29 438 WOUND INFECTIONS OF DIFFERENT ORIGINS form. It is usually secondary to a primary synovial tuberculosis, pursues a chronic course, and is accompanied by an exudate into the joint. Severe pain and fever are absent, and, as a rule, a diagnosis Fig. 185. — Healed Tuberculosis of the Knee Joint. Bony anchylosis with backward displacement of the tibia. of hydrops is made, especially if the knee joint is involved. Con- tractures frequently do not develop. If the disease is accompanied by fever, and if abscesses develop in the soft tissues, the diagnosis is no longer difficult. Prognosis. — The prognosis of tuberculous arthritis depends upon the general condition of the patient and upon whether or not there are foci in other organs. A majority of these cases die of tuberculosis of one of the viscera, of exhaustion, or amyloid degeneration. In other cases patients die of an acute general miliary tuberculosis or of a general infection following a suppurative or putrefactive inflammation which extends along fistulae to the diseased joint. The prognosis is better in the cicatrizing than in the suppurating forms of tuberculous arthritis. In Bruns's statistics 77 per cent of the non-suppurating forms of tuberculous coxitis healed, 23 per cent ended fatally, while in the suppurating form only 42 per cent recovered and 52 per cent ended fatally. There is also some difference as regards prognosis depending upon the age of the patient, it being considerably more favorable before than after the fifteenth year. Only in rare eases is the function of the joint completely restored. This occurs most frequently in tuberculous hy- drops. Some limitation of motion is the rule; complete anchylosis is frequent. Recovery, even with function, is frequently only apparent, for tuber- culous tissue, from which recurrences may develop, remains encap- sulated. Treatment. — Many forms of tuberculous arthritis tend to heal spon- taneously, and therefore the first treatment which is instituted should be conservative. If conservative treatment is unsuccessful, an opera- tion (which is usually required only in severe cases or in those cases TUBERCULOSIS 439 in which the general condition of the patient is poor) is indicated. In the conservative treatment an attempt should be made to promote the healing of the tuberculous process with preservation of the structures entering into the joint, if possible, with motion. If this is impossible, an attempt should be made to promote healing with the parts in the most useful position. A correctly applied plaster-of-Paris bandage is extremely valuable in tlie treatment of tuberculous arthritis. It places the joint at ab- solute rest, protects it from injury, and hastens by even and mild compivssion the absorption of the exudate. If contractures are pres- ent they should gradually be corrected by extension with weight and pulley. Rest in bed is absolutely indispensable if the joints of the lower extremity are involved, as any movement or pressure injures the dis- eased joint. It should be maintained as long as the joint is painful to pressure or when weight is borne upon it and there is an elevation of temperature. The plaster-of-Paris bandages should be applied after the contracture has been overcome by extension with w-eight and pulley. This bandage should be changed after six or eight weeks, at which time the skin should be washed and a powder or salve applied in order to prevent eczema. If there are fistulse, fenestra should be cut in the cast in order that the dressings may be changed frequently. If the painful stage has passed (frequently it requires months) and the swelling has subsided, the proper dressing or apparatus may be applied and the patient allowed to get up. The dressing or apparatus used should be so applied that the joint is kept at absolute rest, is in the proper position, and bears no weight. [A proper apparatus may be procured from different instrument makers. A special surgery should be consulted for the different apparatus used in the treatment of tuber- culosis of the various joints.] A simple plaster-of-Paris dressing which includes the entire extremity and pelvis is very satisfactory in the treat- ment of lesions of the lower extn^mity. The bandage should fit the pelvis, especially the ischial tuberosities, w-ell, as the entire weight will be transmitted to them. Later, Avhen the joint is able to bear some weight, a light dressing made of plaster-of-Paris, w^ater-glass, leather, or felt, which can be removed at night, should be worn to prevent contractures. These may be discarded when there is no longer any tendency to the development of contractures. The contractures due to reflex nmscular contraction and cicatricial contraction of the capsule, which are almost always present when the patients present themselves for treatment, may be overcome in a few days by extension with weight and pulley. If ambulatory treatment 440 WOUND INFECTIONS OF DIFFERENT ORIGINS is indispensable and a plaster-of-Paris cast must be applied, the con- tracture may be gently corrected under anaesthesia. If the contracture is due to the cicatricial contraction of the para-articular tissues and shortening of the muscles, gradual extension with the weight and pulley is the best procedure, as forcible correction {brisemeni force) may rup- ture encapsulated foci and cause a local exacerbation or a general mil- iary tuberculosis. If it is absolutely necessary that ambulatory treat- ment be instituted, the correction should be made at a number of different sittings, the correction obtained at each sitting being main- tained by the application of a well-fitting plaster-of-Paris dressing. Frequently an operation (resection of the joint, osteotomy) is re- quired to correct the deformities resulting from fibrous and bony anchylosis. The intra-articular medicinal treatment, introduced by Hiiter, Bill- roth, and von Bruns, is of great value in the conservative treatment of these cases. Of the many agents which have been tried, ten per cent iodoform-glycerin emulsion, employed first by von Bruns and others, is the most useful. (For details concerning iodoform-glycerin emulsion, vide p. 427). Injection of lodoform-Glycerin Emulsion. — After the removal of the exudate 10 to 20 c.c. of the emulsion, in children 5 to 10 c.c, should be injected into the large joints. The joint should be gently rubbed or kneaded after the injection in order to distribute the emulsion. In fungous tuberculosis small amounts should be injected at a number of different points, the injections being repeated after intervals of from two to four weeks, and the exudate which has reformed being removed if necessary. Between injections the joint should be immobilized in a plaster-of-Paris cast as described above. Of course the asepsis must be as nearly perfect as possible when these injections are made. Para-articular abscesses and fistulas should also be treated by in- jections {vide Tuberculosis of Bone). A two to three per cent solution of carbolic acid may be used in patients who are very susceptible to iodoform. The conservative treatment (immobilization), which is frequently combined with injections of iodoform-glycerin emulsion, is indicated in every recent case of tuberculous arthritis and should be tried for some time in old cases. If the local or general condition 'does not improve, if the tuberculous process is extending, if there is a large primary osteal focus or severe secondary involvement of cartilage and bone, operative treatment should no longer be delayed. Conservative treatment is not suited for the cases in which there is a tuberculosis of some of the viscera (lung or kidney), in which the general condition is not good (old people), and in which the fistula TUBERCULOSIS 441 coiiimunicntiiin- with tlio joints luivc Ixm-ouk" infected willi pNouciiie or putrei'active baeteria. Usually, conservative treatment must l)e eonliiiued for a number of years, as recurrences are frequent and the process of repair is prolonged. Aceordin*;- to Konig', the results of conservative treatment are more favorable in those cases developing before the fifteenth year than later. His statistics concerning the results of the conservative treatment of tuberculosis of the knee joint are as follows: Before the fifteenth year, 52 ])ei- cent recover; after it, 22 per cent. Ilenle believes that 79.3 per cent of the eases of tul)ercnlosis of the large joints recover before the fifteenth year; 62.5 per cent after it. Bier has observed that patients with passive congestion of the kings (e. g., in heart lesions) ac(inire a certain immunity against tubercu- losis, and has advised and used extensively passive hyperannia in the treatment of tuberculosis of bones and joints. Helferich had formerly employed passive hypera'mia in the treatment of delayed union follow^- ing fractures, and it had been employed earlier by Dumreicher in the treatment of old ununited fractures. In producing the hyperiemia an elastic constrictor should be applied above the diseased joint. It should exert just enough pressure to induce a warm passive hyper- a'mia. If the extremity becomes blue and cold, the constrictor should be loosened er removed and reapplied. Surgeons differ as to the value of passive hypera-mia in the treatment of tuberculosis of bones and joints. Operative treatment is indicated in those cases in which there is tuberculosis of some of the viscera (lung and kidney), in those in w^hich there is extensive bone involvement, and in those cases which do not improve under conservative treatment. The operation should be per- formed under artificial ischa^mia, and incisions should be employed which give the best view of the parts involved. All diseased or appar- ently diseased tissue should be removed with knife, scissors, and sharp spoon. When the diseased synovial membrane is entirely removed, the bone should be examined and any foci which are found should be re- moved. Para-articular abscesses and foci of granulation tissue should be opened; their walls should be excised or removed with a sharp spoon. In simple eases this partial arthrectomy is sufficient. If the articular cartilages and the epiphyses are d&stroyed, a typical resection must be performed. In young subjects the epiphyseal cartilage should be preserved in order to prevent later shortening of the bone. The wound should not be completely closed ; any recesses should be tamponed or drained. Healing, with fibrous anchylosis with some move- ment or comi)lete bony anchylosis, occurs in about two months. A light splint, a plaster-of-Paris or starch dressing, w^hich may be easily re- 442 WOUND INFECTIONS OF DIFFERENT ORIGINS moved, should be worn during the after-treatment to prevent the con- tractures which are apt to develop. In some cases amputation is better than resection. Amputation is especially indicated in old people, in patients with tuberculosis of the viscera, in extensive involvement of bone, and in those cases in which there is secondary infection with pyogenic bacteria. According to Poncet, there is an articular rheumatism which is of tuberculous origin. It develops in tuberculous subjects and presents different clinical pictures, occurring in acute, chronic, and anchylosing forms. It is probably due to the toxins of tubercle bacilli or to attenu- ated forms of the same (Mohr). Lexer once saw an acute form of this arthritis follow an extirpation of tuberculous lymph nodes, a general miliary tuberculosis developing soon afterwards. (h) TUBERCULOSIS OF TENDON-SHEATHS AND BURS^ The clinical course of this form of tuberculosis is as protean as that of tuberculous arthritis. In spite of the many transitions four prin- cipal forms may be differentiated: 1. Serous tuberculous hydrops, tuberculous hygroma: Synovial membrane covered with tuberculous granulation tissues. Pure serous exudate. 2. Serofibrinous tuberculous hydrops, rice-body hygroma: Synovial membrane covered with tuberculous granulation tissue, or with villous, fibrinoid growths, little serous exudate, few or many corpora oryzoidea (cf. Joints). 3. Granulating form with cicatrization, fungus : The connective tis- sue of the sheath is transformed into tuberculous granulation tissue varying from 1 to 2 cm. in thickness. There is little or no exudate; occasionally nodular masses of granulation tissue develop, which may become as large as a pigeon's egg. 4. Granulating form with suppuration, cold abscess : "Walls of sheath covered with caseated granulation tissue. Pus and granulation tissue, which may rupture externally, are present in the sheath. All these different forms may be primary or secondary to some neighboring focus in bone or joint. They may develop in one or many sheaths and may also occur symmetrically. Tuberculous tendo-vaginitis is most frequent in the upper extremities, the large synovial sheaths of the flexor tendons at the level of the wrist joint and of the extensor communis digitorum on the dorsum of the hand being most frequently involved. In the foot the disease attacks most frequently the sheaths of the extensor and peroneal muscles. Primary tuberculous bursitis may develop in any bursa. It is much rarer than secondary tubercu- lous bursitis. TUBERCULOSIS 443 Clinical Course. — The clinical course is, as a rule, chronic. The first synii)t()nis are radiating pain, limitation of motion, -weakness of the jnirt involvetl, and the development of a lon^r, flat swell- ing alonir the tendon. The connection with the tendon is indicated when movements are made. In the fore- arm and palm an honr-glass swellin<; is often produced by the constriction of the annular lij,'ament, beneath ■which the Ihiitl passes readily from one swelling to tlie other. Diagnosis. — The diagnosis of secondary tubt'rculous tendo-vaiiinitis, when there are evidences of tuberculosis of a neighboring bone or joint, is not difficult. It may be diffi- cult, however, to make a diagnosis in the jirimary forms. The rice-body hygroma may be recognized by the grating of the fluctuat- ing contents of the swelling, and the more rare suppurating form, if fistula' are present or abscesses are about to rupture, can scarcely be confused with any other lesion. On the other hand, it is difficult to distinguish the pure tuberculous hydrops from that due to other lesions (trauma, chronic irritation, rheu- matism, gonorrhea, syphilis). INIistakes may easily be made if there are no other evidences of tuberculosis. [Frequently a microscopic examination of the contents and animal in- oculation nuist be made before a definite diagnosis is possible.] In the granulating, non-suppurating form of tuberculous tendo-vaginitis, a pseudo-fluctuating or firm, resistant swelling develops along the course of the tendon-sheath. The rare lipoma arborescens has much the same clinical appearance. Firm nodules in the walls of the tendon-sheaths may be mistaken for tumors. It is often difficult to ditt'erentiate tuber- culosis of deep-lying bursw in which there are masses of granulation tissue from a tumor. Treatment. — The following fundamental principles should be fol- lowed in the treatment of these forms of tuberculosis. In the serous form, with but little thickening of the synovial sheath, the exudate should be removed by aspiration and iodoform-glycerin emulsion should then be injected; the other forms should be operated upon. A long incision should be made corrasponding to the long axis of the swelling, the synovial sheath incised, and the fluid contents allowed to escape. The parietal and visceral layers of the synovial sheath, with Fig. 186. — Tvberculosis of THE TeXDON-SHEATH OF THE Flexor Tendons of the Index Finger (Granulat- ing, Cicatrizing Form). Granulation tissue raises the flexor tendons some distance from the bone. 444 WOUND INFECTIONS OF DIFFERENT ORIGINS the suppuratiug fibrous tissue and the superficial layers of the dis- eased tendon should then be removed. After the sutures have been inserted and tied, from 5 to 10 c.c. of iodoform-glj^cerin emulsion should be injected between the sutures. Active and passive motion and mas- sage should be begun as early as ten days after the operation (provid- ing the tendons are not extensively involved and fibrillated), as a good functional result is obtained earlier in this way. (i) TUBERCULOSIS OF SEROUS CAVITIES AND DIFFERENT VISCERA These forms of tuberculosis will be but briefly mentioned and merely from the viewpoint of surgical treatment. Tuberculous pleurisy most frequently demands surgical interference because of the pressure Avhich the exudate exerts upon the lung. The operations usually performed are puncture wdth aspiration, incision through an intercostal space, or resection of a rib with drainage. Tuberculosis of the pleura is rarely primary, being, as a rule, secondary to tuberculosis of the lungs, ver- tebree, or ribs, or developing in the course of a general miliary tuber- culosis. Attempts have been made to cure tuberculous peritonitis, which, in children especially, is secondary to tuberculosis of the mesenteric and retroperitoneal lymph nodes, of the intestines, or of the abdominal vis- cera, or which results from infection through the blood stream occurring after operative procedures. The favorable results following laparotomy in many cases is due to the passive hyperajmia which is induced, and to the removal of the exudate. Tuberculosis of the kidney, the urogenital apparatus, the breast, the thyroid gland, and large, solitary cavities in the lung, if favorably situ- ated, may be cured by operative procedures. GENERAL TREATMENT IN LOCAL TUBERCULOSIS The general treatment, improvement of nutrition, should never be neglected in the surgical treatment of local tuberculosis. The general condition of the patient improves most rapidly when good, nutritious, and easily digestible food is supplied. The patient should seek a favorable climate as soon as possible. Those climates are most suitable which permit of an out-of-door life and an abundance of good, fresh air. The patient should not return home and assume family relations again, as other members of the family may be suffer- ing with the same disease, or the quarters may be cramped and the hygiene poor. The children of poor people and poor patients should go to sanitaria or state institutions which are devoted to the treatment of this disease. Mountain and sea air or residence in the South are to TUiilORCHLOSlS 445 be I'spccially rceoiiiiiiciulcd. Sun baths also have a favorable influence upon the ji'eneral condition. Tlicfe ai'c no specific remedies for tuberculosis, Tuberciilin, of Mliich so nnu'h was expi'cted at one time, has no therapeutic value. Of the many (lruj;s which have been reconnnended, the creosote i)repara- tioiis are still preferred. | Although tuberculin has of late years fallen into disrepute as a therapeutic at;ent, attention has again been attracted to it by the work of Wright and his colleagues. Minute doses of tuber- culin seem to have a favorable effect upon some cases of tuberculosis, and may be tried to advantage, O.OOl mg. being injected once a week, 'riie work which has been done of late seems to indicate that it is not necessary to take the opsonic index in these cases, the tuberculin being injected once a wtvk and controlled by the condition of the patient.] ACUTE GENERAL MILIARY TUBERCULOSIS Tubercle bacilli may invade the blood stream in large enough num- bers to produce an eruption of miliary tubercles in a number of the viscera and in the different tissues of the body. This form of tuber- culosis, which proves fatal in a short time, is of no surgical significance. The larger viscera, the bones, joints, and the serous cavities are most fre;inniniiiokc.) Fig. 203.- -CONGENITAL SYPHILITIC DAC- TYLITIS. 474 WOUND INFECTIONS OF DIFFERENT ORIGINS 'm m W^x m pansion occurs as in tuberculosis. This form of the disease, called syphilitic dactylitis by Liicke, may be primary or secondary to gum- matous inflammation of the surrounding soft tis- sues. Ulcers and fistulas may result from regres- sive changes in the gummata, and entire necrotic I)halanges may be extruded or absorbed without accompanying suppuration. These changes occur in both acquired and congenital syphilis. In the latter the lesions are frequently multiple and do not rupture externally (Hochsinger). Syphilitic caries of the vertebra is rare. If this develops in the upper part of the spinal col- umn, sudden and dangerous falling together of the bodies of the vertebrae may occur. The spongy articular ends of the diaphysis are but rarely involved. They may become ex- panded, when diseased, to resemble a tumor. The ligaments and cartilages are destroyed when the process ruptures into the .joint cavity. It is sometimes difficult to differentiate this lesion from a central sarcoma or a chronic suppurative osteo- myelitis. The diaphyses of long, hollow bones become diseased more frequently than the articular ends, the bones of the leg and forearm being most commonly attacked. The central gumma pro- duces a slowly developing fusiform expansion of the bone. The bone is infiltrated by the granu- lation tissue of the gumma and becomes porous, and its resistance is so reduced that pathological fractures may occur, notwithstanding the fact that the bone surrounding such a lesion be- comes thickened and sclerotic (von Volkmann, Fig. 204). Diffuse Syphilitic Periostitis and Gummatous Osteomyelitis. — Besides the localized gummatous periostitis and osteomyelitis there is also a diffuse ^ .^ form. This form of the disease, usually running A (loughv, fusifonn ex- . . '' pansion of the bone could its course v/ith suppuration, may cause exten- be palpated. The skin giyg destruction of the bones of the skull ; in the covenng the diseased . bone was perfectly nor- long boncs, especially in thosc of the forearm ^^^' , ifj*^'" ^?^Y' and leg, it may produce large hyperostoses. The manns Diseases of the . <-^ ^ t- Orgaiisof Locomotion.") bonc uivolvcd may gradually become thickened, f' 'H. Fig. 204. — Pathological, Fracture of the Shaft OF thf: Radius. Speci- men removed from aman fifty-six yearsof age, who had suffered from syph- ilis for sixteen years. Fracture occurred while the patient was support- ing himself upon tliearm while turningoverinVjed SYPHILIS 475 sclerotic, and lieavier than normal, or as a result of the osteoporosis more fragile and lighter. If the gummatous inflammation occurs in early childhood (the dis- ease being acquired early or being congenital) a characteristic deform- FiG. 205. — Syphilitic Osteitis Deformans (Thirty Year Old Male Patient) with ROEXTGEN-R.\Y PICTURE. ity develops in the bones of one or both legs. This form of syphilis of bones was first described by Fournier as osteitis deformans syphi- litica. The tibia becomes lengthened, curved forward, and thickened, and a prominence develops upon the anterior surface which becomes more prominent than the calf of the leg. The " saber-sheath " de- formity of the tibia is due to a thickening and leng-thening of the bone 476 WOUND INFECTIONS OF DIFFERENT ORIGINS as a result of the inflammation. The curving of the tibia forward is not to be regarded as static and compensatory (Schuchardt), but is due to the lack of corresponding increase in the length of the fibula and to the traction exerted by the muscles attached to the latter (Weiting). A similar deformity may occur in ricljets, but in this disease the epiphysis will be involved and rachitic changes will be present in other bones (Fig. 205). Osteochondritis Syphilitica. — In congenital syphilis characteristic lesions, called by Wegner syphilitic osteochondritis, are frequently found in the epiphyses. The epiphyses of the newborn become enlarged, the enlargements being painless. Sometimes the epiphyses become sepa- rated, and as a result the diseased limb may appear to be paralyzed (pseudo-paralysis). The process may also extend to the neighboring joint. The pathological changes are most marked in the epiphyses, but not infrequently they extend to the shaft of the bone, differing in this way from rickets. The calcified cartilage nearest the diaphyses becomes friable and opaque and the epiphyseal line becomes widened, irregular, and wavy. The adjacent medullary cavity contains a grayish yellow, translucent, granulation tissue which has undergone fatty degeneration. Separation of the epiphysis may follow the development of this tissue. Gummata may at the same time develop in the medulla and in the inner layer of the periosteum. The interference with endochondral bone formation may be indicated by shortening or lengthening of the bone. Syphilitic Osteopsathyreosis. — Fragility of the bones (osteopsathyreo- sis) occurs in the old, severe cases of syphilis, as in other chronic infec- tious diseases. It is a result of the cachexia. According to Charpy, there is usually in these cases a considerable reduction of the calcium fluorid in the bones. Diagnosis of Syphilis of the Bone. — The diagnosis of syphilitic dis- ease of bone is not difficult when the disease is well advanced and the lesions develop in bones which are frequently affected. On the other hand, the diagnosis may be very difficult when there are no other symp- toms of the disease. Deep-lying, gouty tophi, or tuberculous abscesses attached to the bones of the skull, forearm, hands, and leg resemble very closely periosteal gummata, provided these have not ruptured. When syphilis produces an enlargement and expansion of a section of a bone, a diagnosis of chronic suppurative or tuberculous osteomyelitis, or of a central or periosteal sarcoma may be made. Multiple hyperos- toses also develop in the sclerotizing form of suppurative osteomye- litis. In Paget's disease {osteitis deformans) the bones become ex- panded and deformed. In doubtful cases in which the clinical course SYPHILIS 477 ^'ives no t-lue to the nature of tlie (lis('as(\ anti-syphilitic treatment slionkl be instituted. Koentgen-ray pictures reveal nothinjj: charac- teristic. Treatment. — Besides the general treatment which is etl'ective in the early stages of the disease, surgical measures are often required. Pain- ful and ulcerated foci should be exposed, if necessary, with a chisel, and if possible the gmnmatous masses should be removed with a sharp spoon ; sequestra should be extracted. GummatoiLS abscesses, if small, should be aspirated; if large, they should be incised, curetted, and treated by the open method. Defects in the skull following removal of sequestra may be closed most quickly by an osteoplastic operation. Extensive defects may be reduced much in size by the gradual regeneration of bone (Ilofmeister), (f) SYPHILIS OF THE JOINTS In the course of syphilis, one or many joints may become inflamed and the arthritis may pursue different clinical courses. The knee and elbow joints are most frequently involved. In acquired syphilis a painful arthritis with serous exudate, re- sembling acute articular rheumatism, may develop during the eruptive stage, likewise during the relapses. This may subside after some weeks if the extremities are immobilized and general treatment is instituted. The restoration of function may be complete. Syphilitic Hydrops. — A chronic, resistant hydrops, rarely ending in suppuration, may develop late in syphilis. It follows the development of gummata in the synovial membrane and the articular cartilages. The knee is most commonly attacked, and disease is often symmetrical in its distribution. There is but little interference with motion and but slight pain. The diseased synovial membrane becomes thickened and covered with villous, even tumorlike, masses. The articular cartilage becomes eroded, the pathological changes being more marked in the center than at the edges, and small but deep cicatricial defects form which often radiate, like other syphilitic scars (chondritis syphilitica, A^irehow). The diagnosis is frequently difficult, especially when there are no characteristic .symptoms or signs of syphilis. The involvement of many joints and the relatively little disturbance of function should suggest syphilis. The treatment, in addition to the general treatment, consists of removal of the exudate and the application of a compression dress- ing. Frequently, after a long time, the healing is complete. Not infre- quently the capsule is thickened and the articular cartilages are partly destroved. If this is the case, there will be some limitation of motion 478 WOUND INFECTIONS OF DIFFERENT ORIGINS even when healing is complete. A grating sensation, elicited when the bones entering into the formation of the joints are moved, is indicative of the destruction of the articular cartilages. Palpable, tumorlike growths in the capsule have been successfully extirpated (Borchard). Arthritis Following Rupture of an Intraosteal or Periosteal Gumma. — The arthritis which is secondary to the rupture of an intraosteal or periosteal focus into the joint cavity pursues the severest clinical course. All of the ligaments and the articular cartilages may be destroyed. Flail joints or anchylosis with contractures develop most frequentlj^ in the fingers and toes, the soft tissues, bones and joints of which may all be involved (dactylitis syphilitica). Acute Gummatous Arthritis. — Schuchardt has shown that there is also an acute gummatous arthritis. Operations have been performed upon cases in which a diagnosis of gonorrheal arthritis had been made, and miliary gummata have been demonstrated in the tissues removed from the thickened capsule. In children with congenital syphilis, not infrequently an exudate accompanied by but few symptoms develops rapidly in a number of joints (most frequently in the knee and elbow). This form of arthritis is secondary to a syphilitic osteochondritis or to a gummatous inflamma- tion of the epiphysis and synovial membrane. Suppuration in this form of arthritis is rare. The diagnosis is difficult, unless there are other lesions of syphilis, such as an interstitial keratitis. Under general treat- ment the arthritis subsides without any limitation of motion. Operative interference is indicated only when fistulas persist or the joint suppu- rates. (g) SYPHILIS OF THE TENDON-SHEATHS AND BURS.^ An acute exudative inflammation of tendon-sheaths and bursfe may develop during the eruptive stage of syphilis. It is comparable to the serous arthritis occurring during this period, and like it usually sub- sides rapidly. Frequently gummata develop in bursa, especially in those about the knee joint. They develop slowly and without pain, and may rupture through the skin or through the capsule of the joint. A gumma in the skin or bone may extend to a bursa, the latter becom- ing secondarily involved. Syphilis of the tendon-sheaths is most fre- quently secondary to syphilis of bone — for example, in syphilitic dactylitis. The diagnosis of the acute exudative tendo-vaginitis and bursitis occurring in the eruptive stage is not difficult. The diagnosis of the gummatous form is difficult, especially if the lesion has not perforated the skin, if there are no ulcers or other lesions characteristic of the disease. SYPHILIS 479 The trcntiiioiit consists of exposure and removal of the h., Bd. 79, 190Q, j). 387. — A. Xcisser. Versuche zur Uebertragung tier SJ^3hilis auf Affen. Deutsche med. Wochenschr., 1906, p. 493. — Pielicke. Die syph. Gelenkerkrankungen. Berl. klin. Wochenschr., 1898, p. 78. — Schaudinn und E. Hoffmann. Vorlaufiger Bericht iiber das Vorkommen von Spirochaeten in syphil. Krankheitsprodukten und bei Papillomen. Arbeiten aus dem kais. Gesundheitsamte, Bd. 22, 1905, p. 2; — Ueber Spir. pall, bei Syjih. und die Untcrschiede, etc. Berliner klin. Wochenschr., 1905, p. 673. — Schuchardt. Die Krankheiten der Knochen und Gelenke. Stuttgart, 1899. — Virchow. Die krankhaften Geschwiilste, Bd. 2, p. 392. — Wieting. Zur Sabelscheidenform der Labia. Beitr. z. klin. Chir., Bd. 30, 1901, p. 615. — Handbuch der prakt. Chirurgie von v. Bergmann, V. Bruns und v. Mikulicz, I. Bd., v. Bergmann, p. 137. Literature Concerning the Spiroch.eta Pallida. — Tomnsczewski. Ueber den Nachweis der Spirochaete pallida bei tertiarer Syphilis. Miinchener med. Wochenschr., 3 Juli, 1906, p. 1301. Nachweis von Spirochaeten in offenen und geschlossenen Gum- mata. — Simmonds. Ueber den diagnostischen Wert des Spirochaetennachweises bei Lues congenita. Ibid., p. 1302. Wo Syphilis congenita nicht vorliegt, sind (nach Untersuchungen von 26 Fallen) Spirochaeten in den Organen von Siiuglingen und Foten selbst bei vorgeschrittener Mazeration nicht anzutreffen. Dagegen fanden sie sich bei vier mazerierten Foten sj^ihilitischer Herkunft in der Haut, in Muskeln und Knochen und in samtlichen Organen, ferner sehr reichlich im Mekonium. Bei der sjqjhilitischen Osteochondritis waren sie nur in der Ivnorpelknochengrenze und in dem benachbarten Perioste erkennbar. CHAPTER XIII RHINOSCLEROMA Rhinoscleroma, described fii-st by Hebra and Kaposi (1870), is a chronic, progressive disease wliich usually begins in the mucons mem- brane of the nose, less freqiientlj^ in that of the pharynx, larynx, or 482 WOUND INFECTIONS OF DIFFERENT ORIGINS palate, and then extends to neighboring parts — the nose, tear passages, trachea, and lips. The disease is rare in Germany, very common in Austria and Southwestern Russia; occasionally cases are seen in Central America and Italy. The disease develops most frequently in adults of the middle class. The inflammatory masses, which are infectious granulomata, re- semble those found in tuberculosis, syphilis, actinomycosis, leprosy, and glanders. They develop first in the naso-pharynx and choanae, and then extend either to the mucous membranes of the nose, lips, cheeks, and gums or to those of the upper respiratory passages. Primary as well as secondary foci may develop in the pharynx, trachea, and larynx. The disease develops slowly and pursues a very chronic course. The infiltration of the mucous membranes sometimes appears in the form of nodules ; at other times in the form of tumors or flat, thickened, firm areas of a cartilaginous consistency. The edges of these infiltrated areas may be sharply defined or may gradually fuse with the sur- rounding healthy tissue. The skin or mucous membrane covering such lesions is reddened, tense, and traversed by dilated veins. It is firmly attached to the inflammatory mass and may be dry, fissured, or ulcer- ated. Extensive destruction of the infiltrated areas does not occur; on the other hand, there is a tendency to cicatricial contraction. Car- ^tilage to which the pathological process extends becomes fibrillated or hyperplastic. Gradually the nasal passages become occluded. These masses devel- oping in the pharynx, larynx, and epiglottis may cause considerable interference with respiration and deglutition. When the skin of the nose is involved it becomes hard and bluish red in color, and the nose proper becomes broad and deformed, the al^e nasi become separated, and the hard inflammatory masses extend to the lips. All these changes, which eventually lead to cachexia or favor the development of some lesion in the lungs, develop within ten years. Rhinoscleroma may be confused with sarcoma, carcinoma, and syphi- lis. In doubtful cases a microscopic examination of a piece of tissue should be made. In the beginning of the disease the lesions should be extirpated. If necessary, the nose should be split, so that free access may be had to the lesion. As a rule the results following extirpation are not per- manent, as the disease tends to recur. If complete removal is im- possible, small pieces should be excised in order to reestablish the nasal passages. If the disease develops in the larynx, tracheotomy may be necessary. Microscopic examination of the lesions reveals a characteristic con- BOTRYOMYCOSIS 483 nective-tissne proliferation wliich is most rnarkod about the blood ves- sels. Tlie cells of the connective tissue underlete loss 32 490 NECROSIS of sensation a severe, aggravating pain which is referred to the nerves distal to the line of demarcation continues. Motor paralyses develop when the bellies of the muscles have degenerated. Usually the first symptoms of a dry or moist gangrene develop, when the principal vessels are involved, as early as the second day upon the fingers and toes. Unless a collateral circulation is established in a few days the process extends, involving the entire part below the point of occlusion. In favorable cases the gangrene remains limited to the tips of the fingers or toes or to isolated areas in the skin of the hand or foot, which Fig. 206. — Necrosis (Dry Gangrene) of the Arm following Rupture of a Diseased Axillary Artery while Attempting to Reduce an Old Dislocation of the Shoul- der. Patient was a woman sixty-nine years of age. Appearance of tlie arm four weeks after ligation of the artery. heal after the necrotic tissue is cast off. The death of the tissue is most rapid when infected. Not infrequently, phlegmonous inflamma- tion and lymphangitis develop as the result of infection of the granu- lation tissue of the demarcation zone. Symptoms of Gangrene of the Viscera. — The symptoms of necrosis of the viscera differ, alterations of, interference with or a complete cessation of their specific functions being the most pronounced. The testicle is superficial and presents quite definite symptoms when it be- comes necrotic. The scrotum becomes inflamed and oedematous and a seroha?morrhagic exudate is poured out into the tunica vaginalis. Treatment. — An attempt should be made in the treatment of necro- sis, the direct or indirect result of trauma, to prevent the introduction and development of putrefactive bacteria. The surrounding area should be cleansed and sterilized, and a dry, aseptic dressing should then be applied. Only in dry, superficial gangrene of the skin can a moist dressing be applied without danger. In these cases a moist dressing of acetate of aluminum, or boric acid, without rubber protective, has- tens the formation of granulation tissue and the separation of the necrotic tissue. Such a dressing should be changed daily or oftener. Necrotic viscera, such as the spleen, intestine, kidney, and testicle, NECROSIS THE RESULT OF PRESSURE 491 should be removed as soon as possible in order to prevent the inflam- mation of the membrane (peritoneum) and tissues (loose connective tissue of the scrotum) surrounding them. In gangrene of the extremities the operation should be postponed, unless there are indications for immediate interference, until the line of demarcation becomes well established and distinct. This prevents the unnecessary removal of tissue and the possil)ility of making the ampu- tation through tissues which will later become necrotic. If lymphan- gitis, phlegmonous inflammation, or fever accompanied by putrefac- tion develop, amputation should no longer be postponed. Frequently it is the only procedure which will prevent the development of a general putrefactive infection. In the after-treatment following ligation of the principal artery of the extremity, an attempt should be made to favor the development of a collateral circulation and to prevent necrosis. Bandages should be applied loosely, the extremity should be sup- ported upon soft cushions or pillows, hypera^mic areas in the skin should be punctured, and soft tissues infiltrated with large amounts of blood should be incised down to the vessel. If gangrene from venous stasis, the result of the ligation of a vein or of a vein and an artery, threatens, the extremity should be elevated or vertically suspended at once in order to favor the return tiow of the venous blood. CHAPTER II NECROSIS THE RESULT OF PRESSURE, CONSTRICTION, INVAGINATION, AND TORSION In this form of necrosis the circulation is interfered with or com- pletely stopped by compression of the vessels. Decubitus. — Pressure necrosis (decubitus) occurs most frequently in feeble, emaciated patients who are compelled to lie in a recumbent or any one particular position for a long time. It develops most fre- quently over bony prominences, such as the sacrum, the spines of the vertebrae, the spine of the scapula, and the os caleis. A similar form of necrosis which occurs most frequently upon the lateral margin of the foot, the base of the fifth metatarsal bone, over the heel, the malleoli, the tendo Achillis, the crest of the tibia, the patella, the trochanter major, the spines of the ilium and the chin may follow the use of imperfectly padded or improperly applied splints. INIore rarelv, skin surfaces which are in contact, such as the folds of 492 NECROSIS the groin, the scrotum, and the inner surface of the thigh, undergo pressure necrosis. The pain, which is present in the beginning, gradually subsides un- less maintained by inflammation. The blue and discolored area exposed to pressure becomes anaesthetic and dries to form a hard, black crust, which is gradually separated from the surrounding structures by granu- lation tissue. The ulcer which forms when the crust is removed resists treatment, for usually the general condition of the patient is poor and, besides, the ulcer is subjected to continuous pressure. Such ulcers developing over the sacrum frequently become infected, as they are contaminated by urine and fasces. A painful suppurative or putre- factive inflammation which undermines the skin then develops; the fascia becomes gangrenous and the surface of the bone is exposed. Erysipelas, phlegmons, and severe general infections, associated with metastases which develop from thrombi originating in the inflamed veins of the necrotic area, are frequently terminal events in these cases. The first indication in the treatment of pressure necrosis is to re- move the cause. This is much more easily accomplished when the pres- sure is produced by a tight bandage than when it follows long confine- ment in one position. An attempt should be made to prevent bedsores from developing by providing soft, smooth bed clothing, or by using water cushions or rubber rings. The tissues surrounding the area exposed to pressure should be rubbed daily with alcohol, dried, and dressed aseptic- ally. IMoist dressings macerate the skin, transfer infection, and favor the development of a pustular eczema. A dressing of ten per cent zinc- vaseline ointment lessens the burning sensation and favors the formation of granulation tissue and cicatrization. The prevention of pressure necrosis is one of the most important duties of a nurse. When a patient has been operated upon and his position cannot be easily changed, especial care should be paid to keeping the bed clothing and the nightgown smooth, and to supplying clean linen. Air or water cushions are appreciated very much by weak, emaciated patients. The beginner should learn to protect all bony prominences and pro- jecting tendons when applying a plaster-of-Paris dressing. Necrosis due to constriction may develop when one of the turns of a bandage is too tight or when an Esmarch constrictor, applied to pro- duce an artificial ischa^mia, is allowed to remain too long. Ischtemic necrosis may develop when a constrictor is allowed to remain in position for two and a half hours. It is easily understood how much greater the dangers of necrosis are when the constrictor is allowed to remain much longer. T*laster-of-Pai'is dressings may cause necrosis, especially when applied to an extremity the circulation of which is already inter- fered with by extravasations of blood or pathological changes in the NECROSIS THE RESULT OF INVAGINATION AND TORSION 493 vessel wall (artcrioselorosis). Ncer'osis is preceded, ns a rule, in those cases by marked passive liypera'iiiia, and the tissues are saartially or completely removed. Post-operative Haematomas. — A ha-niatoma may develop in an opera- tion-wound, following hemorrhage from some vessel which has not been ligated. The fluid blood then trickles from the spaces between the stitches and saturates the dressings; the clots separate the tissues form- ing cavities, and cause severe pain by exerting pressure upon them. If a ha^matoma develops in an operation-wound, the skin surrounding it should be sterilized, a few or all of the sutures removed, and the clots expressed by digital pressure applied to the edges of the wound. Dur- ing the manipulation the fingers should not come in contact with the wound. If the bleeding vessel is found, it should be ligated. The wound should then be tampont'd with iodoform gauze and no attempt should be made to suture it for several days. Carelessness in the con- trol of haemorrhage is frequently followed by the development of a ha?matoma. Severe inflammations frequently develop in such wounds, as infection nuiy be ea.sily introduced during the removal of the clot. In all operative work blood vessels should be grasped Avith artery forceps as soon as cut, for the walls of the smaller vessels collapse, and 34 522 THE MECHANICAL INJURIES thej^ are then found with more or less difficulty. These arteries are often opened again when the patient awakes and the blood pressure becomes higher. Careful ha?mostasis prevents the development of hematomas. Post-operative hsematomas develop quite frequently after infiltration ana?sthesia, as the cutaneous veins are closed by the pressure of the solution and are consequently overlooked. Subcutaneous Separation of the Skin. — The severest injuries of the subcutaneous tissues are those associated with a separation of the skin from the subjacent tissues. The skin may be torn loose from the sub- jacent fascia by force acting obliquely (in railroad and machine in- juries). Blood and lymph are then poured out beneath the loosened skin, elevating the latter to form a tense, fluctuating swelling. Lacera- tion of the muscles, blood vessels, and nerves, and injuries of the bone may occur at the same time. A large hajmatoma or an extravasation of lymph forms in these cases, and some of the characteristic signs — swelling, discoloration of the skin, fluctuation, and crepitation — are rarely absent. The characteristic physical findings associated with an extensive sub- cutaneous separation of the skin were first described by Morell-Lavallee under the term of decollement de la peau, and later by Koehler. The findings differ from those associated with the typical extravasations of blood described above. The swelling develops gradually, often several days intervening before it reaches its maximum size, while the swell- ing associated with a typical hematoma develops rapidly. The fluid poured out beneath the separated skin is usually serum, although at times there may be a small amount of blood. As the lacerated lym- phatic vessels are not closed by thrombi, the extravasation continues until the pressure of the exuded lymph equals the intravascular lym- phatic pressure. As the latter is low the swelling never presents the resistance associated with hgematomas, but imparts a flaccid, relaxed sensation. The shape of the swelling varies with changes in the posi- tion of the body, and a distinct wave of fluctuation can be elicited by tapping the swelling with the finger. The separation of the skin asso- ciated with an accumulation of lymph occurs most frequently upon the thigh; occasionally upon the trunk (Fiebiger). Besides this separation of the skin (superficial decollement), there also occurs a stripping of the muscles and periosteum from the bone (deep decollement). The treatment of subcutaneous separation of the skin begins with careful sterilization of the area involved and the aseptic dressing of all excoriations. A compression bandage, when properly applied, favors absorption. The skin, however, is deprived of a number of its nutrient arteries, and necrosis is apt to occur unless the dressing is applied evenly and changed often. The larger accumulations should be removed Mi:ciiANK'Ai. ixjiKiKrf OF Tiir: Dii'ri:Ri;.\T tissues 523 l)y aspiration before the dressing is applied. Aceumulations of lymph may be injected with alcohol or a five per cent solution of iodin before the dressing is applied. Incision is to be recommended only when ne- crosis or inflammation is beginning. Phlegmons find favoral^le condi- tions for development in these cases. Frequently they pursue a severe clinical course after contusions. A complete separation of the scalp from the subjacent tissues lias l)een reported {vide Altermatt). This accident occurs most frequently in people who work about machines, the hair being caught in the belts connecting the driving wheels. The entire scalp may be torn off and the resulting defect must then be skin-grafted. Separation of the skin covering the penis and scrotum has also been observed in accidents caused by machinery. Injuries of Mucous Membranes. — Injuries of the nuicous membranes are quite similar to those of the skin, except that wounds and excoria- tions of the former are not followed by such virulent infections as are those of the latter. However, a submucous ha?morrhage following a gunshot wound or a subcutaneous injury may, if the larjmx is involved, cause a laryngeal stenosis and threaten life. If the stomach or intestines are involved a fatal perforative peritonitis may develop, as a result of the nutritional disturbances, ending in necrosis and perforation, caused by the pressure of the blood clot. Traumatic Emphysema. — Traumatic emphysema presents a rather characteristic clinical picture. It develops after injuries of the air passages, when the expired air is forced into the meshes of the loose subcutaneous tissues and into the cellular tissues surrounding muscles, vessels, and viscera. The mild forms, in which the swelling is not so marked, are asso- ciated with injuries of the nose, frontal and maxillary sinuses, and mastoid process. It develops in injuries of the nose when the pa- tient attempts to remove blood clots by blowing. The severer cases follow perforation of the lung by a fractured rib, bayonet, or pro- jectile, injuries and inflammatory (tuberculous) perforation of the larynx and trachea, especially when the wound canal is narrow and oblique. An emphysema may develop after tracheotomy if the air escapes by too narrow an outlet. I have seen a slight subcutaneous emphysema develop after a laparotomy performed in the Trendelenburg position, the air in the abdominal cavity being forced by vomiting or coughing into the subcutaneous tissues on either side of the wound. Frequently emphysema develops after wounds of the soft tissues, the air having been forced into the tissues through a drain or during irrigation. An emphysema may develop in wounds produced by blank cartridges, the 524 THE MECHANICAL INJURIES shot being fired at very close range and the gases formed during the explosion being driven into the tissues (Hammer, Schaefer). A subcutaneous emphysema is characterized by development of a soft, elastic swelling with indistinct boundaries which has a tympanitic note, crackles when palpated, and is painless. This swelling may in- crease rapidly in size, especially when the patient is restless, and spread over large areas. In marked cases the emphysema may involve the entire skin, which then becomes inflated like a balloon and transformed into a tense, tympanitic, crackling mass. The localized forms of emphysema are the most common. In these cases the emphysema is limited to a small area, the swelling attains its greatest size in a few days and gradually subsides as the air is absorbed. The greatest danger associated with the most marked forms of emphysema is extension to the mediastinum. For example, a case has been observed in which the infiltrating air extended from a wound of the thorax over the entire trunk, neck, face, and extremities, finally beneath the pleurae, and from the loose connective tissues of the neck into the mediastinum. The latter was already affected as a result of an injury of the trachea and larynx before the subcutaneous emphysema developed. The respiratory and cardiac functions were interfered with and death followed, the symptoms being those of suffocation. Traumatic emphysema is readily differentiated from gas phlegmon, as in the former all the symptoms of local and general infection are wanting. The treatment consists of closing the wound from which the air is escaping, when possible, or of incising the tissue and permitting of the escape of air, thus preventing the infiltration of more tissue. The nose may be closed with tampons. "Wounds of the larynx and trachea should be found and closed by sutures. Penetrating wounds of the chest associated with pneumothorax should be tamponed, or, if this is not suc- cessful, the opening should be enlarged and the opening in the parietal pleura closed. If the latter is not successful or the air is discharged from a lung which is adherent to the chest wall, the wounds in the soft tissues should be dilated and a drainage tube, provided with a valve which permits of the escape of air during expiration (von Bramann), inserted (Konig). The same procedures should be followed in treating emphysema developing after injuries of the lungs caused by fractured ribs, when compression does not suffice to prevent the emphysema. It is often possible to prevent the spreading of an emphysema by making free incisions into the tissues primarily involved (Konig). Literature. — Altermatt. Ein Fall von totaler Skalpierung. Beitr. z. klin. Chir., Bd. 18, p. 7G5, 1897- — v. Bramann. Ueber dio Bekainpfiing des nach Lungenverletzung auftretenden allgemeinen Korperemphysems. Chir. Kongr.-Verhandl., 1893. Disk. MECHANICAL IXJURIES OF TFIE DIFFERENT TISSUES 525 K(iiiif^. — Curdua. Uebcr den lii'S()ri)tion.siiit'fhaiii.siiius von Hlutcrgiissen. Prt'i.s.schrift. Jicrlin, 1877. — Fiebiyer. Ein Fall von subkutaner tivtimatiseher LyniplKjrrhagie. Wicn. klin. Wochensc-hr., 18'J7, No. 17. — Gusucnbuuer. Die trauniatischen N'erletzungen. Deutsche Chir., ISSU. — Hammer. Traunuitisches Ilautemphyseni tlurch Pulvergase. Be.itr. z. klin. Chir., Bd. 25, 1899. — Jutl:ow.-' lai'uc vessels, and after severe in- juries death from luvMiorrliage is frequently prevented l)y this curling up of the intinui and media. When an artery is put upon a stretch, the intinui ruptures lirst, and then the media at a jxjint nearer the periphery. These two coats then roll up and occlude the lumen, the adventitia being pulled out to form a thin band of tissue, just like a heated glass eaiuda is drawn out to form a delicate capillary tube. If the artery is twisted at the same time that it is torn the closure is still more tirm. The dangers of open injuries to vessels are partly due to primary luemorrhage, partly to secondary haemorrhage and air embolism. Secondary Haemorrhage. — Secondary hannorrhage occurs quite fre- ([uently after tlie ])i-imary luemorrhage has subsided spontaneously. Sec- ondary luemorrhage occurs nu)st freiiuently when the knife or other foreign body which may have ch)sed the wound is withdi'awn, when the thrombus which nuiy have developed and closed the wound after an in- juiy produced l\v blunt force is destroyed by suppuration or is dislodged by movements, or finally when the arterial wall becomes necrotic as the result of pressure exerted by a displaced fragment of bone. Air Embolism. — The entrance of air into the injured internal jugular or subclavian vein during inspiration leads to the condition known as air embolism. In severe cases the patient dies innuediately or after a few hours; the symptoms being great unrest, a feeling of anxiety, marked dyspncea, cyanosis, weak, fluttering pulse, loss of consciousness, and convulsions. These symptoms are caused by interference with car- diac and respiratory functions, and by cerebral anaemia, for the aspi- rated air reaches the right heart and then passes into the pulmonary arteries interrupting the circulation. As a result of this occlusion of the pulmonary arteries the left heart does not receive enough blood to nuiintain the nutrition of the important centers in the brain and spiiuil cord. Other causes of death in air embolism, besides the sudden anaemia of the brain (Panum), are paralysis of the heart caused by dilatation of the right venti'iele following the accumulation of air, aiul interference with the i)ulmonai'y circulation (Senn). IMild cases of air embolism are observed after operations more often than after injuries. When air embolism occui's during an operation, but little air is, as a rule, permitted to enter the vein, as the condition is immediately recognized and the opening is closed by pressure. In these cases either no symptoms develop or, if they do, they are mild and transitory. Notwithstanding that the symptoms may be mild, an at- tempt should always be made to express the air, as it is impossible to estimate the amount wliich has been aspirated. The chest should be compressed during expiration, and during inspiration digital pressure 3G 554 THE MECHANICAL INJURIES should be made over the opening in the vein in order to prevent the aspiration of more air (Treves). It is well in these cases either not to wipe away the blood which may have accumulated over the wound or to tiood the field of operation with salt solution, preventing in this way the aspiration of air. When the danger of air embolism has passed, the vein should be seized with an artery forceps -without teeth and ligated or sutured. In severe cases aspiration of the right ventricle may be indicated. Diagnosis of Open Injuries. — The diagnosis of an open injury of a vessel is difficult only when the most important symptom — severe hrem- orrhage — is wanting. A non-penetrating wound may escape notice when the vessel is not freely exposed in the wound. It is not unusual for the primary ha:;morrhage to cease rapidly, and for a ha?matoma to fail to develop when the wound is made with a delicate fusiform instrument or by a projectile of small caliber. This is especially apt to happen if the vessel is covered by a thick resistant fascia or an aponeurosis (e. g., the femoral artery in Hunter's canal). In such cases the position of the wound offers the only clew to diagnosis, which is often later verified by the development of a bruit at the point of injury. When a large haematoma develops after a small wound of a vascu- lar region, it is not always possible to determine the nature of the injury to the vessel. If the pulse is wanting in the peripheral parts, the principal artery has probably been completely divided. If the pulse is present, but is weaker than on the uninjured side, and a systolic bruit which is transmitted toward the periphery is heard, one may conclude that the artery has received a lateral injury. If the bruit is transmitted both proximalward and distalward, one may conclude that a communis cation has been established betM''een an artery and a vein, following simultaneous injury of adjacent parts of the walls of the vessels (arteriovenous aneurysm) . Treatment. — The treatment consists of temporary and permanent control of the haemorrhage, precautions being taken against loss of blood and infection during the ligation or suturing of the injured vessels. If a diagnosis of an injury to an artery with or without simultaneous injury of a vein is made, the point of injury should be exposed, even if there is no external hasmorrhage, the blood clots removed, and the vessel ligated or sutured. The treatment becomes much more difficult if operation is delayed until an aneurysm has formed. A stab or gun- shot wound of a vessel may heal with the development of but a small hematoma. After ligation or suture of a large vessel an immobilizing dressing should be worn from two to three weeks. If the haemorrhage is severe the life of the patient often depends MECHANICAL INJIKUOS OF THE DIFFERExXT TISSUES 555 upon the prompt and proper temporary control of the luemorrhag'?. In the extremities it ean be easily controlled by making pressure upon the principal artery proximal to the point of injury, or by constricting the extremity above the wound by a handkerchief, strap, jiiece of rope, or suspenders. If the wound is so situated that a constrictor cannot be applied, the artery sliouUl be compressed pi-oximal to the point of injury. Venous hteniorrhage will be increased if the veins are constricted above the injury, but enough pressure is not exerted to completely close tlie artery. The femoral artery may be compressed against the pubic bone with the second and third fingers of the left hand, reinforced if need be by the right thumb. The subclavian artery in the supraclavicu- lar fossa may be compressed against the fir.st rib; the common carotid artery against the transverse processes of the cervical vertebrie. The entire fist may be used to compress the abdominal aorta against the lumbar vertebnw Hyperextension may be used instead of compression to control haem- orrhage from the femoral and subclavian arteries. The femoral artery may be stretched over and closed by the head of the femur if the thigh is hyperextended ; the subclavian artery may be compressed between the clavicle and first rib if both elbows are bound behind the back, or if the arm on the side in question is drawn forcibly' backward and to the opposite side. Hamiorrhage is most dangerous from those arteries which, because of anatomical relations, are constricted or compressed with difficulty. In ha?morrhage from one of these vessels, compression should be resorted to immediately, the possibilities of infection being disregarded — as, for example, in ha?morrhage from the innominate artery or vein. Permanent control of haemorrhage is accomplished by ligation or suture of the injured vessel. Ligation of Blood Vessels. — The ligature may be employed whenever closure of the vessel in question is not followed by severe nutritional disturbances. In ligating a vessel the injured point is first exposed under artificial ischa?mia. If the vessel is completely divided, both ends should be seized with artery forceps, drawn somewhat out of the w^ound and ligated. In a lateral injury the vessel should be freed above and below the point of injury from its sheath, and then with the aid of an aneurysm needle a catgut ligature should be passed about the vessel above and below the wound. The segment of the* vessel lying between the ligatures should then be resected. Suture of Blood Vessels. — An attempt should be made to sutui-e the vessels or vessel, if both the artery and vein are injured, or if ligation of the vessel is followed bv severe nutritional disturbances, such as 556 THE MECHANICAL INJURIES occur frequently after ligation of the common carotid artery, more rarely after ligation of the femoral artery. A lateral or a circular suture may be performed, depending upon the conditions found at the time of operation. Lateral suture was attempted before circular suture. The suture was first attempted upon veins, after it had been demonstrated by experimental work (Braun) and by clinical experience (Schede, 1882) that thrombosis did not occur if the operation was performed asep- tically. Important animal experiments in circular suture of vessels were per- formed by Gluck (1882) and by Jassinowsky (1891). The latter espe- cially demonstrated that in spite of the technical difficulties, a cir- cular suture can be inserted without secondary hgemorrhage or thrombus formation occurring and without an aneurysm developing. The first circular suture of an artery in man was performed by Murphy in 1897, the lumen of the femoral artery being reestablished. While the suture is being inserted the artery should be closed above and below the point of injurj'- by digital pressure or by a delicate clamp (the blades of which are covered with rubber tubing, such as a Crile clamp). The ordinarj^ hemostatic forceps should not be used, as it injures the endothelium, causing thrombus formation. [Carrel's method of suture is the most successful; a very fine needle and silk which is vaselined are used in performing the suture.] A lateral suture maj^ be emploj^ed in closing longitudinal wounds, and transverse and oblique wounds which do not involve more than one half of the circumference of the vessel. In applying this suture a fine non-cutting needle armed with the finest silk, which should be vaselined, is carried through all of the coats of the vessel, a continuous suture being inserted (Doerfler). The edges of the wound should be held firmly together, and the margin of the endothelium, in which the proliferative changes first occur, should be accurately approximated. Some interrupted sutures which include only the adventitia, and the connective tissues about the vessel should then be inserted to protect the line of suture. After the operation is completed, the forceps should be gradually removed so that the stitches may gradually tighten as the blood courses through the vessel. It is sometimes advisable to exert gentle pressure over the line of suture for a little while before closing the wound. The same preeautfons should be taken in applying a circular suture as described above. The circular suture is employed to reunite the ends of a completely divided arterj' or close a large defect. It is more dif- ficult to apply a circular than a lateral suture. Murphy's method, in which the jjroximal end is invaginated into the distal by sutures passed MECHANICAL IXJlllIES OF THE DH'FEKEXT TISSUES 557 tliroiiiih all llu' coiits of the vessels, pi-cseiits many tcclmical (lifficult i<'s. [Carrel's method is best suited for circular suture. J Mechiiuiatl Mdliods for licpairiiig Vessels. — Of the ditt'erent uie- ehauical methods that introduced by Payr is the most successful. The mauiiesium tube u.sed by him in making an ana.stomosis is very thin, measures from 0.)^-! cm. in length, and presents two grooves upon its outer surface. The tubes, of course, come in diiTerent sizes, which cor- resj)ond to those of the arteries for which they are employed. In mak- ing an anastomosis, the proximal end of the artery or vein is drawn througli the tul)e and is then everted hy sutures or forceps so that the endothelium faces outward. The everted end is then tied with a fine silk ligature in the second groove. The tube covered by the proximal end is then slipped into the distal end, which is then tied over the tu])e. Endothelium is then applied to endothelium, and there is no foreign body in the blood stream. Union occurs within ten days, and then the magnesium tube is gradually absorbed. A distance of 5 cm. may be overcome by placing the extremity in the proper position, rendering suture without tension possible. Naturally lateral and circular suture can onl.y be performed on the larger vessels. Smaller vessels, about 3 mm. in diameter, are sutured with difficulty, and besides thrombosis is apt to occur. Repair of Woioids in Vessels. — Agglutinaticm of the margins of the wound, assisted by the formation of a thrombus composed of blood plate- lets and of a layer of fibrin, is the first step in the repair of arteries and veins after ligation or suture. Evidences of endothelial prolifera- tion may be found a few hours after ligation or suture. The rapidly growing endothelial cells repair the defect upon the inner surface of the vessel, grow in between the edges of the wound, and cover the sutures which have been inserted. The fibrous elements of the media and ad- ventitia soon proliferate and aid in repair. But few elastic fibers are found in the adventitia and media. They are, however, relatively nu- merous in the iutima (Jacobsthal). The same changes are observed in the spontaneous healing of small wounds of vessels, provided the h£emor- rhage is controlled In' the resistance offered by the soft tissues. The clot which then closes the wound in the vessel wall is organized to form a scar. VII. INJURIES OF LYMPHATIC VESSELS Injuries of lymphatic vessels are of less importance surgically than are injuries of blood vessels. Injury of the thoracic duct or of one of its largest branches is the most important of the injuries affecting lymphatics. The thoracic duct may be injured at its point of junction with the left subclavian vein 558 THE MECHANICAL INJURIES during the removal of deeply situated and adherent tuberculous lymph nodes. It may also be divided in stab or gunshot wounds of the supra- clavicular fossa. The loss of chyle following its division may cause severe nutritional disturbance. Usually, however, the discharge of chyle gradually ceases as healing progresses. If the divided duct is seen in the wound, the thoracic end should be grasped by artery forceps and ligated. If the divided duct cannot be found, the external discharge of chyle can easily be prevented by packing the wound with gauze. In the majority of cases division of the duct is not followed by bad results, as a rich collateral circulation is soon established or the duct empties into the vein by a nmnber of branches (Wendel). Injuries of the thoracic portion of the duct may be associated with contusions of the chest and fractures of the thoracic vertebrae. If death is not caused by the injury to the chest or vertebrae, chyle is then poured out into both pleural cavities. Chylothorax may also be caused by the pressure exerted by tuberculous or carcinomatous lymph nodes upon the duct. A chylous ascites may be caused in the same ways as mentioned above. Exploratory puncture reveals a milky fluid which contains fat, albu- min, and usually sugar, if there is a chylothorax or a chylous ascites. Recovery may take place spontaneously after traumatic rupture of the duct, as the opening in it may be closed by the pressure of the extravasated fluid. If in chylothorax the respirations become embar- rassed, the fluid should be aspirated. Only enough should be removed to relieve the respirations, as more fluid is poured out after aspiration. Lymphatic vessels of different sizes are injured in all wounds and in all subcutaneous injuries. Large amounts of lymph, however, rarely accumulate, as the collateral lymphatic circulation is very free, and the lymph passes into other vessels. In many subcutaneous injuries lymph is extravasated and assists in the formation of the swelling. In subcu- taneous separation of the skin (decollement) lymph mingles with the blood, giving rise to a characteristic clinical picture. Dilated lymphatic vessels in the skin may rupture spontaneously or burst as the result of a blow or pressure. A permanent lymph fistula may then form. LiTERATUHE. — Apollonlo. Mikroskopische Untersuchungen iiber die Organisation des Unterbindungsthronibus in den Arterien. Beitr. z. pathol. Anat., Bd. 3, 1888. — Baumgarten. Ueber die Schiclcsale des ]31utes in doppelt unterbundenen Gefasstrecken. Wien, med. Wochenschr., 1902, No. 45;— Ueber die sog. Organisation des Throm- bus. Centralbl. f. die med. Wissensch., 1876, p. 593. — v. Brunn. Beitrag zur traumatischen Gangriin durch Ruptur der inneren Arterienhaute. Beitr. z. klin. Chir., Bd. 41, VMi.—Ddbet. Maladies chirurg. des Arteres, Dentil et Delbet. Traits de chir., Paris, 1897, p. 141, Part lY.—Dorjicr. Ueber Arteriennaht. Beitr. z. klin. MECHANICAL LNJUillES OF THE DHTERENT TISSUES 559 Chir., Bd. 2.3, 1899, p. 781. — Fischer. Ueber die Gefahren des Lufteintrittes in die Venen wiihrend einer Operation, v. Volkmanns Samml. klin. Vortrage, 1877, No. 113. — Hare. The Entrance of Air into the Veins. Americ. Journal of the Med. Sciences, 1902, November.— //p//er. Ueber traumatische Pfortaderthroinbose. Vcrhandl. d. pith. Gescllsch., Zentralbl. f. allgeni. Pathol., Bil. 15, Erganzungsheft, p. 182, IWn.—IIopfner. Ueber Gefiissnaht, Gefa^istransplantationen uiid Replantation von amputierten Ex- tremitiiten. Arbeiten aus v. Bergnianns Khnik, 17, 1904, mit Lit. und Arch. f. klin. Chir., Bd. 70, 1903, p. 417. — Jacobsthal. Zvir Histologic der Arteriennaht. Beitr. z. klin. Chir., Bd. 27, 1900, p. 199. — Jordan. Luftaspiration in die Venen des Halses. Handb. d. prakt. Chir., 2. Aufl., Bd. 2, p. 43. — Korte. Ueber Gefassverletzungen bei Verrenkungen des Oberarmes. Arch. f. klin. Chir., Bd. 27, 1882, p. 631. — Kiimmell. Chylothorax. Mit Lit. im Handb. d. prakt. Chir., 2 Aufl., Bd. 2, p. id7.—Linser. Ueber Zirkulationsstorungen im Gehirn nach Unterbinr'ung der Vena jugul. int. Beitr. z. klin. Chir., Bd. 28, 1900, p. 642. — Marchaiul. Der Prozess der Wundheilung. Deutsche Chir., 1901, Wunden der Gefasse, p. 330. — Payr. Beitrage zur Technik der Blutgefass- und Nervennaht. Chir. Kongr.-Verhandl., 1900, II, p. 593 and Arch. f. klin. Chir., Bd. 62, p. 67; — Weitere Mitteilungen iiber Verwendung des Magnesium bei der Xaht der Blutgefasse. Ibid., Bd. 64, 1901; — Zur Frage der zirkularen Vereini- gung von Blutgefassen mit resorbierbaren Prothesen. Ibid., Bd. 72, 1903. — E. Pick. Ueber die RoUe der Endothelien bei der Endarteritis post ligaturam. Zeit- schr. f. Heilkunde, Bd. 6, 1885, p. 457. — Raab. Ueber die Entwicklung der Narbe im Blutgefiiss nach der Unterbindung. Arch. f. klin. Chir., Bd. 23, 1879, p. 156; — Neue Beitrage zur Kenntnis der anatomischen Vorgange nach Unterbindung der Blutgefasse beim Menschen. Virchows Arch., Bd. 75, 1879, p. 451.^ — -Rotter. Ueber Stichverletzungen der Schliisselbeingefasse. v. Volkmanns Samml. klin. Vortr., 1893, N. F., No. 72.— Schmitz. Die Arteriennaht. Deutsche Zeitschr. f. Chir., Bd. 66, 1903. — Schopf. Verletzungen des Halsteiles des Ductus thoracicus. Wien. klin. Wochen- schrift, 1901, No. 48. — Senn. An Experiment and Clinical Study of Air-Embolism. Centralbl. f. Chir., 1886, No. 23. — Thole. Querdurchtrennung des Duct, thoracicus am Halse. Deutsche Zeitschr. f. Chir., Bd. 58, 1900, p. 95. — v. Wahl. Die Diagnose der Arterienverletzungen. v. Volkmanns Samml. klin. Vortr., 1885, Xo. 258. — Wendel. Ueber die \'erletzung des Ductus thoracicus am Halse und ihre Heilungsmoglichkeit. Deutsche Zeitschr. f. Chir., Bd. 48, 1898, p. 437. Vin. INJURIES OF JOINTS (a) SUBCUTANEOUS INJURIES Subcutaneous injuries of joints may be divided into contusions, sprains, and dislocations. A contusion may be caused by direct or indirect violence. In the former the force is applied over the joint, while in the latter it is trans- mitted from some distant point, the articular surfaces being driven together. For example, the knee or hip joints may be contused by a fall upon the feet, the elbow joint by a fall upon the hand. In contusions caused by direct force the soft tissues surrounding the joint are injured as well as the .synovial membrane. In contusions caused by indirect force, fragments of bone may be separated, tlie articular surfaces fissured, the spongy ends of the bones crushed, and the articular 560 THE MECHANICAL INJURIES cartilage separated from the subjacent bone by an accumulation of blood. Haemarthrosis. — The most prominent symptom of a contusion of a joint is an extravasation of blood into the joint cavity (ha-m arthrosis) . The contour of the joint is changed, as its normal lines are obliterated by the distention of the capsule. The haemarthrosis develops rapidly after the injury, and reaches its maximum development on the following day. INIovements of the joint involved are painful and its function is interfered with. The prognosis of a contusion uncomplicated by a fracture and asso- ciated with but a small extravasation of blood is good. Recovery with good function usually occurs within a short while. Functional disturbance may develop if the blood is incompletely or slowly absorbed. The absorbing power of synovial membrane is not great, for the lymphatic plexuses are not in direct communication with the joint cavity, differing in this way from the lymphatic plexuses of serous cavities. Large exudates are not removed unless absorption is favored by compression, massage, and gentle active and passive move- ments, or unless the capsule is torn opening in this way lymphatics of the surrounding tissues. Coagulated blood causes the greatest disturb- ance. Riedel has shown by experimental work on animals that one third of the blood poured out into a joint becomes coagulated. The changes which blood undergoes in a human joint vary. Sometimes coagulation occurs early, while in other cases the blood remains fluid for a number of weeks. In those cases in which the blood remains fluid for a long time there is always considerable fat in the joint cavity which is appar- ently derived from contused bone marrow. Fat probably prevents or delays the coagulation of blood. Regressive changes occur much more slowly in clotted than in fluid blood, and clotted blood is absorbed much less rapidly. The irritation of the synovial membrane induced by the blood may be followed by a serous exudate, giving rise to the clinical picture of a chronic or recur- ring hydrops. Long-continued immobilization of such a joint may be followed by organization of the fibrinous masses lying between the articular surfaces, causing fibrous anchylosis. A large chronic exudate may so distend and weaken the capsule that the joint becomes flail. Other complications of a contusion are subcutaneous suppuration and tuberculosis of the injured joint. They may develop as hEematogenous infections or after the rupture by the force causing the contusion of the capsule of some latent focus. Infections of the haematoma and joint may develop from small wounds in the skin and from excoriations. MECHANICAL INJURIES OF THE DIFFERENT TISSUES 561 Diagnosis. — The diagnosis of a simple contusion of a joint, nneom- plieated by a fracture, is based upon the character of the injury and the findings elicited by an examination. Distention of the capsule, fluc- tuation, the ."^o-ealled " snowball " crepitation, which can be elicited by pressure at certain points and is caused by displacement of blood clots, and the signs of a contusion of the soft ti.ssues are indicative of a ha?mai'- throsis. Severe pain elicited by pressure made at definite points and abnormal lateral mobility indicate the laceration of ligaments. Frac- tures involving most of the joints are very typical. Fissures and frac- tures of the epiphysis Avithout displacement cannot be recognized unless a Roentgen-ray examination is made. Treatment. — The first indication in the treatment of a contusion of a joint is to put the part at rest. If one of the joints of the lower ex- tremity is involved the patient should remain in bed. If a bandage Avhicli exercises mild compres.sion is applied immediately, and the joint is then innnobilized upon a papier-mache or a molded plaster-of-Paris splint, the pain is relieved more rapidly and less blood is poured out into the joint than when an icebag is applied and massage is employed to hasten absorption. The immobilizing dressing should not be em- ployed longer than one week, provided there is no fracture. At the end of a week massage, active and passive motion, and baths should be be- gun in order to prevent stiffness of the joint. No weight, however, should be borne upon the joint at this time. If the blood is absorbed slowly and the exudate is large, it may be necessary and advantageous to aspirate the joint. After aspiration a dressing which exercises mild compression should be applied over the joint. Such a dressing should be worn for some weeks. Sprains. — An injury in which there is a sudden momentary displace- ment of bones entering into a joint, the parts returning immediately to their normal relations, is classified as a sprain. A sprain may be caused by movements carried beyond the normal range of motion peculiar to the joint (for example, a sprain caused by hyperflexion or hyperextension of a hinge joint), or by some move- ment which normally does not occur in the joint involved (for example, a sprain of a hinge-joint caused by forceful attempts at rotation). The cause of sprains of the various joints differs. The most frequent and best-known examples are sprains of the ankle caused by a misstep, and sprains of the wri.st caused by falling upon the flexed or extended hand. Next in order of frequency are sprains of the knee caused by abduction or rotation of the leg. Joints with a very free range of motion, such as the shoulder and hip, are more frequently dislocated than sprained. Pathology of a Sprain. — The capsule and ligaments are nearly always lacerated at the points where they have been exposed to the greatest 562 THE MECHANICAL INJURIES tension during the exaggerated or abnormal movements. The tear may involve one or all of the layers of the capsule and may vary greatly in extent. Strong accessory bands in a capsular ligament are often very resistant and frequently are not torn, a piece of bone to which they are attached being torn away (as in Colles' and Pott's fractures). Bony prominences, such as the coracoid process, tendons and muscles, inti- mately related to the joint and inhibiting the movements of the same, may be torn off and partially or completely ruptured. Intra-articular nbrocartilages may be displaced and parts of the capsule or tendons and muscle may become caught between the articular surfaces. Symptoms. — The first symptom of a sprain is severe pain. The pain soon subsides if only the capsular ligament is lacerated. If the liga- ments are badly torn or if there is also a fracture, the pain persists until the part is immobilized. Within a few hours the joint becomes swollen, as blood is extravasated into the joint cavity and periarticu- lar tissues. Ecchymoses develop in the skin surrounding the joint, especially at the points where the ligaments have been lacerated or a fragment of bone separated. Movements are avoided and no at- tempt is made to bear weight upon the joint, as the pain is increased thereby. Clinical Course and Prognosis. — The clinical course and prognosis of a sprain are much the same as those of a contusion. Simple sprains without extensive laceration of the ligaments or injuries of bones go on to complete recovery in a short time. If, on the other hand, the articular cartilages are displaced or a piece of the capsule becomes incarcerated, the pain persists for a long while. A fracture, if not rec- ognized or if neglected, may heal in malposition, causing marked func- tional disturbance. Too early use of an extremity after the laceration of important ligaments may cause abnormal mobility (lateral mobility of the knee joint), and faulty positions (genu valgum, pes valgus). Sprains readily recur, as the ligaments which may not have completely healed become weak and relaxed when used early. Diagnosis. — The diagnosis of a sprain is not always easily made. The character of the injury, and the development of a painful swelling of the joint which interferes with every motion make the diagnosis of a sprain probable. The laceration of a ligament, if there is no, fracture, is recognized by tender points corresponding to the position of the tear. In sprains of the ankle joint these tender points are found over the deltoid ligament; in spr-ains of the knee joint about the joint line. Even if but a small ha?matoraa has developed, these points will be more re- sistant than corresponding points upon the uninjured side. The deformities associated with fractures involving joints (Pott's and Colics' fractures, fracture of the patella) are usually characteristic MECHANICAL INJTTRIES OF THE DIFFERENT TISSl'ES 563 and typical. These fractures should not be mistaken for sprains. Quite fre(|uently, however, but a small fray;inent of lione is broken off and the typical deformity is concealed by a hivniatoma. In doubtful ea.ses a positive diagnosis can be made by a Roent Face and Neck 1,063 8.65 23 3. 62 65 3 y Trunk 1,534 12.68 8 1,396 . 132^ 534 61 325 179 6 223 316 . Tapper extremity 5,781 47.89 1,007 272 102 14 873 1,737 j 422 ] 154 764 907 169 27 > Lower extremity 3,136 25.98 23 136 255 279 J Different Forms of Displacement. — Some forms of displacement are more common than others. Four principal forms ai-e recognized : 1. Angular displacemoit is produced by the fracturing violence. Subsequently it is often increased by the weight of the part distal to 57S THE MECHANICAL INJURIES the seat of fracture, by contraction of the muscles when the patient attempts to move, and by other influences, such as spasmodic muscular contractions, when the parts are improperly immobilized. As a result of the action of one or more of the factors above mentioned an angular displacement may be transformed into one of the other varieties about to be mentioned. 2. Lateral displacement may take place forward, backward, or to either side, and may be partial or complete. The pure form of lateral displacement is rare and occurs only in transverse fractures. It is usu- ally associated with overriding or angular displacement, or both. 3. Displacement in the longitudinal axis may be associated with shortening or lengthening of the extremity, depending upon whether the ends of the bones override or are separated by muscular action. In fractures through the diaphysis shortening is marked, especially in oblique and comminuted fractures, as the distal fragment is drawn upward b}^ the muscles arising from bones above the seat of the frac- ture. Wide separation of the fragments may be produced by contrac- tion of muscles attached to the proximal fragment. The most striking example of wide separation of fragments is seen in fractures of the olecranon process and patella. 4. Fotatory displacements usually occur in torsion fractures, and are caused by the fracturing \doleuce or by some secondary factor, most frequently to the weight of the extremity distal to the line of fracture. In fractures of both bones of the leg the internal malleolus may be directed forward or even outward, while the patella occupies its normal position. DLsplacement of the fractured ends in a transverse axis occurs in fractures of the head of the humerus and patella. 5. IrregnJar displacements, such as occur in comminuted fractures and in bursting and depressed fractures of the skull and facial bones, should also be mentioned. Diagnosis. — In making a diagnosis of even a simple fracture, a defi- nite line of procedure should be followed. History of Accident, Pain, Impairment of Function. — The history of the accident and a description of the direction in which the force Avas applied or the blow delivered may give a clew to the diagnosis. Pain at the seat of fracture, and impairment of function, when attempts at movement are made, are suggestive but not conclusive, as simi- lar symptoms are frequently associated with injuries of tendons and nerves. Whether the impairment of function is caused by a contusion, a sprain, a fissured fracture, or. if the loss of function is complete, by a dislocation must be determined by a more careful and exhaustive examination. MECHANICAL INJURIES OF THE DIFFERENT TISSUES 579 Inspection. — III iiiakiiiy: an exainiiiation tlic injured part should firet be ins{)('cte(l and compared with the uninjured one, for frequently in typical fractures the lindinjis revealed by inspection are so character- istic that there is but little need for manipulations which are often painful. A deformity, even when slight, will be apparent to the eye of a trained surgeon if the contour of the injured side is compared with that of the uninjured one. The deformity frequently becomes more pronoiniced when attempts at movenient are made. If the injured l)art is greatly swollen and the deformity therefore masked, shortening of the extremity determined by use of the tape measure and the findings elicited by gentle manipulation are of great diagnastic value. I'alpation. — The diagnosis of a fracture can be made and the relative position of the fractured ends determined by palpation in most cases. If the finger is passed over the surface of a bone, a depression or fi.ssure, or perhaps merely a loss of resistance, which indicates the position of the fracture, can be determined. Exquisite pain is usually elicited when pressure is made at the seat of fracture. This localized tenderness is an important diagnostic sign. If an articular end of a bone has been fractured and displaced, the end can usually be felt in a false posi- tion, and it can no longer be palpated in the position it ordinarily occupies. False Point of Motion and Crepitus. — After inspection and palpa- tion, an attempt may next be made to determine whether or not a false point of motion exists at the seat of deformity, or, if there is no deform- ity, at the point of tenderness. In eliciting a false point of motion, the part of the extremity distal to the fracture should be grasped and gentle traction made, while the proximal part is supported. The distal part is then either gently rotated or moved to and fro to determine whether or not a false point of motion exists. A false point of motion cannot be determined in impacted and green-stick fractures unless more force than is usually warrantable is employed. In determining whether or not there is a false point of motion in suspected fractures of the upper part of the femur and humerus, one hand should grasp the head of the bone while the other rotates the shaft. Naturally if there is a false point of motion the shaft and head of the bone will not rotate together. In fractures of the ribs and pelvic bones, the fingers should be placed upon either side of the supposed seat of fracture and alter- nately raised and depressed to determine whether a false point of motion exists or not. A false point of motion is the most positive sign of a fracture. Crepitation should not be relied upon too much, as is so frequently the case with the beginner. In fractures involving the joints in which a false point of motion can only be determined with difficulty, if at all, 580 THE MECHANICAL INJURIES crepitation is of considerable value. When elicited in fractures of the shaft, it is a valuable diagnostic sign. It also indicates that the frac- tured ends are not overriding or separated by soft tissues. Crepitation elicited by pressure over the seat of the injury may be due to the dis- placement of blood clots, but crepitation elicited by torsion or move- ments is never caused in this way. The determination of a false point of motion and the elicitation of crepitus are, as a rule, painful to the patient and injurious to the soft tissues. They should be omitted whenever possible. Roentgen-ray Examination. — The Roentgen-ray examination is the most important aid in the diagnosis of a fracture. It is essential that one should have an accurate knowledge of the shadows cast by nor- mal bones taken at various angles in order that normal shadows and the lines representing epiphyseal cartilages will not be interpreted as fractures. When the dressings are changed a fluoroscopic examination should be made to determine whether or not the fragments are in appo- sition. If a deformity still persists, attempts at correction should be made. In all cases a careful examination should be made to determine whether large blood vessels, nerves, and tendons have been contused and lacerated. Traumatic and Pathological Fractures. — It may be exceedingly dif- ficult to differentiate between a traumatic and a pathological fracture if the disease (tumor, chronic inflammation, atrophy) has given rise to no symptoms before the fracture occurred, or if trauma has been an accessory factor. If the trauma was not severe enough to have frac- tured a healthy bone, then the suspicion of abnormal fragility due to some pathological process should arise. If the Roentgen-ray picture gives no assistance in making the diagnosis, the subsequent clinical course alone can decide whether the fracture is pathological or not. Tumors which develop at the seat of a fracture are classified as " cal- lus " tumors. They are usually sarcomas. Clinical Course. — A swelling varying in size usually develops at the seat of fracture during the first two or three days. Discoloration of the skin which rapidly develops is due to the infiltration of the soft tis.sues with blood. It is most marked in fractures associated with dis- placement and comminution, for in these cases the soft tissues are contused and lacerated by the fracturing violence. Fractures involving the joints are always accompanied by an extravasation of blood into the joint cavity. Frequently the swelling is aggravated by an oedematous infiltration of the tis.sues, the result of an inflammatory reaction which, as a rule, continues but a few days. Quite frequently serous and sero- haemorrhagic blebs develop in the swollen, tense, and discolored skin. MECHANICAL INJURIES OF THE DIFFERENT TISSUES 581 During the first weok a slight elevation of teniperatnre (so-called aseptic fever) is common. This fever is caused by the absorption of blood and tissue fluids from the tissues about the seat of fracture. Fat may be liberated and gain access to and circulate in the blood after crushing injuries of the bone marrow. If present in large amounts it may cause fat embolism, the symptoms of which vary depending upon the viscus or organ chiefly involved. The fat is excreted in the urine, and if there is a suspicion of fat embolism, which usually develops in from fifty- four to seventy-tv/o hours, the urine should be carefully examined. If the part is not immobilized soon after the fracture, the patient experiences severe pain, which is aggravated by manipulation and at- tempts at movement. The swelling and discomfort are usually greatly relieved by the application of a well-fitting, immobilizing dressing. In from one to two weeks the swelling disappears and the pain sub- sides. Then a spindle-shaped swelling which surrounds the fractured ends can be felt. This SAvelling enlarges for several weeks, but grad- ually becomes smaller and harder, resulting in firm union of the frac- tured ends. This new tissue which develops at the seat of fracture is called the callus. Callus Formation. — The regenerative changes leading to callus for- mati(m may be best followed in animal experiments. The first change indicative of regeneration consists of a proliferation of the cells of the periosteum and medulla. Proliferative changes may be seen within twenty-four hours after the fracture of a bone. A vascular granulation tissue develops from the periosteum, which frequently is lacerated and separated from the subjacent bone by blood clots. At the end of the fii'st week islands of osteoid and cartilaginous tissue, between which lie marrow cells, are found within this newly formed tissue. Bone is formed from the external or pei'iosteal callus, which extends some dis- tance on either side of the fracture, as the result of the deposition of calcium salts. During this process the embryonal granulation tissue gradually becomes transformed into bone of an adult type. AVhen the fractured ends are not properly immobilized and are subject to repeated disjilacements, the cartilage persists and is not transformed into bone. The internal or medullary callus forms more slowly in long bones than the external callus. It is composed of osteoblasts, which first produce osteoid tissue and later bone. The medullary cavity of the fractured ends of the bone are at first closed by this tissue. If the fractured ends are held in apposition, bone formed by the periosteum and bone marrow rapidly unites them. If the ends are widely separated, the external and internal callus proliferate to fill in the gap and bridge over the space between them. The fibrous tissue about a fracture assists in the formation of new 582 THE MECHANICAL INJURIES bone when its regenerative activity is stimulated by contusion and lacer- ation. The proliferating fibrous tissue forms a granulation tissue which sends processes out into the intermuscular septa and bridges over joints, causing anchylosis. These changes resemble somewhat those observed in the traumatic forms of myositis ossificans. After fracture of adjacent bones union of the two masses of callus may lead to synostosis. Synos- tosis of the radius and ulna occasionally occurs after fracture of these two bones. Consolidation of the Callus. — A callus gradually enlarges for four or five weeks and then undergoes ossification, which is, as a rule, com- pleted in the following four weeks. The spongy mass of callus then becomes condensed and transformed into a less massive but firmer tissue, which resembles histologically the compact substance of normal bone. During this transformation the excessive callus is absorbed, the jagged ends of the bone are smoothed off, and the displaced splinters encapsu- lated or digested. The medullary canal is reestablished when the frac- tured ends are in fairly good apposition in the same axis, but it remains closed when the ends override and are displaced longitudinally. After a few years a distinction can no longer be made between old and new bone, and only a small irregularity can be noted at the seat of the former fracture. The Amount of Callus Formed. — The amount of callus formation in different fractures varies widely. A small amount of callus is formed in fractures with but little laceration of the periosteum and in fissures. An excessive amount of callus is formed when the periosteum is badly injured, when the bones are comminuted, and when the soft tissues are contused. Necrotic tissue and extravasated blood stimulate the tissues to proliferation and favor the development of large amounts of callus. Ordinarily callus formation is more marked in fractures of the diaphysis than in those of the epiphysis, but even in the latter, espe- cially if comminuted, excessive callus formation is not at all infrequent. In fractures of the short and flat bones but little callus is formed, and it develops from the bone marrow. Bepair of Cariilage. — Fractures of the chondral and laryngeal carti- lages are repaired by a callus which develops from fibrous tissues and later resembles histologically spongy bone. Fissures of the articular cartilages are repaired by fibrous tissue. Time liequired for Repair of a Fracture. — The time required for the repair of a simple fracture is usually about sixty days. Gurlt's statistics show that two weeks are required for the repair of fractures of the phalanges, three weeks for those of the metatarsal bones and ribs, four weeks for those of the clavicle, five weeks for those of the bones of the forearm, six weeks for those of the humerus and fibula. MECHANICAL INJURIES OF THE DIFFERENT TISSUES 583 seven weeks for those of the neck of the humerus and tibia, eight weeks foi- those of both bones of tlie leg, ten weeks for those of the shaft of the femur, twelve weeks for those of the neck of the fenuir. Consolida- lion occurs rapidly in children, and is complete in most bones in from 1\vo to three weeks. Union is much more rapid when the individual is healthy than when diseased. Belayed and Non-union. — The causes of delayed and non-union may be local or general. If the general condition of the patient is bad as the result of previous sickness union may be delayed. Cachexia (fol- lowing and associated with infecticms diseases and malignant growths), senile marasmus, atrophy of bone associated with diseases of the central nervous system, and diseases of the bone, such as rickets and osteo- malacia, interfere with callus formation. Among the local causes inter- fering with repair may be mentioned marked displacement and over- riding of fragments, the interposition of soft tissues, large hiematomas between the fractured ends, extensive destruction of the periosteum and medullary substance with comminution of the bone, poor nutrition of a fragment following a fracture into the joint, the separation of an apophysis or the thrombosis of the nutrient artery, and finally sup- purative osteitis, the infection occurring at the time of the fracture or later through the blood. Pseudarthrosis and Nearthrosis. — As a result of one of the above con- ditions callus formation may be either delayed or completely interfered with. If union is delaj'ed, a marked enlargement persists for some time, but finally after a relatively long interval the callus becomes condensed and firm union occurs. Not infrequently when union is delayed the bone is refractured by attempts at movement, but the convalescence is not markedly prolonged, as the repeated insults stimulate the germinal tissue to the more rapid formation of solid bone. If bony union fails a false point of motion persists and a pseudarthrosis develops. In a pseudarthrosis the fractured ends are either separated by soft tissues or are united by a connective-tissue bridge. ]\Iore rarely a true joint forms between the fragments, the ends of w^hich are rounded off and covered with cartilage and enclosed in a mass of connective tissue re- sembling the capsule of a joint. Such a false joint contains a fluid resembling synovia, and simulates closely a joint which has undergone the pathological changes associated with arthritis deformans. The amount of interference with function in these cases depends upon the position of the bone involved. A pseudarthrosis involving a rib causes no functional disturbance, while a pseudarthrosis in one of the bones of the extremities prevents the bearing of weight upon the bone. At times the extremity may be used, after the fragments have been fixed by muscular contraction. 584 THE MECHANICAL INJURIES The bad results following simple fractures are usually due to asso- ciated injuries of the soft tissues, to the improper reduction and immo- bilization of the fragments, and to the loss of function following long- continued immobilization. Complications. — Crushing of the bone marrow, which occurs to a greater or less extent in every fracture, may be followed by the absorp- tion of fat and fat embolism. Injuries of arteries, veins, nerves, mus- cles, and tendons may be caused by the fracturing violence, or by the displacement of fragments insufficiently or improperly immobilized. Extravasations of blood, pulsating ha?matonias, traumatic aneurysms, thrombosis, gangrene of an extremity, paralysis, and muscular con- tractures may follow such injuries. Intra-articular fractures are accom- panied by an extravasation of blood into the joint which frequently causes a synovitis and subsequent fibrous anchylosis. In intra-articular fractures the displaced fragment may interfere with motion, and be- sides free bodies may develop or changes resembling those of arthritis deformans occur after contusion and laceration of the tissues forming the joint. In some cases the changes following the extravasation of blood into the joint, such as serous synovitis and distention of the cap- sule, are very pronounced. A number of functional disturbances which develop depend upon the conditions at the seat of the fracture. Besides functional disturb- ances caused by vicious union, pseudoarthrosis and synostosis, are those caused by the pressure of fragments of bone and callus upon the vessels and nerves. Thrombosis, interference with circulation, and nervous dis- turbances, which may even end in paralysis and are often caused by inclusion of nerves in the callus (the museulospiral nerve being fre- quently caught in the callus after fractures of the shaft of the humerus) , are some of the sequehe. Necrosis of the bone following infection and suppuration of the bone rarely occur in simple fractures. Trophic Disturbances. — Long-continued disuse following immobiliza- tion of the injured extremity frequently leads to trophic disturbances. The beginning of trophic disturbances which usually develop after some weeks is indicated by a diminution in the size of the part. The skin becomes soft, thin, and smooth, the muscles atrophy as a result of dis- ease and trophic changes in the spinal centers which follow peripheral irritation associated with the trauma or accompanying inflammation ( Paget- Vulpian reflex atrophy). In these cases a Roentgen-ray picture taken after six or eight weeks reveals a marked atrophy of the bone and changes in its internal structure (Sudeck). The muscles and fascia atrophy, the tendons no longer glide freely in their sheaths, the func- tion of the joints is interfered with, even when not injured, as the result of adhesions and degeneration of the articular cartilages. The MECHANICAL INJURIES OF THE DIFFERENT TISSUES 585 joint clianges associated with iiiiiiiobilization are most marked in adults and old peo{)le. If a stiff joint is used or inanij)ulated too roughly at first, an acute serous or seroha'inorrhagic exudate may form as the result of laceration of the vessels in the contracted capsule. In children the growth of the entire extremity may be interfered with if a pseud- arthrosis develops or the function of the part is interfered with as the result of anchylosis of one of the joints. (Edi'ma Following Fractures. — Circulatory disturbances are most conniion after fractures of the bones of the lower extremity. They appear after the first attempts are made to use the parts. Passive con- gestion and o'dema are due to weakness of the nuiseles, which interferes with the venous circulation, and to venous thrombosis. Decubitus and Hypostatic Pneumonia. — Old people are prone to develop bedsores and hypostatic pneumonia when confined to bed for any length of time. Thromhosis and Eniholism. — Pulmonary and cardiac embolism, which are usually fatal, may follow thrombosis of the veins about the fracture. A persistent and troublesome cedema, frequently associated with nutritional disturbances, is due to venous thrombosis. Thrombosis may be due to a weak action of the heart, to rupture and laceration of tlu^ deep veins, and to pressure exerted by the fractured ends of the bone or l)y the callus. These complications occur most frequently after frac- tures of the bones of the leg and in old people. Persistent pain at the seat of fracture is another sequela which often interferes with the usefulness of the extremity. It is always present when the callus is recent, but usually disappears as it becomes older and more solid. In old people, however, it may persist or return after excessive use of the part or with every change of weather. Prognosis. — The prognosis of fracturas of the different bones dif- fers widely. Fissures, green-stick fractures, and fractures with but slight displacement offer the best prognosis. The prognosis of com- minuted fractures, of fractures with marked displacement, and of those associated with injuries of the soft parts and neighboring joints is bad, as shortening, pseudarthrosis, and stiff'neas may follow and persist. Fractures in young people heal much more readily than those in old people, and the prognosis is nnieh better in healthy people than in those debilitated by chronic infections or constitutional diseases. Statistics showing the results following different fractures are given by Haenel, Jottkowitz, Loew, Bliesener, Wolkowitch, and others. Treatment. — The success of the treatment depends largely upon the way in which the first dressing is applied. In all fractures which occur outside of the patient's home, an emergency dressing should be applied which should immobilize the fragments during transportation to the 38 586 THE MECHANICAL INJURIES home or hospital, preventing the displacement of the fractured ends, so that they cannot injure the soft tissues, penetrate the skin, or cause excessive pain. A broken arm may be immobilized against the chest by a bandage or sling and supported by the uninjured arm. Temporary immobilization of fractures of the lower extremity is far more difficult. Wooden splints, broom handles, branches of trees, boards, and in war sabers and guns and other weapons, have been used to immobilize the parts during transportation of the wounded. These improvised splints are placed upon either side of the fractured part over the clothing, and extend far enough to immobilize the joints above and below the seat of fracture. In fractures of the femur the temporary immobilizing dressing should extend from the external aspect of the foot to the costal margin, and should be held in place by handkerchiefs, straps, cords, or suspenders. If there is nothing at hand which can be used to immo- bilize the part, the injured leg may be bound to the uninjured one. [A most useful dressing is the blanket splint, made by folding a blanket lengthwise once and rolling each end up into a firm roll over a lath or piece of wood. The fractured part is then placed between the rolls, which are held in place by three or four pieces of a roller bandage.] If the individual is injured at home, he should be placed in bed and the fractured part should be immobilized between long sandbags. Fre- quently a physician is called to adjust a temporary dressing which will permit of ea.sy and safe transportation of the patient to a hospital. In "Soing this the part should be handled gently and the following pro- cedure should be followed: The parts above and below the seat of frac- .ture should be held firmly, and the limb should then be gradually ele- vated, gentle traction being maintained upon the lower fragment. The clothing should then be removed. If there is any difficulty in doing this the clothes may be opened along the seam or cut off. The fracture should then be reduced as well as possible without ana-sthesia, and after covering the bony prominence with cotton a wooden or a molded plaster- of-Paris splint should be applied. The object of the treatment of a fractiire is to secure firm union, in good position, of the fractured ends, and complete return of func- tion as early as is compatible with the character of the fracture. Spe- cial works on fractures by Scudder, Hoffa, Helferich, and Stimson in- dicate the line of treatment Avhioh should be followed to secure good cosmetic and functional results in the different types of fractures. Reduction of a Fracture. — The first indication in the treatment of a simple fracture is to bring the fractured ends in good apposition, thus correcting the deformity. This is called reduction or setting of a fracture. When the displacement is great and severe pain is experienced when MlXilAMCAL LNJL'RIES OF THE DIFFKlllONT TISSUES 587 tlio part is luanipulatod, the fracture slioiiUI be reduecd under gas aiui'sthosia. The skin about the part should be shaved and sterilized in order that the infection of ha'matomas and of the small cutaneous or serous blebs may be prevented. Fractures of the bones of the trunk and face can usually be reduced by pressure. ■Many fractures into the joints may be reduced by chang- ing the position of the joint involved. Reduction of fractures of the bones of the arm or leg should be performed as follows: The |)art jiroxinial to the fracture should be grasped and held firndy by an assistant, and the surgeon should then grasp gently the distal frag- ment and exert traction. By traction, torsion, bending, or lateral mo- tion combined with eoimterpressure, the deformity is reduced. If the I>roximal fragment is so short that it cannot be controlled, the distal fragment should be dressed in line with it. [A good example of this principle is aflt'orded by fractures of the femur just below the lesser trochanter. The upper fragment is flexed, abducted, and rotated slightly outward by the action of the muscles attached to it. It is im- possible to reduce and maintain this short fragment in position, so the long fragment, which can be controlled, is dressed in line with it. The fragment which can be controlled should always be dressed in line with the fragment which cannot be controlled.] At least one quarter of the fractured ends should be in apposition after reduction. The results of attempts at reduction can best be determined by Roentgen-ray exami- nations. In fractures of the olecranon the forearm should be dressed in exten- sion. In fractures of the upper third of the fenuir the lower frag- ment should be flexed, abducted, and rotated outward. Fractures about joints should always be dressed in the position of overcorrection ; for examjde, in Colics 's fracture the hand should be dressed in flexion, in Pott s fracture the foot should be rather strongly inverted. Immobilization. — The fragments, when reduced, should be held in place by appropriate dressings. It is, as a rule, more difficult to main- tain the fragments in good position than it is to reduce them. Plastcr-of -Paris Dressing. — If the injury is recent and there is no marked swelling of the soft parts, it is best to employ a plaster-of-Paris dressing, during the application of which the fragments should be main- tained in correct position by traction and counterpressure. If there is considerable swelling, the extremity may be immobilized in a box or papier-mache splint until the swelling has subsided, and then a plaster- of-Paris dressing should be applied. The plaster-of-Pai-is bandage is employed in two ways: As a circular dressing, encasing the part (Matthysen, 1852), and as a molded splint (Beely, 1878). The band- age, as usually employed, consists of crinolin or cheese cloth, which is 588 THE MECHANICAL INJURIES infiltrated with powdered plaster of Paris. The bandage is applied after the extremity has been covered with a flannel bandage or cotton, which is held in position by a light mull or flannel bandage. Bony prominences and projecting tendons should be carefully protected. The bandage may be reinforced by pieces of wood, aluminum plates, or strips of tin. Many considered the molded plaster-of-Paris dressing safer than the circular. In applying such a dressing to the leg, strips of flannel are cut of the desired length and width, and then a number of layers of a plaster bandage, enough to afford sufficient strength, are laid upon these. The dressing is then molded to the part and held in position by a roller bandage. This dressing can be easily removed when it is desired to massage the limb, and there is less danger of ischemic con- tractures, gangrene, etc., when it is employed. Fig. 226.- -Beely's Molded Plaster-of-Paris Dressing for Fractures of the Leg. The dressing is provided with rings to be used for suspension. Bad Results Follotving Poorly Applied Splints and Casts. — Any im- mobilizing dressing may be followed by bad results if applied too tightly or if the turns composing it are applied unevenly. When a cast is applied to an extremity, the fingers or toes, as the case may be, should not be included. They should be inspected frequently, their color and freedom of motion noted. The dressing should be split open or re- moved at once if the parts become congested or anasmic or paralyzed. The most serious cojisequences, such as gangrene of the extremity, thrombosis of the principal vessels, and ischa?mic contractures, may follow the pressures of a poorly applied plaster-of-Paris dressing. Ulcers caused by pressure of a tight cast are a source of danger, as they provide infection atria for pyogenic bacteria. All bony promi- nences, sharp fragments, and prominent tendons should be padded in order to prevent pressure necrosis. The first plaster-of-Paris dressing should be changed at the end of MECHANICAL INJURIES OF THE DIFFERENT TISSUES 589 tho first week, ov, at the latest, after the seeond week. The first dressing hec-oines loose when tlie swelling subsides, and, besides, the position of the fragments ean often be improved and massage given when tlie dressing is changed. When the dressing is changed the skin should l)e wa.shed off, and if there is an eezenui it should be dressed with a dusting powder or an ointment. The inuiiobili/.ed joints and the muscles should be mas.saged before another dressing is applied, unless thei-e is some contra- indication. Application of the Second Cast. — The amount of ])addiug in the second cast may be greatly reduced as a rule. [Some advise applying the plastei'-of-Paris dressing directly to the skin after it has been oiled or covered with vaseline. If a light flannel bandage is applied before the ])iaster dressing is put on, the patient will be more comfortable, and at the same time the parts will be better protected. There are no advan- tages in applying the cast directly upon oiled or vaselined skin.] Ambulatory Dressing. — Convalescence is hastened if the muscles receive massage, atrophy being prevented in this way, and if the joints adjacent to the fracture are massaged and moved early. An ambulatory splint is employed in the treatment of fractures of the lower extremity by many surgeons. The best ambulatory splints are Ilessing's molded iron splint, Thomas's hip splint, the molded iron splint of von Bruns, and the circular pla.ster easts advised by Krause, Bardeleben, Korsch, Albers, and others. When applied they are carefully molded to fit over bony prominences, such as the tibia, the condyles of the femur, the tro- chanter, and the pelvic bones in fractures of the femur. These dress- ings permit the patient to leave the bed before callus formation is complete, Avhich is of the greatest importance in treating fractures in old people. Extension Dressings. — The extension dressing devised by Buck is preferable in many cases to the iron splints and plaster-of-Paris dress- ing. This dressing is especially valuable in reducing and maintaining in correct position certain fractures characterized by marked displace- ment. In applying this dressing, broad strips of adhesive plaster are applied on either side of the limb and carried a little above the seat of fracture. These strips of adhesive plaster are attached to a foot- or hand-board, as the case may be, to which is attached a cord which runs over a pulley and is secured to a weight. The adhesive plaster is bound to the leg or arm by turns of a roller bandage. The cord usually sup- ports a weight of from eight to ten pounds, and continuous longitudinal traction is made in this way. This dressing is effective in any position of the part. If the foot of the bed is elevated, the weight of the body usually affords sufficient counterextension. The extension dressing is frequently combined with Volknumn's sliding splint (Fig. 227). This 590 THE MECHANICAL INJURIES extension dressing has a number of advantages: (1) The displacement is gradually overcome without much pain, and the fragments are held in good position; (2) the part may be easily inspected and the position of the fragments improved, if necessary, by pressure and counterpres- sure; (3) the joints may be moved after a few days, and the stiffness Fig. 227. — Buck's Extension Combined with Volkmann's Sliding Splint in the Treatment of a Fracture THROUGH the Middle Third OF THE Femur. Counter traction by a perineal band; also lateral traction upon upper fragment to correct outward displacement. and synovitis associated with long-continued immobilization may be pre- vented (Bardenheuer). Eepair of the fracture is not delayed, but rather hastened by the limited amount of motion permitted by such a dressing. Buck's extension has been generally adopted by the profes- sion in the treatment of fractures of the shaft and neck of the femur. The same principle is being used more and more in the treatment of other fractures, especially those involving joints. Bardenheuer has devised an adjustable apparatus for the treatment of fractures of the upper extremity, in which extension is secured by a spring, instead of by a weight and pulley. Massage and early passive motion are important factors in securing a return of function. The function of the part may be impaired: (1) By stiffness of the joints and adhesions of the tendons to their sheaths; (2) by muscular atrophy; (3) by malposition of the fragments of the bone or bones. Earhj Massage and Passive Motion in the Treatment of Fractures.— Stiffness of the joints and adhesions between the tendons and their sheaths may be the cause of severe functional disturbances. Lucas Championniere demonstrated some twenty-five years ago that in a num- MECIIAMCAL LNJLlllES OF THE DIFFERENT TISSUES oUl bcr of fractures the frajiiueiits have no tendency to become displaced when they are once properly retluccd, and that most excellent functional results could be obtained without any prolongation of the period of re- pair by early massai^e of the joints and tendons adjacent to the frac- ture, lie also found that even in fractures with a tendency to marked displacement, the wearing of an inunobilizing di'essing for two weeks was sufficient. He has done a great service in emphasizing the so-called functional treatment of fractui'cs, but has carried it too far. The advantage to be derived from early motion and massage cannot be denied. An effort should, however, be made to maintain the frag- ments in good apposition, even if clinical experience has demonstrated that the fimctional results following union in poor position, but asso- ciated with free motion of the joints and the absence of muscular atrophy, are better than those following union of the fragments in per- fect position, but associated w'ith stiffness of the joints and atrophy of the muscles. Jordan and others pursue the proper course when they combine immobilization and the Championniere treatment. Bardenheuer lays great stress upon the treatment of fractures by extension combined with early motion and massage. The fragments should be maintained in good apposition by immo- bilization or extension until union is firm enough to give fairly good support, but not as formerly, until the callus has undergone complete consol- idation. In many fractures immobil- ization for two or three weeks is suf- ficient, but occasionally a much longer time is required. If the period of innnobilization exceeds two weeks, mas- sage should be employed, especially if the fracture involves a joint. An exception to this rule should be made in the treatment of fractures occurring in children. Early massage of a frac- ture in the young often leads to exces- sive callus formation, while even long- continued immobilization in a cast which may be required in difficult cases does not cause the slightest im- pairment of function. I do not believe that massage of a recent fracture is indicated. Im- mobilization continued for one week prevents pain and causes no im- pairment of function, even when the fracture involves a joint. Immo- FiG. 228. — Supracondylar Fracture OF THE HUMERt-S, UsUAL TyPE. (von Bergmann's " Handbook of Practical Surgery.") 592 THE MECHANICAL L\ JURIES bilization protects against a number of complications, such as secondary ha?morrhage caused by displacement of the fragments and laceration of the soft tissues. The pain and swelling rapidly subside when an immobilizing dressing is properly applied. Massage, when first applied, should consist of gentle rubbing of the seat of fracture, the part being rubbed from the periphery toward the trunk for fifteen or thirty minutes. If there are abrasions or large wounds of the skin, massage should not be begun until these are healed. Osteoclasis and Beduction hy the Open Metliod. — If union of the fragments has occurred in malposition it may be necessary to resort to osteoclasis. In cases in which it is impossible to reduce the fragments by manipulation and to maintain them in good apposition, it may be necessary' to resort to reduction by the open method. (a) Osteoclasis — artificial fracture of the callus — is resorted to in those cases in which union has occurred in malposition, as a result of neglect or imperfect immobilization, or because of the inherent dif- ficulties of the case. If the callus is not consolidated it may be easily fractured by manual force and the fragments then placed in proper position. If consolidation has become complete, it may be necessary to use some form of an osteoclast. The osteoclast holds firmly the part of the bone above the fracture, and by slowly bending the distal seg- ment the fracture can be produced at any desired point. In some apparatus (the Schneider-Mennel) the force is obtained by means of a pulley, traction being exerted upon the fragment to be broken. (h) The open method of reduction has been employed for some time in the treatment of pseudarthrosis and in old cases which have healed in malposition. In this method the fracture is exposed, the connective tissue about the fracture removed, the bone is cut through by a chisel, and the fractured ends are given some definite form, so that they will fit together fairly well. The fragments are then maintained in appo- sition by sutures, ivory pegs, or nails. Frequently it is of advantage to chisel indentations or serrations in the fragments, so that they wall fit together accurately. The open method is frequently emplo^-ed in the treatment of frac- tures when the fragments are widely separated by muscular action — for example, in the treatment of fractures of the olecranon, patella, and os calcis. A number of surgeons (Pfeil-Schneider, Lane, Tuffier, Fritz Konig, ]\Iartin, and others) employ the open method in the treatment of fracturas in which the simple, closed method is employed by other surgeons. Fritz Konig especially is a champion of the open method in the treatment of the various types of fractures. He considers it necessary MECilAMCAL l.NJLltlES OF THE DIFFEUE.NT TISSUES 593 or at least of advantaj^'-c in tlu' treatment of fractures of the shafts of the femur and humerus with marked disphicement or an interjxtsition of soft tissues, of simple fractures of the shaft or ulna to avoid synos- tosis, of multiph' fractures of the lower extremity, for the separation of frajfjiients of bone caused by muscular action, for fractures involving joints with a rotation or dislocation of the fragment into the joint, for fractures associated with a dislocation, and for intracapsular frac- tures of the neck of the femur. The most favorable time to attempt reduction by the open method is at the beginning of the second week (Fritz Konig). At this time the blood has been absorlied, the injured tivssues are in a state of active regeneration, and the blood clot and the fragments of tissue which stinuilate callus formation have become united with the surrounding parts. If an operation is performed early and the loosened tissues and the blood clots are removed, the bone is deprived of the natural stimu- lus sui)plied by them. A deficient callus which predisposes to pseudar- throsis is then apt to form. (c) Tcchnic of Rcduciion by ihc Open Method, Bone Suture, etc. — The fi-agments should be exposed under artificial Lschannia obtained by an Esmarch constrictor or a ]\Iartin bandage. After the ends of the fragments have been freed of fibrous tissue and approximated, they should be united by suture, wire nails, screws, ivory or bone pegs. In applying sutures the bones are first drilled and catgut, aluminum- bronze, or silver wire is passed through the drill holes and tied or twisted after the fragments are placed in apposition. Nickel-plated or silver-plated pins, bone or ivory pegs, silver-plated screws, and the bone plates introduced by ]Mr. Lane may also be used. If the wound can be closed, primary union usually occurs when the neces- sary aseptic precautions have been taken. Frequently deformities are not prevented, even when fractures of the diaphysis are reduced and fixed in the ordinary way by the open method. In these cases it is often advisable to use an intramedullary splint, a piece of bone or ivory peg' being placed in the medullary canal and the fragments being ap- proximated over it. []\Iurphy and Xetf have obtained very good results in a number of cases by sawing off obliquely the ends of one of the fragments and then forcing this end into the medullary cavity of the other fragment. The results are the same as those obtained by use of a medullary splint, with this advantage that there is no foreign body to interfere with the process of repair.] "When the medullary splint is used, a wire which includes the splint should be passed through the bone. After closure of the wound an immobilizing dressing is applied as in simple reduction, and massage and passive motion are begun early. 594 THE MECHANICAL INJURIES Treatment of Delayed Union anel Fscudarthrcjsis. — The treatment of dela^-ed callus formation has already been discussed in the paragraph devoted to the bloodless treatment of pseudarthrosis. Injections of alcohol, oil of turpentine, tincture of iodin, zinc chlorid, lactic acid, or blood freshly -vvithdra^\•n from a vein are employed. Hot baths, massage, and rubbing together of the fragments may be used to stimulate and increase regeneration and calliLS formation. Passive hypera'mia obtained by applying daily an elastic constrictor proximal to the point of fracture for a period of from one to three hours may hasten repair. Ambulatory splints may be of advantage in treating delayed union of the lower extremity', for the irritation to which the fragments are exposed when the patient is walking about hastens the development of bone. In many cases firm union which has been delayed for many months occurs after this treatment. It is a mistake to apply immo- bilizing dressings which cannot be easily removed and prevent early massage and passive motion. Union following reduction by the ox^en method is more rapid and complete when the freshened ends can be brought together directly. If a space remains between the fragments after dissecting out a near- throsis or the fibrous tissue between them, there are a number of plastic procedures which may be resorted to. The defect may be overcome by transplanting bone taken from a neighboring bone; by resection of the neighboring bone, causing shortening of the part; by transplanting a section of dead bone which has been sterilized for some hours. The transplanted bone is attached to the fractured ends by sutures or is wedged into the medullary canal. In some cases it is advisable to take flaps of periasteum and bone from the fractured ends to bridge over the defect (AV. Mueller, von Eiselsberg). In large defects of the tibia the method advised by Hahn, in which the lower fragment of the fibula is saA^Ti through and then inserted into the medullary cavity of the tibia, may be used to advantage. If, on account of the age, the general condition, or lowered resistance of the patient, a pseudarthrosis cannot be treated by the open method, a molded splint of the type suggested by Hessing should be employed. This splint is especially valuable in treating pseudarthrosis of the lower extremity. (b) OPEN INJURIES OF BONES AND CARTILAGE Diflferent forms of wounds occur in bones and cartilage. Injuries of the periosteum and perichondrium are of less consequence than are injuries of bone and cartilage. Simple wounds of the cartilages of the nose, ears, larynx, and ribs are of no special significance, but open in- .Mi:(IIA.M( AL L\.jrRIi:S OF TIIK DIFFERENT TISSUES 595 juries (^ ('(impound fractures) are always serious beeaiLse of the danfjers of infection, and associated injuries of important structures. Com- pound tr;ictures associated with small, rapidly healinfj: wounds may pur- sue much the same clinical course as simple fractures. Fractures asso- ciated with extensive laceration of the soft parts or almost complete separation of the extremity may be of secondary importance when com- I^ai-ed to the gravity of the complications. Relative Frequency of Compound Fractures. — The statistics of Gurlt, AVeber. Moritz, and Billroth show that from 16 to 27 per cent of all frac- tures are compound. The followinii; fig:nres indicate the relative fre- (piency of compound fractures in the different bones : 72 per cent of 88 fractures of the phalanges of the fingers and toes, 44 per cent of 52 fractures of the metacarpal and metatarsal bones were compound, while 17.9 per cent of the fractures of the leg, 11.6 per cent of those of the forearm, 7 per cent of those of the thigh, and 6 per cent of those of the humerus were compound (von Bruns). A compound fracture may be produced by either direct or indirect violence, the object penetrating the soft tissues and fracturing the bone, or the fragments of the bone being forced through the soft tissue by the fracturing violence. A compound fracture by indirect violence may be caused by a displacement of the fragments at the time of the fracture, or from necrosis following pressure due to imperfect reduction of the deformity or careless treatment. Decubitus developing over a sharp edge of a fragment may transform a simple into a compound fracture. Fractures of the nasal bones and of the base of the skull nuLst usually be regarded as compound frac- tures, because the mucous membranes at the seat of the fracture are, as a rule, torn. Fractures produced intentionally in operative work must be con- sidered as a special class of compound fractures. A bone may be sawn or chiselled through in order to gain room for operative work (temporary resection of the mandible in removing a carcinoma of the tongue, of the clavicle, bones of the skull, ribs. etc.). Frequently long bones are divided oljlicpiely or a cuneiform piece is removed to correct malformations due to bowing of the shaft or differences in length. Fractures associated with gunshot wounds form another class of compound fractures. Complete separation of the extremities from the trunk, such as occasionally occurs in explosions, machinery, and railroad accidents, are closely related to compound fractures (Klauber). The same principles should be followed in examining and making a diagnosis of a compound fracture as have been discussed in dealing 596 THE MECHANICAL INJURIES with simple fractures. It is a great mistake, often followed by second- ary infection, to probe a wound associated with a fracture in order to determine whether it is superficial or extends to the point of fracture. Treatment. — In serious cases the treatment should first be directed to counteracting the shock, which frequently is present in compound fractures, to controlling the haemorrhage, and to preventing infection. Von Volkmann maintained that the first dressing determined the fate of the patient and the course of repair. His method (which consisted of opening the wound widely and sterilizing it) has not been employed for some time, von Bergmann having shown that healing frequently occurred under the first dry dressing, incision of the parts and drainage having been omitted. Everyone should be acquainted with the general principles which control the application of the first dressing, for in this way severe in- fections (which so often develop in contused and lacerated wounds) may be prevented. The wound after the clothing is removed should be cov- ered with dry aseptic gauze, or in case of emergency with fresh, clean linen. Some sort of a splint should then be applied to prevent dis- placement of the fragments. Hemorrhage should be controlled by an Esmarch constrictor or by an appropriate bandage. It is exceedingly dangerous to manipulate a compound fracture, to sponge out or irri- gate the wound, and to replace protruding fragments unless the aseptic arrangements are very complete. Acute, progressive suppurative, and gangrenous infections of the soft tissues, pyogenic infections of exposed joints, necrosis of bone, and tetanus may be caused by the undue zeal of some good but ignorant Samaritan. The patient, after being undressed, should be placed on an operating table. During and after the removal of the emergency dressing, the limb should be held by an assistant or assistants. The wound should then be carefully protected from the surrounding parts by sterile towels. If, after examination, a fracture is found, an aneesthetic should be administered. Then while the wound is protected by a sterile dress- ing, the surrounding area should be sterilized. The larger particles of foreign matter should then be removed with sterile forceps, the smaller by gentle irrigation of the wound with a three per cent solution of hydrogen peroxid or physiological salt solution. After thorough cleansing of the wound the fracture is reduced, and if it is thought necessary the fragments should be held in place by a bone suture or some other device. "Whenever it is indicated, counter-openings should be made to provide for drainage. The wound should then be loosely packed with iodoform gauze, which provides MECHANICAL INJlllIluS OF THE DlEEEllE.NT TISSUES 597 eajiillary drainaiic A plastcr-of-Paris baiulau:!' should then be ap- plied. A feiiestnmi shoukl be cut in the east over tlie wound through wliieh tlie dressings can be changed when indicated. In favorable eases the Avound may be partially sutured after the removal of the drainage. It is a mistake to close wounds associated with compound fractures completely, for then an opportunity is afforded the bactei'ia whieh have been carried into the wound to develop. The mildest forms of infec- tion may then become exceedingly virulent. Tetanus developed in two compound fractures whieh were closed by suture in von Bergmann's clinic. Immediate amputation may be indicated if the soft tissues al)out the fractures are badly crushed, if the distal part of the extremity is aniemic and no pulse can be felt, rendering it probable that the prin- cipal artery has been destroj^ed. Occasionally, however, amputation is indicated later even when the limb can be saved, because of the con- tractures following the loss of large areas of skin and the laceration of the muscles. If an extremity is torn off from the trunk, the vessels should be ligated, the projecting fragments cut off, and crushed and contused tissues removed. In the treatment of compound fractures of the fingers and toes, it is advisable to attempt to save the projecting phalangeal fragment, and after the development of healthy granulation tissue, skin-grafting can be resorted to. It may be necessary to incise phlegmons which develop during con- valescence. If an osteomyelitis develops, good drainage should be pro- vided, and the pieces of necrotic bone removed. Suppurative arthritis demands drainage of the joint, resection when the conditions indicate it. xVmputation may be necessary because of a general infection or tetanus. An attempt to improve the function of the part should be made after the infection has subsided. Extension apparatus, passive motion, and massage may be employed for this purpose. jMalposition of the fragments and anchylosis are frequent when the patient is compelled to remain in bed for some time because of the poor condition of the Avound. Not infrequently union is delayed in compound fractures and pseudarthrosis is common. This may be due to the extensive destruction of the periosteum, to infection, necrosis, or resection of the fragments. Literature. — Alberfi, v. Bardelehen, Korsch. Ueber Gehverbande. Chir. Kongr.- Vorhandl., 1894, II, pp. 6.3-93. — Rardenheiier. Leitfaden der Behaudlung \an Frakturen und Liixationen der Extreniitiiten inittels Feder- resp. Ciewichtsextension. Stuttgart, 1890. — BiirdcnhcHcr iind Grdssmr. Die Behandlung der Knochelbriiche init lOxten.sions- verbanden und die daniit erzielten Result ate. Kolner Festschrift, 1904, p. 113. — 598 THE MECHANICAL INJURIES Bayer. Ueber Spiralbriiche an den oberen Extremitaten. Deutsche Zeitschr. f. Chir., Bd. 71, 1904, p. 204. — Beely. Zur Behandlung der einfachen Frakturen der Extremi- taten mit Gips-Hanfschienen. Konigsberg, 1878. — v. Bergmann. Erste chirurgische Hilfeleistungen an Verungliickten, in Meyers erste arzliche Hilfe, Berlin, 1903.— 5ier. Die Bedeutung des Blutergusses fiir die Heilung des Knochenbruches. Med. Klinik, Bd. 1, Heft 1, 1905. — Bliesener. Ueber die durch die Bardenheuersche Extensions- methode an den Briichen der unteren Gliedmassen exhaltenen funktionellen Ergebnisse. Deutsche Zeitschr. f. Chir., Bd. 55, 1900, p. 276.— Blohm. Ueber Vereiterung sub-, kutaner Frakturen., I.-D., BerUn, 1898. — P. Bruns. Die Lehre von den Knochen- briichen. Deutsche Chir., Stuttgart, 1886.— Sum. Die Entwicklung des Knochenkallus unter dem Einflusse der Stauung. Arch. f. khn. Chir., Bd. 67, 1902, p. 652.—Demisch. Ueber Temperatursteigerungen bei der Heilung subkutaner Frakturen. I.-D., Zurich, 1885. — V. Eiselsberg. Zur Heilung grosserer Defekte der Tibia durch gestielte Haut- periostknochenlappen. Chir. Kongr.-Verhandl., 1897, II, p. 278;— Die heutige Behand- lung der Knochenbruche. Deutsche KHnik, Bd. 8, p. 521, BerUn, 1903. — Flatu. Muskelatrophien nach Frakturen, etc. Zentralbl. f. Grenzgeb., 1902, p. 305. — Franke. Behandlung komplizierter Frakturen. Arch. f. klin. Chir., Bd. 62, 1901, p. 680. — Hahnle. Die gerichtsarzliche Beurteilung schlecht geheilter Frakturen und Luxationen, wenn in Frage steht, ob Kunstfehler vorliegt. Deutsche Medizinalzeitung, 1903. — Hdnel. Ueber Frakturen mit Bezug auf das Unfallversicherungsgesetz. Deutsche Zeitschr. f. Chir., Bd. 38, 1894, p. 129. — Helferich. Atlas und Grundriss der traumati- schen Frakturen und Luxationen. Mixnchen, Lehmann, 1903. — Hoffa. Lehrbuch der Frakturen und Luxationen. Stuttgart, Enke, 1904. — Jordan. Die Massagebe- handlung frischer Knochenbrlicke. Miinch. med. Wochenschr., 1903, p. 1148. — Jottkowitz. Ueber Heilungsresultate von Unterschenkelbriichen mit Bezug auf das Unfallversicherungsgesetz. Deutsche Zeitschr. f. Chir., Bd. 42, 1896, p. 610. — Klauber. Ueber komplizierte Frakturen der Extremitaten. Beitr. z. klin. Chir., Bd. 43, 1904, p. 319. — Fritz Konig. Ueber die Berechtigung friihzeitiger blutiger Eingriffe bei subkutanen Knochenbriichen. Arch. f. klin. Chir., 1905. — Kristinus. Bericht iiber 130 Gehverbande. Wien. med. Wochenschr., 1902, No. 51. — Loew. Kondylenbriiche des Kniegelenkes. Deutsche Zeitschr. f. Chir., Bd. 44, 1897, p. 422. — Lossen. Grundriss der Frakturen und Luxationen. 1897. — Lucas Championniere. Traitement des frac- tures par le massage et la mobilisation. Paris, 1895; — -Quelles sont les fractures qui peuvent etre traitees sans appareil mamovible par le massage et la mobilisation? Resul- tats de ce traitement. Zentralbl. f. Chir., 1900, p. 1303. 13. internat. mediz. Kongress, Paris. — Matas. Remarks on some Controverted Questions in the Treatment of Frac- tures. Zentralbl. f. Chir., 1902, p. 777. — W. Muller. Ueber die heutigen Verfahren der Pseudarthrosenheilung. v. Volkmanns Samml. klin.Vortr., No. 145, 1896. — Reichel. Zur Behandlung schwerer Formen von Pseudarthrosis. Chir. Kongr.-Verhandl., 1903, II, p. 239. — Riedinger. Die ambulatorische Behandlung der Beinbriiche. Wiirzburg. Abhandl., 1902, Bd. 2, Section 9. — Svdeck. Zur Altersatrophie und Inaktivitats- atrophie der Knochen. Fortschr. auf dem Gebiete der Rontgenstrahlen, Bd. 3, 1900. — Valenzuela. Erfolge der Behandlung durch Bewegung und Massage in 61 Frakturfallen. Zentralbl. f. Chir., 1901, p. 666. — v. Volktnann. Die Behandlung der komplizierten Frakturen. Samml. klin.Vortr., 1877, Nos. 117-118. — Die Krankheiten der Bewegungs- organe. In Pitha-Billroths Handb. d. Chir. — ■/. Wolff. LTeber die Wechselbezie- hungen zwischen der Form und der Funktion. Leipzig, 1901. — Wolkowitsch. Ueber die von mir angewandten Behandlungsmethoden der Bri'iche der grossen Extremitaten- kiiochen, etc. Deutsche Zeitschr. f. Chir., Bd. 63, 1902, p. 203.—Ziegler. Ueber das mikroskophische Verhalten subkutaner Briiche langer Rohrenknochen. Deutsche Zeitschr. f. Chir., Bd. 60, 1901, p. 201. MECHANICAL INJURIES OF THE DIFFERENT TISSUES 599 X. INJURIES OF BODY CAVITIES AND DIFFERENT VISCERA These injuries may be subcutaneous or open; naturally the two forms are frecjuently combined. Subcutaneous injuries are produced by blunt force, such as a fall or a blow. In many cases the symptoms are those of internal haemor- rlia.ije. The symptoms may differ a great deal, depending upon the organs or organ injured. I hematomas of the cranial cavity following lacerations of the me- ningeal arteries or the cranial sinuses give rise to most serious symptoms. Ihemorrluige from the middle meningeal artery, associated with a frac- ture of tlie skull or contusions, is especially dangerous, as the blood forces its way between the dura mater and the skull, giving rise to the symptoms of brain pressure which is often followed by death. Subcutaneous injuries of the abdomen may be associated with the laceration of large vessels or the rupture of a vascular viscus. So much blood is then lost rapidly, unless the hannorrhage is checked, that death soon occurs. The dangers of haemorrhage into the chest cavity are not so great as those of pressure exerted by the extravasated blood, except when the heart is ruptured. In injuries of the chest hfemorrhage may occur from the intercostal and internal mammary arteries, from the lung which has been pierced by a fractured rib, or from some of the hirger vessels about the heart. After very forceful compression of the abdomen and thorax, an extravasation of blood into the tissues of the neck and head, associated with disturbances of vision, may occur. According to Perthes, Braun, and Sick the extravasation of blood in these cases is due to a sudden in- crease of pressure in the capillaries with subsequent rupture of the same as the result of the ra]ud increase in intrathoracic pressure. In these cases it is probable that the lungs are distended and that the glottis is involuntarily or reHexly closed, thus preventing escape of air from the lungs when the pressure is exerted. Of the subcutaneous injuries, those of the brain, such as are asso- ciated with injuries and fractures of the skull, are the most impor- tant. Contusions and lacerations of the spinal cord accompany frac- tures of the vertebrae. Laceration of the lung and rupture of the heart may be associated with fractures of the ribs. The same lesions nuiy occur, however, without fracture of the bones surrounding these organs. Subcutaneous injuries of the abdomen may be associated with rupture or extensive laceration of the liver and spleen followed by fatal ha^iior- rhage, or with rupture of the stomach and intestine followed by a rapidly developing fatal peritonitis. The urinary bladder is readily ruptured when full, if a blow is delivered upon the abdomen. In 600 THE MECHANICAL INJURIES fractures of the pelvis the bladder may be lacerated by the displaced fragments of bone. The kidney may be torn, lacerated, or completely separated from its pedicle as a result of a subcutaneous injury'' of the abdomen. Open wounds of the body cavities are most frequently caused by knives, stilettoes, or projectiles; occasionally by sharp pieces of iron, pickets, canes or umbrellas, axes and scythes. Hgemorrhage and infec- tion, which latter is carried in with the vulnerating force or develops after rupture of a hollow viscus, are the principal dangers. Extensive open injuries are often caused by explosions. The symptoms, diagnosis, and treatment of these various injuries are fully discussed in text-books devoted to special surgery. Literature. — -v. Bergmann, v. Bruns, v. Mikulicz. Handb. d. prakt. Chir. Enke, Stuttgart, 2. Aufl. — Konig. Lehrbuch der speziellen Chirurgie. Hirschwald, Berlin, 8. Aufl., 1904. — Milner. Die sog. Stauungsblutungen infolge Ueberdruckes im Rumpf. Deutsche Zeitschr. f. Chir., Bd. 76, 1905, p. 85. — Perthes. LTeber ausgedehnte Blutex- travasate am Kopf infolge von Kompression des Thorax. Deutsche Zeitschr. f. Chir. Bd. 50, 1899, p. 4,36;— Ueber Druckstauung. Ebenda, Bd. 55, 1900, p. 384. XL GUNSHOT WOUNDS Gunshot wounds demand special consideration. They may be caused by firearms of small caliber or by artillery. WOUNDS CAUSED BY FIREARMS OF SMALL CALIBER Small shot and ordinary bullets are made of either soft or chilled lead and are round, conical, or shaped like an acorn. The bullets used in the army are made of chilled lead, and are completely or partially jacketed with steel or some other metal. Rifles used at the present time are of much sujaller caliber f0.25"-0.31") than those formerly employed (0.44"-0.50"). Wound of Entrance and of Exit — Wound Canal. — Bullet wounds have a wound of entrance, a canal, and if the projectile perforates, a wound of exit. The wound of exit is usually larger than the wound of entrance, and has irregular, jagged outlines. The wound canal may be straight. The projectile when partially spent may be deflected by bone or resist- ant tissue, and then the canal will be curved. The diameter of the canal corresponds to the diameter of the projectile. The canal near the wound of exit may be funnel-shaped. Under certain conditions the tissues sur- rounding the canal are lacerated. This is especially apt to be the case when the projectile has a high explosive force. There may be multiple wounds when a bone is comminuted and the fragments are driven through the skin, or when the projectile explodes. MECHANICAL INJURIES OF THE DIFFERENT TISSUES 601 The form of a gunshot wound depends upon the character of the projectile, the vek)city with which it travels, and the range at which the projectile is tired. Soft projectiles which are altered in form or split into a number of fragments by bone or resistant tissue cause more extensive wounds than hard projectiles or those which are partially or completely jacketed. Jacketed bullets do the most damage when fired at a range of about 200 yards, for at this distance the small caliber projectile has a high initial velocity and great potential force. Bullets made of soft lead or soft compounds which permit of mushrooming when they come in con- tact with solid or resistant tissue lacerate the tissues, producing enor- mous cavities and large wounds of exit. Because of this mutilating action the use of the soft-nosed or Dum-Dum bullet and of tJie hollow- FiG. 229. -I)estructk)X of the Elbow Joixt Cavsed by .\ Leaij-poixted (Dcm-Dim) Bullet Fired at Close Raxge. nosed bullet has been prohibited by the International Peace Congress meeting at The Hague. The form of even a completely jacketed bullet may be altered by .striking a rock or some other very hard object before it enters the body. Powers of Penetration. — The penetration depends upon the initial velocity of the proji-etile and upon its potential force and hardness. Small pointed projectiles have greater penetrating force than large round ones. The full-jacketed projectile used in modern rifles has a penetrating power which enables it to pass through a number of bodies when fired at a range of from 600 to 1.000 yards. It therefore pene- trates more deeply, lodges less frequently, causes much less damage, and 39 " 602 THE MECHANICAL INJURIES has smaller wounds of entrance and exit and a narrower canal than the lead bullets which were formerly used. Frightful wounds are associated with gunshot injuries of bones and of those organs which contain fluids or of encapsulated tissues rich in fluids, such as the skull, the heart, the full stomach and intestines, the liver, spleen, and kidney. The greatest damage is probably inflicted when the projectile is fired at close range and has a high initial velocity. The minimum of damage is inflicted by a projectile with a medium velocity, while a bullet which is well spent inflicts a little more. The sjonptoms of a gunshot wound naturally depend entirely upon the tissues or the viscera which are injured. Gunshot wounds of the heart, brain, and large vessels are usually fatal, death occurring im- mediately or soon after the reception of the wound. Symptoms of a Gunshot Wound. — The first symptom is usually a short sharp pain. The pain associated with wounds inflicted by projectiles of small caliber may be very slight, and even in gunshot wounds of the Fig. 230. — Roentgen-ray Picture of Fig. 229. abdomen and chest it is frequently compared to the pain associated with a wound produced by a small stone. The impact is more painful when a bone, joint, or nerve is injured. A gunshot wound of the brain causes unconsciousness, of the spinal cord paralysis. Sensation is rapidly lost in the tissues about a gunshot wound. In severe injuries the part of the body involved may be cool, pale, incapabh^ of motion, and MECIIANKAL LNJIRIKS OF THE DIFFERENT TISSUES 603 without sensation. This local wound shock may pass over into general shock. Haemorrhage. — The amount of hiemorrhafre varies. The smaller the cutaneous woimd and the narrower the canal, the less marked the ex- ternal hu'inorrhaue will be. The canal is quickly closed by clots, and besides the tension planes in the tissue diit'er, so that when the tissues are divided the canal is quickly closed by their overlapping. The amount of external haemorrhage may be small, even when large vessels are injured. In such a case, however, an extensive ho'matoma may form in the soft tissues and in the body cavities, and even after the injury of a small vessel the hannorrhage may be great enough to cause death. The elastic vessels were often pushed aside and escaped injury when the old-style lead bullets were used. The modern small steel-jacketed ])ullet passes directly through the artery or cuts it off, and is very apt to cause severe haemorrhage (von Bergmann). When the wound is small internal ha'morrhage is much more to be feared than external haniiorrhage ( Kiittner ) . Varieties. — Gunshot Wounds of the Skin. — Gunshot wounds of the skin present the greatest variety. A spent bullet causes merely a con- tusion of the skin. If the bullet strikes the surface of the body ver- tically the wound of entrance will be round. It will correspond in size to the caliber of the bullet. A wound caused by a steel-jacketed bullet is smaller than the projectile, as the pointed nose of the bullet makes the skin tense before it perforates. The margins of the wound are more or less contused, and frequently the wound itself is funnel-shaped. If the skin lies directly over bone the margins of the wound may be everted, and in this case the w^ound will be larger than when soft tissues intervene between the skin and bone. If the projectile has been fired at very close range, the skin surrounding the wound will be burned and filled with deeply imbedded grains of powder, the removal of which is very painful. Some of the superficial grains may be discharged if an artificial inflammation of the skin is produced by a one per cent subli- mate solution (Hebra). If the weapon is fired at very close range, as in attempts at suicide, the skin or mucous membrane may be badly lacer- ated by the gases formed when the powder explodes. In a simple gun- shot wound of the soft tissues the wound of exit is similar to the wound of entrance. "When, however, the explosive action is great, the wound of exit is much larger than the wound of entrance, and has notched, irregular, and undermined edges beneath which lie shreds of tissue and splinters of bone. Large gaping wounds of exit are caused by lead bullets of large caliber and by partially jacketed bullets fired at ranges varying from a few feet up to 200 yards. If the projectile strikes at an angle, the wounds of entrance and exit 604 THE MECHANICAL INJURIES will be large and oval or irregular, if the form of the projectile has already been altered by striking some hard object. Multiple wounds of entrance and exit may be produced by the modern small-caliber projectile if it perforates different parts of the body, cutaneous folds, or muscular prominences. A projectile striking the body tangentially produces long, grooved wounds, the edges of which are undermined. If the bullet passes just beneath the skin, the course of the wound canal will be indicated by ecchymoses. If the bullet is perfect the canal will be smooth and narrow, corre- sponding in size to the diameter of the former. If the bullet is fired at short range, if its form is altered by coming in contact with bone, or if its explosive force is great, the tissues along the wound will be exten- sively lacerated and the wound of exit will be large. Injuries of Vessels. — Contusion of vessels with subsequent necrosis of their walls occurs in both penetrating and perforating gunshot wounds. Small arterial wounds caused by jacketed bullets are much like other wounds of the arterial wall and end in scar formation with complete healing or in the development of an aneurysm. An arterio- venous aneurysm may develop if the projectile passes between an ar- tery and a vein, injuring corresponding parts of the walls of both vessels. Injuries of Nerves. — Complete division of peripheral nerves is more frequently caused by large lead bullets than by the small jacketed ones. The latter may penetrate a nerve, merely making a slit in it, even when the nerve is of the same diameter as the bullet. The symptoms of an incomplete paralysis which follow such an injury disappear after a few weeks. Neuralgia and neuritis are frequently caused by a bullet lodged immediately adjacent to a nerve. Injuries of Bones. — A bone may be contused, fractured, or perfor- ated by a projectile. A soft-lead bullet, the form of which is easily altered, when traveling with but little velocity becomes flattened out when it strikes bone and causes merely a contusion, associated with an extravasation of blood beneath the periosteum and into the bone mar- row. Occasionally the projectile does not perforate the skin, merely contusing the latter and producing a subcutaneous fracture. Jacketed bullets fired at close range perforate spongy bones and the ends of long bones. If the projectile passes at right angles to the bone, it produces a straight canal, the wound of exit being larger than the wound of entrance. If it strikes tangentially, a groove is formed in the bone. The large soft-lead bullets formerly used comminuted and fis- sured the bones and lodged in the spongiosa, lacerating it. They rarely perforated the bone. MECHANICAL INJURIES OF THE DIFFERENT TISSUES 605 The dia{)liyses of Umpths by the direct action of the heat (most commonly by contact Avitli red-hot metal or flames), and a hard, insen- sitive, sometimes yellow, at other times brown or black mass, the vessels of which are closed by thi-ombi, forms. This mass, like any other form of necrotic tissue, is separated from the surrounding parts by the de- 624 THERMAL INJURIES velopment of granulation tissue. Tlie escliar following freezing develops slowly, while that following burns develops immediately. Burns of the first and second degree are usually found in the area surrounding the eschar. During the separation of the necrotic mass mild pyogenic and putrefactive infections, accompanied by local and general symptoms, frequently develop. Occasionally the separation of an eschar involving deep tissues is followed by the opening of joints and body cavities, the erosion of large blood vessels, thrombosis and em- bolism, and the devel- opment of chronic sup- puration ending in amyloid degeneration of the viscera. When the eschar is cast off a granulating wound, which is in- clined to form exces- sive amounts of scar tis- sue when contraction occurs, is exposed. The radiating, red and hard, frequently keloidlike scars which follow burns are to be feared, not only because they are disfiguring, but also because they frequently cause adhesions be- tween different parts, thus interfering with the functions of the same. Scars upon the face and neck produce frightful disfigurement (ectropion of the lids and lips and cicatricial adhesions, for example, between the chin and neck) . Developing in the groin, in the pop- liteal space and axillary fossa, about the elbow, and upon the flexor sur- face of the wrist joint, they may cause contractures. The arms may become immovably attached to the thorax when a burn involving corre- FiG. 2 WHICH |i>i,l,i»\\ l-,l> fill-. Jll.Al.iNl BY Hoii.iNfi Watdu. 1 1: Chin and Chest !■ A ScAi^D Produced BURNS 625 si)()iuliii^f sui-rnces of these two i);irts cicjiti'izcs (Fig. 238). If traction is contiinuiUy exerted upon a scar, lissures develop whi(;li suppurate and .^ Fig. 238. — Cicatricial Adhesions betwekn the Arm, Thorax, and JAack FOLLOWING Scalding. lead to the t'oi'iuation of chronic nlcers. Occasionally a carcinoma de- velops within such an ulcer. The ti-eatnient is the same as described Avlien disenssinp; burns of the second degree. 'I'he crust foi-med by the desiccation of the secretion is the best protection against i)utrefactive infections. The area may l)e dre.ssed with ])ismuth ])owder until the burns of the second degree are healed. As soon as the granulation tissue begins to secrete pro- 626 THERMAL INJURIES fiisely, dry dressing (which should be changed frequently) should be applied. In extensive burns, after separation of the necrotic tissue, cleansing of the granulation tissue may be hastened by placing the patient in a warm-water bath. The same results may also be obtained by the use of ointments and moist dressings. If the granulating wound appears clean, skin-grafting should be performed at once, in order to reduce to a minimum the amount of cicatricial tissue. If the scar is disfiguring or interferes with function, it is often advisable to excise it and to graft the resulting wound. If the scar is extensive, it may be neces- sary to perform a number of operations, or merely to excise the part of the scar which causes the greatest functional disturbance. An at- tempt may be made to soften the scar by injecting thiosinamin, if exci- sion is not desired or is impossible. Secondary phlegmons, M^hich develop most commonly during the sep- aration of the eschar, should be incised. If they are associated with severe general infection, amputation should be considered. Carbonization. — Carbonization is observed in cadavers found after fires and mine explosions. Single extremities or parts of the same may be carbonized when molten metal is poured over them. An imbecile or insane person occasionally holds an extremity in the fire until carboni- zation occurs. The burned part, when carbonized, becomes transformed into a charred, brittle mass which requires amputation. Generar Symptoms. — General symptoms are wanting if the area af- fected is small and there is no infection. If the temperature is carefully observed it will often be found that a general reaction accompanies even the milder burns. The temperature gradually rises, returning to normal in about twelve days, and albumoses, indicating increased destruction of albumins, appear in the urine (Wilms). If more than one half of the surface of the body is burned, inde- pendent of the degree of the burn, severe general symptoms, which almost always terminate fatally within the first few days, may develop. Any burn that involves one third of the surface of the body is serious, and is apt to prove fatal. This fact was first emphasized by Billroth. Even if the individual withstands the immediate shock of an extensive burn and the general symptoms which develop during the first few days, he may die later of infection or pneumonia. A badly burned patient is at first conscious, but has no idea of the gravity of his condition. Tie is restless, throws himself about, cries out with severe pain, pleads for relief, and complains of great thirst. The unburned skin is white; the temperature is two or three degrees lower than normal. I'his reduction in temperatin-e is partly due to the rapid radiation of heat from the capillaries which are exposed in the burned BURNS 627 area, and partly to cardiac weakness. Vomiting, occurring soon after the burn is received, is a bad prognostic sign. In the severest cases the patient becomes apatlictic and unconscious in a few hours; the pulse becomes small antl rapid; the respirations very rapid and superficial. Vomiting, diarrhcpa, cyanosis, delirium, clonic spasms, coma, and col- lapse, which are more pronounced in some cases than in others, com- pleti' the clinical picture, which soon ends in death. The urine is scanty; anuria may be present. Frequently the temperature rises rap- idly before death. Because of the rapid radiation (tf heat from the skin, the rectal tem])ci-ature may be three or four degrees higher than the axillary temperature. Pathological Anatomy. — The pathological changes found by post- mortem examination are so slight that they can scarcely account for death. A'enous congestion of the viscera and of the cranial sinuses; slight Q'deuui of the brain and its membranes; ecchymoses of the mucous membrane of the gastrointestinal tract, of the muscles, and of the serous membranes ; rarely duodenal ulcers following thrombosis and subsecjuent digestion of the necrotic area, and often slight parenchynuitous degen- eration of the kidneys are found. Causes of Death. — Opinions dififer widely concerning the cause of death following burns when it is not due to secondary diseases and in- fection. Sonnenburg believes that death following immediately the reception of a severe burn is due to overheating of the blood. In other cases death is due apparently to a combination of different causes. In some cases death is probably due to the destruction of red corpuscles, and the injury done the kidneys by the excretion of degeneration prod- ucts; in other cases to the shock following a reflex loss of vascular tone and secondary cardiac paralysis ; and in still other cases to extensive capillary thrombosis following the degeneration of blood corpuscles. Recent investigators lay more stress upon the diminutiini in the amount of blood plasma as the cause of death, especially in burns of the second degree (Wilms), and upon the absorption of toxic substances from the burned area, especially in burns of the third degree. Thf^se toxic sub- stances, when absorbed, probably interfere with the metabolism of albu- mins (Wilms) and cause degeneration and inflammatory changes in the viscera, especially in the brain (Dohrn). It has not been possible, how- ever, to demonstrate toxic substances in the burned tissues (Ilelsted) or in the blood (Burkhardt). Therefore the solution of the red cor- puscles is not to be regarded as due to toxins, but the result of the direct action of the heat (Burkhardt, H. PfeiftVr, Ilelsted). Indications for Treatment. — The indications in the treatment of severe burns are: (1) To control pain; (2) to combat shock; (3) to restore the fluids which are being lost by the exti*avasation of serum; 628 THERMAL INJURIES (4) to aid in the elimination of* toxic materials from tlie body; (5) to jjrevent infection. If collapse is threatened, subcutaneous or intra- venoiLS injections of salt solution should be given. The loss of heat fol- lowing the destruction of large areas of skin is often followed by col- lapse. It should be counteracted by placing the patient in a warm bed and enveloping the uninjured parts of the body in cotton and warm clotlLs. It is often advisable to float the patient in a bathtub filled wdth warm water. X-ray Burns.— X-ray burns, resulting from too close, too long, and too frequent exposures, are divided into the acute and chronic. They do not appear immediately after exposures, but become evident some- what suddenly after a week. In the mild cases there may have been no premonitory symptoms after the exposure, except a slight transitory redness. In the acute cases the pathological changes correspond to those already described in discussing burns. The mild burns are character- ized by erythema, the severe ones by the formation of vesicles, the severest by the destruction of tissue. When the eschar is cast off, the painful X-ray ulcer remains. The mildest changes consist of a falling out of the hair in the area exposed to the rays. All these changes gradually disappear within a number of weeks. The hair grows again after six or eight weeks and the ulcers heal. The skin in which vesicles have formed frequently remains atrophic. The chronic lesions which not infrequently develop, even w^hen the exposures are made by skilled physicians and technicians, consist of atrophy of the glands of the skin and falling out of the hair, of atro- phy of the skin with abnormal pigmentation and fissuring of the nails, and of the development of painful, progressive, chronic ulcers. Other changes w'hich are frequently associated with an obliterating endarter- itis may also develop (Miihsam). The number of X-ray burns have been greatly reduced of late by carefully regulating the time of exposure, and by using lead plates and other devices which protect the parts. Similar pathological changes have been observed after the use of radium (Halkin). The same treatment should be employed for these lesions as already advised in discussing burns. Lightning-stroke. — Lightning may lacerate or burn the part which it strikes. Burns produced by it are often accompanied by severe shock (.Sonnenburg). The shock produced by a lightning-stroke is, as a rule, followed by immediate death caused by a paralysis of the vasomotor and respiratory centers. An individual ^ho is not killed instantly presents the symp- BURNS 629 toms of cerebral concussion. An individual who has suffered a light- ning-stroke becomes unconscious and niotioidess, the pulse is weak and slow or cannot be felt, the respirations are superficial, the extremities are paralyzed, and there is no response to external stimuli. These symp- toms may subside within twenty-four hours or more slowly, the con- valescence extending over a period of many weeks. Often a feeling of anxiety and unrest and a paralysis of some of the muscles remain. As a rule these disappear completely, but it may be a long time before the condition of the patient may be regarded as normal. People surround- ing an individual who is struck by lightning are usually stunned, but the effects are transitory and rapidly disappear. The lacerating force of lightning is so great that not only may the clothing be torn in shreds, but an entire extremity nuiy be torn from the trunk. Other injuries are often sustained, as the individual may be forcibly thrown to the ground or hurled some distance by the shock. Besides burns of different degrees, there are also found the points of entrance and exit of the lightning, the course of which may be traced in the skin and deeper tissues. Deep, round eschars, which correspond to the areas burned in the clothing, are often found in the skin. Red- dish brown streaks with vinelike branches and markings radiate in various directions through the skin from the point of entrance. The so-called " lightning figures " are caused by burns of the cutis, by laceration of the cutaneous vessels, and coagulation of the extravasated blood. At the point of exit of the lightning the skin is perforated at a number of points, the skin surrounding the perforations being charred and discolored. Burns, often of the third degree, may be found where the clothing is applied closely to the body, or where there is metal (but- tons, coins, spectacles), which is melted by the lightning. In the treatment an attempt should be made to correct the cardiac and respiratory disturbances by cardiac massage and artificial respira- tion and by administering cardiac stinudants. The paralyses which remain after recovery should be treated by electricity and massage. The bums should be dressed as described above. Sunstrokes and Heat Strokes. — Sunstrokes and heat strokes, which not infrequently terminate fatall}', are usually due to a high elevation of body temperature. Sunstrokes are caused by the direct action of the sun's rays upon the body, especially upon the bare head, of individuals who work or sleep in the sun. The prodromata, consisting of severe headache, dizziness, ringing in the ears, and spots before the eyes, are rapidly followed by unconsciousness associated with convulsions. The face is reddened and injected, the skin hot, the pulse rapid and weak. The temperature may rise to 109° F. or higher. Death may occur within a fcAv hours as a result of cardiac paralysis, the patient not having re- 630 THERMAL INJURIES gained consciousness. In less severe cases the patient may gain con- sciousness after a longer or shorter period and recover completely, if the body temperature is reduced by sponging or by an ice-pack. Post- mortem examination reveals in these cases a hypersemia of the mem- branes of the brain and a cerebral oedema. Heat stroke is due less to overheating of the body by the action of external heat than to an interference with the radiation and conduction of heat produced by metabolism and muscular activity. In the tropics a heat stroke may be caused by an interference in the loss of heat alone, while in temperate climes there is also, as a rule, an increased formation of heat resulting from muscular action (Musehold). People who succumb most easily and frequently to heat strokes are those who are com.pelled to perform hard physical labor in humid weather, and who wear clothing which interferes with evaporation from the skin. Heat stroke is very common in soldiers when marching in closed columns in hot weather and in alcoholics. Profuse sweating, weakness, distress, and great thirst are the pro- dromata. Severe headache, dizziness, a feeling of anxiety, and vomit- ing rapidly follow. The speech becomes thick, the sight dim, the patient holds himself erect with difficulty, or staggers until he suddenly falls, and becomes unconscious and motionless. The face is puffy and cya- notic; the pulse is rapid and thready, if palpable. The heart-tones are weak, often irregular; the breathing is superficial and rapid; the skin is dry and hot ; the clothing is wet ; the temperature is 104° or 105° F. ; the reflexes are diminished or lost; the pupils are narrow and scarcely react. Sometimes general clonic spasms, associated with rigidity of the muscles of mastication and of the back, develop. A majority (sixty-six per cent) of the severe cases die within a few hours of cardiac paralysis. The milder cases recover, but even when convalescence is well established, disturbances of the central nervous system (headache, dizziness, impaired memory, transitory mental eon- fusion) and cardiac weakness remain. Post-mortem examination reveals a venous congestion similar to that which occurs in asphyxia, systolic contraction of the left ventricle and dilatation and filling of the right, indicating cardiac paralysis. A heat stroke is to be regarded as a carbonic acid intoxication due to exhaus- tion of the cardiac and respiratory centers following excessive physical effort and interference with the mechanism controlling the loss of heat. Treatment demands, as in sunstroke, an immediate reduction of body temperature and stimulation of the heart. Artificial respiration and cardiac massage; injections of camphorated oil; rubbing of the skin; the pouring of cold water over the body and the use of ice-packs; the administration of large amounts of water, or, if the patient cannot BURNS 631 s\vall«iw, ivctal injection of pliysioloyieal salt solution, are of great value. The prodroniata of a heat stroke are hest treated by removing the patient to a eool, shaded spot, by loosening the clothing, and by admin- istering large qiiajitities of water. A heat stroke may be avoided by wearing proper clothing, by drinking freely of small (piantities of water, mild tea or eoflt'ee, and by the avoidance of alcoholic drinks. L1TER.A.TURE. — V. Bardeleben. Ueber Behandlung von Verbrcnnungen. Deutsche med. Wochenschr., 18!>2, Xo. 23. — Burkhardt. Ueber Art unci Ursache der nach ausgedehnten Verbrennungen auftretenden hiiniolytischen Erscheinungen. Arch, f. klin. Chir., Bd. 75, 1905, p. 845. — Dohrn. Zur pathologischen Anatomie des Friihtodes nach Haut verbrennungen. Deutsche Zeitschr. f. Chir., Bd. 60, 1901. — Eyff. Die Hypothesen iiber den Tod durch Verbrennen und Verbriihen im 19. Jahrhundert. Sammelreferat (1835 bis 1900). Zentralbl. f. d. Grenzgeb., Bd. 4, 1901, p. 428.— Halkin. Ueber ilen Einfluss der Becquerelstrahlen auf die Haut. Arch. f. Dermatol, u. Syphil., Bd. 65. — .4. Hiller. Der Hitzschlag auf Marschen. Bibliothek von Coler-Schjerning, No. 14, 1902. — Kienbock. Zur Pathologie der Hautveranderungen durch Rontgen- bestrahhmg bei Mensch and Tier. Wien. med. Presse, 1901, No. 18. — Musehold. Sonnenstich, Hitzschlag. In Eulenburgs Realenzyklopadie, 3. Aufl., 1899, Bd. 22. — • Miihsam. Ueber Dermatitis der Hand nach Rontgenbestrahlung. Arch. f. klin. Chir., Bd. 74, 1904. — Sacconaghi. Sulle alterazioni anatomo-patologiche degli organi interni in seguito a scottatura. Lo sperimentale, 1901, Nos. 5-6 (Hildebrands Jahresber., 1901, p. 174). — Sonnenburg. Verbrennungen uml Erfrierungen. Deutsche Chir., 1879. — Tschmarke. Ueber Verbrennungen. Deutsche Zeitschrift f. Chir., Bd. 45. — Wilms. Studien zur Pathologie der Verbrennungen. Mitteil. aus d. Grenzgeb., Bd. 8, 1901. IV. GENERAL RESULTS OF INJURIES CHAPTER I COLLAPSE, SYNCOPE, SHOCK CoLiiAPSE, syncope, and shock will be considered together, as they are closelj^ allied conditions. They follow frequently, although not ex- clusively, injuries of all sorts, and are characterized by a sudden depres- sion of all the vital forces, which may be transitory ending in recovt " or may be fatal. The clinical pictures are very similar, and often ^ are due to common causes, and therefore it may be readily under' )d that frequently one passes into the other. Collapse. — The most prominent symptoms of the condition known as collapse are a sudden giving way of the strength of the individual and a weakening of the heart. There are a number of different causes of collapse, such as severe ha?morrhage occurring in accidents c?r oper- ations; injuries of the heart, overexertion of the latter in valvular ':ns- ease, myocarditis, and disease of the cardiac vessels, and when sudden demands are made upon it, as in pulmonary embolism, when one of the larger branches of the pulmonary artery is occluded and the part of the lung supplied by it is thrown out of action ; anemia of the brain, due to embolism, or occurring when an anaemic patient or one recover- ing from an anaesthetic is placed in an upright position; poisonings (with snake venom, long-continued anaesthesia, with chemical agents) and bacterial intoxications in which, according to Romberg and others, a central paralysis of the vessels is the principal cause of collapse. Symptoms. — The symptoms are pallor or cyanosis of the face; cold sweat; cold, usually cyanotic, extremities; dilated pupils; small, rapid, scarcely palpable, irregular pulse; mild delirium; superficial breath- ing (either rapid or slow) : after a short time a clouded mentality, or just before death loss of consciousness; vomiting, and a marked fall of temperature (95° to 96° F.) even in febrile disease. These symptoms may develop in rapid succession, death occurring quickly or after slight temporary improvement, if the heart action cannot be maintained. 632 COLLAPSE, SYNCOPE, SHOOK 633 Treatment. — If collapse occurs tlie f)iili('iit should l)c placed in tli<' head-down posture, which should he ninitilaiiied. Injections of cain- phornted oil should be given to stimulate the heart. A hyixxleniiic syriiieel'ul of this oil may be given every fifteen ininutes until the con- dition is i-elieved. In collapse due to luemorrhage, i)liysiological salt solution should be given subcutaneously oi" inti-avenously, depending upon the urgency of the case. Saline transfusions ai'c also very valu- able in collapse associated with poisonings and general infections. Arti- ficial heat should be supplied by wrapping the patient in warm blankets or by placing hot-water bottles about him. Whisky may be adminis- tered by mouth if the patient is conscious and can swallow, or may be given by rectum with hot coffee. [Crile has made some important observations on resuscitation when collapse from any cause has reached the stage of suspended animation: that is, when the circulation and respiration have ceased. He describes the method in Keen's " System of Surgery," Vol. I, p. 945, as follows: " The patient is placed in the hori''ontal or head-down position. The tongue is held well forward, rapid, rhythmic pressure is applied upon the chest over the heart, thci , j^' providing sufficient artificial circulation during the insertion of tb'^ infusion canula directed toward the heart into the peripheral artery or vein. As soon as the salt solution begins to flow into the ves- sel, thrust a needle of a hypodermic syringe filled with adrenalin chlorid (1:1,000) through the rubber tube near the canula, and during about one nnnr.te inject from 10 to 30 minims. In suitable eases the heart will promptly begin vigorous beating, and after some time spontaneous respiration will be established. The circulation should be closely ob- served, and should there be evidence of failure, a continuous intra- venous infusion of a 1 : 20,000 solution of adrenalin chlorid in normal soluticm should be given as long as recpiired, at the rate of 2 to 3 c.e. per minute. In the mean time the extremities and the abdomen should be firmly bandaged over plain cotton, or the rubber pneumatic suit should be applied."] Syncope. — Syncope is a sudden, usually transitory, loss of conscious- ness due to reflex anaemia of the brain caused by psychical influences. It occurs most freriuently in nervous, irritable women and in men addicted to alcohol. The sight of blood or surgical instruments, the change of dressings, .severe fright, or the view of an injured person may be the cause which produces the reflex paralysis causing the anaemia of the l)rain and the symptoms associated with it. Symptoms. — Cadaveric paleness, nausea, cold sweat, dizziness, and darkening of the field of vision are the pi-odromata of syncope. With fixed stare and widely dilated pupils the patient sinks, having lost con- sciousness rapidly and completely, and remains motionless and insensible. 41 634 GENERAL RESULTS OF INJURIES The pulse is rapid and small but regular, the respiration slowed and superficial. As a rule, the symptoms rapidly disappear, a fatal termina- tion being extremely rare. Fatal syncope has been most often observed in greatly excited patients shortly before surgical operations or during operations undertaken under local anaesthesia. Consciousness usually rapidly returns when the patient is placed in a head-down position, thus counteracting the cerebral anaemia, and when the clothes are loosened. The horizontal position should be maintained for some time after the patient recovers, and small amounts of whisky or wine may be given to advantage. If the patient remains in a deep faint for some time, the same treatment as described under collapse should be instituted. Shock. — Shock is a condition closely related to collapse in which there is a reflex depression of all the vital forces. Theories of Shock. — According to many authors (von Leyden, Groningen, and others), shock is due to an exhaustion or inhibition of the centers in the medulla and spinal cord following excessive irritation transmitted from the periphery. This inhibition or exhaustion of the centers is followed by a depression of the functions of the heart and lungs, the vasomotor, sensory, and motor nerves. Schieffer, as the result of animal experimentation, supports this theory, for he found that shock was much less easily produced in animals in which spinal anaesthesia had been induced than in normal ones. According to others, especially H. Fischer, a reflex vasomotor paralysis is the cause of shock. As a result of this vasomotor paralysis, just as in Goltz's tapping experi- ments, the veins of the splanchnic area become filled with blood and the blood pressure sinks so low that an anaemia of the nervous system develops. Finally, as a result of these circulatory disturbances the heart ceases to beat. Irritation of the sensory, splanchnic, and other sympathetic nerves, and of the branches of the vagus also plays a role in the cardiac inhibition, for a transitory inhibition of the heart can be caused by stimulation of the sensory nerves supplying the abdominal viscera. Shock may be caused by the concussion or contusion of areas abun- dantly supplied by sensory nerves, as in severe injuries, or by the injury of a special group of nerves. Shock follows not only machine injuries and gunshot wounds of the trunk or extremities, extensive freezing and burns, but also contusions of the thorax, in which the branches of the vagus nerve are stimulated, and subcutaneous injuries of the abdomen, in which the nerves supplying the peritoneum are irritated by the trauma or by the contents of the stomach or intestine when the latter are ruptured. Irritation of the nerves caused by packing aside and handling the intestines in laparotomies, and by excessive traction upon COLLAl'SE, SYNCOrE, 8HUCK 035 the spermatic cord during the freeing of a hernial sac may cause shock. Age, general weakness, cachexia, and antemia caused by haemorrhage or disease are predisposing causes. Sijniptotti.'i. — Tlie symptoms of shock are rapid loss of strength; de- pression of cardiac activity, usually associated with a reduction of body temperature; irregular respiration and interference with the spinal functions as indicated by relaxation of the nmscles, diminution or loss of i-eHexes and impairment of sensation, consciousness being retained (Sanniel). In the milder forms of shock the skin is pale and cold, the patient is apathetic or restless, movements and reflexes are sluggish, the pulse is small and running rather than slow, and the respirations are slowed. In the severer forms the skin has a cadaveric pallor and is cold; the lips and cheeks are cyanotic, due to the accumulation of blood in the veins; cold sweat covers the body; the pupils are dilated and react sluggishly, and the patient lias a fixed stare; he may belch, hic- cough, or vomit; the pulse is slow or but slightly faster than normal, and is scarcely palpable ; the respirations are superficial and slow, inter- rupted by deep inspirations; the body temperature is lowered; the acuity of perception is reduced ; the reflexes are sluggish ; and the faeces and urine are discharged involuntarily. The mind is always clear, but cerebration may be somewhat slow as the result of the cerebral anajmia. Torpid and ErctJiistic Shock. — The condition of apathy in which the patient lies prostrate and perfectly relaxed may be followed by a stage of excitement or anxiety in which the limbs are tossed about and the patient rolls about in bed, attempting to rise. Therefore a torpid shock is differentiated from an erethistic shock. During the stage of excite- ment the pulse becomes small ajid rapid, the respiration very rapid, and the face reddened. Frequently torpid passes into erethistic shock; at times merelv transitory periods of restlessness occur. PsycJiicai Shock. — A condition which is caused by some psychical excitement, the symptoms of which are usually transitory but may ter- minate fatally as a. result of inhibition of the heart is called psychical shock. This form is most often produced by sudden fright, the sudden announcement of good or bad news, by unexpected noises (e. g., when a gun is fired near by without warning). In psychical shock conscious- ness is retained, differing in this way from syncope. Shock, even in mild cases, not infrequently terminates fatally. The fatal termination, as a rule, is not due to the interference with the function of the central nervous system alone, but is due especially to tlie loss of blood. If the patient is going to recover the symptoms generally subside within a few houi*s. 636 GENERAL RESULTS OF INJURIES Nothing is more difficult than to determine when the symptoms of shock are subsiding in a patient severely injured, especially if the symp- toms of shock are combined, as is often the case, with those of internal hcemorrhage or beginning inflammation (e. g., peritonitis). A rise of temperature is generally associated with infections, and the pulse, which was slow or normal, becomes rapid in both haemorrhage and infection. Severe collapse resembles shock very closely, and if it develops immedi- ately after an injury it can hardly be differentiated from shock. The differentiation is more easily made when there is some cause for the collapse, such as pulmonary embolism, febrile disease, etc. Pathologic Physiology of Shock. — The experimental work done by Crile has given us a very clear idea of the pathologic physiology of shock, and also the methods of preventing and treating shock. [In Keen's ' ' Surgery, ' ' Vol. I, p. 926, he writes : ' ' An abnormally low blood pres- sure is the essential phenomenon of the state commonly designated sur- gical shock. There are many other physiologic changes accompanying shock, but these may for practical purposes be regarded either as results of low blood pressure or as factors of minor importance. Among these secondary factors or results are alteration in respiration and car- diac action, modified mental state, loss of power of both the voluntary and involuntary muscular systems, diminution of the secretion of urine, and lowering of body temperature. So long as blood pressure and cir- culation are sufficient for normal physiologic purposes, a serious state of shock, despite the presence of any other phenomena, cannot be pre- sumed. As ]\Iummery has pointed out, the fall in temperature in shock is largely a result and not the cause of the low blood pressure. The exact physical state of the vasomotor center during the existence of shock has not as yet been satisfactorily demonstrated. The result of that physical state is an inactivity of the center or centers, thus causing a low blood pressure. But it is not certain that we can at present state just what exhaustion or paralysis is. In a certain sense the vasomotor center in a state of shock may be designated as paralyzed, or in a cer- tain other sense as exhausted. We do know, however, that whatever the exact physical state is, one may conclude from the physiologic test of complete recovery that the centers are not physically damaged, that the impairment or breakdown is functional and temporary. It is at once apparent that in the management of operations prevention is more im- portant than treatment."] [The accompanying blood-pressure tracing indicates the sudden fall in blood pressure obtained by irritation of the inflamed pleura by a trocar. The sudden deaths associated with aspiration, which are not infre(iuent, are apparently due to shock induced by stimulation of the filaments of the pneumogastric and sympathetic nerves supplying the CULLAPSi; SV.XCOPE, SHOCK 637 centers in the nd a continued diac stimulants -0, is < 11 M < a. z > 7. < pleurn, leadiui; to a reflex i)aralysis of the vasomotor medulla ()l)l()ii^ata and spinal cord (('a])ps and Lewis). | Prognosis. — A marked lowering ol' tlif temperature a depression of cardiac function, t'ven when powerful car are administered, are bad prog- nostic signs. Trid t tn nit. — The indications in the treatment of shock are to l)revent further irritation, espe- cially pain, and to improve the cardiac function and circulation. Painful manipulation should therefore not be attempted, and friction of the skin and the appli- cation of mustard plasters are to be avoided. Just as in collapse, attempts should be made to aid the circulation by placing the pa- tient in the head-down position, to stimulate the heart bj' injec- tions of camphorated oil and heart massage, to aid breathing by arti- ficial respirations, and to supply heat by hot-water bottles or bags. Whisky in hot coffee and hot ex- tract of beef given by mouth or rectum have a favorable influ- ence. If erethistic shock has de- veloped, the patient should be quieted by a hypnotic, preferably by morphin. As these cases are apt to be accompanied by fever, there is no necessity of supplying external heat. [Crile summarizes the treat- ment that should be employed in shock as follows: " Physiologic rest is the most important con- sideration in the treatment of shock. The patient should be kept at rest mentally and physically. Surgeons and nurses should bring assur- ance and confidence. The patient should be made comfortable. If this cannot be satisfactorily accomplished by management and nurs- S ^ 2 3 a(lischen iMngriffen iiiid Verletzuiigeii. Zeitschr. f. Orthopiidie, Bd. 7, 1900, p. 338. — Prcindelsbirger. Kin Fall von Fettembolie naeh Redressement. Zeitschr. f. Heilkunde, Bd. 24, 1903. — Jiibbcrt. Zur Fettembolie. Deutsche ined. Wochenschr., 1900, p. 419. 642 GENERAL RESULTS OF INJURIES CHAPTER IV TRAUMATIC DIABETES It has been shown by the physiological experiments of Claude Ber- nard that injury of a definite area in the floor of the lower part of the fourth ventricle, between the points of origin of the vagus and audi- toi^^ nerves, is followed in a few hours by glycosuria if the center controlling the vasomotor nerves of the liver is injured, by polyuria if that controlling the vasomotor nerves of the kidney is affected. Disturbances of sugar metabolism and of the mechanism controlling the excretion of urine are not infrequently observed after injuries (espe- cially after injuries of the head, after fractures, and injuries of the pancreas, liver, kidney). As a rule, these disturbances develop a few days after the injury. It cannot be demonstrated, however, that there is any lesion of the centers above mentioned. The glycosuria is tran- sitory, subsiding usuallj^ within a week. The urine which is secreted never contains more than one per cent of sugar. A true diabetes mel- litus or insipidus occasionally develops after an injury. They are much rarer than the temporary glycosuria above mentioned. Nothing definite is known concerning the nature and cause of trau- matic glycosuria. The treatment is conducted along the lines prescribed in internal medicine. Literature. Kausch. Beitrage zum Diabetes in der Chirurgie. Chir.-Kongr. Verhandl., 1904, II, p. 650. — Morris. Diabetes in Surgery. Medical News, 1901, June, 29. PART V IMPORTANT SURGICAL DISEASES, EXCLUD- IJ^G INFECTIOJSTS iVND TUMORS CHAPTER I DISEASES OP THE SKIN AND MUCOUS MEMBRANES (a) CONGENITAL SKIN DEFECTS Congenital defects of the skin appear in a iiiiniber of different forms, usually associated with disturbances in development. Besides fissures and iistula" resulting from incomplete fusion of embryonal clefts, there are also adhesions between different parts of the body which are also to be regarded as developmental defects. Cutaneous syndactylism, in which neighboring fingers are contained in a common cutaneous envelope or are connected by a membrane re- sembling a web of a goose foot, belongs to the latter class of anomalies. Broad cutaneous adhesions resembling a Aving occur in the popliteal space, in the axillary fossa, and between the neck and chest. These malformations are frequently associated with muscular anomalies and other developmental defects. Small nodules about the size of a pea, occurring in the skin at bii'tli, may be the remains of adhesions between the area in which the nodule appears and the amnion. Deep furrows in the face and upon the extremities, which may even extend down to the bone, may be caused by the constriction of amniotic bands. These may be circular and extend deep enough to amputate the extremity. Plastic operations of different sorts are often required to repair the fissures and to overcome the adhesions. Abnormal appendages of the skin and fistula' should be excised. (b) ECZEMA The most superficial inflammations of the skin are grouped under the term eczema. They are of interest to the surgeon in a number of 643 644 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS different ways. An eczema intei'feres with wound repair. In some cases one is compelled to operate upon skin, the seat of an eczema (e. g., an intertrigo of the skin covering a strangulated hernia), and occa- sionally the eczema develops later when the skin is bathed with secre- tion from a deep infected wound in bone or when it is exposed to the action of iodoform. An eczema caused by sublimate solution occasion- ally develops upon the surgeon's hand which incapacitates him for some time, as the vesicles and pustules developing upon the moist, scaling, and fissured area render asepsis impossible, even when the greatest precautions are taken. The diseased area may also furnish the infection atrium for pyogenic infections (lymphangitis, thrombophlebitis, etc.). Causes of Eczema. — The causes of eczema are external and internal. Mechanical irritation by rubbing of opposed sweating surfaces (inter- trigo or chafing of the scrotum and thigh, in the groin and axillary fossa, and beneath large dependent brdasts) , or by scratching in scabies, urticaria, prurigo, and insect bites ; chemical irritation, especially by agents used for sterilization and in susceptible patients by iodoform; and thermal changes produced by radiating heat or dry cold are the external causes. Eczema may appear as a symptom in a number of conditions, such as icterus, diabetes, nephritis, chlorosis, and dysmenorrhoea. These may be regarded as some of the internal causes. Different Forms. — Eczema appears in a number of different forms, one frequently passing into another. The skin itches severely and becomes red (eczema erythematosum) , and small red nodules which never become larger than a pinhead (eczema papulosum) may then develop. Vesicles may develop from these nodules (eczema vesiculosum), and if the con- tents of these vesicles become purulent a pustular eczema (eczema pustu- losum) develops. If the epidermis is lost as the result of long-continued irritation or maceration a weeping surface remains, weeping eczema (ec- zema madidans). When the serum dries the area becomes covered with crusts, or, if pus develops beneath the crusts, with pustules resembling those seen in impetigo. [" It is important to remember that an attack of acute eczema, like other acute diseases, may subside spontaneously, and that this is not less likely to happen because the eruption is extensive. The eruption may become abortive in the first stage (when it resembles a papular erythema) and end with desquamation, or after exudation has taken place. This may gradually become less and dry up, when, after a few exfoliations, the skin becomes sound. The possibility of spon- taneous subsidence should always be kept in mind, and be a warning against too energetic treatment. But unfortunately, in accordance with the observed proclivities of eczema, it more often happens that the acute passes into a chronic inflammation, which requires the treatment appro- DISEASES UE THE SKLN AMJ MlCOlS MEMBRANES C45 priate for tluit form." — T. C. AUbutt, " System of Medicine," Vol. IX, p. 508.] Most Common Sites for Development. — Eczema develops most fre- (lueiitly upon tlie face, head, neek, hands and feet, the external geni- talia, in the axillary fold, and in fat people in all the deep cutaneous folds. Eczema also develops frequently in poorly nourished parts, in paralyzed parts, over large tumors, and in skin the seat of chronic oedema and elephantiasis. Treatment. — Tlie treatment which should be instituted depends upon the cause. The cause should be removed and the affected area should be protected from injuries, among which rubbing and scratching provoked by the severe itching are the most dangerous. The milder acute forms are usually controlled by a generous application of boric acid or zinc oxid ointment, which should be covered with enough dressings to protect the area. In the treatment of scaling chronic eczemas, it is generally best to employ preparations of tar. The eczema developing upon a sur- geon's hands, which usually can be prevented, is readily controlled by the use of a ten per cent zinc vaseline ointment and by wearing gloves until the lesions are healed. (c) CEDEMA OF THE SKIN AND MUCOUS MEMBRANES (EDEMA OF THE SKIN The fluids found in the tissue spaces, which are filtered from the blood by the secretory activity of the cells of the capillary walls, and are again taken up by the lymphatic vessels, may in certain diseased con- ditions collect in the tissues and body cavities. If the fluid collects in the cavities, one speaks of a hydrops articularis, a hydrothorax, a hydro- pericardium, or an ascites, depending upon the cavity involved. If the viscera, the skin, or mucous membrane are saturated with these fluids one speaks of an oedema, or if a large part of the surface of the body is involved of an anasarca. Causes of CEdema. — Voious stasis and disturbed capillary secretion are the most important caiLses of anlema. Lymph stasis is a much rarer cause. In venoiLs stasis there is an increased formation of lymph, as the result of increased pressure in the capillaries. If the venous stasis continues for some time, nutritional disturbances develop, the tissues lose their tone, and then the normal movements of the lymph are inter- fered with and the capillary walls become more permeable. (Edema follows occlusion of the large veins of the trunk and ex- tremities, unless the occlusion occurs slowly enough to permit of the development of a collateral circulation. The oedema which develops 646 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS after the ligation of veins is apt to be transitory. After occlusion by a thrombus, or by the pr&ssure of a tumor, the oedema is apt to be more permanent as the openings of the veins entering into the collateral circulation are apt to be occluded. A transitory oedema frequently de- velops in an extremity which has been immobilized for some time, when attempts are made to use it again. This is due to the impairment of venous circulation, following a temporary atrophy of the muscles. Disturhance of caxnllary secretion is the cause of a number of dif- ferent forms of cedema. The alterations in capillary secretion are either the results of nutritional disturbances, or of toxic, chemical, thermal, or traumatic injuries to the endothelium of the capillaries. As a result of such an injury the vessel wall acts mechanically like a filter. The less the tension of the tissues, which is lowered by the same causes that injured the vessels, and the higher the blood pressure, the more rapidly the fluids are poured out. Clinical Forms. — Inflammatory oedema accompanying inflammation of bacterial, toxic, and mechanical origin develops in different degrees in the skin, mucous membranes, and viscera. HydrcBmic, cachectic, or marantic oedema occurs in those diseases characterized by hydra'mia. The hydraemia may be due to a decrease in the albumen content of the blood (in anaemia, cachexia associated with chronic infectious diseases and malignant tumors) or to an increase of water in the blood (nephritis and cardiac insufficiency). Neuropathic cedema occurs occasionally in hysteria. Myxoedema belongs to the chemical cedemas. It develops when the secretory activity of the thyroid gland is greatly diminished or after its complete removal. The changes are most marked in the skin of the face and extremities. The fluid, which is deposited in the subcutaneous tissues and gives it the tense, somewhat doughy feel, resembles mucin; therefore the term myxcedema. This condition may be relieved by the feeding of thyroid extract (thyroid tablets) prepared from the thyroid glands of calves or sheep. Oedema due to lymph stasis develops only after the occlusion of the large lymphatic ducts of the extremities or of the thoracic duct. Lymph fx-dema of the lower extremity and scrotum may follow the extirpation of inflamed inguinal lymph nodes, the collateral vessels being closed by thrombi. Occlusion of the thoracic duct is usually caused by neoplasms. (Edema ex vacuo occurs principally in the cranial cavity and spinal canal. It develops in all cases in which a portion of the brain and spinal cord is lost and its place is not taken by some other tissue. Appearance of (Edematous Area. — In oedema of the skin the subcu- taneous tissues are also involved, for their anatomical structure permits of the accumulation of large amounts of fluid. Not infrequently the DISEASES OF TIIIC SKIN AND MUCOUS MEMBRANES 647 iluid extends from subeiitaneous into tlu; loose interniusenliir tissues. An wdeniatous area is swollen, the swellinjj gradually being lost in the surrounding healthy tissues, and the skin is cool and of a waxy appear- ance. The skin has a bluish color only when there is a venous stasis. The niovenients of an u'dematous extremity are restricted. It feels heavy and l)eeomes easily exhausted when movements are made. If an incision is made in an (edematous part a clear tiuid pours out from the cut surface, the conditions being very simihir to those found in an area when infiltration auasthesia has been employed. Development of (Edema. — An anlema of the skin never develops sud- denly. The fluid collects gradually and the swelling develops slowly. The time reciuired for the swelling to reach its maximum development naturally varies in the different eases. The oedema is not permanent if the cause can l)e removed or its action is only transitory. Chronic oedema leads to trophic disturbances in the skin, and the latter becomes rough and fissured. As the result of the stinuilation and proliferation of the subcutaneous tissues a pachydermia may follow a chronic oedema. Differential Diagnosis. — An (edema can usually be easily difit'eren- tiated from other somewhat similar conditions, such as the thickening of the skin associated with elephantiasis, diffuse lipomatosis, lymphan- giomas, and recent deeply seated hu'matomas. An (edenui pits upon pressure, as the fluids are driven out of the meshes of the subcutaneous tissue, and the pit that remains when the pressure is removed disap- pears slowly, as some time is recjuired for the meshes to fill again. Pit- ting upon pressure and the slow disappearance of the pit are character- istic of oedema. Treatment. — In treating an oedema, naturally, the cause should first be removed and the venous circulation should be assisted and improved by elevation of the extremity and by the application of an elastic ])and- age, exerting mild compressi(m, fi'om the j^eriphery t(nvard the trunk. In hydra>mic (edemas the disease to which the (edema is secondary should receive proper treatment and the g(^neral condition should be impi-oved. Frequently the latter is impossible, as the anlema is an indication of the beginning of the end. ]\Iassage is of advantage in the treatment of all forms of oedema of the skin, excepting those associated with inflam- matiou and thrombosis. A long-continued inflammatory oedema is often benefited by hydrotherapy, which may also be of value in chronic oedema due to other causes. (EDEMA OF MUCOUS MEMBRANES An oedema of nnicous membranes is associated Avith either inflamtna- tion or circulatory distiirbonces. If it develops acutely as the result of severe inflammati(m or suddc^n stasis, the infiltration of the mucosa 648 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS and snbmucosa causes a marked swelling, which in the upper air pas- sage may produce marked disturbances. CEdema of the nasal mucous membranes, rendering nasal breathing impossible, and swelling of the uvula are constant accompaniments of nasopharyngeal catarrh. CEdema of the glottis may be associated with catarrhal and diphtheritic inflam- mations, submucous phlegmons, and ulcers of laryngeal mucous mem- brane. It may develop secondary to inflammatory processes adjacent to the larynx and may follow stasis due to the ligation of large vessels (in operations about the larynx). The swelling in this condition may interfere with respiration and threaten the life of the individual. Surgical Significance of (Edema.— The chronic cedema w^hich is asso- ciated with general venous stasis (in heart disease and emphysema of the lungs), or follows occlusion or compression of the veins draining the mucous membrane is, as a rule, of less surgical significance than the chronic inflammatory oedema. The latter leads, especially in the nose and accessory sinuses, to thickenings, and to the development of con- nective tissue and pedunculated growths, the so-called polyps. Besides mucous membranes stimulated to proliferation by continued irritation afford a favorable base for the development of a number of different forms of tumors, such as papillomas, fibromas, adenomas (in the form of polyps), and carcinomas. Leucoplakia of the mucous membranes of the mouth upon which carcinoma of the tongue, cheeks, and lips fre- quently develop is apparently caused by chronic irritation (tobacco smoking) . Treatment. — The same methods should be followed in treating inflam- matory oedema of the mucous membranes as have been described in dis- cussing acute and chronic inflammations of the same. A marked oedema due to stasis frequently subsides rapidly after multiple small incisions have been made. An oedema of the glottis may threaten life and demand immediate tracheotomy. (d) ELEPHANTIASIS The condition known as elephantiasis Arabum — to distinguish it from elephantiasis Graecorum (leprosy) — and as acquired pachydermia is characterized by a thickening of the skin and subcutaneous tissues of different parts of the body. In advanced cases the deeper-lying con- nective tissues may also be involved. The thickening of the skin and development of connective-tissue masses produce unsightly deformities of the part involved. Pathology. — Pathologically, two processes — a chronic inflammatory proliferation of the connective tissues and a dilatation of the lymphatic vessels — are combined. Long-continued inflammatory irritation and DISEASES OF THE SKIX AM) iVircOlS MEMHRANES 649 local circiilatoiT disl iifbaiiccs arc llic causes, 'riiickciiiii^', oblitcral ioti, aiul (lilalalioii ol" the veins and allci-ations in llic skin ai-c also conlcihut- iny causes. Clinical Course. — Elephantiasis (lcv('loi)s slowly, the clinical course extcndinli\iiia as an aiiuioiiciii-osis, the eireulatoiy changes eausiiiii' coiuieetive-tissiu' hyperplasia. In some cases tile essential cause is {ji-obably conlastische Chirurgie. Berlin, 1845. — Klaussner. Ueber Missbildungen d. menschl. CSlietlmassen. X. F., Wiesbaden, 190"), p. 9. — Lamlerer. Die Gewebsspannung. Leipzig, 1884. — Lesser. Lehrbuch der Hautkrankheiten. Leipzig, 1901. — Manson. The Filaria Sanguinis and Certain New Forms of Parasitic Diseases. London, 1883; — The Filaria Sanguinis Homi- nis Major arid Minor, etc. Lancet, 1891, p. 4. — Rusch. Zur oi)erativen Behandlung des llhinophjnna. Wien. klin. Wochenschr., 1902, p. 333. — Schcube. Die Krankheiten der warmen Lander. Jena, 1900. — Uiina. Histopathologic tier Hautkrankheiten. Berlin, 1894. — V. Winiwarter. Die chirurgischen Krankheiten der Haut. Deutsche Chir., 1892. 654 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS CHAPTER II DISEASE OF MUSCLES AND TENDONS (a) CONGENITAL MUSCULAR DEFECTS A CONGENITAL miisciilar defect exists if there is an anomalous inser- tion or complete absence of a muscle (e. g., anomalous insertion of the tibialis anterior or of the extensor cligitorum communis). The result- ing disturbance in motion is not to be mistaken for paralj^sis. ]\Ialfor- mations, such as syndactylism, polydactylism, or defects in bone may give a clew to the diagnosis. Congenital absence of the trapezius, which has been demonstrated in the congenital high position of the scapula, has been shown to be the cause of this deformity. (b) ATROPHY OF MUSCLES, SIMPLE AND DEGENERATIVE Anatomically a simple is distinguished from a degenerative atro- phy of muscle fibers. In the former the muscle fibers decrease in size and number, and no other anatomical changes can be demonstrated. In the degenerative atrophy a number of different pathological proc- esses may be combined, such as fragmentation and segmentation of the fibrillge, fatty degeneration, coagulation, or liquefaction of the myo- plasm. The fibrous and fatty tissues later proliferate to replace the degenerated muscle fibers. Simple atrophy develops most frequently after non-use (atrophy of disuse) of a muscle or group of muscles. It may follow cerebral palsies or accompany as a reflex atrophj^ injuries and diseases of the joints. In simple atrophy the electrical irritability of the muscle is reduced, but there is no reaction of degeneration. The results of simple muscular atrophy are a decrease in the size of the muscle, complete or incomplete loss of function, and contractures due to shortening of antagonistic muscles or groups of muscles. Inactivity and Reflex Muscular Atrophy. — Inactivity and reflex mus- cular atrophy cannot be shari^ly separated. It is a well-known fact that muscles decrease in size when patients are bedridden for a long time. It is most pronounced, however, when an extremity is immobilized in splints or a plaster-of-Paris cast for a long period. If there is an injurj' or an inflammation of the articular end of a bone, or a disease or injury of a joint, a pronounced atrophy of the muscles, especially of the extensors, more rarely of other muscles, develops in one or two weeks. Atrophy of the deltoid, triceps, quadriceps extensor, and gluteal DISEASE OF MUSCLES AND Ti:.\DONS G55 nmsclos follows intlamniations and injuries of the shoulder, elbow, knee, and hip joints respectively. The so-called arthritic muscular atrophy is not entirely due to in- activity, as it develops rapidly even when no inunobilizing dressing has been applied, and it rarely occurs in hemiplegia, and when it does it is not pronounced. Paget, Vulpian, Charcot, and others believe that muscular atrophy associated with diseases of joints is of a reflex nature. According to the theory advanced by them, irritation is transmitted from the diseased or injured part along the sensory nerves to the cells in the anterior horns of the spinal cord, which have a trophic influence over the muscles related to the joint, and this irritation produces a change in the cells resulting in atrophy of the muscles. Raymond, Deroche, and Hoffa have been able to prevent this atrophy, after pro- ducing an arthritis experimentally, by cutting the posterior roots of the spinal nerves, interrupting in this waj^ the reflex arc. Degenerative atrophy develops in muscles after injuries, inflannna- tion, and circulatory disturbances; during the course of or following infectious diseases (especially typhoid and tetanus, more rarely recur- rent fever and general pyogenic infections) ; in all peripheral paralyses following injury and inflammation of the nerves ; and in spinal lesions in which the integrity of the anterior horn cells is destroyed. In the degenerative atrophies following lesions of the cells of the anterior horn or of the peripheral nerves the reaction of degeneration will be present. The degenerating muscle becomes shrunken and shortened, and marked functional disturbance's follow the development of contractures. Ischaemic Paralysis and Contractures. — ^Marked interference with the flow of arterial blood is the most dangerous of the circulatory disturb- ances. The most usual causes are injuries, ligation, embolism or throm- FiG. 243. — IscH.EMic Muscular Paralysis and Contracture following the Use of AN Improperly Applied Plaster-of-Paris Dressing. bosis of one of the larger arteries, when a collateral circulation is not established ; long-continued action of great degrees of cold ; poorly ap- plied, constricting plaster-of- Paris casts; and constriction for purposes of artiflcial ischaniiia maintained for more than two or three hours. 656 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS "When the circulation is seriously interfered with the muscles become painful, swollen, of a boardlike hardness, and no longer contract. Pas- sive motion is painful and is no longer free. After a few days contrac- tures which become more marked as the involved muscle undergoes cicatricial contraction develop. These contractures may become very pronounced if an entire group of muscles, such as the flexors of the fin- gers and hand, degenerates. The contractures are less marked, and im- provement may follow mechanical treatment if a considerable number of muscle fibers capable of regeneration remain. Von Volkmann was the first to recognize and describe ischfemic palsies and contractures (Leser). According to Hildebrand, the view held up to the present time that the nerves are not involved in this form of palsy is false. Not infrequently sensor}^ disturbances resulting from injuries of the nerves are also present, the latter being injured by the ischemia or by the pressure exerted by the cicatricial tissue developing in the muscles. Ischaemic muscular paralysis differs from paralysis of nervous origin in its clinical course and in the absence of the reaction of degeneration. Course and Prognosis of Different Forms of Atrophy. — The course and prognosis of the different forms of muscular atrophy depend upon the cause, the character, and the degree of the pathological changes. If the cause can be removed, and the degenerative changes are not so exten- sive as to render regeneration impossible, restoration of function may follow massage, active and passive motion, baths, and, in paralyses fol- lowing nerve lesions, electricity. Contractures which demand special treatment may develop (vide p. 703 j. In the treatment of ischaemic paralysis, Hildebrand recommends that the nerves be dissected out early from the shrinking, contracting muscles, and be placed beneath the fascia. (c) THICKENING AND GANGLION OF THE TENDONS Thickening of the tendons occurs in the form of small nodules or fusiform enlargements upon the flexors of the fingers, and is the most frequent cause of the condition known as trigger-finger. When the patient attempts to open his hand, the finger afi^ected remains flexed when the others are extended, and when the affected finger is extended with the other hand it flies open with a spring or jerk. The finger affected may also remain extended when the other fingers are flexed, and the same spring or jerk occurs when it is flexed with the other hand. There can frequently be felt during these movements a hard, nodular thickening of the tendon which interferes with the free move- ment of the latter within its sheath. When the tendon sheath becomes sufficiently expanded to allow this enlargement to pass, the fingers be- come flexed or extended with a jerk. DISEASES OF THE TENDON SHEATHS AND lilKS^E G57 When the tendon has been exposed for the relief of trigfjer-finfrer, the anther has often fonnd a limited tihrons thiekeninj; npon the snr- face of the tendon, or a small round nodule resembling a fibroma within a fusiform enlargement; once a small cyst (tendon ganglion), such as has been described by Thorn and Fran/. Frequently small exudations of blood within the tendon cause similar changes and the transitory snapping of all the fingers with the excep- tion of the thumb. This is often observed after long-continued rowing, and is the result of pressure and traction upon the tendons. It often develops on the left hand of recruits, and is due to the pressure of the butt of the ritle. Ganglia of the tendons, resembling ganglia developing in the cap- sule of the joint and in tendon sheaths, are probably of traumatic origin, and are to be regarded as degeneration cysts. In rare cases they have been observed in the tendon of the peroneus tertius (Ilofmann), in that of the triceps brachii (Borchardt), and in the extensor tendons of the index finger (iMorian). They are found most frequently in the tendons of the flexors of the fingers and may be the cause of trigger-finger. Literature. — Borchardt. Ganglienbildung in der Sehne des M. tricejis brachii. Arch. f. klin. Chir., Bd. 62, 1900, p. 443. — Flatau. Muskelatrophien nach Frakturen, Luxationenund arthritischenGelenkerkrankungen. Samnielreferat niit Lit. ZentralbL f. d. Grenzgeb., 1902, No. 8. — Franz. Ueber Ganglien der Hohlhand. Arch. f. klin. Chir., Bd. 70, 1903, p. 973. — Hildebrand. Ischiimische Muskellahmung. Deutsche med. Wochenschrift, 190.5. Vereinsbeilage, p. 1577. — Hoffa. Die Pathogenese der arthritischen Muskelkrankungen. Chir.-Kongr. Verhandl., 1892, I, p. 93. — Hojmann. L'eber Ganglienbildung in der Kontinuitiit der Sehnen. Zentralbl. f. Chir., 1899, p. 1315. — Leser. Untersuchungen iiber ischiimische Muskelliihinungen und Muskel- kontrakturen. v. Volkmanns Samml. klin. Vortr., 1884, No. 249. — Lorenz. Die Muskelerkrankungen. Wien, 1898.^ — Moruin. Beitrag zu den intratendinnsen Gan- glien. Miinch. med. Wochenschr., 1900, p. 1766. — Thorn. Ueber part ielle Zerreissung einer Beugesehne am Vorderr.rm mit sekundarer Bildung einer ganglioniihnlichen Degenerationszyste. Arch. f. klin. Chir., Bd. 58, 1899, p. 918. CHAPTER III DISEASES OP THE TENDON SHEATHS AND BURS.« Dry Synovitis. — Dry synovitis (sA^novitis sicca), the counterpart of dry pleurisy (pleuritis sicca), develops in tendon sheaths after over- exertion and laceration of the tendons. The terms tendovaginitis and tenalgia crepitans have been applied to this disease, as a grating and creaking sensation is imparted to the palpating finger whenever the inflamed tendon moves. This sensation is caused by a roughening 658 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS due to the fibrin which is deposited upon both visceral and parietal layers of the synovial membrane secondary to a small serohsemorrhagic exudate. The other symptoms are severe pain when movements are made, and the development of a long swelling, slightly tender to pressure, corre- sponding to the position and course of the tendon. The tissues sur- rounding the tendon also become swollen and infiltrated. A dry synovitis subsides in a short time; within two weeks even in the severest cases. As the disease is caused by strains and sprains received during work, recurrences are common. The extensor tendons of the thumbs of laundresses are frequently involved as a result of the wringing of clothes. Not infrequently the extensor tendons of blacksmiths, locksmiths, drummers, and piano play- ers become involved, especially when the work is so heavy or practice is continued so long that the tendons are strained. It is much more apt to develop in novices than in people who are accustomed to their particular lines of work. The tendons of the peroneal and tibial mus- cles are affected in oarsmen. Similar lesions develop in the tendo Achillis of ballet dancers, although this tendon has no synovial sheath. The diagnosis is easily made. The position and form of the swelling arouses the suspicion of the experienced surgeon at once. The peculiar creaking and grating sensation elicited when the tendon moves to and fro makes the diagnosis positive. This sensation is elicited only when certain movements are made, and only over the course of the tendon; therefore it can easily be differentiated from the crepitus elicited in dis- eases of the joints and in fractures. The treatment consists of the application of a felt or pasteboard splint to immobilize the tendon involved. The pain disappears in a short time; the other symptoms in a few days. If in severe cases there is still some crepitus at the end of a week, mild massage, active and pas- sive motion are indicated. Excessive use of the tendon or tendons should be avoided for some time. Serous and Serofibrinous Tendovaginitis. — Serous and serofibrinous exudates frequently follow hiiemorrhages into the tendon sheaths, asso- ciated with fractures and dislocations. Usually they subside during the treatment of the fracture or dislocation. Chronic hydroi)s of the tendon sheaths is, as a rule, of tuberculous origin (vide p. 442). Ganglia of Tendon Sheaths. — Ganglia of the tendon sheaths are not common. They are similar to the ganglia which develop from the cap- sule of the wrist .joint, Init usually are smaller than these. Usually they are situated near the metacarpo-phalangeal .joint on either side of the sheaths of the flexor tendons. They may exert pressure upon the digi- DISEASES OF THE TENDON SHEATHS AM) HrRS.fl 659 tal iKTvos sufficient to cause a severe neuralj^ia. The neural^'ia rap- idly clisap])ears after the cysts are extirpated (Witzel). Urates iiuiy be deposited in the different tendon sheaths and bursae in gout. Those adjacent to the joint first involved are nearly always jilTeeted (vide p. 725). Hyg^roma. — The hydrops or hj'frronia is the most common form of chronic intlannnation of burste. An hyyroma follows the incomplete absorption of exudations of blood into bursie and long-continued me- chanical irritation. The contents of an hygroma are in the beginning thick and mucoid in character, later they become more serous, or, after an injury, ha?m- orrhagic. The walls of the hy- groma are not smooth like those of an acutely inflamed bursa or of one into which blood has been extravasated. They are thick- ened and contain many recesses, masses, and bands of tissue with wartlike and villous outgrowths (Fig. 244). Often the villous outgro\\i;hs are so large and nu- merous that they fill the cavity of the bursa, which then con- tains l)ut little fluid, while the thicker and more delicate bands of tissue extend from one to the other wall of the sac. Often the surfaces of these villous masses and bands are covered with old blood clots, which may have become calcified. Free bodies, occasionally a ])oint of a knife or a bullet, may be found in the hygroma. When these foreign bodies are found, they should be regarded as the cause of the chronic inflammation wliich resulted in the formation of the hygroma. Chronic inflammation, such as leads to hyperplastic changes in the joints, does not account entirely for the changes in the walls of the bursa above described, although it and the subsequent organization of the fibrinous deposits certainl}' play an important part. Even in a recent hygroma one finds, as might be expected, not a simple, but a multilocular cavernous cyst (Schuchardt). Some of the masses in the wall of a hygroma and of the free bodies are formed by the cicatricial contraction of the inflamed fatty tissue surrounding the bursa (Graser). According to Langemak. as the inflamed fatty tissue contracts it is transformed into a mass of collagenic scar tissue. After the formation of an interstitial substance which resembles fibrin, this scar tissue lique- Fic. 244. — Hygroma Biks.e Olecrani. 660 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS fies, and as a result degeneration cysts form in the wall of the bursa and in the tissues surroimding it. These cysts eventually rupture through the wall of the bursa, and a communication is established with its interior. This accounts for the formation of recesses and evaginations in hygromas. Hj^gromas are closely related pathologically to ganglia, which are also formed by the liquefaction of tissue (vide p. 731). In the majority of instances an hygroma develops as a painless hemi- spherical swelling with a smooth surface, covered by normal or slightly thickened skin. In some instances, however, the bursa enlarges rapidly after a trauma when blood is poured out into its ca^-ity and the swelling does not subside. An hygroma may become as large as a hen 's egg or an apple ; in rare eases even larger. The swelling, sharply defined externally, fuses below with the deeper tissues and is attached, depending upon its position, to the surface of a bone or tendon. It can therefore be displaced but little. As a rule, fluctuation can be elicited when the sac is not too full. Nodu- lar areas can frequently be palpated in the thickened walls of an old hygroma. A peculiar grating or creaking sensation can be elicited upon pres- sure, even when there is little fluid. Most Common Posi- tions for Hygromas. — Hygromas develop upon those parts of the body where a bursa is normally present, or where a bony Fig. 24.5.— Hygroma Bur-s-e Olecraxi. ^^I^' prominence is continu- ously exposed to pressure and the development of a bursa is favored. Hygromas of the prepatellar and olecranon bursae are the most frequent, for these bursa? are not only exposed to injuries, but also to mechanical irritation in a number of dif- ferent occupations — prepatellar bursa in housemaids and scrub women (housemaid's knee), olecranon bur.sa in ininers (miner's elbow). Hygromas of the bursae about the shoulder and hip joints, and pop- liteal space, follow sprains and dislocations of the joints. Inflammation of the acromial bursa is caused by pr&ssure (being of rather frequent occurrence in hod carriers). The largest hygromas developing in newly DISEASES OF THE liLOOD AND LYMPHATIC VESSELS 661 formoil bursa' are found on the outer niar<;in of a clubfoot. The hy- gromas developing in other varieties of bursa,' are usually small, the best-known examples being the hygro- ma developing over the head of the first metatarsal bone in hallux valgus, and over fractures in which there is a subcutaneous angular deformity. Multiple Hygromas. — The develop- ment of nmltiple hygromas always sug- gests some infectious cause (gonorrhea, tuberculosis, syphilis), as hygromas of mechanical origin are usually single, or the corresponding bursa on the other side is the only other one involved. Deep-lying hygromas about the hip or in the popliteal space may resemble tumors or gravitation abscesses, and it may be necessary to aspirate the swell- ing in order to make a positive diag- nosis. Treatment. — The amount of thick- ening in the wall of the bursa deter- mines the treatment Avliich should be instituted. If the hygroma is recent and the walls are not thickened, as- piration of its contents, followed by the injection of iodin or carbolic acid and compression, may result in a permanent cure. If the walls of the bursa are thickened and indurated, complete excision Avill probably be necessary. Complete excision js also to be preferred if a fistula is present. Literature. — Graser. Ueber die sogenannte Bursitis proliferans. Zcntralbl. f. Chir., 1902, p. 4G. — Heinekc. Die Anatomie untl Pathologic der Schleiinbeutel und Sehnenseheiden. Erlangen, 1868. — Langemak. Die Entstehung der Hygroine. Arch, f. klin. Chir., Bd. 70, 1903, p. 946. — Schuchardt. Ueber die Entstehung der subkutanen Hygrome. Chir.-Kongr. Verhandl., 1890, II, p. 1. — Witzcl. Ganglien an der Greifseite der Hand als L^rsache von Neviralgien. Zentralbl. f. Chir., 18SS, p. 137. Fig. 246. — Hyc.rom.\ Burs.e PK.ErATELLARIS. CHAPTER IV DISEASES OF THE BT.OOD AND LYMPHATTC ^^:SSELS (a) ARTERIOSCLEROSIS, ATHEROSCLEROSIS ARTERiosciiEROSis (chronic deforming endarteritis, atheroma of the arteries, atherosclerosis of l\Iarchand) may be the cause of a number of important surgical lesions. G62 .SLRtjiCAL DLSEASES, EXCLI'DLXG INFECTIONS AND TUMORS The entire process, which is chronic, is of a degenerative nature. It usually begins in adult life, in people of about forty years of age, more rarely in young people. The entire or greater part of the arterial sys- tem may be involved in the pathological process. Fatty degeneration and proliferation of the intima, resulting in the formation of foci filled with detritus, ulceration, fibrous induration (sclerosis), and calcification of the vessel wall go hand in hand. A localized form characterized by the formation of small flat nodules, which may undergo fatty degenera- tion and form atheromatous ulcers (arteriosclerosis circumscripta or nodosa; , is frequently combined with a diffuse proliferation of the intima (arteriosclerosis diffusa), which leads to the occlusion of the lumina of the smaller arteries (endarteritis obliterans). Fibrous changes also occur in the tunica media and lime salts are deposited in its muscular fibers. This is often associated wdth the formation of nodules, especially in the arteries of the lower extremities. The cellular infiltration and thickening of the tunica adventitia in arteriosclerosis is never so marked as in the arterial changes of syphilitic origin {vide p. 505 j. The arteries affected become hard, irregular, slightly tortuous, and may be easily palpated. Upon section it may be easily seen that the lumina of the arteries are greatly reduced in size. The arteries are Fig. 247. — Sclerotic Aktekies as they Appear ix a Roextgen-ray Picture. Male patient, fifty-five years of age, suffering with dry gangrene of the distal phalanx of index finger. often SO hard and fragile that they are ligated with difficulty. When di.ssected free they appear as yellowish white, irregular, nodular strands; and in Roentgen-ray pictures, if there are enough lime salts, as faint beady shadows, rr^sembling a necklace (vide Fig. 247). Causes of Arteriosclerosis. — There are a number of different views concerning the cause of arteriosclerosis. It may be due to nutritional disturbances in the intima resulting from injury of the media or of the elastic elements of the vessel wall (IMarchand), to primary inflammation of the vessel wall CKoster), or to a weakening of the media with com- pensatory proliferation of the intima (Thoma). DISEASES OF THi: HI.OOI) AM) LYMPHATIC VESSELS 663 The pi-incipal etiological factor is increased intraarterial pressnre, ■which may be continnons or int-niiittent (Marchand). Thei-e are a number of <;eneral and local j)re(lis{)()sing' causes, such as diseases of the central nervous system and peripheral nerves (tabes, syringomyelia, neuritis) ; the action of a numl)er of ditterent poisons (alcohol, tobacco, ergot, lead, mercury, phosphorus) ; infectious diseases of all kinds, of the chi'cnic type, especially syphilis and leju-osy; ct)nstitutioiud diseases (gout, diabetes) ; excessive physical ett'ort (with acute dilatation of the artei'iesj ; thei-mal influences (action of niiltl degrees of cold) (Zoege von ]\lanteuffel). Results of Arteriosclerosis. — The residts of arteriosclerosis are: (1) Disturbances of tlie general circulation and the function of the diflterent viscera, resulting from the lessened distensi])ility of the arteries and narrowing of the lumina of the vessels. The interference with the cir- culation is most marked when the veins are also diseased. (2) Occlu- sion of the vessels by proliferation of the intima, thrombosis, or em- bolism, tbe embolus arising in an atheromatous ulcer in a vessel nearer the heart. If the lieart action is bad and the vessels entering into the collateral circulation are diseased, gangrene of the tissues supplied by the artery frequently follows its occlusion (senile gangrene of the toes, embolic gangrene of the extremities). (3) Kupture of the diseased vessel, which is most frequent in the cerebral arteri&s, causing apoplexy. (•4) Aneurysm. (5) Thrombosis. Literature. — Fr. Fischer. Die Erkrankungen der Lymphgefasse, Ljinphdriisen und Blutgefasse. Deutsche Chir., 190L — Jores. Wesen und Entwicklung der Arterio- sklerose. Wiesbaden, 1903. — Marchand. Arterien. Eulenburgs Realenzyklopiidie, 1894; — -Die Arteriosklerose (Atherosklerose). 21. Kongress f. innere Medizin. Leipzig, 1904. VerhandL, p. 2.3. — Romberg. Ueber Arteriosklerose. Ibid., j). 60. — v. Schrotter. Erkrankungen der Gefiisse. Xothnagels spez. Path. u. Ther., Bd. 1.5. Part 3. — Thoma. Die diffuse Arteriosklerose. ^'irchows Arch., Bd. 104, 1S8G, p. 209. — Zoege v. Manteuffel. Arteriosklerose. Kochers Enzyklopadie, 1901. (b) ANEURYSMS By aneurj'sm (from the Greek a.v€vpvv€Lv, meaning to widen) is understood a pathological dilatation of an artery. Aneurysms occur in two principal forms, the simple or arterial and the arteriovenous. In the former there is a dilatation of the arterial wall ; in the latter a communication between an artery and a vein, with or without an inter- vening sac. Because of the similarity of clinical symptoms the pul- sating or arterial hcematoma must be classified with aneurysms, even if the sac is not formed by the wall of an artery, but by blood which has been poured out into the tissues and has coagulated. A true is dis- tinguished from a false aneurysm. In the former all the tunics of the 664 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS ve.ssel are present, while in the latter the sac of the aneurysm contains little or none of the original tunics of the vessel wall. [This distinction, as Cohnheim has said, is artificial and not based upon sound pathological principles.] The form of an aneurysm differs, depending upon whether the entire circumference of an artery or only a portion of it is involved. If only a portion of the arterial wall becomes dilated a saccular aneurysm, if the entire circumference, a cylindrical (spindle-shaped, fusiform) or cirsoid aneurysm (or better angioma racemosum) develops. A number of different varieties of true arterial aneurysms have been described, the descriptions being based upon the mode of devel- opment. Congenital Aneurysm. — In rare cases congenital aneurysms of the abdominal aorta (Phaenomenow), of the ductus Botalli (Thoma), and multiple aneurysms of the small arteries, due to congenital defects in the elastic elements of the walls of the vessels, have been observed. Spontaneous Aneurysm. — Tw^o different forms of spontaneous aneu- rysm. have been described, depending upon the way in which they are produced: aneurysm hy distention (Thom.a), aneurysm by rupture (Ep- pinger). In the former the arteriosclerotic, inflamed, or healing arterial wall is stretched, and the least resistant portion gives way and becomes dilated or evaginated; in the latter the elastic elements of the media and one of the other tunics of the vessel wall are ruptured by a sudden rise in blood pressure, the result of physical effort or mental excite- ment. The aneurj'sm by distention is diffuse, sometimes associated with evaginations, and occurs as the fusiform or cylindrical aneurysm. An aneurysm by rupture is, as a rule, a saccular aneurysm. Spontaneous aneurysms develop most frequently in arteries surrounded by loose connective tissues, which afford but little support to the arterial wall. Aneurysm by Erosion. — If the wall of an artery within an acute or tuberculous abscess becomes inflamed and necrotic, an aneurysm may develop within the necrotic area if immediate rupture does not occur. In these cases the intima often projects through the defect in the media and adventitia, and sometimes these aneurysms are spoken of as Iternial aneurysms. Embolic Aneurysms. — An embolic aneurysm develops after the in- tima has been injured by a hard, sharp embolus which has been set free from a hard, calcareous plaque in an arteriosclerotic artery, or after infection of the intima following lodgment of an embolus containing bacteria (mycotic aneurysm) . True Traumatic Aneurysm. — The dilatation occurs in that part of the artery the walls of which have been crushed or lacerated, but not com- pletely destroyed. DISEASES OF THE BLOOD AND LYMPHATIC VESSELS G65 Dissecting Aneurysm. — The dissecting aneurysm develops when the intiiiia and media have been ruptured and the adventitia remains intact. [" The blood spreads between the layers oi' the vessel wall, stripping up the inner from the outer half, the line of cleavage being within the middle coat, half going with the adventitia, half with the intima." — Ro.se and Carless, " Manual of Surgery," p. 306.] If the blood spreads around the entire circumference of the artery a diffuse cylindrical aneu- rysm develops; if it is confined to one portion of the arterial wall, a saccular aneurysm forms. The extravasated blood either coagulates in the vessel wall or ruptures thi-ough the adventitia. A false traumatic aneurysm develops as a saccular aneurysm from a pulsating or arterial hamiatoma which follows a wound (punctured, con- tused, gunshot, or lacerated) of the vessel wall. The connective tissue surrounding the ha-matoma becomes thickened to form the sac of the aneurysm which contains none of the tunics of the vessel w'all. The blood enclosed within the thickened connective tissue coagulates and sur- rounds a cavity into which the blood passing out of the opening in the vessel wall flows. The arterial wall proper is not dilated. This variety of aneurysm may develop about the end of an artery in an amputation stump. The small projectiles used in modern rifles produce traumatic aneurysms more frequently than the larger ones formerly used (vide Gunshot AVoiinds). Age at Which Aneurysms Most Commonly Develop — Vessels Most Commonly Involved. — The simple arterial aneurysm is about twice as frequent in the male as in the female, and develops most frequently be- tween the thirtieth and fiftieth years of life. Aneurysms are most com- mon in the thoracic aorta; then in the popliteal and femoral arteries; appearing next in order of frequency in abdominal aorta, the sub- clavian, innominate, axillary, iliac, visceral, cerebral, and pulmonary arteries (Crisp). If the small aneurysms are considered, the arteries of the lungs and brain are most fre(|uently involved (Orth). Character of Aneurysmal Sac. — The sac of a true aneurysm has a thin wall, the tunics of which are altered by the original di-sease or by the scar in the vessel wall. In the dissecting aneurysm the tunics of the vessel wall are .separated from each other by blood, while the small sac of the herni;d aneurysm is conqtosed of endothelium alone. The sac of an aneurysm may be thickened by inflammatory proce.s.ses, and may become closely adherent to surrounding ti.ssues. The sac of a false aneurysm consists of dense connective tissue. It is adherent to the surrounding tissues and has no endothelial lining. Large false aneurysms contain stratified layers of blood clot which strengthen the wall of the sac and protect it for a long time against rupture. These clots may, however, narrow and occlude the arteries 43 666 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS which anastomose and provide for a collateral circulation or project into the lumen of the artery and be the source of emboli. Size of Aneurysms. — The size of an an- eurysm varies, de- pending upon the caliber of the vessel involved. The sac of f an aortic aneurysm may become as large as a fist. Enlargement of an Aneurysm. — The growth of an aneu- rysm is slow, except in the embolic or my- cotic variety, and is often retarded or in- terrupted by throm- bus formation and inflammatory thick- ening of the sac. Symptoms. — In the beginning the symp- toms are not distinct. Even in a false aneu- rysm, when blood is poured out into the tissues, the symptoms may be obscure or in- significant at first, as the hai'matoma may be deeply situated Fig. 248.— vl, Fusiform Aneurysm of the Popliteal Artery Developing in a Male Patient Fifty-nine Years of Age. The thigh was amputated above the knee because of gangrene of the foot, e. Advanced arteriosclerosis; g, small saccular evaginations in the posterior tibial artery. B, Longitudinal Section of the Same Prepara- tion. /, Thick, laminated thrombus in the popliteal aneurysm. The thrombus extends into the posterior tibial artery (c) down to the origin of the peroneal artery (6), the lumen of which is greatly narrowed. The posterior (c) and anterior tibial (a) arte- ries are closed by thrombi. The peroneal artery (6) is closed by endarteritis, (d) Cal- cified plaque. DISEASES OF THE BLOOD AND LYMPHATIC VESSELS 667 and covered by resistant tissues. The symptoms first become distinct and pronounced when a visible and palpable tumor develops, or when the tumor exerts pressure upon imj)ortant structures. Pulsation may be seen in the round, oval, rarely sharply defined tumor, if it is su- perficial. The pulsation is expansile in character — i. e., the entire tumor increases in size with each systole and evenly in all directions, so that if the tumor is lightly grasped in any positicm the fingers will be separated. Pulsation may be transmitted to a tumor or ab- scess lying near or upon an artery. This pulsatitm, however, is never expansile, the tumor or abscess being merely lifted with each beat of the artery and not expanding evenly in all directions. Expansile pul- sation is therefore of great diagnostic importance. There is felt upon palpation of an aneurysm a soft thrill or fremitus, there is heard upon AUSCULTATION, whcn the stethoscope is held over the tumor, a blow- ing, buzzing bruit, which is synchronous with systole, but may also be heard in diastole. The latter is produced by whirls in the blood current, formed A\hen the stream entering and leaving the sac meet. The tumor may disappear completely, or almost completely, when pres- sure is made upon it, to reappear when the pressure is released. The expansile pulsation disappears when pressure is made upon the artery proximal to the tumor. Pressure upon the vessel distal to the aneurysm causes the latter to enlarge. All these symptoms may be indistinct or absent if there are thick layers of blood clot \Wthin the sac. The 2)1^1 se on the diseased side distal to the aneurysm is weaker than on the healthy side and is slightly delayed, and the apex of the pulse wave obtained in a sphygmographic tracing is lower and more rounded. Pressure Symptoms. — Pressure upon adjacent nerves frequently gives rise to severe and distressing symptoms. Unpleasant sensations and pain at the beginning increase to severe neuralgia as the pressure iacreases. Eventually sensory disturbances and paralyses develop. Pressure upon adjacent veins is indicated by passive hypera:*mia, distention of the sub- cutaneous veins and cedema. The compressed vein may be completely closed by a thrombus. All these symptoms increase as the aneurysm enlarges. The same symptoms (especially sensory disturbances, numbness, formication, pain) frequently develop immediately after the injury of the artery in trau- matic aneurysms, and are caused by the pressure exerted by the htema- toma. They disappear as the wound heals, but return after a number of weeks, as the sac forms and increases in size. Clinical Course. — Spontaneous cure of an aneurj'sm by filling of the sac with a thrombus or thrombosis of the artery proximal and distal to the opening communicating with the sac is rare, and occurs only in the 66S SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS smaller aneurysms. As a rule an aneurysm, excepting the mycotic variety, undergoes a continued growth, gradually enlarging until it ruptures. A bone adjacent to an aneurysm may be gradually worn away by the pulse beat, as a stone is worn away by water drops. The bone undergoes pressure atrophy. An aneurysm of the thoracic aorta, if it grows forward, gradually destroys the sternum and ribs and reaches the skin. If it grows posteriorly, it destroys the vertebrae and may eventually exert pressure upon the spinal cord or nerves if the sac does not rupture or the patient does not die of some intercurrent infection. The skin covering an aneurysm becomes more and more tense, and finally necrotic, so that eventually the sac of the aneurysm becomes exposed. It may then rupture externally and cause death. If before rupture the poorly nourished skin becomes inflamed, a sub- cutaneous phlegmon may develop. Eupture of the sac occurs at the point where the blood stream exerts the greatest pressure ; that is, where the deposition of layers of blood clot is prevented. Rupture into the pericardial, pleural, and peritoneal cavities is as surely fatal as external rupture and soon causes death, the symptoms being those of internal hemorrhage. The rupture of a deep aneurysm in an extremity is indi- cated by the rapid development of a large swelling which soon ruptures externally, as the tissues covering it soon become necrotic as a result of the pressure exerted upon them. A h£ematoma of the neck, resulting from rupture of an aneurysm, may cause suffocation. The rupture of an aneurysm into a vein produces the secondary form of arteriovenous aneurysm. Complications. — Complications may be caused by separation of par- ticles of a thrombus and embolic closure of the peripheral vessels with subsequent gangrene. Gangrene is more apt to develop when the vessels entering into the collateral circulation are closed by thrombi or are obliterated by arteriosclerosis. ARTERIOVENOUS ANEURYSM There are three varieties of arteriovenous aneurysm (Hunter's aneu- rysm by anastomosis, 1784) (vide Fig. 249). The arteriovenous aneurysm with a venous sac, the so-called varix aneurysmaticus (Scarpa), develops most frequently after the simul- taneous injury of the artery and vein at corresponding points. After agglutination of the openings in the vessels the arterial stream passes through the opening in the vein (arteriovenous fistula) and causes a dilatation of the wall of the vein opposite the opening, resulting in the formation of a varix. The spontaneous development of a varix aneu- rysmaticus is rare. In the cases in which such an aneurysm has devel- oped spontaneously the calcified arterial wall has probably exerted DISEASES OF THE BL(X^D AND LY.MPIIATIC VESSELS 669 l)i-('ssur(> upon the vimm, jhhI bitcr .-iii iillicnmialous nicer luis extended troiii tlie artery throujili the vein wall. The varix usually lias vei-y Ihiii walls and can be easily shelled out tVoui the surrounding tissues. The arteriovenous aneurysm with a false sac, the so-ealled (uicurysnia varicosutn (Seari)a), likewise develops after sinndtaneous injury of an artery and vein at eorrespondiny: points. In this form, however, a A V A V V V ill 1 J^ D M la 16 2 3 Fig. 249o. — The Three Principal Forms of Arteriovexous Axevrysm. 1. Arteriovenous fistula (a). Arteriovenous aneurysm with venous sac, Varix aneurysmaticus (b). 2. Ar- teriovenous aneurysm with false intermediate sac, Aneurysma varicosum. 3. Arterio- venous aneurysm with arterial sac, secondary arteriovenous aneurysm. b d V A A V A V ^ (i| n u G lb 1 2a 2b 3 Fig. 2496. — Special Forms. 1. Arteriovenous aneurysm with false sac and varix on outer side of the vein. Single injury of the artery, double injury of the vein. 2. Arterio- venous aneurysm with direct commiuiication in (a) and witli a false intermediate .sac in (6) and with a false arterial aneurysm. (Single injury of vein, double injury of artery.) 3. Arteriovenous fistula, following double injuries of both vessels. The sacs lie opposite each other. comniunieation is not established directly, as the vein and artery are at first separated by a blood clot. Both the artery and vein connnuni- cate with the false, or, according to its })osition, intermediary sac, which is formed from the blood clot. The wall of the sac consists of the re- mains of the luematoma and thickened connective tissue. It is therefore firndy attached to the surrounding tissues and can be separated with difficulty from nerves, nuiscles, etc. ^\n aneurysm of this kind may develop at the ends of arteri(\s and veins in an amputation stump. ' The arteriovenous aneuiysm Avith an arterial sac should probal)ly be classified as a varicose aneurysm. It is rare, and develops when a true 670 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS aneurj'sm erodes the wall of a vein and ruptures into it (secondary arteriovenous aneurysm). Different special forms of arteriovenous aneurysm may develop if, in addition to perforation of corresponding parts of the walls of the artery and vein, one or both vessels perforate at another point. Then the wall of the vein opposite the point of communication with the true or false sac may develop a varix, the artery may develop a false aneu- rj'sm, or the varix and aneurysm niaj' be combined in the same case (\-ide Y\s) are to be diirerentiated from aneu- rysms by observing carefully tlie character of the i)ulsation. These are mei-ely raised or displaced liy the pulsation transmitted to them, Aviiich is never expansile in char- acter and besides no bruit can be heard. Cavernous aiul i-acemose angio- mas are pulsating tumors, and have to be differentiated at times from arteriovenous aneu- rysms. The vessels of a cav- ernous angioma are never so full as are those of an arterio- venous aneurysm, and the covering such an angioma has a bluish discoloration. The racemose angioma is composed of tortuous, dilated arteries. Sometimes it is very difficult to differentiate be- tween an aneurysm and a pulsating sarcoma. Treatment. — The following arc the principal indications which arc followed to-day in the surgical treatment of simple and arterio- venous aneurysms: (1) Wherever possible complete or incomplete removal of the sac with double ligation of the artery (vein also in arteriovenous aneurysms) above and below the aneurysm, and ligation of all the conununicating lateral branches; (2) restoration of normal conditions, obliterating the aneurysm, Avithout oc- cluding the original lumen of the vessel, by suture (]\Iatas's operation). Complcie extirpation of the aneurysm was first empl(\vcd in the treat- ment of arterial aneurysm by Philagi-ius. After an artificial ischa'mia has been produced by the Esmarch method, the npper and lower limits of the sac are exposed, the vessels are doubly ligated and divided, and the sac removed. Frequently, in operating upon large false aneurysms, parts of the sac which are closely adherent to veins and nerves nnist be left behind. "When in such cases it is seen that the sac eainiot be enucle- ated, it should be split open and as nnich removed as is compatible with Fig. 251. — The Fusiform Aneurysm. The first row of sutures closing the orifices by fine chromicized catgut or silk. (Matas, Bryant's "Operative Surgery.") 674 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS safety. This method has given the best results in the treatment of arteriovenous aneurysms (von Bramann, von Bergmann). The dangers of gangrene following circulatory disturbances induced by this opera- tion (according to Delbet, gangrene j ; occurs in 5.66 per cent of the cases) "ll are to be avoided by applying im- "^n^v mobilizing dressings, loose tampons where they seem necessary, and by elevating the extrem- ity. Digital compression ap- plied intermittently for some time before the operation fa- vors the development of a col- lateral circulation. An at- tempt should be made to restore the lumen by suturing Fig. 252. — The Fusiform Aneurtsm. The second row of sutures. These may be the interrupted or continuous. If floor be rigid the second row may be omitted. (Matas, Bryant's "Operative Surgery.") the cut ends of the vessels, if after re- moval of a small sac they are not too far removed, from each other. In a small saccular aneurysm, aneurysmal varix, and arterio- venous fistula it is possible to restore the lumen of the vessel. After removing the sac or separating the vessels at the point of communica- tion, the defects in the walls should be closed by lateral su- ture, using the remnants of the sac in making the closure (Matas) . Fig. 253. — The Fusiform Aneurysm. The second row of sutures (continuous) intro- duced ; the final obliterating sutures passed at either side. On the left, transfixion of floor is made. On the right ends of simi- lar sutures passed through integuments. (Matas, Bryant's "Operative Surgery.") r DISEASES OF THE liLOOD AND LYMPHATIC MuSSELS 075 Incision of the sac and, turning out of the blood clots after lijra- tioii of the artery above and l)elovv the aneurysm is a niotliod Avhich dates back to Antyllus. It is used instead of extirpation in the cases in which the latter seems to be impossible because of the size of the aneurysm. After the interior of the sac is exposed, the lateral branches are looked foi- and ligated and tlien the cavity of the sac is tamponed. Proximal ligation of the afferent arterial trunk close to the aneurysm (Anel), or at some distance from it (Hunter), may cause coagulation within and contraction of the sac and re.sult in a cure. Blood mav be I I Fig. 254. — The Fusiform Aneurysm. The deep supporting sutures in place, and passing their ends through skin and aneurysmal wall. poured into the sac again when the collateral circulation is establi.shed after these operations, and then the aneurysm recurs. There is also a possibility that pieces of thrombi which follow proximal ligation may become loosened and may lodge in the eff'erent arterial trunk, causing embolic gangrene. Proximal ligation should not be employed in the treatment of an arteriovenous aneurysm, as it is followed quite frequently by gangrene, the arterial blood, when the collateral circulation is estab- lished, passing into the vein below the ligature, and enough blood does not reach the peripheral parts to maintain the life of the tissues. Ac- cording to von Bramann, gangrene developed in six out of thirty-one cases of arteriovenous aneurysms in which proximal ligation of the artery was performed. 676 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Central and peripJieral ligation of the artery in simple aneurysm (Vigier), of the artery and vein in arteriovenous aneurysms with divi- sion of the vessels gives better results than proximal ligation alone. Fig. 255. — The Sacciform Aneurysm, its Main Orifice and the Dotted Outline OF the Main Vessel. (Matas, Bryant's "Operative Surgery.") Fig. 256. — The Sacciform Aneurysm. The closure of main orifice by continuous su- tures without special removing of lumen. (Matas, Bryant's "Operative Surgery.") Even after this operation the aneurysm may recur, as the lateral branches have not been ligated. Brasdor and Wradrop have recommended peripheral ligation of the artery in the treatment of aneurysms so situated that it is impossible or- impracticable to deal with the aneurysm on the cardiac side of the sac. The blood becomes stagnant in the sac after distal ligation, thrombi form which later become organized, resulting in obliteration of the sac and healing. In an aneurysm of the ascending aorta and innominate artery, the right subclavian and common carotid arteries should be ligated. According to H. Jacobs 's statistics, thirty-six out of sixty -nine cases treated in this way were cured. DISEASES OF THE BLOOD AM) LYMPHATIC VESSELS 077 If symptoms (especially bruits) of a piilsatinf; ha'inatoma or of an arteriovenous fistula develop after an injury, the vessel or vessels involved should be exposed and closed by lateral arterial or venous suture or ligated depending upon the conditions found. The develop- ment of a traumatic or arteriovenous aneurysm may be prevented in this way. Amputation must be considered in the treatment of large aneurysms of the extremities associated with nuti'itional disturbances and necrosis, or if embolic gangrene develops. There are a number of bloodless methods which may be employed in the treatment of inaccessible aneurysms, such as those of the aorta, Fig. 257. — The Sacciform Axeirysm. Closure of the main orifice by interrupted sutures without special removing of lumen. (Matas, Brj^ant's "Operative Surgery.") internal carotid, etc., or when operation is contraindicated because of the age or weakened condition of the i)ati('nt. The object of all these meth- ods is to produce a thrombosis, for when the thrombi become organized the aneurysm becomes smaller aiul its walls thicker. Of the large num- ber of old and new methods, only two demand consideration. 678 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Compression. — Continuous or intermittent compression of the affer- ent artery may be employed, some special apparatus or the fingers being used for the purpose. The object of the compression is merely to slow or arrest the arterial stream, not to produce a passive hypersemia. Cir- FiG. 258. — The Sacciform Aneurysm. Ob- literation of orifice completed, lumen in- tact. Operation completed as in fusiform aneurysm. (Matas, Bryant's "Operative Surgery.") Fig. 259. — The Sacciform Aneurysm with Catheter Introduced to Maintain Caliber of Lumen; Suti;res Placed Over Catheter. (Matas, Bryant's "Op- erative Surgery.") cular constriction should therefore not be employed for this purpose. Some arterial aneurysms have been observed in which the symptoms dis- appeared and the sac decreased in size after compression for a number of hours. In other cases intermittent compression has been employed for days and weeks before results were obtained, and then often without success. The object of compression is so to reduce the blood pressure as to permit of coagulation within the sac of the aneurysm. According to Vanzetti, in the treatment of arteriovenous aneurysms by this method the artery should be compressed just above the aneurysm until the puLse disappears, and the vein at the point of communication with the sac at the same time. Compression, combined with rest in bed and im- DISEASES OF THE BLOOD AND LYMPHATIC VESSELS G79 iii()l)ili/,ation of the (wtreniity, should he ('Miph)yo(l a sliort time before operative treatment is instituted. Compression, even if it does not cure tlic aneurysm, favors tlie development of a collateral circulation and may j)revent subsequent gangrene. In suitable cases forced flexion of the extremity may be employed instead of instrumental or digital com- pression. The hypertiexed parts are maintained in position by band- ages. This method can be employed safely only in the treatment of small aneurysms, as the larger ones are apt to rupture, and in the treat- ment of aneurysms in certain localities, at the bend of the elbow, in popliteal space, and in the groin. It should be remembered th there is danger of rupturir large aneurysms when using digi tal or instrumental compression Gelatin Treatment. — Dastre and Floresco dem- onstrated experimentally that subcutaneous injec- tions of a solution of gela- tin increased the coagula- bility of the blood. Lan- cereaux and Paulesco (1898) recommended gela- tin injections for the treat- ment of saccular aneurysms. One hundred c.c. of a one or two per cent solution of gela- tin (1-2 gm. of white gelatin is dissolved in 100 c.c. of physi- ological salt solution, and is sterilized for five successive days for one half hour over live steam at 212° F. and heated to 09° F. before being used) should be injected about every week. Beck, among others, cured a large aneurysm of the aorta in two months by this treatment. This method, which promised much, has been disappointing. If the heart is Aveak the increased coagulability of the blood may lead to the formation of thrombi in the large veins (iliac femoral), and if the sterilization is not thor- ough and reliable, tetanus may follow the injection (vide Bass). Injections of chemical agents into the sac, and the ajjplication of Fig. 260. — The Saccifokm Aneurysm. The re- moval of catheter before final closure of the mahi channel. (Matas, Bryant's "Operative Surgery.") 680 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS elastic bandages about the extremity, are frequently followed by gan- grene and should not be employed. Acupuncture, according to Velpeau (insertion of hot needles into the sac), and galvano-puncture (intro- ducing gold or steel wire through a needle or canula into the sac and passing the galvanic current through them) are not very often indi- cated, as the treatment is often not successful and is associated with the dangers of ha?morrhage, inflammation, and separation of thrombi. If the aneurysm is inoperable, tlie patient should be kept in bed or the extremity should be immobilized. Sudden increase in blood pres- sure, such as follows physical effort, excitement, and the use of al- coholic drinks, should be avoided. Treatment by starvation and blood-letting, as prescribed in Valsalva's methad, should be employed. Digitalis and tincture of strophanthus may be used to quiet the heart, lodid of potassium and sodium have a favorable influence upon the local and general conditions. Literature. — Bass. Erfolge unci Gefahren der Gelatineapplikation. Zentralbl. f. d. Grenzgebiete, 1904, p. 118. — v. Bergmann. Zur Kasuistik des arteriell-venosen traumatischen Aneurysma. Arch. f. klin. Chir., Bd. 69, 1903, p. 515.— ^). Bramarm. Das arteriell- venose Aneurysma. Arch. f. klin. Chir., Bd. 73, 1886, p. 1. — Delbet. Maladies chir. des arteres. Traite de chir. le Dentu et Delbet. Paris, 1897. — Eppinger. Pathogenesis, Histogenesis und Aetiologie der Aneurysmen. Arch. f. klin. Chir., Bd. 35, 1887, Suppl., p. 1. — Fr. Fischer. Krankheiten der Lymphgefasse, Lymphdriisen und Blutgefasse. Deutsche Chir., 1901. — Franz. Klinische und experimentelle Beitrage betreffend das Aneurysma arteriovenosum. Arch. f. kUn. Chir., Bd. 75, 1905, p. 572. — V. Frisch. Beitrag z. Behandl. periph. Aneurysmen. Arch. f. khn. Chir., Bd. 79, 1906, p. olo.—Jacobsthal. Beitr. zur Statistik der operativ behandelten Aneurysmen. I. Das Aneurysma der Art. anonyma. Deutsche Zeitschr. f. Chir., Bd. 63, 1902, p. 550. II. Das Aneurysma der Art. subclavia. Ibid., Bd. 68, 1903, p. 239. — Malkojf. Ueber die Bedeutung der traumatischen Verletzung von Arterien (Quetschung, Dehnung) f iir die Entwicklung der wahren Aneurysmen und der Arteriosklerose. Zieglers Beitrage zur path. Anat., Bd. 25, 1901, p. 431. — Matas. An Operation for the Radical Cure of Aneurism. Transact, of the Americ. Surgical Assn., vol. 20, 1902. — Orth. Lehrbuch der speziellen pathol. Anatomic, I. — v. Schrotter. Die Erkrankungen der Gefasse. Noth- nagels Handbuch d. spez. Path. u. Ther., Bd. 15, Part III, Wien, 1901. — Sorgo. Behand- lung der Aneurysmen mit subkutanen Gelatineinjektionen. Zentralbl. f. Grenzgeb,, 1899, p. 10. — Thoma. Untersuchungen iiber Aneurysmen. Virchows Archiv., 111-113, 1888;— Elastizitat gesunder und kranker Arterien. Ibid., Bd. 116, 1889, p. 1. (c) PHLEBECTASES, VARICES By phlebectases or varices is understood a permanent dilatation of the walls of large and small veins. The former term is used more frequently to designate the fusiform, cylindrical, tortuous (cirsoid) dilatations, while the latter is applied to the circumscribed bulgings of the vein wall (varices), which still maintain their connection with the vein by a broad or narrow neck. There are a number of transitional forms, so DISEASES OF THE BLOOD AND^ LYMPHATIC VESSELS 681 tliat both tonus are usually eiiiijloycd with ahoiil tlic same yciieral sig- nilicaiu'c. Causes of Varicose Veins. — There are a nuniber of etiological factors which contribute to the development of varicose veins. Besides the mechanical factors which interfere with the venous circulation and therefore increase the pressure within the veins, the lessened rt'sistance of the walls of the veins and insufificiency of the valves, which may be congenital or secondary to inflannnatory changes, must be considered. Usually a number of different etiological factors are combined, one following and accentuating another ; for example, if the valves of the veins of the lower extremities have under- gone contraction and become insufificient, the weight of the entire column of blood from the inferior vena cava down is thrown uj)on the wall of the vein. If the reverse happens and the walls of the vein become distended by the weight of the column of blood, the valves become insuf- ficient and are no longer able to break the column of blo(.)d and assist in venous cir- culation. If the stasis is long-continued, the walls of the veins become inelastic and yielding, the circulation in the vasa vaso- rum is interfered with and the nutrition of the tissues of the vein wall gradually is impaired, leading to a dilatation of the vein witli relative insufficiency of the valves and venous stasis. According to Ledderhose, too much importance has been attributed to the valves in assisting in and maintaining venous circulation. Most authorities, hoAvever, at the pres- ent time attribute to the valves a very important function. Pathological Changes in Varicose Veins. — Some parts of a varicose vein may be practically normal, while in other parts the muscular and elastic elements disappear, being replaced by a fibro-cicatricial tissue, while in still other parts (especially where the pouchlike dilatations occur) the vein wall is thin and atrophic. The veins are more or less adherent to surrounding structures, the adhesions being partly due to nutritiimal disturbances, partly to inflammatory changes in the peri- 44 Fig. 261. — Resected Piece of THE Long Saphenou.s Vein (Filled with Paraffine). 1, cylindrical; 2, fusiform; 3, tortuous phlebectases; 4, varix. 682 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS vascular tissues. The slowing of the blood stream and the proliferation of the intima predispose to the development of thrombi. If the thrombi, become calcified, vein stones or phleholiths are formed. A varix, which may become as large as a hen's egg, may become constricted and sepa- rated from the vein wall at the point at which it formerly communi- cated. In this way a blood cyst may develop. Large, tortuous, and convoluted veins may be in direct communication with one another, as the walls of the vein when in contact may under- go a pressure necrosis and a communication may be established (anastomosing varices). Veins Most Commonly Involved — Age, Sex, Occupation. — Haemorrhoids (dilated hcemor- rhoidal veins or plexuses) are the most com- mon type of varicose veins. Normally, even in children, small dilatations may be demon- strated in the veins about the anus (annulus hfemorrhoidalis), which become transformed into varices as the result of chronic consti- pation and inflammation of the mucous mem- brane. Some authors (Reinbach, Gunckel, Rotter, Ziegler) regard hemorrhoids as cav- ernous angiomas and classify them as new growths, while others (Borst, Kaufmann, Ribbert) regard them merely as varicose veins. [Hcemorrhoids are histologically an- giomas in which the venous elements pre- dominate.] Next in order of frequency are varicose veins of the lower extremity, both the super- ficial and deep veins being involved. Vari- cose veins are most common in individuals of middle age, whose occupation re- quires them to stand a great deal, in women who have borne children, in pa- tients with pelvic tumors, and in young people with a congenital weakness of the vein walls. Blue nodules, saccu- lated and tortuous dilatations, and con- volutions are seen in the course of the long and short saphenous veins, over which the skin is more or less thinned. These empty when pressure is made upon them or the extremity is elevated, leaving deep grooves in the thinned skin. When the upright position is assumed again and the pressure is released, the blood flows back into the veins Fig. 262. — Varicose Veins of the Lower Extremity. DISEASES OF Til 10 BJ.UUD AND LYMl'IIATIC VESSELS GS3 from abovo, and the veins do not fill fi'om ])elow as the valves are insuf- ficient. [This test was first used by Trendeleirl)urg and may be employed in the following way : The patient lies down and the veins are allowed to empty. Pressure is then made upon the saphenous vein at the saphe- nous opening, and maintained while the patient is assuming the upright position. When the pressure is released the column of blood drops back from above, showing that the valves are insufficient.] The small veins of the skin are red and injected. Varicose veins in the upper extremity are rare, and are usually due to pressure of tumors upon the axillary or subclavian vein, or are associated with arterio- venous or cirsoid aneurysms. A varicose condition of the pampiniform plexus is known as a vari- cocele. Varicoceles are common in young adults. Varico.se veins also develop in later adult life within the broad ligament, the prostate, about the neck of the bladder and the external genitalia, in the utero-vaginal, vesical, and pudendal plexuses. The veins of the abdominal wall sur- rounding the umbilicus dilate to form the caput ]\Iedus{p Avhen the portal circulation is obstructed by thrombosis or in cirrhosis of the liver, aiding in the establishment of a collateral circulation. The sub- cutaneous veins of the thorax become dilated in tumors of the medi- astinum. Results of Varicose Veins. — The results of varicose veins are circu- latory and nutritional cUsturhances. These are most pronounced when the veins of the lower extremities are involved. The skin becomes thinned and atrophic, susceptible to all kinds of infection, injuries, and necrosis {vide p. 506). Varicose ulcers, eczema, and thrombophlebitis are frequent. An oedema, varying in degree, follows the passive hyper- ipmia and leads to a gradual thickening and induration of the skin and subcutaneous connective tissues (elephantiasis phlebectatica). Weak- ness of the legs and fatigue are common, and are due in part to the circulatory disturbances, in part to the fibrous myositis with secondary degeneration of the muscle fibers. Cramplike muscular contractions and neuralgic pains are of frequent occurrence when the deeper veins are involved. Submucous varices may cause an atrophy of the mucous membrane, a varicocele, atrophy of the testicle. Dangers of Varicose Veins. — The dangers of varicose veins are Jicem- orrhage and thromhophlehitis. Haemorrhage follows rupture of a pouch- like dilatation of the vein wall and the atrophic skin or mucous mem- brane covering it. It is usually due to a sudden increase in venous pressure resulting from the imperfect application of an Esmarch con- strictor or the dependent position of the extremity. Such a haemorrhage may prove fatal, as a column of blood extending to the right auricle is opened near its lower end. 684 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Haemorrhoids rupture and bleed very frequently (therefore the name). Occasionally varicose veins rupture into the hollow viscera (rupture of oesophageal varices in cirrhosis of the liver and of varices of the brain) terminating fatally. A sudden, frequently painful, swelling develops when varicose veins in a muscle rupture. Diagnosis. — The diagnosis of superficial varicose veins is difficult only when the dilatations are limited to a small part of the vein and are circumscribed. In these cases a diagnosis of a cavernous ha?man- gioma may be made. Deep varicose veins give rise to no definite symp- toms. The dilated, pulsating veins occurring in arteriovenous aneurysm offer no difficulty in diagnosis if a careful examination is made. The varices occurring over the saphenous opening and varicocele are some- times mistaken for femoral and inguinal hernia respectively, but differ from hernia in that the swelling disappears so readily when pressure is made or when the patient lies down, and recurs so readily when the patient stands up. Treatment. — The treatment which should be instituted depends upon the cause, the situation, and the complications of the varicose veins. Varicose veins frequently subside after tumors (which have exerted pressure upon the principal vein and have caused an increased venous pressure) have been removed. Ligation of the long saphenous vein at the saphenous opening, as suggested by Trendelenburg, breaks the long column of venous blood and prevents pressure upon the wall of the vein. Elastic bandages properly applied and elevation of the extremities have a favorable influence upon varicose veins of the extremities. A suspensory improves the circulation in a varicocele, and the pain and discomfort usually soon disappear after it is used. Large varicose veins and varicoceles should be extirpated after the veins have been exposed and ligated. In varicose veins of the leg exten- sive and thorough resection of the diseased veins (Madelung) or ligation and resection of the long saphenous vein at the saphenous opening are recommended (Trendelenburg). fC. H. Mayo has devised a very in- genious instrument, called a " vein stripper," which permits of a sub- cutaneous removal of the greater part of the varicose vein. It is a long instrument, provided with a steel eye. The vein is exposed above through a small transverse incision, cut and ligated, and then threaded upon the instrument. The vein is then separated from the tissues, and its collaterals are broken by gently forcing the " stripper " along the vein. Another small incision is then made over the end of the instru- ment, the distal portion of the vein is ligated, and the part which has been separated is removed.] ITiemorrhoids should be removed with the actual cautery or transfixed at the base with heavy silk and ligated. Bleeding from varicose veins subsides if the extremity is elevated DISEASES OF THE BLUUD AMJ LYMPHATIC VESSELS 685 or mild couipressiou is exerted by a bandage. Haemorrhage from hivmor- ihoiils gonorally eoases when the prolapsed, strangulated masses are reduced. Extirpation of the larger ruptured varices is advised. The treatment of other complications, such as thrombophlebitis and varicose ulcers, will be found in the chapters devoted to these subjects. Literature. — Fr. Fischer. Krankheiten der Lymphgefiisse, Lj-mphdriisen und BlutgefiLsse. Deutsche Chir., 190L — F. Fraenkel. L'eber die Behandlung tier Varizen der Unteren Extremitiit diirch Avisschalung nach >Lidolung. Beitr. z. klin. Chir., Bd. 36, 1902, p. 547. — Kashimura. Die Entstehimg der Varizen der Vena saphena in ihrer Ab- hangigkeit voni Gefiissnervensystem. Virchows Arch., BiL 179, 190.3, p. 37.3. — Ledder- hose. Die Bedeutung der Venenklappen und ihre Beziehungen zu den Varizen. Deutsch. nieiL Wochen-schr., 1904, p. 1563. — v. Schrotter. Erkrankungen der Gefiisse. Xoth- nagels Spez. Path. u. Ther., Wien, 1901. — Schwarz. Maladies chir. des veines. Traite de chir. le Dentu et Delbet. T. IV, p. 349. Paris, 1897. (d) THROMBOSIS AND EMBOLISM THROMBOSIS The coagulation of blood within the vessels during life is known as thrombosis, and the resulting solid mass as a thrombus (from the Greek Opofx/So's, meaning coagulum). Varieties of Thrombi and Histological Changes Occurring in Throm- bosis. — Red, white, and mixed thrombi have been distinguished since Zahn first described the microscopic changes occurring in thrombosis of the mesenteric vessels of a frog. The color of a thrombus depends upon the number of red blood corpuscles it contains. The red throm- bus contains, besides granules and threads of fibrin, all the component parts of the blood, and is formed when stagnant or slowly flowing blood coagulates. Thrombi formed from blood in circulation, which not in- frequently occur upon the internal surface of the heart and blood ves- sels, are composed mostly of fibrin, with a variable number of the color- less elements of the blood, and contain sometimes a few red cells. "White and mixed thrombi are formed when the circulating blood coagulates. [The following description of the formation of thrombi is found in Ziegler's " General Pathologj^" pp. 117 and 118: " The formation of thrombi in circulating blood may be observed distinctly under the micro- scope, in suitable subjects, both in warm-blooded and cold-blooded ani- mals, and in this line it is more particularly the observations of Bizzo- zero, Ebertli, Sehinmielbusch, and Lowit which have led to very weighty conclusions. "When the blood flows through a vessel with its normal velocity, you may see under the microscope (Bizzozero, Eberth, and Schimmelbusch) a broad, homogeneous, red stream in the axis of the blood vessel, while at the sides lies a clear zone of blood-plasma free from red blood corpuscles. 686 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS " This may be observed in both arteries and veins and in the larger capillaries, but is best seen in the veins. In the capillaries just large enough to permit of the passage of the blood corpuscles, this differen- tiation into an axial and peripheral stream does not hold. In the axial stream the different constituents of the blood are not recognizable ; in the peripheral stream, however, isolated white blood corpuscles appear from time to time, and these may be seen to roll slowly along the vessel wall. If the blood current becomes retarded to about the degree which allows the observer to make out indistinctly the blood corpuscles of the axial stream, the number of white blood corpuscles floating slowly along in the peripheral zone, and adhering also at times to the vessel wall, becomes increased, and they finally come to occupy this zone in consid- erable numbers. If the current be still further retarded so that the red blood corpuscles become clearly recognizable, then in the peripheral zone alongside of the white blood corpuscles appear blood platelets, which increase more and more in number with the progressive retarda- tion of the flow, while the number of leucocytes becomes again dimin- ished. When total arrest of the blood current finally occurs, a distinct separation of the corpuscular elements in the lumen of the vessel follows. " When, in a vessel in which circulation is retarded, the intima is injured at a certain point by compression or by violence, or by chem- ical agents, such as corrosive sublimate, nitrate of silver, or strong salt solutions, and the lesion of the vessel wall is of such a character that it does not cause arrest of the blood current, we may observe (Bizzozero, Eberth, Schimmelbuseh) blood plates adhering to the vessel wall at the injured point, and before long they cover the site of the injury in several layers. " Frequently more or less numerous leucocytes or colorless blood corpuscles become lodged in the mass (Bizzozero), and their number is proportionate to their abundance in the peripheral zone. Under some circumstances the number of leucocytes may be very considerable, and they may largely cover over the accumulation of blood plates. In case of great irregularity of the circulation or of extensive lesions of the vascular wall, red blood corpuscles aLso may separate from the circula- tion and become adherent to the intima or to a layer of leucocytes pre- viously deposited upon it. Not infrequently portions of the separated mass are swept away, in which case a new deposit of blood plates is formed. Through a long-continued deposition of the elements of the blood the vessel may finally become completely closed. " Should a blood vessel suffer a lesion, as above described, while the current of blood within it still remains swift, there is no adherence of blood plates or of blood corpuscles. When at any point blood plates have become adherent in considerable numbers, after a time they be- DISEASES OE Tlir: JJLUOD A.NU LYMI'UATIC VESSELS 087 coiiio coarsely granular at the center, lower animals, and we judge tliat their formation is directly dependent upon two causes: (1) Upon a retardation of the blood current or other disturbance of the circulation, such as the forma- tion of eddies which would direct the blood plates against the vascular wall, and (2) upon local changes in the wall of the vessel. Probably, too, thrombosis is favored by pathological changes in the blood. From the variety of conditions under which thrombosis occurs in man w^e must assume either that now one and again another of these causes plays the principal part in the formation of thrombi, or that all these may concur ecjiially in the process; and, on the other hand, that one of the causes alone is not ordinarily sufficient to cause thrombosis."] Origin of Blood Plates, Fibrin Ferment, etc. — The finer processes of thrombus formation are not well understood. The origin and signi- ficance of the blood plates discovered by Bizzozero are not clear. Accord- ing to the prevailing view they are formed from degenerating red blood corpuscles, yet it is possible that they have no single source (Grawitz). Liberation of fibrin ferment or thrombin (Alex. Schmidt) precedes coagulation. It apparently is derived from degenerating cells (white and red blood corpuscles and endothelial cells) and acts upon fibrinogen, an albuminous substance in the blood plasma. According to Arthus and Pages a third factor, a calcium salt, must be present before coagu- lation can take place. Pekelharing believes that calcium is transferred by the fibrin ferment to the fibrinogen, and that the latter, Avhich was jireviously soluble, undergoes a chemical metamorphosis resulting in the formation of an insoluble calcium-albumin compound, fibrin. Factors Concerned in Thrombus Formation. — Three different factors are conc(>rne(l in thromlius formation: (\) Slowing of the blood current, (2) changes in the vessel wall, and (3) alterations in the composition of the blood. Slowing of the blood stream, following the general circulatory dis- turliances due to cardiac asthenia which occur in a numl)(M- of different 688 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS diseases, is the main factor in the development of the so-called marantic (marasmic) thrombi. Local causes interfering with circulation are nar- rowing of the lumen of the vessel caused by disease of the vessel wall (arteriosclerosis), or compression of the vessel by tumors, displaced fragments of bone, dislocated bones and constricting bandages, and the development of whirls and eddies in aneurysms and in pouchlike dila- tations in the walls of varicose veins. A very insignificant injury of the endothelium lining a vessel may be followed by thrombus formation, and of course a thrombus is much more apt to form M^hen the injury to the vessel wall is more extensive. Large arteries are closed spontaneously when crushed or lacerated by the separation and rolling in of the intima. [The rolling up of the intima prevents haemorrhage after crushed and lacerated wounds of even the largest arteries. "We have seen an axillary artery completely plugged by endothelium in a crushing injury of the shoulder. At least an inch of the intima could be imroUed when the artery was divided after being ligated. The endothelium had formed a complete plug for the vessel.] Spontaneous healing of small wornids of vessels begins with thrombus formation (vide Injuries of Vessels). Changes in the vessel walls due to chemical and thermal agents, to diseases, such as arteriosclerosis, sujDpurative and tuberculous inflammation favor thrombus formation. Thrombus formation may also follow penetrating wounds (e. g., needles) and infiltration of the vessel wall by tumor masses. Alterations in the composition of the hloocl may increase its coagu- lability. The increased coagulability of the blood in general infections (general pyogenic infections, typhoid fever, influenza, etc.), in diseases of the blood (chlorosis), and after extensive burns is probably due to the increase in fibrin ferment resulting from an increased destruction of cells. Mural and Obturating Thrombi. — Parietal, or mural, and obturating thrombi are described, depending upon their relation to the vessel con- taining them. Fibrin may be deposited upon a parietal thrombus, which then enlarges until it may become an obturating thrombus. A throm- bus either remains limited to the point at which it develops, in which case it is firmly attached, or gradually grows as new masses of fibrin are deposited, and extends from a small into a larger vessel or vice versa; for example, a thrombus developing in a small vein of the foot may extend to the inferior vena cava. Such a thrombus, however, is never firmly attached throughout to the intima. Upon section thrombi often have a streaked appearance and irregular markings, brighter and darker areas alternating. Not infrequently it happens that a red throm- bus is superadded to a white or mixed thrombus as the coagulation began in circulating blood, and after the vessel is occluded the blood DLSKASES UF Till': BLOOD AND LY.MriiATIC VESSELS GJSU hccomes .stagiiant and the whole mass then coafrulates. Thrombi form- ing in aneurysmal sacs are fre(iiiently laminated, for thrombo.sis is not continuous and progressive, but occurs at intervals, so that the newly formed layers of coaguluni do not become firndy attached to the old. Changes Occurring in Thrombi. — Throndji may undergo a number of (lill'erent changes, such as contraction, calcification, simple and septic softening, and onjaniznlion. A thrombus in the beginning is soft and contains fluid, but after a time the fibrin contracts, expressing the fluid, the cells enclosed within the meshes of the fibrin degenerate, and the mass becomes dry and firm. A vessel which has been completely closed may become patent again when the thrombus contracts. If lime salts are deposited in the thrombus or the mass which replaces it, vein or artery stones (phleboliths and arterioliths) are formed. When a throm- bus undergoes siniple softening the central portion becomes transformed into a grayish red, caseous, degenerating mass which, after the external layers degenerate, is broken up and discharged into the blood stream, giving rise to emboli. Suppurative or putrefactive softening is due to inHammation of the vessel wall, resulting from the invasion of pyogenic or putrefactive bacteria. It may be followed by the discharge into the blood stream of numerous infected emboli. The most favorable change in a thrombus is organization. A vascular, germinal tissue which de- velops from proliferating endothelium invades and replaces the throm- bus which becomes transformed into firm connective tissue, and the vessel is either permanently closed or its wall is thickened. Symptoms of Thrombosis. — The symptoms of thrombosis are not pro- nounced unless one of the larger arteries is completely occluded. Nu- tritional disturbances then develop which may end in gangrene unless a sufficient collateral circulation is established. Stasis is the principal symptom of venous thrombosis. Other symptoms due to separation of particles of the thrombus and subsequent embolism are frequent. Thrombi develop in arteries after injuries of the vessel wall, in aneu- rysms, in acute inflammation or chronic diseases of the vessels, and after the lodgment of emboli originating from thrombi within the heart or larger vessels. VenoiLs thrombi develop very frequently in phlebitis and in chronic diseases in which cardiac weakness and the absorption of toxins co- operate in producing conditions favoring thrombosis. The veins of the lower extremity are involved most frequently, for the circulation is not only poor in thase veins if they are dilated, but i)hlebitis is also common. When venous thrombosis occurs there may be found along the course of the subcutaneous veins hard, painful, tortuous cords and considerable oedema. In thrombosis of the femoral vein there develops, besides the hard cord the size of a thumb, cyanosis and marked oedema which fre- 690 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS quently becomes chronic, resulting in permanent enlargement of the limb. Thrombi may develop in the veins of the pampiniform plexus of the female after infections and operations, and extend by way of the internal iliac into the femoral vein. OEdema of one or both legs then develops, and the resulting clinical picture resembles that known as phlegmasia alba dolens, following puerperal infections. Suppurative otitis media is frequently the cause of thrombosis of the sigmoid sinus. The thrombus forming in this sinus may extend to communicating sinuses and to the internal jugular vein. Thrombosis of the veins of the mesentery may follow internal strangulation or the incarceration of intestinal loops or omentum in a hernia. The thrombi may then extend to the portal vein, causing marked stasis in the territory drained by the radicles of this vein. Large veins, such as the superior and inferior vena cava and subclavian, may be closed by thrombi extending into them from smaller radicles or by thrombi caused by the pressure of large tumors or aneurysms. If a sufficient collateral venous circulation is established the oedema gradually subsides. Gangrene develops only when all the veins draining an area or organ become closed by thrombi. EMBOLISM The dangers of embolism are associated with thrombosis. Particles of thrombi may be broken off by trauma, separated by violent move- ments, or discharged spontaneously when the thrombus undergoes sim- ple or puriform softening. The advancing end of a thrombus which has extended from a small vein or artery into the lumen of a larger vein or artery may be separated and carried away into the blood stream. Lodgment of an Embolus. — An embolus originating in the left heart or one of the larger arteries may be carried in the blood stream until it either lodges at the point of bifurcation of an artery, where it may remain attached as a saddle-shaped embolus occluding both branches, or may be carried along until the lumpen of the artery is so reduced that it becomes caught. If an important artery is occluded, gangrene of the part supplied by the artery accompanied by violent symptoms frequently follows, as a collateral circulation sufficient to provide for the nutrition of the tissues is not established rapidly enough {vide p. 497). Infected emboli may cause arteritis and embolomycotic aneurysms. Pulmonary Embolism. — Venous emboli, originating not only in large thrombosed vessels, but also in small veins adjacent to insignificant in- juries and inflammatory foci (e. g., fracture of the fibula, furuncle), are much more frequent and are usually more dangerous than are arte- rial emboli. They pass from the vessel into the right heart, thence into the pulmonary arteries, occluding the principal artery or its branches. . If the principal artery or one of its large branches is occluded, marked DISEASES OF Till. liLOOl) AM) LVMPITATK" VESSELS ()0l (lys|)ii(r;i develops suddenly, the lienrt beeouies rapid, \veal<, and soon exhaiLsted, and death oeeurs. IT one ol' the less important hi-anches becomes oeeluded — this oecurs especially in liie ri<;ht h)\ver lobe — \hc symptoms of hcvmorrhagic infarct soon develop. In rare cases an embolus may pass through a patent foramen ovale into the general circulation (paradoxical eiiil)olus) or an embolus in a large vein may be carried backward (reti-ogi-ade embolism) in a direction opposite to the current, when there is venous stasis and the pulse wave is transmitted to the bh)od in the veins (Ribbert). IMetastatic hnig abscesses may be cansed by infected emboli. Emboli arising from intiammatory foci in the lungs (especially tuberculous foci) may pass into the general circulation and fretiuently produce infaret-shaped foci in the viscera. Diagnosis. — The diagnosis of thrombosis can be made only when the lai-ge vessels are involved. Chronic oedema resulting from venous throm- bosis may be easily mistaken for oedema due to other causes. Treatment. — Rest in bed and immobilization with elevation of the affected part should be maintained for many weeks — for at least three. These measures favor the contraction or organization of the thrombus and the establishment of a collatei-al circulation. If the cedema per- sists, a bandage or elastic stocking exerting mild compression should be worn. Absolute rest is the best protection against embolism, especially against i)ulmonary embolism, which is always of the gravest significance. Large doses of morphin are often indispensable in quieting the patient. Cardiac stinnilants should not be given unless cardiac weakness becomes serious, as the increased force of the heart beat may easily separate and set free particles of a thrombus. Sudden death from pulmonary embolism is a ccmstant menace, even Avhen convalescence from infiannnatoiy processes adjacent to the veins of the abdomen and pelvis (especially in appendicitis and infiannnation of the adnexa and aftei- operations performed for the relief of the same) is well advanced. Improv(>ment of the general condition and of the heart and complete rest in the recumbent position ai'c the only methods by which this serious accident can be prevented. LiTKiiATUKE. — Grawitz. Klinische Pathologie dos Blutes. Berlin, 1902. Die l'>luti)l:lttchen, p. 128. — v. Schrottrr. l-'-rkriinkungen tier CJefilsse. Wien, 1901. — Zicylir. Thrombose. Eulcnburgs Realenzyklopiidie, 3. Aufl. (e) LYMPHANGIECTASES Lymphangiectases of the thoracic duct and the larger lymphatic vessels occur especially as the result of the pressure of tumors, and are of importance only in those cases in which they rupture into the pleural or peritoneal cavities, causing chylothorax and chylous ascites. 692 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Causes of Lymphatic Varices — Lymph-CEdema. — Varices develop in the lymphatic vessejs of the skin and subcutaneous tissue after frequently recurring or continued inflammations followed by thrombosis and oblit- eration of the vessels (in habitual erysipelas, recurring lymphangitis, and invasion of the lymphatic vessels by the filaria sanguinis) ; occasion- ally after extirpation of sux^purating inguinal Ij^iiph nodes ; after exten- sive crushing injuries and phlegmons. Not infrequently dilatation of lymphatic vessels resulting from inflammation is associated with pachy- dermia. If the cutaneous lymphatics are involved, the skin becomes swollen, the boundaries of the swelling being indistinct, and covered with small, closely set vesicles which never become larger than a pea. The skin is also filled with dilated, tortuous lymphatic vessels. If pres- sure is made upon the swollen area, the fluid, as in oedema, may be forced into the surrounding tissues, and a pit which slowly disappears remains when the pressure is removed. If the larger vessels in the subcutaneous tissues are dilated, tor- tuous cords resembling anglewornxs may be seen. The skin over these is covered with small vesicles and presents the signs common to a lymph-oedema. [The characteristic appearance of lymph-oedema is seen in the pigskdnlike changes associated with carcinoma of the breast. The peculiar appearance of the skin in these cases is due to a Ijonph-oedema following occlusion of the IjTnphatic vessels by carci- noma cells.] Clinical Course and Diagnosis. — The growth of a lymphangiectatic swelling is very slow or, after acute inflammatory processes, intermit- tent. It is scarcely possible to difi'erentiate less extensive lymphangiec- tases from a lymphangioma. All congenital dilatations of lymphatic vessels should be classified with lymphangiomas. They can scarcely be mistaken for varicose veins, as the bluish color of the skin indicates that the dilated vessels contain blood. Complications. — Inflammations of the skin and lymphorrhoea are common when the lymphatics of the skin and subcutaneous tissues are involved. A scratch or an insignificant injury may rupture a lymijli- vesiele, from which is discharged large quantities of lymph. [" In one case of lymphangiectasis invoMng the labia majora in which a fistula developed, Xieden found that in four hours there was an escape of one and a half liters of a millrv^, slightly yellowish liquid containing fat and resembling chyle." — Tillmanns' " Text-book of Surgery," Vol. I. p. 544.] The discharge of lymph may continue for days and weeks with- out impairing the general condition of the patient. It, however, mac- erates the skin which is continually bathed by it, and provides infection atria for phlegmonous inflammations and erysipelas. A lymphorrhoea is frequently followed by lymphangitis. DISEASES OF THE riOUIPIlERAL NERVES 693 Treatment. — The treatineiit of the less extensive lymplian}i!;iectases liiiiited to the skin and subcutaneous tissues is the same as that em- ployed for lymphangioma. The dilated lymphatic vessels should be excised. Extensive swellings subside gradually under the pressure of well-applied bandages and elevation of the extremity. If there is a lymphorrhd'a, dressings of oxid of zinc ointment should be applied to protect the surrounding skin. Lymph fistultc frequently close after repeated cauterizations with silver nitrate. In the more resistant cases incision and tami)oning of the wound with iodoform gauze is often necessary. LiTEiiATUKK. — Fr. Fifschcr. Krankheiten tier Lymphgefasse, Lyniplulrusen und lilutgefasse. Deutsche Chir., I'JUl. CHAPTER V DISEASES OF TUIO 1M;K1PHERAL NERVES (a) NEURALGIA Definition — True and Symptomatic Neuralgia. — By neuralgia is un- derstood a disease of the sensory nerves, the chief symptom of which is pain. It may occur as an independent affection (true neuralgia) or be merely symptomatic (symptomatic or secondary ncniralgia) of some local or general lesion influencing the nerves. When occuri-ing as an in- dependent affection, no pathological changes are found in the nerves. Characteristics and Symptoms. — The most important characteristics of neuralgia are intermittent or remittent attacks of severe, often ago- nizing, pain which radiates along nerves, nerve trunks, or plexuses, and subsides completely or incompletely after lasting for a few minutes or hours. The pain may recur upon the slightest pi-ovocation, such as pressure upon the nerve or movement on the part of the patient. The symptoms which usually develop in middle life either begin sud- denly, reaching their maxinuim intensity early, or ai-e mild in the begin- ning and gradually increase in severity. Sometimes the pain begins without warning, at other times there are prodromata, such as mild shooting pain and tingling sensations. A few hours or days may inter- vene between the attacks. Frequently, when the attack is at its height, the pain is no longer limited to the nerve primarily involved, but radi- ates along adjacent nerve trunks (irradiation). Neuralgia may extend over days, weeks, months, or years. The symptoms may disappear and not recur, or they may extend to other branches of the same nei-ve or plexus. Sometimes, especially in tri- 694 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS facial neuralgia, the patients are scarcely free from pain, which is so severe that they have often committed suicide. A number of disturbances, of which the following are the most pro- nounced and frequent, follow interference with nerve function: (1) Sensory disturbances (the area supplied by a diseased sensory nerve is often hypergesthetic, more rarely anesthetic) ; (2) increase of glandular secretion (epiphora, increased flow of saliva and sweat) ; (3) blanching and flushing of the skin, depending upon the condition of the vessels; (4) reflex fibrillary muscular twitchings during an attack (e. g., twitch- ing of the facial muscles in trifacial neuralgia) ; (5) trophic disturb- ances, such as atrophy of the skin, falling out of the hair, tendency to eczema, and the development of herpes (herpes zoster in intercostal neuralgia) . The general condition of the patient suffers when the neuralgia lasts for any length of time. Pain deprives the patient of sleep, and in trifacial neuralgia the taking of food is interfered with, as the move- ments of the jaws frequently incite attacks of pain. Psychic changes (irritability, melancholia) develop in the protracted and severe cases. Causes of Neuralgia.— The causes of neuralgia are general and local. Among the general causes are a neuropathic temperament, exhausting physical labor, mental worry — all of which are frequently associated with strong emotions and sexual excesses, lessened bodily resistance, gen- eral weakness, and chronic constipation (in trifacial neuralgia, Gus- senbauer) ; infectious diseases (malaria, typhoid fever, smallpox, in- fluenza) ; and toxic agents, such as lead, copper, mercury, alcohol, and nicotin. Neuralgia also occurs in diabetes mellitus, being secondary to the changes in metabolism. The local causes are chilling of the part involved ; crushing and laceration of nerve trunks ; pressure by pene- trating foreign bodies ; traction and pressure exerted by scar tissue upon the surrounding nerves; pressure upon nerve trunks by displaced frag- ments of bone, aneurysms, varicose veins, gummas, and tumors ( also amputation neuromas) ; and, finally, inflammation about nerve endings or trunks, such as periostitis of the mandible, suppuration of the acces- sory sinuses of the nose, carious teeth, ulcers of the mucous membranes, tuberculosis of the vertebra, sacrum, and ribs. Neuralgialike pains may also be associated with tumors and diseases of the central nervous system (tumors at the base of the brain and of the spinal cord, tabes dorsalis, syphilitic meningitis, multiple sclerosis) (Oppenheim). Nerves Most Commonly Involved — Pain Points and Diagnosis. — Neu- ralgia of the trigeminal nerve is the most common. Then follow in order of frequency, neuralgia of the sciatic, intercostal, and occipital nerves, of the nerves of the lumbar, pudendo-hsemorrhoidal and coc- DISEASES OF TIIi: PERIPHERAL NERVES 695 eyyval plcxusos, and of the extivinitics. The prculiaiitics in tlic onsut, syinptoiiis, and clinical course of each oi' these diiTercnt forms belong to the province of special surgery and nervous diseases. In making a diagnosis of neuralgia it is important to note that the pain corresponds to the anatomical distribution of the nerve involved, and that it extends beyond the areas supplied by the nerve primarily involved only at the height of the attack. Certain points, the so-called pain- points, are very sensitive to pressure, and an attack may be pro- voked ])y making pressure at these points. Such pain points are found where the nerve trunks or branches leave a bony canal, or where they can be easily pressed against some resistant band; for example, in neu- ralgia of the sciatic nerve at the border of the gluteus maximus muscle, in the middle of the popliteal fossa and below the head of the fibula, in neuralgia of the supraorbital nerve at the supraorbital notch, and of the infraorbital nerve at the corresponding foramen. The local or general causes of the neuralgia should always be looked for, as the treatment which should be instituted depends upon the cause. A good example of this is malarial neuralgia (which subsides under quinin, or sciatic neuralgia (which often gives a clew to a pelvic tu- mor, or tuberculosis of the spine [perhaps still curable], or a tumor of the rectum). Bilateral neuralgias involving symmetrical nerves al- ways suggest some central lesion, such as a tumor of the skull or of the base of brain; an intercostal neuralgia suggests a tumor of the cord or a tuberculous spondylitis. The symptoms may be unilateral in these lesions, and then the diagnosis is difficult if there are no other symp- toms (cf. psamomma of the dura illustrated in Chapter VI, Part II, which caused a trifacial neuralgia, the ganglia being extirpated under the wrong diagnosis). Neuralgia may be mistaken for the false neu- ralgia occurring in hysterical patients, attacks in whom are generally induced by some psychic disturbance. It may also be mistaken for neuritis when a careful examination is not made. Treatment. — The treatment of neuralgia is generally successful if the cause can be removed. This is less difficult when the cause is local and peripheral than when it is general or central. As a rule, the neuralgia disappears when scar tissue pressing upon the nerves, the tumor, frag- ment of bone, foreign body, etc., is removed and the inllammation sub- sides. Genei-al diseases should receive appropriate treatment, a hygienic mode of life should be adopted, the general condition of the patient improved, and constipation corrected. If no cause can be foimd, or if the general or local cause has been removed without success, the remedies and procedures used in internal medicine should be tried (ride Edinger). Only the most important of these will be mentioned. Quinin (not in malarial neuralgia only), I 696 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS arsenic in the form of Fowler's solution, potassium bromicl, aconite, aspirin, and pyramidon are especially to be recommended. Local appli- cations of heat (warm compresses, poultices, hot-water bags and bottles) and electricity, both the galvanic and faradic current, may be tried. Sometimes weak solutions of cocain, eucain, or Schleicli's solution are injected about the affected nerve trunks to produce transitory anaes- thesia or a one per cent solution of osmic acid is injected into the nerve to produce a degeneration of its fibers. Injections of alcohol along the tract of the nerve have recently been employed with some success. In severe cases morphin is required, but operative treatment should be instituted before the patient becomes accustomed to large doses and contracts the morphin habit. If all these different methods have been tried without success, or if the general condition of the patient rapidly becomes worse, as the attacks recur more frequently, surgical treatment is indicated. Results can be promised only when there is no central cause, for in the latter case the pain persists even after removal of the nerve. Neurotomy, Neurectomy, and Nerve Stretching. — Neurectomy (in- troduced by Abernethy, 1793) soon replaced neurotomy (first per- formed by Schlichting in 1748). The results following the latter were only temporary, as the sensory nerves rapidly regenerated. Even after neurectomy there is danger of the continuity of the nerve being rees- tablished unless long pieces are removed. Nerve extraction devised by Thiersch (1889) is more reliable than either of the methods above men- tioned, and should be tried in trifacial neuralgia before the removal of the ganglion is considered. In this method the nerve trunk is ex- posed at a suitable point, then grasped with forceps and twisted until all its connections are gradually torn. If patience is exercised, sections of the nerve from 10 to 20 cm. in length may easily be removed. Even after extraction recurrences are frequent, especially in tri- facial neuralgia. These recurrences are due to the regeneration of the nerve from central fibers which were not accessible when the nerve extraction was performed. Hartley and Krause (1892) performed a more radical operation in cases of this character, removing the Gasser- ian ganglion (literature by Lexer and Tiirk). Shortly before this Hors- ley had cut the sensory root behind the ganglion. In the treatment of persistent neuralgias of the mixed nerves supply- ing the trunk and extremities, it may be necessary to perform a laminec- tomy, and after incising the dura mater to resect the posterior or sensory roots of the nerves involved (Chipault and others). In eases in which there are also muscular spasms it is not necessary to open the dura mater, as both roots may be resected where they join to form the nerve before it divides into its anterior and posterior divisions (cf. Schede). DISEASES OF THE PERIPHERAL NERVES 697 Xtriu .sire tell ill (J Avas lirst practiced by Billroth in 1869, then by Xussbaum iu 1872, and was especially recommended by the latter. It was tirst employed for the treatment of epileptiform attacks fol- lowing contusions of nerves. Gartner (1872) was the first to employ this method for the treatment of neuralgia involving the brachial plexus. It was soon tried in a number of different diseases; for example, the sciatic nerves were stretched for the relief of tabes dorsalis (Langen- buch), the facial nerve for convulsive tic, the spinal accessory for con- vulsive wryneck, the fifth cranial nerve for trifacial neuralgia. Finally the nerves were even stretched in tetanus (Vogt and others). The re- sults which had been expected were not obtained, and the method was finally abandoned. According to Scliede, however, nerve stretching is to be recom- mended not only in the treatment of resistant neuralgias of mixed nerves and painful muscular spasms, but also in the treatment of nerve changes following neuritis. "While a complete and permanent cure can- not be promised, considerable improA'ement may be expected. In spinal affections it has no effect upon the course of the disease, and in the treat- ment of neuralgias of sensory nerves, nerve extraction has been used in its place (Schede) for a long time. In performing the operation of nerve stretching the nerve is ex- posed at the point desired, is isolated by blunt dissection, is then grasped between the thumb and index finger or by suitable tractors, and stretched both ways until it has been plainly lengthened. The benefits derived from nerve stretching are due to the lessened conductivity following the trauma, to the degenerative and regenera- tive changes occurring in the nerve following the operation, and to the separation of the nerve from the cicatricial tissue which may sur- round it. The best results have been obtained in the treatment of sciatica. Bloodless stretching of the sciatic nerve has also been attempted. In the latter procedure the patient is anaesthetized and the straightened extremity is flexed at the hip joint until the leg comes in contact. with the face. The extremity is then maintained in this position for five minutes. (b) NEURITIS Definition. — Neuritis is an acute or chronic, serous or seropurulent inflammation of the perineurium and interstitial tissue of nerves, result- ing in the degeneration of the fibers with secondary proliferation of the connective tissues of the nerve. The part of the nerve affected presents a fusiform swelling and is reddened, as a result of the inflammatory infiltration and hyperaemia. After the development and induration of 45 698 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS new connective tissue the nerve becomes hard, irregular, and nodular, and firml}^ adherent to adjacent structures. Etiology. — The most common causes of neuritis are injuries of vari- ous kinds, and toxemias associated with infectious diseases, chronic poi- sonings, and constitutional diseases. The most common injuries affecting nerves are lacerations and contusions, repeated blows or long-continued pressure on nerve trunks received in certain occupations (occupation neuritis) or while using a crutch (crutch palsy), the pressure of frag- ments of fractured bones and ends of dislocated bones, foreign bodies (such as a fragment of glass, point of a knife, a bullet), tumors, cer- vical ribs, etc. In open injuries involving the nerves and in cases in which pyogenic, tuberculous, or gummatous lesions have extended from bones or joints and have involved the nerves, bacterio-toxic and mechan- ical causes are combined. Neuritis may develop during the course of or subsequent to a number of infectious diseases, such as general pyogenic infections, especially of puerperal origin, typhoid fever, diphtheria, syphilis, etc., and in chronic poisoning due to lead, arsenic, alcohol, and nicotin. Cold, rheumatism, gout, diabetes mellitus, leukaemia, and arte- riosclerosis are also to be considered as causes. The inflammation following local causes gradually extends in the form of an ascending and descending neuritis toward the cord and periphery. When the cause is general, not infrequently a number of different nerves are involved (polyneuritis). In chronic alcoholism, lead and arsenic poisoning, paralysis of the extensors of the hands and feet, more rarely of the flexors, develops, while in diphtheria (vide p. 351) any nerve may be attacked. Symptoms. — Acute neuritis may begin with chills and fever. Pain of a boring, tearing character, localized in the nerve primarily affected, which is increased by movements and pressure, is the most important symptom. Symptoms of irritation of the sensory and motor nerves consisting of paraesthesia, hj^pera'sthesia, and contractures follow the pain. As the lesion advances the nerves no longer conduct impulses, and then the reflexes disappear; anaesthesias, trophic disturbances, pal- sies, and later flaccid paralyses with muscular atrophy and the reaction of degeneration develop. Chronic neuritis, unless it develops from an acute form, begins more insidiously. The pain in chronic neuritis is less severe, and nodular thickening may develop along the nerve involved (neuritis nodosa). Acute cases of neuritis may subside after a few weeks, the nerve fibers regenerating. In chronic neuritis, functional disturbances which resist treatment or become permanent develop more frequently. Diagnosis. — It is not always possible to make a diagnosis between neuritis and neuralgia. The character of the pain is of diagnostic value. DISEASES OF JOINTS 699 Jn neuritis it is contiimons, while in neuralgia it occurs at intervals. In neuralyia the tenderness is limited to certain points (pain points, p. 695), while in neuritis the pain extends along the entire nerve, which is often perceptil)ly thickened. Finally the marked sensory, motor, and trophic disturbances which develop rapidly in neuritis are wanting in neuralgia. It may be difficult at times to differentiate multiple fibromas of nerve trunks from the nodular form of neui'itis. The former, however, are usually associated with soft fibromas of the skin and pigmented areas, and besides there is no interference with nerve conduction. Treatment. — In the treatment an attempt should be made to remove the mechanical or infianniiatory cause, and then to immobilize the ex- tremity involved. Morphin, sodium salicylate, salol, and aspirin are the drugs usually recommended. []\lorphin should be used sparingly, however, as there is always the danger that the patient may contract the habit.] In chronic cases an attempt should be made to favor regen- erative processes by massage, electricity and baths. Contractures and paralyses should receive appropriate treatment. If an attempt is made to remove a local cause, such as a foreign body or cicatricial tissue, the nerve should be exposed for some dis- tance, the adhesions between adjacent tissues and the perineurium dis- sected away, and the nerve stretched. Nerve stretching in chronic cases has a favorable action. It not only frees the nerve from adhesions, but stimulates regenerative processes. Literature. — Chipault et Demoulin. La resection intradurale des racines medul- laires post. Gaz. des hopitaux, 1895, No. 95. — Edinger. Behandlung der Neuralgie. Handb. der Therapie von Penzoldt u. Stintzing, Bd. 5, Part II, p. 553. — Th. KolUker. Die Verletzungen und chir. Erkrankungen der periph. Nerven. Deutsche Chir., 1890. — Fedor Krmise. Die Neuralgie des Trigeminus. Leipzig, 1896. — Lexer. Zur Operation des Ganglion Gasseri nach Erfahrungen an 15 Fallen nebst Zusammenstellung der ausgefiihrten Ganglionexstirpationen von W. Tiirk. Arch. f. klin. Chir., Bd. 65, 1902, p. 843. — Oppenheim. Lehrbuch der Nervenkrankheiten. Berlin, 1904. — Schede. Chirurgie der peripheren Nerven und des Riickenmarkes. Handb. d. Therap. von Penzoldt u. Stintzing, Bd. 5, Part II, p. 738. — Thiersch. Ueber Extraktion von Nerven. Chir. Kongr.-Verhandl., 1889, I, p. 44. CHAPTER VI DISEASES OF .JOINTS (a) DISLOCATIONS AND SUBLUXATIONS Dislocations and subluxations may be confjenitdl or acquired. Of congenital dislocations, those of the hip are the most frequent. This malformation is more frequently unilateral than bilateral, and is more 700 SURGICAL DISEASES, EXCLUDIxNG INFECTIONS AND TUMORS common in girls than in boys. Congenital dislocations of the shoulder, knee, and elbov/ joints are infrequent, as are also those of the head of the radius, of the external malleolus, of the wrist, of the fingers, of the patella and clavicle. Congenital Dislocation.- — Theories as to Causes. — The causes of con- genital, frequently also of acquired dislocations, are not clear. There are a number of theories as to the cause of congenital dislocation of the hip. [It is probably due in some cases to malposition of the fcetus in the uterus, or to some irregularity in the shape of the uterus.] If in the beginning of pregnancy there is an insufficient amount of amniotic fluid, the walls of the uterus will be closely applied to the foetus, its thighs will be forcibly flexed and adducted, and the head of the femur will be forced out of the acetabulum (Hoffa). Abnormal amniotic bands may interfere with the normal development of any of the other joints. Symptoms and Signs of Congenital Dislocations. — The deformity resulting from a congenital dislocation may be more or less marked at birth. The symptoms, however, as is usually the case in congenital dislocations of the hip, may not be noted until the child begins to walk. [Patients with a congenital dislocation of the hip have a peculiar waddling gait, which becomes very pronounced when but one side is affected.] The signs common to the acquired are found in congenital dislocations, but the head of the femur is usually freely movable, and movements cause no pain. In fat children the head of the femur can- not be palpated unless there is considerable displacement. X-ray pic- tures should be taken. The most accurate diagnosis can be made in this way. Reduction of Dislocation. — Reduction of the dislocation is, as a rule, difficult only in the old cases with contracted soft tissues, and in those cases with secondary joint changes resembling those of arthritis defor- mans. After reduction, the parts must be maintained in position for a long time by properly applied bandages. If the dislocation cannot be reduced after the shortened muscles have been stretched and length- ened, an operation in which the joint is exposed and the obstacles to reduction are removed should be performed. Prognosis. — Usually the functional results following bloodless reduc- tion are better than those obtained by operative procedures. The latter should be employed only in bad cases, after attempts at reduction by the bloodless method have failed. There is always danger of anchylosis after reduction by the open method. Acquired Dislocation — Pathological and Traumatic. — Acquired dislo- cations which are secondary to some disease of the joints are known as DISEASES OF JOINTS 701 spontaneous oi- patholoirioal dislocations, and arc differentiated from the tra lunatic, which arc produced by force. Causes. — Pathological dislocations may follow intiammation of the joints in which the capsule is distended by a large exudate or the articu- lar surfaces, forming the joint, and the capsule are destroyed. Dislo- cations following distention of the capsule are known as distention dis- locatians; those following destructive changes in the joint as destruction dislocettions. Pathological dislocations may follow deformities due to defects in or shortening of neighboring bones; for example, dislocation of the head of the ulna after resection or pathological shortening of the radius, outward and upward dislocation of the head of the fibula after necrosis of the tibia. Dislocations frequently follow paralysis of the muscles surrounding a joint. If all the muscles are paralyzed, the weight of the entire extremity is thrown upon the capsule of the joint, which becomes stretched and lax. The articular surfaces then fall away from each other and a paralytic flail joint develops. A dislocation of this kind may be easily reduced, but recurs as soon as the pressure exerted l)y the hands or some special apparatus is removed. The diagnasis of a dislocation of this character is easily made, as the soft tissues are atrophic and the exact positions of the articular ends of the bone can easily be determined. A dislocation may occur, even if only a few of the muscles surrounding a joint are paralyzed, as the antagonistic mus- cles which are not paralyzed gradually separate the articular ends of the bone and but little force is required to complete the dislocation. For example, when the abductors and rotators of the thigh are para- lyzed, the adductors produce a dislocation backward. If the conditions are reversed a dislocation forward occurs. Symptoms and Diagnosis. — The symptoms and functional disturb- ances following pathological dislocations dift'er, depending upon the cause. The diagnosis is based upon the abnormal position of the articu- lar ends of the bones and upon the symptoms of the disease of the joints. Treatment. — Reduction of the dislocation and treatment of the ac- companying inflammation of the joint or bones should be combined. If the dislocation follows inflammation of the joint or of the articular ends of the bones, the reduction should be made by gradual extension rather than by the manipulations used in the reduction of traumatic dislocations. If the dislocation is not recent, it may be necessary to reduce it by the open method. Paralytic contractures should receive appropriate treatment. Resection of the ends of the bones is indicated when there is anchylosis and in destruction dislocations. The tendons should be shortened and some apparatus worn after the reduction of paralytic dislocations. 702 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS (b) CONTRACTURES AND ANCHYLOSIS By contracture, strictly speaking, is understood the results of mus- cular contraction — that is, the approximation of two neighboring parts of the body. By the term as it is employed to-day is understood, how- ever, not only the condition produced by active muscular contractions, but also the faulty positions in which joints may become more or less fixed as the result of the contraction and shortening of the soft tissues surrounding them or by the permanent contraction of a group of muscles. Depending upon the position in which the joints become fixed, con- tractures in the position of flexion, extension, adduction, abduction, rotation, pronation, and supination are described. If the contracture is marked (most often in flexion) an acute angle may be formed between the approximated parts; if less marked, an obtuse angle. The joint surfaces may maintain their anatomical relations or be partially or completely separated. In the former case they may be united by fibrous bands or masses of bone (fibrous or bony anchylosis). Congenital Contractures. — Some congenital contractures are due to failures of development; they are then frequently associated with bony defects. Some are due to pressure of the uterus upon the fcetus, when there is insufficient amniotic fluid, or to constriction by the cord and amniotic bands. They occur occasionally as flexion contractures of the hip, of the knee, and of the wrist, and not infrequently of the little finger. Congenital contractures occur frequently in the foot in the form of different varieties of club-foot. Talipes varus is most common, while flat-foot (by pronation), talipes equinus, and calcaneus are rarer. Congenital spastic contractures due to congenital defects of the nervous system or to injuries of the cerebrum during birth also occur. In all congenital contractures malpositions develop as the muscles, fascia, and ligaments contract and the mobility of the joints is de- creased. Acquired contractures are of dermatogenous, desmogenous, myoge- nous, neurogenous, and artlirogenous origin (Hoffa). Dermatogenous Contractures. — Dermatogenous contractures are pro- duced by scars in the skin, and may be overcome by excising the scar and uniting the edges of the resulting defect or covering it with skin grafts. Desmogenous Contractures, — Desmogenous contractures are produced by deep scars (for example, after burns, necrosis of tendons and fascia following suppuration and injuries), or in the hand by overgrowth and contraction of the palmar fascia. In the latter the contracture begins, and is most pronounced in the ring and little fingers. As the contrac- DISEASES OF JOINTS 703 turos advance the fin!;rers involved ])ee()me flexed (Dnpuytren's con- tracture). 'J'lie thiniil) is more i-arely involved. Excisi(Mi of the sear tissue, in Dnpuytren's contracture of the altered palmar fascia, is the most efficient treatment. The portion of the skin which is sometimes involved in the seai'iike tissue should also be excised. After removal of the scar and correction of the contracture, the defect should be covered with pedunculated skin flaps or skin grafts (Lexer). It is most difficult to correct contractures following phlegmonous in- flammation of the tendon sheaths (tendogenous contractures). When the tendons are destroyed forcible extension with immobilization in the corrected position, and even excision of the scar with skin grafting, freeing of the tendons from surrounding sear tissue, and lengthening of the same give but temporary results. Adhesions soon form again, and the prognosis as regards function is hopeless. Myogenous Contractures. — IMyogenous contractures are due to short- .ening of the nuiscle fibers, which may be the result of certain forms of atrophy, of injury, and of inflammation of muscles. If an extrem- ity is held in one position for a long time, the points of origin and in- sertion of the muscles become approximated, and finally the muscles become adapted to their new conditions. These contractures develop in certain occupations (habit contractures with flexion of the fingers in cabmen and handicraftsmen, adduction and flexion of the thigh in patients confined to bed for a long time), when an extremity is inten- tionally held in a certain position (for, example, when the foot of a shortened extremity is held in the position of talipes equinus), and finally when an extremity is immobilized in a definite position for a long time (pronation and supination, flexion of the forearm, flexion of the foot, flexion of the thigh when elevated after amputation) or when the bed clothes are allowed to exert pressure for some time upon the anterior part of the feet of very sick patients. The weight of the foot also contributes to the development of the last type of contractures. Myogenous contractures are frequently caused by diseases and in- flammation of the muscles. In the beginning the muscles involved are contracted and held rigid, as extension causes pain. The best-known example of this condition is the so-called rheumatic wryneck, which often quickly subsides after massage. In suppurative inflammation, in tuberculosis and syphilis of the muscles, in fibrous myositis, in ischfemia, and inflammation following contusions and lacerations of the muscle fibers cicatricial tissue forms, w^hich later contracts, producing distress- ing and often unsightly deformities. The best known of these are con- tractures of the fingers after phlegmonous inflammation of the muscles upon the anterior surface of the forearm, flexion contracture of the thigh in tuberculous spondylitis following cicatricial contraction of the 704 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS ilio-psoas muscle, claw hand after ischaemic paralysis of the muscles of the forearm (Fig. 243), cicatricial wryneck following laceration of the sterno-cleido-mastoid muscle during labor or secondary to fibrous myositis. In the milder cases marked improvement follows massage and passive motion. In the severer cases, if results are not obtained by forcible correction under general anaesthesia, division, lengthening and trans- plantation of tendons may be tried. Sometimes relief follows resection of the bones. [A number of cases have been reported lately in which ischaemic contractures have been greatly improved by resecting the bones. Resection of the bones of course produces a relative lengthen- ing of the shortened tendons.] When muscles are inflamed an attempt should be made to prevent contractures by dressing and maintaining the parts involved in a correct position. According to Hildebrand an attempt should be made in ischaemic contractures to dissect the nerves free from scar tissue and to place them where they will no longer be compressed by it {vide p. 656). Neurogenous Contractures. — Neurogenous contractures are often ac- companied by shortening of the muscles, but the principal lesion is in the nervous system. Reflex, spastic, and paralytic forms of neuroge- nous contractures are described. Reflex contractures, due to irritation of sensory nerves, may occur in almost any painful lesion, and are fre- quently the first symptom. In arthritis the joint assumes the least pain- ful position, and is maintained in it by muscular contraction. In order to prevent pain the anterior abdominal wall becomes boardlike and is held rigid, and abdominal respiration is suspended in the beginning of acute peritonitis; the head is held rigid in acute suppurative inflammation involving the side of the neck ; and the jaws are held closed when phlegmonous inflammation attacks the muscles of mastication or the tissues surrounding them. A painful, immobile flat-foot is an example of a reflex contracture. Sometimes foreign bodies situated upon nerves or scar tissue pressing upon them cause changes which result in con- tractures. These contractures usually subside when the cause is removed. If the reflsx contracture continues for some time, the muscles become shortened and contracted, and the treatment described above for myoge- nous contractures must then be employed. Pure reflex contractures may be easily corrected under auEesthesia. Recurrences should be prevented by immobilizing the parts in a proper position. The spastic forms are due to abnormal innervation or to a patho- logical irritation of a motor nerve (Hoffa). They may be unilateral or bilateral and are almost always of central origin — that is, they follow a number of different lesions of the brain and cord (cerebral tumors and DISEASES OF JOINTS 705 ha?inorrhti<4es, iiuiltipU' sclerosis, hydroeoplialns, •conipr(>ssinn myelitis, sclerosis of the cord, chronic meningitis, hysteria, etc.). Congenital spastic contractures are due to defects or birth injuries of the cere- l)rum. [Spastic contractures of the fingers, known as writer's cramp, Avhich occurs in bookkeepers and stenographers, is a neurosis.] The mus- ch's are in a state of pathological contraction, but are weak, and for this reason a spastic is differentiated from a flaccid pai-alysis. The nniscU's feel hard and rigid, can be extended only with difficulty by passive motion, and return to the contracted position as soon as the pressure is released. The tendon reflexes are exaggerated. In con- genital spastic contractures frequently only the legs are involved, and especially the flexor and adductor muscles. As a result of the talipes equinus, of flexion of the knee and hip joints and adduction of the thigh, the gait is awkward. The adductors become stronger than the abductors, and a peculiar, characteristic, cross-legged gait is produced. Whenever an attempt is made at walking a number of other nuiscle groups are thrown info action. In severe cases Avalking is inqiossible. Mechanical treatment (massage, extension of the muscles by passive motion, and extension apjiaratus), often combined with divisicm of the tendons of the nuiscles most involved with subsequent innnobilization in plaster-of-Paiis dressings, is indicated. Resection of the motor nerves has also been reconnnended. Paralytic contractures are most frequently the result of anterior poliomyelitis, of injuries of the peripheral nerves, of neuritis, and of different lesions of the brain and spinal cord. These contractures fol- lowing flaccid paralysis of a single muscle or group of muscles are due to the contraction, and later, if not used, to the shortening of the an- tagonistic non-paralyzed muscle or group of muscles (Seeligmiiller's antagonistic-mechanical theory) or to the weight of the extremity, which, is thrown upon the joints. Sometimes the intact muscles hypertrophy. Paralytic talipes efjuinus develops after paralysis of the extensor gnmp of nniscles, and is due to the contraction of the muscles of the calf and to the weight of the foot. The weight of the foot may, on the other hand, be sufficient to prevent the development of a talipes calcaneus, which may follow a paralysis of the flexor groups of muscles. Etiology, Pathology, and Symptoms of Anterior Poliomyelitis. — The etiology of infantile paralysis (poliomyelitis anterior) is not ex- actly clear. | ' ' The onset is usually sudden, and the paralysis may occur before the development of the general symptoms. The legs are more frequently involved than the arms; the muscles are usually aff'ected in functionally similar groups, such as the flexors of the forearm, and then very rapidly begin to undergo contractures. These produce de- formities, particularly various forms of club-foot, scoliosis or lordosis, 706 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS and contractures of ■ the hand. ' ' — Musser, ' ' Medical Diagnosis, ' ' p. 1038.] There are no sensory, bladder, or rectal disturbances; the re- flexes are abolished or weakened. The pathological changes, consisting of degeneration of the anterior horn cells with subsequent degeneration of the fibers arising from them and the muscles supplied by them, are most marked in the cervical and lumbar enlargements of the cord. Massage, electricity (galvanic), active and passive motion, warm baths, and inunctions are indicated in the treatment of paralytic con- tractures. Supporting apparatus or immobilizing dressings should be applied to maintain the parts in correct position. Elastic bands, by the contraction of which the absence of muscular action is partially com- pensated, may be attached to the mechanical apparatus. In some cases tendons may be transplanted to advantage. The mal- formations due to shrinkage and contraction of antagonistic muscles may be relieved by tenotomy. If the paralysis is extensive a mechanical support must be worn or the joint opened, the articular surfaces re- moved, and an attempt made to secure a bony anchylosis (arthrodesis) in a good, useful position. The results of the latter operation are, however, always doubtful, as the callus formation may be insufficient and the union poor. Frequently a good position of the parts may be obtained by shortening the tendons involved. Arthrogenous Contractures. — Arthrogenous contractures following in- juries and inflammation of joints are due to shrinkage and contraction of the soft tissues, such as the synovial membrane, ligaments, and peri- articular tissues, entering into the formation of the joint. In inflam- mations of joints the contractures are reflex and myogenous at first, but later become arthrogenous when the capsule contracts. Long-con- tinued immobilization after injuries favors the development of con- tractures. The stiffness of the joint or anchylosis develops in different ways. Contraction of the capsule alone may interfere with the movements of the joint, as in all forms of contractures connective tissue develops in the joint which is no longer used, uniting the articular cartilages, and if these are destroyed, the exposed surfaces of the bones. These fibrous adhesions (anchylosis fibrosa intercartilaginea) later become ossified, and bony anchylosis (anchylosis ossea) develops. Bony anchylosis may develop without a preceding fibrous anchylosis, when the articular car- tilages are destroyed or when callus forms within the joint after frac- tures involving the articular ends of bone. The treatment of arthrogenous contractures depends upon the degree of anchylosis. In fibrous and capsular anchylosis the deformity may be corrected or improved by gradual extension by weight and pulley. Passive motion may often be combined with gradual extension to ad- DISEASES OF JOINTS 707 vantiiye. If the lighting up of an old inllanuiiatory process is not to he feared — for example, in traumatic anchylosis — the deformity may he forcibly corrected under general ana'sthesia. When there is a firm fibrous, cartilaginous, or bony anchylosis, re- section of the joint is generally indicated, the object being the for- mation of a movable joint or one fixed in a position which will be useful. In resection of the knee and ankle joint an atteiiii)t should be made to obtain a bony anchylosis in a useful position; in resection of the shoulder and elbow an attempt should be made to secure movement by instituting early active and passive motion. [Murphy has recently ob- tained some brilliant results in cases of bony anchylosis of the elbow and knee by an operation called arthroplasty, in which, after resecting the anchylosed joint, a movable joint is obtained by placing between the bones a flap of connective tissue and fat from which a new synovial membrane is formed, securing a movable joint.] If, as is frequently the ease in pathological dislocations, the adhesions are very extensive, oste- otomy below the line of the former joint is generally to be preferred to resection. If the bone is cut through obliquely (Konig and Hoffa) the deformity cannot only be corrected, but the .shortening can also be overcome by making traction during the process of repair by weight and pulley. Tenotomy, lengthening, shortening, and transplantation of tendons are the operations most frequently employed for the correction of myog- enous contractures. Technic of Tenotomy. — Tenotomy or cutting the tendons of the short- ened nniscles may be performed by the subcutaneous or open method. In the subcutaneous operation a narrow-bladed knife or Dieffenbach's sickle-.shaped tenotome is iLsed. [Tenotomy is discussed in Bryant's " Operative Surgery," Vol. I, pp. 329 and 330, as follows: " Tenotomy consists in making a subcutaneous or open division of a tendon for the purpose of overcoming or alleviating a deformity usually due to mus- cular ctmtraetion. Since the advent of antiseptic surgery, open division can be practiced witli comparative uniformity if a rigid adherence to its tenets be maintained. " However, it is wiser to hold to the subcutaneous method than to invite unnecessarily the mishaps that may follow a faulty technic in the open one. In order to practice tenotomy successfully the exact loca- tion of the offending structure should be determined, together with the important contiguous vessels, nerves, etc. ^Many of the large tendons are easily located by their natural prominence. Others that ordinar- ily lie concealed become apparent if contraction and deformity have occurred, and still more conspicuous if placed upon the stretch by 708 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS the surgeon. The principles governing tenotomy should be well con- sidered before a tendon is divided, otherwise an expedient of great good may become mischievous and even destructive in its results. Fig. 263. — Dieffenbach's Tenotome and Subcutaneous Tenotomy of the Tendo achillis. " The operation of tenotomy is simplified by attention to the fol- lowing order of procedure : " 1. Secure complete aseptic technic. " 2. Indicate on the handle of the scalpel the direction of the cut- ting edge. " 3. Carefully note the length of the blade, so as to regulate the extent of the division of the tissues. " 4. Avoid, if possible, the division of a tendon as it passes through a special sheath. " 5. Divide the tendon at a point of greatest forced prominence, provided the division be consistent with the safety of important con- tiguous structures. Tf reflex spasm be provoked by ' point pressure,' the tendon should be divided at the point exhibiting the greatest reflex manifestation ( Sayre) . " 6. Make tense the structure to be divided, and so pinch up or push aside the skin at the point of proposed division that when the skin is relaxed the opening in it will not correspond to the divided tendon. DISEASES OF JOINTS 7uy " 7. Insert the blade on the fiat close to the surface of the ten- don to be divided, turn the edge toward the tendon and carefully sever it with a guarded sawing motion, aided by pressing the tendon on the cutting surface of the knife. If incautious force be made, not only the tendon but the superimposed tissue may be divided, thus com- plicating the treatment and recovery. " 8. Cany the edge of the blade away from important structures when possible. '' 9. Withdraw the blade while upon the fiat. Follow tlic with- di'awal with firm pressure upon the parts with tlu' thuiiil) which should finally rest on the incision. This act will press the blood and air from the wound, as well as prevent air from entering it. Close the wound with a horsehair stitch and seal it with antiseptic collodion. The appli- cation and confinement to the wound of an antiseptic pad is often quite sufificient for the requirements of healing. " 10. Rectify the deformity and confine the part immovably until repair is well advanced."] This operation, devised by Stromeyer, was very popular in Dieffen- bach's time. At the present time it is almo.st never em])loycd except for division of the tendo Achillis, of the tendons about the popliteal space, and the adductors. The last is really a myo- tenotomy, as the muscle fibers are also di- vided. The open method, in which the tmidon is divided after having been exposed by a free dissection, has a number of advantages: (1) The relations of the different structures can be seen, (2) injuries of the blood vessels may be avoided, (3) and shortened con- tracted bands of fascia as well as the af- fected tendon may be divided. In cica- tricial Avryneck the contracted fascia and iiitiscle are both important factors in pro- ducing the deformity. Tenotomy throws a nniscle out of action for a short time only. The blood clot form- ing between the divided ends soon becomes infiltrated with germinal tissue which is later transformed into a scar, and the con- tiiniity of the tendon or muscle is then reestablished. The scar is com- parable to the callus uniting fragments of a fractui-cd l)one. Passive motion should be begiui at the end of a week, in order to maintain the lengthened condition of the tendon or nniscle and to prevent the reeur- FiG. 264. — Andkr.son'.s Douhle- FLAP Method. A, Longitudi- nal division; B, flaps formed; C, tendon lengthened, flap vinited. (Bryant's "Operative Surgery.") 710 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS rence of shortening and contractures, which is frequent when proper after-treatment is not instituted. Tenoplasty, Indications and Technic. — Tendon lengthening may be employed to correct the deformities resulting from the shortening of tendons or muscles. It is practiced most frequently upon the larger tendons, such as the tendo Achillis and the ligamentum patellae. A tendon may be lengthened, after it has been exposed, by making alter- nate free incisions at its borders, with subsequent forcible extension. According to Boyer, the tendo Achillis may be lengthened by mak- ing two lateral incisions in it with the tenotome, one incision being just above the heel, the other somewhat higher on the other side of the tendon. [Bryant says that the making of al- ternate free incisions at the borders of a tendon — '' the accordion plan — so as to cause the tendon to assume an accordionlike appearance when length- ened is much more ingenious than practical.] Fig. 265. — A. Poxcet's AccoHDiox Method. (Bryant's "Operative Surgery.") t i Fig. 266. Fig. 267. Fig. 266. — Incision Method. (Bry- ant's "Operative Surgery.") Fig. 267. — Tendon Lengthened in Incision Method. (Bryant's "Op- erative Surgery.") Fig. 268. — Lengthen- ing Tendo Achillis. (Bryant's "Operative Surgery.") Tendons may be lengthened and their continuity still be preserved by making a Z-shaped incision into the tendon and then making ex- tension. When the tendon is extended the ends of the Z can be dis- DISEASES OF JOINTS 711 placed and sutured together. Tendon lengthening is used in place of tenotomy when the shortening is extreme, and in the treatment of contractures involving the tendons of the muscles of the fingers where subsequent failure of union of the divided ends is feared. Tendon shortening is employed for the purpose of improving the action of muscles where power is lessened as the result of a complete or incomplete paralysis, and for the pur- pose of maintaining the joints in a correct / ^ or iLseful position. [Bryant shortly sum- " cr ^: z=. ^i marizes the general principles of tendon shortening as follows: "The removal of a proper segment of a tendon and union of the divided extremities can be accom- plished by either a simple oblique incision ^ „ ^ ^ "^ . Fig. 269. — Plication of a Tex- or lateral apposition and union or by the do^, (After Lange.) introduction of the wedge-formed extrem- ity of one into the split end of the other and fixation with sutures."] Tendons may also be shortened without division by plication or folding upon a liea\y silk suture. In paralytic flail joints, shortening of a num- ber of the tendons of the muscles surrounding the joint (tendinous fixation) may be done to advantage. Transplantation of Tendons. — The displacement or transplantation of tendons may be performed for the correction of paralytic con- tractures. This method, the description of which has already been given in discussing the repair of traumatic tendon defects, may be combined in a number of different ways with tendon lengthen- ing and shortening. The following are simple examples of this most useful procedure : In paralytic club-foot the paralyzed peronei mus- cles may be divided and their distal ends united with a flap from the functionating tendo Achillis {vide p. 536) ; in paralytic flat-foot the tendon of the paralyzed tibialis anticus may be divided and its distal end united with the non-paralyzed extensor hallucis longus; in paralysis of the quadriceps extensor, F. Krause has separated the tendons of the flexors at their attachment and sutured them to the patella ; in the case of paralysis of the musculospiral nerve Hoifa used a similar method, separating the flexor carpi radialis and iilnaris at their insertions and suturing them into the distal parts of the ex- tensors. In all cases the tendons must be united under such tension that the deformity will be overcorrected. If repair occurs, after immobilization in the overcorrected position for six or eight weeks, the results are usually very good, as the displaced or transplanted muscle or tendons assume the fimetion of the paralyzed ones. 712 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Literature. — Bardenheuer. Ischamische Kontraktur. Festschrift zur Eroffnung der Akademie. Koln, 1904, p. 34. — -Bayer. Eine Vereinfachung der plastichen Achil- \otomie. Zentralblatt fiir Chirurgie, 1901, p. 37. — Drobnik. Ueber die Behandlung der Kinderlahmung mit Funktionsteilung und Funktionsiibertragung der Muskeln. Deutsche Zeitschr. f. Chir., Bd. 43, 1896, p. 473. — Gerlach. Klinisch-statistischer Beitrag zur Frage der Sehnenplastik und Sehnentransplantation. I.-D. Rostock, 1904. — -Hoffa. Die Orthopadie im Dienste der Nervenheilkunde. Jena, 1900; — - Lehrbuch der orthopadischen Chirurgie. Stuttgart, 1906; — Ueber Enderfolge der Sehnenplastik. Chir. Kongr.-Verhandl. BerHn, 1904, I, 24. — Fedor Krause. Ersatz des gelahmten Quadriceps femoris durch die Flexoren des Unterschenkels. Deutsche med. Wochenschr., 1902, p. 118. — Nicoladoni. Nachtrag zum Pes calcaneus und zur Transplantation der Peronealsehne. Arch. f. klin. Chir., Bd. 27, 1882, p. 660. — Oppen- heim. Lehrbuch der Nervenkrankheiten. Berlin. — Rosenkranz. Ueber kongenitale Kontrakturen der oberen Extremitaten. Zeitschr. f. orthop. Chir., Bd. 14, 1905, p. 52. — Vulpiits. Ueber die Heilung von Lahmungen und Lahniungsdeformitaten mittels Sehneniiberpflanzung. v. Volkmanns Samml. klin. Vortr. N. F., No. 197, 1897. (c) SPECIAL DISEASES OF THE JOINTS (1) CHRONIC SEROUS SYNOVITIS Nature of Chronic Synovitis. — The symptoms of chronic irritation of the synovial membrane which leads to the formation of a serous exudate, thickening of the joint capsule, and hypertrophy of the syno- vial villi are similar to those of acute serous synovitis, with this dif- ference, that there is little or no inflammatory reaction. Chronic syno- vitis is much more frequently the result or symptom of some other disease of the joint than an independent clinical entity. It follows rheumatism, ha-marthrosis, floating bodies, and arthritis deformans, or develops in a previously healthy joint as the first symptom of some specific disease, such as tuberculosis, syphilis, arthritis deformans, or neuropathic arthritis. Usually, chronic serous synovitis develops in but one joint. The knee is affected most commonly, but it also occurs frequently in the elbow, ankle, and wrist joints. Involvement of many joints is rare and suggests some general cause, such as chronic articular rheumatism, articular syphilis, etc. The changes in the form of the joints are rather characteristic as the capsule is distended and prominent at all yielding points and the normal contour of the joint with its prominences and depressions is obliterated. Chronic seroiLS synovitis develops slowly and may remain stationary for a long time. Exacerbations following use of the joint are frequent, but sometimes the synovitis subsides spon- taneously when care is exercised. If the synovial fringes become hyper- trophied and inflammatory masses form in the capsule, a condition resembling osteoarthritis develops. The sharp contour of the tense capsule then becomes lost and the palpable thickenings and nodules DISEASES OF JOINTS 713 in the inflaiiKHl oapsnlo i^radually become fused with the surroiiiKlins tissues. Symptoms. — 'I'hc symptoms in tlie beginning: arc insignificant. Un- less the synovitis follows a luvnuirthrosis or souu^ acute painful inflam- mation, the patient is often unable to state exactly when the trouble began. A sense of fullness in the joint, of uselessness and weakness of the extremity is fre(|uently the only complaint. Later in neglected cases when the ligaments have become relaxed malformations (such as genu valgum, g. varum, g. recurvatum, and subluxations) develop. Painful anchylosis develops if the capsule becomes thickened and the villi hypertrophied. Diagnosis. — The diagnosis of chronic serous synovitis is not dif- ficult. The chronic, almost painless, course, the changes in the form of the joint, the signs of liuid elicited by palpation and patellar balotte- ment are characteristic. Hypertrophied synovial fringes and inflam- matory masses in the capsule are most easily palpated after the exudate has been partially removed. Then, when the joint is moved, a crepitus and rubbing can be felt and heard. It is frequently difficult to determine the cause of the synovitis when it is the tirst symptom and not the result of some previous disease of the joint. In these cases further observation is necessary before an exact diagnosis can be made. Treatment. — If the exudate is small in amount, rest, elastic com- pression, massage, and passive motion are indicated. If the symptoms do not subside after this treatment, or if the effusion is great, the latter should be removed by aseptic puncture, with subsequent washing out of the joint with a three per cent solution of carbolic acid. After aspiration and injection the joint should be immobilized for a few days. Absorption of an exudate is favored by massage and hot-air treatment ; active and passive motion prevent the formation of adhesions. Painful thickenings of the synovial membrane may require removal. (2) CHRONIC ARTICULAR RHEUMATISM Nature and Pathology. — By chronic articular rheumatism is under- stood a chronic, painful inflammation of the synovial membrane, cap- sular ligament, and periarticular tissues. Hypertrophy of the synovial membrane causes a swelling of the joint, contraction of the tissues of the capsule, limitation of motion. Frequently the articular cartilages become fibrillated and destroyed, and replaced by a vascular connective tissue. In this way the joint cavity is gradually obliterated ; anchylosis and contractures, to which atrophy of the muscles surrounding the joint and contraction of the capsule contribute, develop. The dry form (arthritis sicca) of chronic 46 714 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS articular rheumatism is more common than the form associated with a seroiTS exudate and ending in hydrarthrosis. [" Chronic articular rheumatism never leads to suppuration and never to true caries, the pathological changes presenting more of a similarity to arthritis de- formans, except that in the latter disease there is more of an increased growth of cartilage, while in the former the cartilage is replaced by vascular connective tissue. But deformities of the joints, subluxations and luxations develop in chronic articular rheumatism as they do in arthritis deformans." — Tillmanns' " Text-book of Surgery," Vol. I, p. 670.] The nature of articular rheumatism is obscure. There are a num- ber of transitional forms between chronic serous synovitis and chronic articular rheumatism, and between the latter and arthritis deformans. It is frequently mistaken for gout, arthritis deformans, gonorrheal arthritis, even for tuberculosis. It should also be remembered that a number of lesions which differ clinically and etiologically are grouped under the term chronic articular rheumatism, as characteristics which make a differential diagnosis possible are wanting. jB Etiology. — Nothing definite is known concerning the etiology of this disease. It is questionable whether the short bacillus demonstrated by Schiiller is to be accepted, and yet it cannot be doubted that at least some of the cases are due to bacterial infections. The not infrequent development of chronic articular rheumatism from the acute form, the similarity of the former to the arthritis of gonorrheal origin, the acute and subacute exacerbations, which are frequent during the chronic course of the disease, all indicate a bacterial origin. Clinical experi- ence has demonstrated that getting wet, exposure to cold, and residence in damp, cold dwellings or regions favor the development of the disease. The disease is observed almost exclusively in adults, the female being more frequently attacked than the male. Chlorosis seems to be an etio- logical factor in young girls, arteriosclerosis in old people. Usually a number of different joints are involved, rarely a single one. In severe cases all the joints may be attacked. The disease is most common in the knee and shoulder joints and in the joints of the fingers and toes. Symptoms and Course. — The onset is at times slow and insidious; at other times the disease develops as a sequela to acute articular rheu- matism. Schiiller has differentiated three forms — the simple, severe, and anchylosing — depending upon the clinical course of the disease and the pathological changes in the joints. In the simple form the pain in the joints, which gradually become swollen as the capsule thickens, is slight. It is increased by movements and pressure, is most marked in the morning after the night's rest, and when the patient attempts to DISEASES OF JOINTS 715 walk after sitting for a number of hours. The pains come and go. Exacerl)ations, accompanied by an effusion into the joint rendering motions more difficult, become frequent, while the swelling of the joints increases and becomes more distinct as the muscular atrophy increases and the stiff' joints assume abnormal positions. The deformities are most marked in the hands. The meta- carpo-phalangeal joints become very prominent upon the dorsum of the emaciated hand, the proximal pha- langes become extended, while the remaining ones become flexed and the hand (on account of its weight) becomes displaced to the ulnar side (Pig. 270). Subluxations of the proximal and lateral displacements of the distal phalanges in extension are frequent. In the larger joints, where the capsule is accessible, the hypertrophied synovial fringes may be palpated as small nodules. Dur- ing movements these masses rubbing upon each other produce a peculiar creaking and rubbing sensation. The symptoms and pathological changes remain stationary or pass into those of the severe form. In the severe form the hypertrophy of the synovial villi is marked. In the course of time the entire surface of the synovial membrane be- comes covered with simple, club-shaped or branched villuslike growths which are very vascular and develop from the normal synovial fringes. As these develop they fill the entire joint cavity and distend the cap- sule. The sharp, severe pains are increased by acute inflammatory exacerbations, accompanied by oedema and some redness of the skin and a slight elevation of temperature. Movements become more and more painful and limited as the thickened capsule contracts, as it gradu- ally fuses with the surrounding tissues, and as the margins of the articular cartilages become fibrillated and transformed into fibrous tis- sue. The joints become considerably swollen. The boundaries of the swelling, which become more pronounced as the muscles atrophy and the contractures develop, are not sharply defined. The swelling often is comparable to that which occurs in tuberculous arthritis (von Volk- mann). Hard nodules in the capsule and the liypertrophied villi may be palpated through the soft tissues. When passive movements are made a grating may be felt and heard. If almost all the joints are involved Fig. 270. — Chronic Arthritis of the Joints of the Fingers. (Woman fifty-five years of age.) 716 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS the patient lies helpless in bed, dying after a number of years of exhaustion. The third form (arthritis chronica rheumatica ankylo-poetica) is the most advanced. It may be preceded by one of the forms above described or develop independently. The hypertrophied and thickened capsule shrinks and contracts, while the articular cartilages become fibrillated and destroyed by the pressure of the newly formed, vascular masses of connective tissue. The articular surfaces are denuded and become ad- herent. Bony anchylosis may develop from this fibrous anchylosis, which is accompanied by subluxations and contractures. Strlimpell and P. Marie have described a progressive anchylosis of the spinal column (chronic anchylosing spondylitis) proceeding from below upward which is associated with anchylosis of some of the larger joints. Bechterew has also observed cases of anchylosis of the spine accompanied by pain and symptoms due to compression of the roots of spinal nerves (neuralgias, flaccid paralyses of the muscles of the extremities). The form of anchylosing spondylitis described by Bech- terew differs, however, in a good many respects from that described by Striimpell and Marie. The anatomical investigations of E. Frankel have shown that both these forms of spondylitis have about the same pathological basis, namely, an inflammation of the small vertebral joints leading to an an- chylosis. The periosteal growths are secondary and are due to altered static conditions. Both of these forms, therefore, belong to chronic articular rheumatism and not to arthritis deformans. Prognosis. — The cure of chronic articular rheumatism is not to be expected. Even the mildest forms may continue through life. The severest forms may, however, be somewhat alleviated except when all the joints are involved and anchylosed. Diagnosis.— It is often impossible to make an absolute diagnosis be- tween chronic articular rheumatism, chronic gonorrheal arthritis, gout, and arthritis deformans. Often tuberculoiTS arthritis cannot be posi- tively excluded. Treatment. — The greater part of the treatment of chronic articular rheumatism belongs to internal medicine. Salicylates, hydrotherapy (steam and Turkish baths, hot compresses), massage, and gymnastic' exercises have been employed. A prolonged stay at hot springs, such as Teplitz, Wildbad, Gastein, Wiesbaden, Baden-Baden, Hot Springs (Ar- kansas), White Sulphur Springs (Virginia), and change of residence to a warm, dry climate, are often of value. Bier's passive hypera?mia lessens the pain and favors the separation of fibrous adhesions. It may be alternated with treatment by the hot-air apparatus {vide p. 310). The oedematous infiltration of the tissues and DISEASES OF JOINTS 717 the iniprovcineiit of the eiivulatioii delay the cicatricial conti-action of the tissues and render tlie joint more niovabh'. Aceordinjuc to 15iidin;^er, the injection of stei'ili/.etl vaselin (1-4 c.c.) into the atl'ected joint is of value. The contractures may be corrected by gradual reduction b}' weight and pulley, or by forcible reduction under general anaesthesia. If the joints are ])ainful an attemjit should be made to secure anchylosis in a useful position bj^ immobilizing the part in a plaster cast; otherwise, an attempt should be made to prevent anchylosis. Resection should be considered when contractures in poor positions develop. Large capsular growths and hypertrophied synovial fringes should be removed. (3) ARTHRITIS DEFORMANS— OSTEO-ARTHRITIS CHRONICA DEFORMANS Nature and Pathology of Arthritis Deformans. — The pathological processes occurring in arthritis deformans differ from those of chronic articular rheumatism, but the clinical pictures at the beginning are often very similar. In arthritis deformans the changes in the cartilages and bones (atrophy and proliferation alternating) are the most promi- nent, but the capsule and synovial villi also become hypertrophied and thickened as in chronic articular rheumatism. Arthritis deformans also differs from chronic articular rheumatism in the absence of adhesions between the articular surfaces. In arthritis deformans the articular cartilages become softened, fibril- lated, and fissured at the points where they are exposed to the greatest pressure. The bone is then exposed and becomes smooth and polished off' by the movements of the joint. Nodular masses of cartilage (ecchon- droses), wiiicli later become transformed into osteoid tissue and true bone, develop at the margins of the joint. These cartilaginous masses are at first united by a pedicle, but as they enlarge the pedicle becomes thinner, until finally it is destroyed and the cartilaginous masses become free. Floating cartilages may develop in this way. The bone disap- pears spontaneously by absorption, while the bone-marrow assumes, as the fat is absorbed, a gelatinous, or as liquefaction occurs, a cystic, appearance (Ziegler). The spongy bone lying beneath the articular cartilage becomes softened and yielding, and gradually flattens where exposed to pressure. At the same time bone develops from the perios- teum adjacent to the articular cartilage, which unites with the masses developing from the margins of the cartilage to form large, nodular marginal growths. [A characteristic " lipping " of the margin of the cartilage develops in this way.] Capsular changes are associated with these cartilaginous and bony changes. The capsule becomes thickened and shrunken. At times plates and spiculff" of bone develop within it, while the surface of the synovial membrane may be covered with pro- 718 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS liferating, hypertrophied villi. The latter may be partly fibrous, partly fatty ; often they contain cartilaginous foci. Floating cartilages are often formed by the detachment of thickened calcified villi. The entire joint becomes greatly changed by these processes. The articular ends of the bones become flattened, broad, and surrounded by an irregular row of osteophytes ; the articular surfaces become widened, their margins thickened and irregular. Depressions and cavities alter- nate with grooved and smooth surfaces. The deformed ends of the bones entering into the formation of the diseased joint are surrounded by nodular masses of bone or cartilage and knoblike tuberosities. Be- tween these masses, in the depressions and grooves, are often found in- numerable, larger or smaller, free or pedunculated, bodies. It may be years before the changes become as marked as described above. The disease is characterized by a slow but steadily progressive course, and although it may remain stationary for a time, a subsidence is extremely rare and has been observed only at the beginning of the disease. Joints Most Frequently Involved.— Arthritis deformans is most com- monly observed in tlie hip and knee joints, and then in order of fre- quency in the elbow, wrist, shoulder, and ankle joints, in the spinal col- umn and interphalangeal joints. The disease may develop in a single joint (especially the large ones) or simultaneously in a number of joints. It is more frequent in the male sex. It begins, as a rule, in middle life, but may develop in children and young adults. Nothing definite is known concerning the cause of arthritis de- formans. We only know that injuries to the joints and the factors already mentioned in chronic articular rheumatism play a role. Malum Senile. — This is a chronic disease of the joints occurring in old people and attacking most frequently the hip joint, but also the shoul- der and elbow joints. It differs from arthritis deformans in the absence of bony and cartilaginous growths. The atroph}^ and destruction of the ends of the bones are probably due to senile nutritional disturbances, and resemble the processes occurring in arthritis chronica ulcerosa sicca (Ziegler). The capsule, however, becomes thickened and the synovial villi hypertrophied. Similar changes occur in patients of advanced age whose extremities have been immobilized in dressings for a long time and have not been used. Symptoms. — Arthritis deformans has an insidious onset. For a long time slight pain, creaking and rubbing of the joint on movement, and a sense of stiffness most marked after keeping the joint at rest for a long time, and disappearing rapidly when the limb is used may be the only symptoms. From time to time a serous exudate is poured out into the joint. The effusion recurs frequently when there are free bodies DISEASES OF JOINTS 719 in the joint which irritate the synovial membrane. It is frequently the first thiny: to direct the attention of the patient to the disease, (jlradu- ally the form of the joint chans synovitis, are due to the incarceration of the free body between the articular surfaces. Joints in which Free Bodies Occur Most Commonly and Diagnosis. — Free bodies are found inost frequently in the knee, elbow, and hip joints, especially in powerful men of middle age. The diagnosis is not difficult when the symptoms are pronounced, and a history of a number of previous attacks of locking of the joint can be elicited. If the free bodies are in an inaccessible part of the joint and cannot therefore \ DlSEASi:S OF JOINTS 721 be palpated, tlioy may be demonsti-ated in X-ray pictures unless tliiy consist merely of lihrous tissue or cartilage. [It sliould be remembered in interpretinu- X-i-ay pictures of the knee joint, that there is frequently a sesamoid bone in the internal head of the gastrocniMiiius which casts a sliadow. The shadow cast ])y this sesamoid bone shouhl not be inter- preted as due to a free body.] IiKlicatioHs for Treatment. — If the free bodies cause symptoms they should be removed. As a rule, these bodies can be removed through a small incision in the capsule. AVhen they can be i)alpated, cocain ana'sthexia is sufficient. Of course these operations sliould be performed uiuler ar- tificial isclurmia and under the greatest possible precautions to secure asepsis. If there are a number of free bodies a large incision may be recpiired. If during the operation the free body becomes lost in the joint cavity, pressure should be ex- erted at different points and movements made. Often the free body can be forced out of the incision by proper manip- ulations. After suture of the incisions in the capsule and in the skin, the joint should be innnobilized for a week. Neuropathic Arthritis. — The joint changes occurring in loco- motor ataxia and syringomy- elia, occasionally al.so after compression and injuries of the spinal cord and after in- flannnation and division of the peripheral nerves, are classi- fied as neuropathic (Charcot joints) and are ch)sely allied to those found in arthritis de- formans. In neuropathic ar- thritis, however, the destructiim is much more extensive, the atrophy and proliferation more pronounced, and the course much more rapid. Fig. 272. — Arthritis Neuropathica (Tabica) of TiiK Rhjht Knkk and Anki.k Joints. 722 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS The symptoms frequently begin acutely after exertion or slight trauma with a serous exudate into the joint and an extensive, tense oedema of the para-articular tissues. Neuropathic arthritis differs from all other lesions of the joints in that it is absolutely painless. Accord- ing to Charcot, in a mild or benign case there are but slight changes in the cartilage and bone. In the severe or malignant cases all the structures entering into the formation of the joint are involved. An atrophic and a hypertrophic form may be differentiated. In the former the ends of the bones become small and atrophic, while in the latter proliferation of the cartilage and bone leads to the formation of marginal osteophytes, of knoblike tuberosities, and of plates of bone within the capsule and surrounding tissues. These two forms may be com- bined, and as a rule they are, in the same case. In these cases the joints in- volved become flail as a result of the rapid destruction , and are capable of assuming extreme abnormal positions. Irregularities in form and marked enlargement and expansion of the ends of the bones give to neuropathic joints a very char- acteristic appear- ance, upon which alone the diagnosis can often be made (Fig. 272). A serous exudate, free bodies in the joint, spontaneous fractures of the fragile bones, and pathological dislocations complete the picture. The painless de- velopment and extent of the pathological changes, the extracapsular formation of bone, and the symptoms of the primary disease enable one to easily differentiate between neuropathic arthritis and arthritis deformans. Neuropathic arthritis occurring in locomotor ataxia is most com- mon in the knee and hip joints, more rare in the joints of the upper extremity. In syringomyelia, on the other hand, the joints of the upper extremities are most frequently involved, as the lesions Fig. 273. -Roentgen-Ray Picture of Ca-^l R,lpresented in Preceding Figure. DISEASES OF JOINTS 723 are, as a ni](\ in iho wppov part of the .si)iual eonl. Usually but one joint is involved, although the same joint on the opposite side may be attaeked. 'i'l-ophic distui'banees, ana\sthesia, and analgesia of the bones and joints, fragility of the bones, and mechanieal insults sustained in the ataxic, stamping gait of tabetic patients are im- ])ortant etiological factoi-s in the joint lesions de- veloping in this disease. The treatment is similar to that employed in arthi-itis deformans. The results following resec- tion, especially resection of the bones of the lower extremity, are not as good as the results obtained Fig. 274. Pathological Changes in Elbow Joint in a Case of Syringomyelia. Healed Fracture of the Ulna. in arthritis deformans, because the bones are atrophic. Better results follow the use of a well-fitting, mechanical support. If the destruction of the joint is very extensive, amputation is to be recommended. (4) ARTHRITIS URICA, ARTICULAR GOUT Acute and chronic inflammation of joints form the most prominent features in the clinical picture of gout. It is a constitutional disease, for the most part dependent upon an inherited tendency, in which the metabolic processes are altered and urates are precipitated from the blood and deposited in the tissues, especially in the joints and surround- ing structures, causing attacks of inflammation. Chronic alcoholism, high living, and chronic lead poisoning favor the development of gout, which is most frecjuent in men of middle and advanced age. Symptoms. — Inflammation of the joints is, as a rule, the first and most important symptom of gout, but changes, of which chronic inter- stitial nephritis is the most important, may develop in the viscera. Bladder and kidney stones (urates) are frequent, while obesity, arterio- sclerosis, and diabetes mellitus not infrequently develop later in the course of the disease. If the viscera are not diseased, a patient suffering with gout may 724 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS attain a ripe old age; on the other hand, chronic nephritis, with its complications, may soon prove fatal. Gout in most cases has an acute onset, becoming chronic later; rarely is it chronic from the beginning. Acute Gout. — Acute articular gout usually begins suddenly with severe agonizing pain, increased by movement and pressure, in one joint, as a rule, and with some fever. Sometimes the attack is preceded by Fig. 275. — Arthritis Urica (Gotjt) Involving the Interphalangeal, .Joints of the Little Finger. There are masses of urates in destroyed joints, in the tendons, and beneath the skin. pain in the muscles, weariness, chilly sensations, and indigestion. Gout most frequently attacks the joints of the toes (podagra), preferably the metatarso-phalangeal joint of the great toe. Circulatory disturbances, which are frequent in the terminal parts of the body, the exposed posi- tion of the toes, and the frequent occurrence of arthritis deformans in these joints probably predispose them to attacks of gout. The tissues around the joint become swollen, red, shiny, and (edematous, resembling clinieallj^ acute suppurative or gonorrheal arthritis. The attacks fre- quently begin in the middle of the night, but toward morning the pain and fever subside, and the patient sweats profusely. The general con- dition of the patient remains good. After one or two weeks the night attacks gradually become less and less severe, and the swelling subsides completely, without leaving any noticeable change in the joint. When the joints have been frequently attacked, covering periods. DISEASI':S OF JOINTS 725 of months and j^ears, the articiilai- cartilage may lieeome infiltrated with urates; the ends of the bones, ligaments, and pciM-artieuhu' tissues may become marketUy thickened. While these changes are taking i)lace a number of smaller joints may be attacked. Chronic Gout. — J'allioloyij. — ({out may become chronic after the acute attacks have been frecjuently repeated. In rare cases chronic gout de- velops without an acute stage, and is accompanied by mild inflammatory exacerbations. Wherever the urates are deposited, the cai'tilage, and later the bone, synovial membrane, and ligaments may become necrotic. The surrounding healthy tissue proliferates, forming a graruilation tissue which surrounds tlie necrotic tissue and urates, removing or encapsulating them. The thickening of the capsuk; and anchylosis of the joint are due to the granulation tissue. Abnormal position of the digits and dislocations follow the progressive destruction of the articu- lar cartilages and adjacent bone. The thickening of the joint becomes more marked as the deposit of urates increases. When the capsule of the joint is destroyed, the urates may extend to structures beneath the skin or form encapsulated masses in the tendon sheaths, bursjf, and subcutaneous tissues. These subcutaneous collec- tions of urates give a peculiar, humped appearance to the joint involved, which justifies the name gout nodules or " tophi " which have been given them. The tense skin covering these tophi may become necrotic or ruptured by injury ; then fistula? form from which chalky masses of urates are discharged, or they may become infected, and suppurative or putrefactive arthritis then develops. Tophi. — The more or less painful gout nodules or tophi are of diag- nostic importance. These are round and covered by a tense, thin skin; they gradually increase in size until they may become as large as a walnut or hen's egg. They are hard and movable upon or firmly adhe- rent to the underlying tissues in which they are deposited. Tophi occur most freciuently about the joints of the hands and feet, where they reach considerable size; in the subcutaneous tissue of the scalp, where they can be differentiated from gummatous periosteal nodes only by the fact that they are freely movable; finally, they occur as small nodules, never becoming larger than a pea in the ears, eyelids, and nasal cartilages. The white contents of the tophi shine through the thin skin covering them. If there are no tophi the diagnosis of gout may be difficult, especially in the first few acute attacks, or in cases in which the disease is chronic from the beginning, for gonorrheal arthri- tis resembles very closely acute gout; chronic ai'ticular rheumatism re- sembles chronic gout. The ab.sence of lymphatic involvement speaks against pyogenic infections. Fistula? and marked swelling of the joint suggest tuberculosis. The 726 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS chalk}', milky character of the secretion and the finding of numerous fine, uric acid crystals give a clew to the correct diagnosis. The pathological changes in the joints are very characteristic. The articular cartilages look at first, even when there is but little involve- ment, as if they had been sprinkled over with plaster of Paris or chalk. In time, however, the white substance which is deposited in the ground- work of the cartilage penetrates deeper and deeper, causing a destruc- tion which in advanced cases may even extend to the bone. The joint then becomes filled with crumbling, mortarlike masses M^hich infiltrate the synovial membrane and capsular ligaments. Small masses of this substance are also found in the peri-articular tissues. They are composed mostly of sodium biurate. Theories Concerning Cause of Gout. — Nothing definite is known con- cerning the cause of the precipitation and deposition of sodium biurate in the tissues and the way in which it occurs. [Futcher, in Osier's '' Modern Medicine," speaks of the theories of gout as follows: " Garrod held that in acute gout the alkalinity of the blood is lessened and the uric acid of the blood is increased, owing to the deficient power of elimination on the part of the kidney. The latter is due usually to organic disease, but may be the result of purely func- tional disturbance. He attributes the deposition of sodium biurate in the tissue to diminished alkalinity of the plasma, which is unable to hold the uric acid combination in solution. During an acute paroxysm there is an accumulation of the urates in the blood, and the local in- flammation is caused by their sudden deposition in crystalline form about the joints. " This theory has had many supporters, and in large part can be accepted, but, as we have already seen, any explanation based on the degree of alkalinity of the blood must be received with some skepticism. " Sir William Roberts believed that uric acid normally circulates in the form of a soluble quadriurate, which may be represented by the formula NaIIC5li2N403,H2C5H2N403, which is sodium quadriurate. The sodium atom may have its place taken by an atom of any of the uni- valent metaLs. In the gouty state, according to Roberts, either from deficient action of the kidneys or from overproduction of urates, the quadriurate accumulates in the blood. The detained quadriurate being very unstable and circulating in a medium rich in sodium carbonate takes up an additional atom of the base, and is converted into the biurate as follows: 2(NaHC5H2N,03,H2C5H2N,03) + NaoCO^ = 4NaHC5H.N,03 + COo -|- II^O. The biurate is very insoluble and less easily excreted by the kidneys. It conse' })i'essure n(>crosis of the articuhir cartihi^es, as in tu])er- culoiis arthritis. Jf the joint, is opened (post mortem) there will be found a sei'olucmoi'rhatiic exuchitc; a thiclvcncd and indurated capsule; brownish, hyperti-ophied synovial villi in the recesses of the joint; and at the mar«iins of the ai'ticniar cartilages tlat masses of coagulum, often of the thickness of the finger, and irregular defects in the cartilages due to pressure of these pieces of coagulum. Clinically it is scarcely pos- sil)h' to distinguish this form of arthritis from the granulating form of tuberculous arthritis or from the transitional form between tuber- culous hydrops and the latter. The third stage, characterized by regressive changes, leads to the develoj)ment of contractures. The organized masses of fibrin form an organic fibrous union between the eroded and ulcerated articular sur- faces, while the chronically inflamed capsule and peri-articular tissues contract. Contractures and anchylosis, not infre(|uently accompanied by dislocations, develop. The thickening of the tissues about the joint is the more ])ronounced as there is more or less nuiscular atrophy. The thickening about the joint is not due, however, as it often appears to be, to eidargement of the ends of the bone, but to the thickening of the capsule. Even in this stage the diagnosis of tuberculous arthritis is often made. These three stages do not occur in each patient. In many cases the haemorrhage ceases before there are any marked changes in the joint, while in others the lui'morrhages are repeated again and again until the deformities and destructive lesions characteristic of the third stage develop. In making a diagnosis other symptoms of haMiiophilia are naturally important. The family antl previous history of the patient should be carefully elicited, as they are of the greatest importance. As a rule, haMiiophiliacs ai-e ]iale children or young adults of the male sex. Be- sides tuberculous arthritis, ha'marthrosis following the rupture of a myeloid sarcoma, into the joint should also be considered in the dif- ferential diagnosis. In these cases the X-ray findings are of great value. The treatment is limited to immobilization and compression of the joint involved, to the use of the weight and pulley, or of an extension apparatus (Gocht) to correct the contractures. Forcible reduction and operative procedures should never be employed. The latter are always associated with the dangers of death from hfemorrhage. Aspiration of 47 730 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS the larger exudates with subsequent washing out of the joint with a three per cent sohition of carbolic acid (Kouig) may be done without danger. Concerning the local and general treatment Avith gelatin vide p. 679. Literature. — Barth. Die Entstehung und das Wachstum der freien Gelenkorper. Arch. f. klin. Chir., Bd. 56, 1898, p. 507. — Bennecke. Beitrag zur Anatomie der Gicht. Arch. f. klin. Chir., Bd. 66, 1902, p. 658. — Borchard. Die Knochen- und Gelenker- krankungen bei der Syringomyelie. Deutsche Zeitschr. f. Chir., Bd. 72, 1904, p. 513. — Borner. Klin. u. path.-anat. Beitrage zur Lehre von den Gelenkmausen. Deutsche Zeitschr. f. Chir., Bd. 70, 1903, p. 3Q3.—BMinger. Die Behandlung der chron. Ar- thritis mit Vaselininjektionen. Wien. klin. Wochenschr., 1904, No. 17. — E. Frankel. Ueber chron. ankylosierende Wirbelsaulenversteifung. Fortschr. a. d. Geb. d. Rontgen- strahlen, Bd. 7, 1904. — Gocht. Ueber Blutergelenke u. ihre Behandlung. Chir.-Kongr. Verhandl., 1899, II, p. 359. — Graf. LTeber die Gelenkerkrankungen bei Syringomyelie. Beitr. z. klin. Chir., Bd. 10, 1893, p. 517. — Heiligenthal. Die chron. Steifigkeit der Wirbelsaule (Bechterew) u. die chron. ankylosierende Entziindung der Wirbelsaule (Striimpell), Spondylose rhizomelique (P. Marie). Zentralbl. f. d. Grenzgeb., 1900, p. 11. — Janssen. Zur Kenntnis d. Arthritis chronica ankylo-poetica. Mitteil. aus d. Grenz- geb., Bd. 12, 1903. — Konig. Zur Geschichte der Gelenkkorper in den Gelenken. Chir.- Kongr. Verhandl., 1899, II, p. 1; — Die Gelenkerkrankungen bei Blutern mit besonderer Beriicksichtigung der Diagnose, v. Volkmanns Samml. klin. Vortr., N. F., 1892, No. 36. — -Kredel. Die Arthropathien und Spontanfrakturen bei Tabes, v. Volkmanns Samml. klin. Vortr., 1888, No. 309. — Linser. Beitrag zur Kasuistik der Blutergelenke. Beitr. z. klin. Chir., Bd. 17, 1896, p. 105. — Mermingas. Beitrag zur Kenntnis der Bluter- gelenke. Arch. f. klin. Chir., Bd. 68, 1902, p. 188. — Riedel. Die Entfernung der Urate und der Gelenkkapsel aus dem an Podagra erkrankten Grosszehgelenke. Deutsche med. Wochenschr., 1904, p. 1265. — Rosenhach. Zur pathol. Anatomie der Gicht. Virchows Arch., Bd. 179, 1905, p. 35^.— Rotter. Die Arthropathien bei Tabiden. Arch. f. klin. Chir., Bd. 36, 1887, p. 1. — Schmieden. Ein Beitrag zur Lehre von den Gelenkmausen. Arch. f. khn. Chir., Bd. 62, 1900, p. 542. — Schuchardt. Die Krankheiten der Knochen und Gelenke. Deutsche Chir., 1899.— Schiiller. Chirurg. Mitteil. iiber die chronisch rheumatischen Gelenkentziingen. Chir. Kongr.-Verhandl., 1892, II, p. 404. — Stem-pel. Die Hamophilie. Sammelreferat. Zentralbl. f. d. Grenzgeb., 1900, p. 721. — v. Volk- mann. Die Krankheiten der Bewegungsorgane. v. Pitha-Billroths Handb. der Chir., Bd. 2, 2. Abt., Erlangen, 1872. — Walkhoff. Ueber Arthritis deformans. Verhandl. d. deutsch. pathol. Gesellsch., Sept., 1905, p. 229. — Ziegler. Subchondrale Veranderung der Knochen bei Arthritis deformans. Virchows Arch., Bd. 70, 1877. (e) GANGLION Ganglion is a term given to a localized cystic formation which de- velops frequently in the tissues of the capsule of joints, occasionally from a tendon-sheath or tendon. Occurrence. — Joint ganglia are found most frequently upon the dor- sal surface of the wrist, in the depression between the tendons of the exten.sor indicis and the extensor carpi radialis brevis. As a ganglion develops in this situation it pushes the ligamentum carpi dorsale in front of it. Ganglia are less frequent upon the flexor side of the wrist DISJOASIOS OF JOLNTS 731 joint. When they (leveh)]i here they are usually situated beneath the radial artery, beside the tendon of the fiexor ear[)i radialis. They also occur on the dorsum of the foot, and occasionally about the knee joint. The thinned, translucent connective tissue of the cai)sular ligament forms the wall of the sac, which contains a clear, transparent colloid or tii'latinous substance. After unsuccessful attempts at cure the sac contracts lirm adhesions with the neighbor- ing; tendon sheaths. The cyst is attached to its point of orijiin by a broad base or short pedicle, and is separated from the cavity of the joint by a delicate membrane, the re- mains of the joint capsule, unless it has already ruptured into the joint. While old cysts are usually unilocular, recent cysts are nniltilocular and contain upon their inner wall prominent projecting folds. Even in the walls of unilocular cysts small recesses or cavities can be demonstrated microscop- ically. Etiology. — Ganglia were formerly con- sidered to be due to the constriction of an evaginated portion of the synovial mem- brane; in other words, they were regarded as synovial hernine. This explanation was suggested by Gosselin in 1852. More re- cently Falkson and Riedel, basing their observations upon clinical experience, have shown that the cysts originate within the tis- sues of the capsular ligament and not within the synovial membrane. Virchow and von Volkmann had previously suggested that this might be the case. The histological investigations of Ledderhose, and later those of Ritschl, Thorn, and Payr, have verified the clinical findings of Falkson and Riedel. They have found that these cysts are the result of degenerative changes in the capsular and para- articular tissues (more rarely in the tendinous and paratendiuous tis- sues) resulting in the formation of a gelatinous substance, the contents of the ganglion. Nutritional disturbances, caused apparently by an obliterating endarteritis of traumatic origin, precede the degenerative changes. Later several of these small cysts fuse to form one large one. Ganglia occur most eonniionly in young people, during and after the age of puberty, but may develop even at an advanced age. They are more frequent in the female than in the male. ^. Fig. 276. — Ganglion on the Dorsum of the Foot. 732 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Symptoms. — The first symptoms are indefinite for a long time. Some- times impairment of motion, at other times neuralgic pains direct the attention of the patient to the swelling, which is supposed to be the result of a sprain. As a matter of fact, ganglia are frequently caused by insignificant lacerations or injuries due to overexertion of the wrist in piano playing, rowing, fencing, etc. The cyst slowly enlarges, but rarely becomes larger than a walnut. Frequently it remains of the same size, and often becomes somewhat smaller spontaneously. Not infrequently the smaller ganglia subside completely without any treat- ment. A slight limitation of motion may be the only symptom of even the larger ganglia. The appearance of a ganglion is very characteristic. The smooth or uneven surface of the cyst, which is firmly attached to the surround- ing structures or is slightly movable when attached by a pedicle, is cov- ered by norma] skin. The smaller cysts may be hard and non-fluctu- ating. Fluctuation can be easily elicited in the larger cysts. The diagnosis can be made upon the position of the swelling and the characteristics above given. It is important to differentiate ganglia from hygromas of the synovial sheaths and bursEe. Treatment. — In the treatment an attempt should first be made to cure ganglia by non-operative methods. The author has repeatedly cured ganglia by rupturing them by one blow with a wooden hammer, or by binding a lead button over the swelling until the wall of the cyst has become thinned and has ruptured subcutaneously. Recurrences — large cysts developing from small accessory ones — are frequent after this method of treatment. If the treatment is repeated a permanent cure may be obtained. If the non-operative treatment has been unsuccessful, an operation, which should be performed with the greatest aseptic precautions, should be advised. In the complete removal it may be necessary to open the joint or synovial sheath, and even the mildest infection may be followed by most serious results. The operation should always be performed under artificial ischsemia, as in this way the anatomical relations may be better exposed, and the fingers should not come in contact with the wound. Recurrence follows extirpation only when a part of the pedicle or some of the diseased tissue of the capsule is left. Subcutaneous discission with the tenotome, aspiration and subse- quent injection with alcohol and carbolic acid, and incision combined with tamponing are sometimes but not uniformly successful. Literature. — Franz. Ueber Ganglien in der Hohlhand. Arch. f. klin. Chir., Bd. 70, 1903, p. 973.— Kilttner. Zur Klinik der Ganglien. Zentralbl. f. Chir., 1905, p. 1333. — Ledderhose, Die Aetiologie der karpalen Ganglien. Deutsche Zeitschr. f. DISEASES OF l^ONE 733 Chir., Bd. 37, 1803, p 102. — A(;/r. Boitnige zuin fcineren B;m mid der Eiitstolmiig der karpalcii (lanfilien. Deutsche Zeitschr. f. Chir., lid. 4<), 189!), p. :i2':).~RitschL Beitrag zur Pafhogenese der Ganglien. Beitr. z. klin. Chir., Bd. 14, 1895, p. 557. — Thorn. Ueber die Entstehung der Ganglien. Arch. f. klin. Chir., Bd. 52, 1896, p. 593. CHAPTER VII DISEASES OF BONE (a) CONGENITAL DEFECTS IN SKELETAL DEVELOPMENT There are a niiinber of iiialt'ormations cine to the failure of develop- ment of bones. These may be dne in part to arrested (aplasia), in part to the inhibition of normal development. Examples of such malfor- mations are complete or incomplete absence of bones of the extremities, of the clavicle and sternum, or defects in the skull bones and vertebrae and fissures in the maxilla. The loss of distal parts of the extremities due to constriction by anniiotic bands is also classified with the failures in development. Malformations may be due to excessive development. The most common examples are supernumerary phalanges, metacarpal and metatarsal bones, cervical ribs and additional vertebrae (in tail formation). Atrophy of the bones (the result of intra-uterine lesions or fractures), the different hypoplastic and hypertrophic conditions of bone which are present at birth or develop soon after are frequently the causes of malformations. Hypoplasia may affect the entire body, in which case a dwarf re- sults, or a portion of it only, giving rise then to imperfect formation of single parts or organs, such as hypoplasia of the extremities (micro- melia) and congenital skeletal atrophy (so-called fcrtal rickets). Foetal Chondrodystrophy and Periosteal Dystrophy. — There are two varieties of fcetal rickets. In the one (cartilaginous dysplasia, foetal chondrodystrophy of Kaufmann, fcetal cretinism of Ilorsley) there is impaired endochondral bone formation, while the periosteal bone for- mation is normal. The bones are therefore thick and hai'd, but shortened and distorted. In the other (perio.steal dystrophy) the peri- osteal bone formation is interfered with, while endochondral bone for- mation is normal, and the bones are malformed, soft, and fragile. Hypertrophy of bones may be the cause of general (macrosomia) or partial giant growth. The latter may be confined to parts of the feet or hands. Bone Changes in Cretinism. — The more or less imperfect development of bones in cretinism, a disease occurring endemically in young people 734 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS living in goiter regions, is due, as are the other symptoms of the disease (myxo'dema, hypoplasia of the genitalia), to a disturbance of the func- tion of the thyroid gland, which is either absent, atrophied, or altered in structure (goiter). The relationship between cretinism and the thy- roid gland has been demonstrated experimentally (Hofmeister, von Eiselsberg). In cretinism the epiphyseal cartilages do not become ossified for a long time, but they are unable, because of regressive changes, to produce bones of normal length. The centers of ossification in the epiphyses develop late. If the feeding of thyroid gland or thy- roid preparations is begun early and continued the symptoms may im- prove and the growth of the bones may be increased. Literature. — -v. Eiselsberg. Die Krankheiten der Schilddriise. Deutsche Chir., 1901, Kretinismus, p. 197. — Nasse. Die Krankheiten der unteren Extremitaten. Deutsche Chir., 1878, Riesenwuchs des Fusses, p. 1. — Schuchardt. Die Krankheiten der Knochenund Gelenke. Deutsche Chir., 1899, p. 58.— P. Vogt. Die Krankheiten der oberen Extremitaten. Deutsche Chir., 1881. (b) ATROPHY OF BONE Atrophy of bone occurs in the form of lacunar resorption. The resorption in diseased bones is not actually in excess of that occurring in normal developing bone (Pommer), but only relatively so, as new bone is not formed to replace that lost by resorption (Schuchardt). Concentric and Eccentric Atrophy of Bone. — Sometimes the resorption begins upon the surface of the bone and extends inward, while at other times it begins in the medulla and advances outward. In the former (concentric atrophy) the bone becomes thinner and smaller, while in the latter (eccentric atrophy) the medullary cavity, the Haversian canals, and the spaces in the spongy bone become enlarged as the trabeculse of bone disappear and fat accumulates in these enlarged spaces. If the entire bone becomes porous and light the condition is known as osteoporosis; if decayed and fragile, as osteopsathyrosis; if, after considerable loss of calcium salts, it becomes flexible, as osteomalacia. The fragility of atrophic bones is of greatest surgical interest, as the diseased bones may be fractured by very slight injuries, even by bear- ing the body weight upon them. Delayed Kepair After Fracture. — Repair of such fractures is often delayed; non-union is frequent, except in the pathological fractures occurring in neuropathic atrophy, as there is but little tendency to the formation of callus. For the same reason it is often difficult to obtain union after operation upon joints in which anchylosis (e, g., paralyzed extremities) is useful and desired. DISEASES OF BONE 735 Causes of Atrophy of Bone. — There are a number of dift'crent causes oi" atntpliy ol' Ijoiie. JSoine of these may be local, the majority are <;en- eral. Among the local causes are aneurysms, tumors, and echinococeus cysts. These develop either without the bone and later extend to it, producing a pressure necrosis of the cortex, or within the bone, and as they enlarge cause a pressure necrosis and expansion of the cortex, finally rupturing through it. The atrophy following long-contiruied non-use (atrophy of disuse) is also placed in this class. Disuse atrophy is most frequent in the bones of the extremities, which have been thrown out of function for a long time or permanently as the result of severe injui'ies, inflammatory lesions, paralyses, or after fractures with vicious union in which the extremity cannot be used to support the weight of the body. The conical form which the bones in an amputation stump assume may be prevented if an artificial limb is used and weight is borne upon the stump. NutritioiKil and iropliic disturhcniccs are the most important of the general causes. In old age a general osteoporosis occurs, and frac- tures, especially of the neck of the femur, following insignificant in- juries and curvature of the spine are frequent. Atrophy of the alveolar borders of the jaws following extraction of the teeth, and shortening of the lower parts of the face are the best-known examples of this form of atrophy of bone. Superficial, sometimes perforating, defects of the bones of the skull may result from senile atrophy. Similar changes occurring in young people suffering from chronic infectious diseases are known as marantic atrophy of bone. If the cause of the atrophy depends upon some disease of the peripheral nerves or central nervous system, it is called neurotic atrophy. This form of atrophy is due wholly or in part to the loss of trophic influ- ences. It is indicated in growing bones by shortening, in fully developed bones by osteoporosis, sometimes accompanied by osteomalacia. Of course if there is paralysis, disuse is also an etiological factor. The pure form of neurotic atrophy is found only in diseases, such as syringomyelia, locomotor ataxia, and paretic dementia, in which the use of the extremi- ties is not interfered with. Painless, spontaneous fractures are frequent in this form of atrophy. Often the repair of these fractures is rapid, and excessive callus is formed, as the bones are analgesic and mechanical irritation of the fractured ends is not prevented by pain as in ordinary fractures. Sudeck has shown by Roentgen-ray pictures that the bony atrophy developing acutely after injuries and inflammation is due to trophic disturbances. The rapid loss of the contour of the aft'ected bone in these cases cannot be explained by disuse alone. It is probably of a 736 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS reflex nature, similar to the muscular atrophy occurring in arthritis (vide p. 655). After the primary lesion has healed the atrophy may gradually subside. In tuberculous arthritis it is often difficult to determine whether the indistinct, clear shadows in the X-ray pictures correspond to tuberculous foci or to atrophic bone. If due to atrophy the shadows will be much more extensive. Idiopathic Osteopsathyrosis. — Idiopathic osteopsathyrosis is a pecul- iar but rare form of atrophy of bone, the cause of which is unknown. The disease, characterized by frequent, sometimes multiple fractures, develops in early childhood. Schuchardt writes of a girl twelve years of age who had sustained forty-one fractures in ten years, the first one occurring when she was two years old. In a large proportion of cases the disease is inherited. Inflammatory atrophy of bone, the result of rarefying osteitis, is found in pyogenic, tuberculous, and gummatous lesions of bone (see p. 425). Literature. — Adler. Ueber tabische Ivnochen-und Gelenkerkrankungen. Sammel- referat mit Lit. Zentralbl. f. d. Grenzgeb., 1903, p. 849. — Schlesinger. Die Erkrank- ungen der Knochen und Gelenke bei Syringomyelie. Zentralbl. f. Grenzgeb., 1901, p. 625. — Schuchardt. Die Krankheiten der Knochen und Gelenke. Deutsche Chir., 1899, pp. 58-83. — Siuleck. Ueber die akute (reflektorische) Knochenatrophie nach Entziindungen und Verletzungen an den Extremitaten und ihre klinischen Erschein- ungen. Fortschritte auf dem Gebiete der Rontgenstrahlen, Bd. 5, 1902, p. 277; — Zur Altersatrophie (einschl. Coxa vara senium) und Inaktivitatsatrophie der Knochen. Ibid., Bd. 3, 1900, p. 201. (c) HYPERTROPHY OF BONE Hypertrophy of bone is frequently the result of inflammatory proc- esses, which lead (especially in syphilis) to the formation of hyperos- toses, in periosteal tumors and in ulcers adjacent to bone to the forma- tion of osteophytes, in suppurative osteomyelitis to the formation of the involucrum, and in fractures to callus formation. Suppurative and tuberculous lesions of bone occurring during the period of growth often lead to an increase in length of the bone involved. Leontiasis Ossea. — There are but two forms of independent hyper- trophy of bone, and these are rare : Leontiasis ossea and acromegaly. The disease called leontiasis ossea by Virchow begins in young people without any distinct symptoms, and gradually leads after a number of years to a symmetrical thickening and induration of the bones of the face and skull. The changes usually begin in the maxillge. The skele- ton of the face gradually becomes transformed into a heavy, bony mass, and all semblance to normal human features is lost. The symptoms DISEASES OF BONE 737 Fig. 277. — Lkontia.sis Ossea. which follow the painless proliferation and hypertrophy of the bones are secondary, as the skull bones of from 4 to 5 em. in thickness press upon the brain, causinu: head- aches, convulsions, ])aralyses, and men- tal disturbances. The thickening of the facial bones occludes the nasal passages, forces the eyi's out of the orl)it, caus- ing exophthalmos, and destroys the optic nerves, causing blindness. The foramina and canals through which the cranial nerves pass are narrowed and symptoms of pressure result (loss of sense of smell, trigeminal neuralgia, etc.). Frequently suppurative dacro- cystitis and erysipelas of the face and head precede the development of the disease, but it is not probable that they have any etiological relation to it. Treatment has no efl'ect upon the course of the disease. Even resection of the bones first involved does not delay its progress. Acromegaly was first described by P. IMarie in 1886. In this disease there is not only a hypertrophy of the bones of the distal parts of the extremities, of the skull and face due to a proliferation of the peri- osteum, but also a thickening of the soft parts. In the head the hyper- trophy affects most commonly the lower jaw, nose, lower lip, and tongue. In, some instances the penis or clitoris is hypertrophied. [In a number of cases, the external genitalia have been smaller than normal.] The disease begins in young or middle-aged people and produces changes in the physiognomy and in the shape of the feet and hands which are very characteristic. The disease is supposed to be due to diseases of the hypopln'sis (tumors, hypertrophy, cysts, and sclerosis). [" Tam- burini's suggestion that acromegaly is dependent upon excessive func- tion of the hypophysis is highly important. As yet no cases of undoubted acromegaly have been reported in which changes in the gland were absent upon both gross and microscopic examinations, and in those in- stances where necrosis and softening (probably post mortem), sclerosis, colloid degeneration, etc.. have been found, no mention is made of the relation between chromophile and chromophobe elements. Experimental removal of this gland, its destruction by neoplasm, infectious granu- lomata, and aneurysm do not produce the disease, so that it seems I)ro])er to assume that acromegaly is not dependent upon an abolished or lessened function of the hypophysis." — Lewis, The Joints Hopkins 738 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Hospital Bulletin, Vol. XVI, May, 1905, p. 164.] Para:,sthesias and slight pain in the extremities, loss of the finer sensations in the hands and feet, and loss or decrease in sexual desire are common. The hands and feet gradually become clumsy and pawlike or spadelike, as the bones become thickened by the formation of new bone, which is most pronounced near the ends. The bones of the forearms and legs also become considerably thickened. The changes in the face are most striking, as the lower jaw enlarges and projects beyond the upper, as the lips, eyelids, nose, ears, tongue, and cheeks become thickened, often causing folds in the skin. Gradually kyphosis develops, while the bones of the trunk widen. Cachexia gradually develops, the heart and large vessels become diseased, and the disease terminates fatally after a number of years. Acromegaly is especially frequent in giants. The only relation between gigantism and acromegaly is that the former seems to predispose to the development of the latter. According to Arnold there is no increase in the length of bones in acromegaly. Acromegaly cannot be mistaken for leontiasis ossea if a careful ex- amination is made, as in the latter the fingers and toes are not involved. Usually arthritis deformans can be easily difl^erentiated, as the changes in acromegaly, although they involve the ends of the bones, are extra- articular {vide Schuchardt). Similar changes, involving especially the terminal phalanges of the fingers and toes, and the epiphyses of long, hollow bones, occur in young children suffering from chronic diseases of the heart and lungs (Bam- berger) . The enlargement is due to the proliferation of the periosteum. P. Marie has grouped these pathological manifestations and described a distinct clinical entity which he calls osteoarthropathie hypertrophiante pneumique. Literature. — Bardenheuer und Lossen. Leontiasis ossea Kolner Festschrift, 1904, p. 154. — Mauclaire. Maladies non traumatiques des os. Traite de chir., le Dentu et Delbet. Paris, 1896. T. II, p. 723. — Schuchardt. Die Krankheiten der Knochen uiid Gelenke. Deutsche Chir., 1899, pp. 150, 225. (d) RICKETS Definition. — Rickets from the Greek paxi?, meaning spine) is a general disease of malnutrition occurring in children and manifesting itself mainly in lesions connected with the bones. It usually commences within the first three years of life, but sometimes appears later (Rose and Carless, " Manual of Surgery," p. 597). The disease was first accurately described by Glisson, an Englishman, and therefore the dis- ease is often referred to in Germany as the English disease. DISEASES OF BONE 739 Pathological Changes. — Rickets is chai-actcrized by changes in nor- mal bojic (li'vel()i)iii('nt consisting of an excessive formation of osteoid tissue whicli is prepared for bone formation, a diniinished dei)Osit of lime salts in this tissue, and an increased resorption of newly formed bone. The most striking symptoms of the disease are enlargements of the epiphyses due to broadening of the epiphyseal cartilages, and the (U'velopment of deformities, the result of softening and flexihility of the bones. The calcium content of the bones is reduced more than one half. Osteoid tissue develops upon the surface of the bone and in the medulla, especially upon the metaphyseal side of the epiphyseal car- tilages, foi'ming vascular, spongy, soft, grayish red masses of tissue. The periosteal deposits of this osteoid tissue are localized and may be removed with the thickened periosteum. The myelogenous deposits in severe cases are not localized, but are distributed throughout the entire metaphysis. Normal endochondral bone formation is greatly altered. The epiphyseal cartilages are greatly widened, and there is a consid- erable increase in the number of columns of proliferating cartilage cells. Normally the epiphyseal cartilage is a well-defined, bluish white or white line, cartilage and bone being sharply differentiated from each other. In rickets the epiphyseal cartilage becomes broadened and ir- regular, its sharp outlines are lost and medullary spaces and osteoid tissue extend into the cartilage, and the delicate white streak indica- tive of primary calcification disappears. The epiphyseal cartilages appear broad, and are provided -with irregular processes and outgrowths which may become separated to form islands of cartilage within the osteoid tissue. Bony trabeculas and calcified cartilage are also found within the latter. [The development of multiple osteomata or chon- dromata is supposed to be secondary to rickets, the displaced island of cartilage forming the nuclei for these benign tumors.] There is also an increased lacunar resorption of the newly formed bone, and in this way the medullary spaces and the Haversian canals become enlarged, an osteoporosis developing. Areas may be found in flat bones in which the normal bone is entirely replaced by osteoid tissue. Decalcification may be as marked as in osteomalacia (von Reckling- hausen ) . Calcification of this osteoid tissue does not occur at all or inter- mittently, depending altogether upon whether the disease progresses without abatement or improves. As the patient is recovering from the disease, the osteoid tissue becomes transformed into hard sclerotic bone, which may completely occlude the medullary cavity. The deformities which may have developed then become permanent. Slight bending of the bones may be corrected during subsefpient growth. 740 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Etiology. — The cause of these alterations in the development of bone is iniknown, notwithstanding the number of investigations that have been made. One view held by Pommer, Heubner, and Zweifel is that the deficient calcification of the osteoid tissue is the result of nutritional disturbances. Kassowitz ascribes the changes to a chron- ic inflammatory hyperEemia, the cause of which is unknown. A number of impor- tant objections have been raised against each of these views. In spite of this, one cannot help thinking that the changes are due to the action of some toxic material which accumulates in the blood, as the result of the loss of function of some one of the ductless glands (according to Stoitz- ner, possibly the suprarenal) and acts upon the bone, especially upon the articu- lar ends where there is a physiological hypera?mia. It can be definitely stated, in spite of the fact that the breast-fed children of the well-to-do classes are not spared by the disease, that insufficient or improper food is an important etiological factor, and that poor hygienic conditions, the want of air and light, uncleanliness, and intestinal catarrh predispose to it. The disease develops most commonly during the second year of life ; very rarely after the fifth or sixth. The cases ob- served during the fifth and sixth years are usually merely exacerbations of mild cases which have persisted for some time. It is a disputed question whether the changes observed in rickets are ever congenital. The changes ob- served in the so-called foetal rickets (p. 733) have no relation whatever to the changes found in the disease under consideration. In the so-called late rickets (rachitis tarda) developing at puberty, the bones become soft and yielding, and deformities such as curvature of the spine (ha- bitual scoliosis) and of the ends of the long bones (genu valgum and varum adolescentium, coxa vara) develop, the softened bones yielding under the weight of the superimposed parts. The pathological changes in late rickets differ from those occurring in earlier life, being limited to that part of the metaphysis, poor in lime salts, immediately adjacent to the hypertrophied epiphyseal cartilage (Fig. 279). Fig. 278. — Coronal Section THROUGH THE LoWER EnD OF THE Femur of a Child Two AND A Half Years of Age Suffering with Rickets. (After Kaufmann.) a, Lower epiphysis, normal cartilage; h, mottled, bluish red, swollen, soft zone of proliferating car- tilage; c, zone in which the vessels and medullary spaces with osteoid tissue have pene- trated the soft cartilage; d^ osteoid tissue; e, dilated me- dullary cavity with but little spongy bone; /, thinned com- pact bone covered by a layer of osteoid tissue. DISEASES OF BOxNE 741 The severest and most resistant cases occur chieHy in the children of the poor classes living in cities, among whom the disease is also most common. The disease is rare among the children of the middle classes, and if it does develop it is mild and is easily cured. Onset and Changes in Bones. — It is not possible to state definitely when the disease begins, as it has an insidious onset. Frequent and pro- fuse swcati)t(j, tenderness of the bones, anremia, and myasthenia are recognized as prodromata by physicians experienced in children's dis- eases. Suspicion may be aroused when the child first attempts to walk. The course of the disease is always chronic. As a rule the earlier the disease develops the more rapid the course. In the beginning the rapid involvement of the different bones is often quite striking. From time to time the symptoms subside, but exacerbations are frequent, especially dur- ing the winter months, when the hygienic conditions are apt to be poor. The osteal symptoms vary a great deal, and only in the severest eases are they equally prominent in all the bones. In these cases growth is retarded (rachitic dwarf), the epiphyses become enlarged and expanded, the flat bones become thickened, sometimes atrophied, and de- formities of the long, hollow bones, caused by muscular action or by the weight of the superimposed parts, develop and frac- tures may occur. In the milder cases growth is scarcely interfered with, there is less tendency to bending of the bones, deformities are wanting, or if they do develop they are limited to the ends of the b(mes (e. g., genu valgum), and the enlargement of the epiphyses is not marked. Changes in the Skull Bones. — In the skull, especially in the occipital regions, the bones may become .soft and yielding, and as a result of the loss of bone, some portions may become membranous again (cranio-tabes). The fontanelles are wide long time, luitii the third or fourth year forehead appears square in shape, while the parietal and frontal emi- nences are enlarged by deposits of osteoid tissue beneath the periosteimi. Fig. 279. — Genu Valgum Adoles- CENTIUM. (From a patient sev- enteen years of age.) and may remain open for a The head is large, and the 742 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS Sometimes the changes in the skull are associated with hydrocephalus. The hard palate becomes high and arched, the alveolar border of the maxilla projecting forward like a beak, while the symphysis of the mandible becomes flattened. The teeth do not erupt until late, are stunted, defective in enamel, and decay early. Changes in the Thorax. — In the thorax there develops at the junction of the ribs with the cartilages a row of round nodules (rachitic rosary) which may often be seen through the skin. If there is any obstruction to the entrance of the air (tracheitis or bronchitis) the atmospheric pressure may cause the softened bones and cartilages to sink in, and as a result the sternum is pushed forward, producing a typical deform- ity known as the " chicken breast " or pectus carinatum. The natural curves in the clavicle may also be accentuated. A transverse groove (Harrison's), corresponding in position to the attachment of the dia- phragm, often develops across the lower part of the chest. It is pro- duced by the traction of this m.uscle upon the softened ribs and carti- lages. The projection or flaring of the ribs below this line is caused by the enlargement of the abdominal viscera. A kyphosis develops in the lower dorsal and lumbar regions, espe- cially in children who are carried a great deal. [This kyphosis, which extends over a number of vertebree, is never angular as in tuberculosis.] Scoliosis is rare. Changes in the Pelvis. — The changes in the pelvis may be marked, but are of interest chiefly to the obstetrician, as they may interfere with childbirth. The pelvis becomes flattened from before backward, and the cavity becomes contracted as the promontory of the sacrum projects forward and downward and the bone surrounding the acetabulum is forced inward and the symphysis forward. Changes in the Bones of the Extremities. — The changes in the bones of the extremities are the most striking. Tender thickenings may be palpated upon the ends of the long, hollow bones (especially upon the carpal ends of the radius and ulna and upon the malleoli) which are not covered by thick soft tissues. The entire or part of the diaphysis becomes bowed. The bowing is most common in the femur and tibia, being most commonly forward and outward. The lower third of the tibia bows forward, and may become so flattened from side to side that it resembles a saber sheath. The angular deformities developing at the metaphysis or in the diaphysis are secondary to green-stick fractures. If the direction of the articular ends of the bones is changed by a bending of the softened metaphysis, typical deformities, such as genu valgum, varum, recurvatum, rachitic flat-foot, and coxa vara, develop, the diaphysis remaining normal or becoming bowed. [The bowing of the diaphysis in these cases is usually secondary and compensatory.] DISEASES OF BONE 743 Similar deforniitics in tlie l)()nes of the upper oxtremity occur oilly iii cliildrcn wlio havi' ])ecn accustoiiicd to creep about on all fours. Sclerosis of Bones When Disease Improves. — When the acute stag:es o'f the disease have passed and ini- ]>rovement begins, sclerosis of the bones occurs. This process of hard- ening may be frecjuentiy interrupted ])y exacerbations of the disease. As the sclerosis progresses the epiphys- eal enlargements become smaller, the fontanelles close, growth becomes more rapid, and the general condition im- proves. Spontaneous Correction of De- formities. — The deformities gradually improve, rarely remaining as great as they were at the time they devel- , oped. It has been observed for a number of years that the improvement is gradual, and that, as a rule, the de- formities have become less marked or have completely disappeared at the age of puberty. The more rapid the growth, the more rapid the ira- pi-ovement in the deformities is. Usu- ally from two to four years are re- quired for the correction. Clinical observations made by Schlange and Veit in von Bergmann's clinic have shown that the deformities in rachitic children whose growth has not been stunted or retarded subside sponta- neously and completely in the sixth or seventh year. According to Kamp's investigations, this occurs in seventy- five per cent of the cases. In cases in which the growth has been stunted, some improvement may occur, but con- siderable deformity remains. After the age limit above mentioned has been reached, an increase in the de- FiG. 280. — Rickets. The changes are most pronounced in the legs which are con.siderably sliortcned. The thighs are rotated outward because of the (hstortion of the neck of the femur. The shaft of eacli femur is bent forward and outward. The tibia^ at the position of the upper metaplivses are bent inward, pro- ducing genua valga. Tlie deformities at the lower metaphyses, resulting from a bending forward, are less pro- nounced. Other changes associated with rickets, such as double flat-foot, some thickening of the lower epiph- yses of the radius and ulna, widen- ing of the costal arch, and the rick- ety rosary, are also present. 744 SURGICAL DISEASES, EXCLUDING INFECTIONS AND TUMORS formities cannot be determined, even when the disease persists, but the bones remain shortened, are capable of but little growth, and the patient remains a dwarf. Some bowing of the diaphysis and enlarge- ment of the epiphyseal ends of the bones may remain permanently in even the most favorable cases, and often are indicative of a previous rickets. Cliangcs in the Bones Shown hy X-Bays. — Recently X-ray pictures of the diseased long bones have shown a number of other changes be- sides the deformities. The epiphyseal cartilages are broad, irregular, and fibrillated, the cortical layer of bone is thin, and in it are indis- tinct, localized shadows due to the absence of lime salts. If heal- ing has occurred, the epiphyseal lines become almost as narrow as in healthy bone, and delicate, parallel streaks (calcification lamellae) run- ning out from the epiphyseal cartilage appear in the metaphysis. A thickening is found in the cortex which is most marked upon the concave side of the deformity, as the greatest weight is placed upon this side. General Symptoms. — The general symptoms may be mild or severe, and vary from a slight muscular weakness and atrophy to a decided ana-mia and emaciation. Intestinal disturbances (meteorism with diar- rhoea or obstipation), a tendency to catarrhal inflammations of the lungs resulting from narrowing of the thorax, swelling of the lymph nodes, sweating, eczema, and finally, nervous disturbances, such as unrest, con- "STiLsions, and laryngeal spasm, are frequent. The principal dangers which accomi:)any the severer forms of rickets are weakness and the loss of r&sistanee to infections. Catarrhal inflam- mations of the lungs, diarrhoea, and infectious diseases may run rapid and fatal courses. Complications such as tuberculosis and syphilis are to be especially feared. ]\rany rachitic children die of some of the acute infectious diseases of childhood. The disease tends to undergo spontaneous cure, and even the deformities which have developed in earlier timas may be corrected or improved as the patient grows. Some of these deformities remain, however, and may give rise to serious com- plications in later life (e. g., rachitic pelvis in childbirth). Diagnosis. — The diagnosis is usually not difficult, even when the sj'mptoms are not pronounced. The X-ray findings, when positive, are so characteristic as to leave no doubt as to the diagnosis. Treatment: Medicinal and Surreal. — The treatment in the beginning belongs to internal medicine. In the treatment, as well as in the proph- ylaxis, special emphasis should be laid upon the improvement of the hygienic conditions and the nutrition of the patient. Phosphorus is supposed by many to have a favorable influence upon the diseases. Kassowitz, basing his conclusions upon animal experiments, believes DISEASES OF BONE 745 11i;it pliosplidfus, ^\lli(•ll \\;is advised by Wcjinr in tlir 1 rcatiiit'iit ui" this (liscjisc, li.is n<» aclioM jii nil. Sur'.'cry has to do with the rtductioii and dicssino- of frt;f'tnre.s wliit'h occur diiriiiir the disease and witli the correction of deformities. The Fir.. 281. — X-Ray Pictlkk of Dkkuk.med, R.\tHrric lio.vKs of the Liog (IIe.\ling h.\s Occurred). The epij^liyseal cartilago.s are almost normal. The cortex is especially thickeiu's of Cohnheim and Kibbert, according to which tumors develo}) from cells which have been separated from their organic con- nections and displaced either during embryonal or extrauterine life. In the second gi'oup may be combined all those hypotheses according to which tumors develop from cells normally placed, but which have aecjuired the property of unresti-ained growth as the result of the action of some unknown influences (irritation of different sorts) (Virchow) or perhai)s (n'en of ]iarasites. 4. Cohnheim's Theory. — Accoi-ding to Cohnheim, all true tumors de- velop from superfluous, misplaced, or abnormally persisting centers of embryonic tissue which may be stinnilated to growth by a number of different causes (increased nutrition, decrease of resistance to growth, physiological increase or decrease of local or general growth, Borst). Dei'moids and teratomas, tumors of accessory organs and displaced adrenal rests, c^'sts arising from the branchial clefts, the urachus, vitel- line and thyreoglossal ducts, which undoubtedly develop from displaced or non-involuted embryonal tissue, su})port this theoiy. Cohnheim's theory, however, lacks anatomical foundation, and there are a number of facts which make it impossible to apply it to the development of tumors in general. In the first place it is scarcely possible to conceive that tumors developing in advanced life have sprung from displaced tissues which have maintained their embryonal char- acteristics through all the preceding years. Besides the transplantation of embryonal tissues into animals of the same species has never been followed by tumor formation, the embryonal tissue, if it has remained 756 GENERAL PART alive and has developed, becoming transformed into tissues resembling more or less closely those of the adult type (Zahn, Leopold, Birch- Hirschfeld and Garten, Fere, Schmieden, Wilms, and others). 5. Ribbert's Theory. — According to Ribbert, true tumors develop from germinal tissue which is either displaced during development or later in life by traumatism or after inflammatory processes. "When dis- placed this germinal tissue is separated from its normal physiological connections and becomes an independent center of growth. Ribbert believes that the independence of this tissue explains satisfactorily its unlimited growth, for the tension of the tissues no longer exercises a restraining influence, as the normal tissues do. Inflammatory hyper- aemia, and the hypera^mia associated with different forms of trauma, favor rapid and excessive proliferation. The development of epithelial cysts, such as occur in the palm of the hand, supports Ribbert's theory of the post-embryonal separation of groups of cells from their organic connections. These small cysts de- velop from pieces of epidermis which are carried beneath the cutis by foreign bodies or by injuries. The separation and displacement of groups of cells can be frequently demonstrated in chronic inflammatory processes. The composition of the germinal tissue determines the char- acter of the tumor; for example, a fibroma develops from displaced fibrous tissue, a lipoma from fatty tissue, a carcinoma from epithelium. A sarcoma develops if the germinal connective-tissue matrix remains of an embryonal type. This theory, like Cohnheim's, attempts to place tumor formation upon a single, definite basis. It has gained more and more recognition of late. It, however, also presupposes the action of some unknown influence, for apparently the displaced cells are incapable of spontaneous prolif- eration, and it has been established by a number of experiments that tumors do not develop after the transplantation of tissue of various kinds. Besides, in many diseases cellular and tissue emboli (bone marrow and giant-cells, fat, liver, and placental cells, and chorionic villi) are deposited in viscera and other tissues without giving rise to tumor formations. Ehrlich's work throws some light upon the nature of the unknown influence which prevents proliferation in these cases. According to Ehrlich's theory, the organism possesses a certain protec- tive mechanism (atreptic immunity) which prevents abnormal growth. When the immunity is decreased the tumor germs may take from the body the food-stuffs required for proliferation. According to Ilauser, tumor formation may begin in cells normally placed. But in this theory it must be presupposed that there are cer- tain special biological changes in the cells which lead to tumor forma- tion. It may Ijc; assumed, for example, that the normal cells, which ETIULOCJY OF TUMORS 757 may be stiiinilated to incivascd jirolifcration by all sorts of irritation, ^u:ain an increased energy for growth while their functional activity is decreased (Beneke, Ilauser, Lubarsch, O. Israel), or that they assume toxic properties (IMarchand) which destroy adjacent tissues and render an infiltrating growth possible. Thiersch attempt(>d to explain the development of carcinomas by supposing that the connective tissues undergo a certain atrophy, associated with a relaxation of their strata, and that they then no longer oppose a barrier to the epithelium still l)ossessed of its full power of reproduction. Von Hansemann presup- poses in malignant tumors an anaplasia of the cells from which they develop, and therefore the tumor remains of a primitive structure as the anaplastic cells are not capable of differentiation into tissues of an adult type. According to this theory, anaplastic cells respond to stimu- lation by developing into malignant tumors, while normal cells form merely hyperplasias in the broadest sense of the ^vord. It is a fact that tumor cells are very primitive in structure, resembling closely the embryonal prototypes of the tissue from which they spring; for exam- ple, large connective-tissue cells which do not form intercellular fibrillae are found in sarcomas; epithelial cells which do not cornify and do not secrete are found in many carcinomas of the skin and mucous mem- brane respectively. Ribbert does not consider this return of cells from an adult, and differentiated to a primitive and simple type as necessary for tumor formation, but merely as a factor which favors growth when tumors develop from fully differentiated elements. 6. Parasitic Theory. — Bacteria which have been found in tumors have been shown to be merely harmless saphrophytes and not the essential cause. Critical examination has shown that the blastomyees, protozoa, rhizopoda, infusoria, and sporozoa (among the latter coccidia, gre- garinse, plasmodia, psorospermia) which have been described in tumors were altered tumor cells undergoing regressive changes, such as vacuole, keratohyalin, and colloid formation, or cell inclusions, consisting in part of tumor cells, in part of degenerated leucocytes or epithelium {vide Borst). L. Pfeift'er and Adamkiewicz regard the carcinoma cells proper as the parasites. A number of different investigators (Busse, Jiirgens, Schiiller, Sjobring, and others) have been successful in cultivating parasites from fresh tumor tissue, but they have never been able to produce by inocu- lation any changes which could be regarded other than of an inflam- matory nature. Only the transplantation of living tumor tissue — for example, the ti-ansplantation of carcinomatous tissue from one to another part of a patient suffering from the di.sease (Hahn, von Bergmann, Cornil), or of tumor tissue from one animal to another animal of the same species 758 GENERAL PART (dog, rat, mouse) (Novinsky, Weber, Hanau, von Eiselsberg, Geissler, Moran, Jensen and others) — has led to any definite results. The experiments made by Gaylord, of the New York State Cancer Laboratory, and by Ehrlich have given the most important results, which are also of significance in another direction. These investigators have been able, by carrying inoculations through a number of mice, to in- crease the power of growth or virulence of the tumor masses, just as the virulence of bacteria is increased by passing. them through animals, so that finally almost all inoculations with the most virulent material are successful. Sometimes in these experiments a carcinoma becomes transformed into tissue resembling that of a sarcoma or into pure forms of sarcomas, as the epithelium is finally suppressed by the more rapidly proliferating stroma. As regards the parasitic theory, all these find- ings (similar to the so-called inoculation recurrences in the scar after operations for carcinoma) merely show that encapsulated, well-nour- ished tumor cells may develop in other parts of the body, being similar, therefore, to metastatic growths. Transplantation experiments also show that the tumor cells may retain their growth energy, not, however, that a parasite has been inoculated with the tumor tissue and has caused the development of a new growth. From a clinical view-point, practically, only facts w^hicli relate to carcinoma have been employed to sustain the parasitic theory of the origin of tumors (Czerny) ; such as, that carcinomas develop upon parte most frequently exposed to external influences (face, neck, hands) ; are most common where wounds are common, and apparently provide infection atria (ulcers of all sorts, fistulse, eczema, scars resulting from wounds or ulcers, fissured nipples, erosions of the cervix) ; or where there are changes resulting from chronic irritation (chronic inflam- mation of the skin, hyperkeratosis, seborrha?a, eczema, leucoplakia, chronic balanitis in phimosis). The frequent involvement of those parts of the gastro-intestinal tract most often exposed to traumatic and in- flammatory irritation (margin of the tongue injured by carious teeth, oesophagus, cardia, pylorus, flexures of the large intestines, rectum) also supports this theory. Uncleanliness seems to play a role and to speak for a parasitic cause (frequent occurrence of carcinoma of the face among the poorer classes, of cancer of the mouth when the teeth are badly cared for, of carcinoma of the breast when the nipples are dirty and scaly). The occurrence of multiple carcinomas in the gastro-intes- tinal tract; the few cases of so-called implantation carcinomas, for ex- fimple, implantation from the tongue to the mucous membranes of the cheek lying opposite (Liicke), from the lower to the upper lip (von Berg- mann), from one peritoneal surface to the opposite (Beneke) ; and the occurrence of carcinoma in many members of the same family or in a FORM, GROWTH, AND CLINICAL SIGNIFICAXCIO OF TUMORS 759 uiinibcr of families liviiii;' in the same liouso or iH'i;^lil)orliood have l)een supposed l)y many to si)eak foi- a i)arasitic origin. Hfoea has carefully reported the history of a family in which sixteen out of twenty-six members, representing three generations, were afllicted with carcinoma. Objections to the Parasitic Theory. — There are a number of objec- tions which may be raised against the parasitic theory, and even the lre(pient involvement of the parts above mentioned may l)e satisfactorily explained without resorting to it. In the first place, certain types of tissue are always reproduced in the ditt'erent tumors, even in the dif- ferent varieties of carcinomas. How would it be possible that in a l)arasitic infection only one definite form of cell is always stinndated to proliferation (for example, only the epithelium), wiiile the connec- tive, endothelial, and glanduhir tissues are acted ui)on by the infection at the same time? In this case there nuist be at least as many varieties of parasites as there are varieties and sub-varieties of tumors, leaving out of consideration mixed tumors, the complicated structure of which alone speaks against a parasitic origin. The development of metastases, composed of cells resembling those of the primary growth, and the growth of the tumor without stimulating the surrounding tissues to l)i-oI iteration are weighty arguments against the theory (cf. Borst, Ribbert). CHAPTER III FORM, GROWTH, AND CLINICAI. SICNIFICANCE OF TUMORS Different Forms which Tumors may Assume. — Among the many forms which tumoi's situated superficially or deejjly may assume, the round, r.odular form is the most conmion. x\s a tumor develops it may change into a tuberculated, bulbous mass, the form being influenced by ana- tomical relations. The following forms of tumors are ditt'erentiated ui)on the surface of the skin and nnicous membranes: Tumors with broad and thin pedicles; fungoid, pendulous, verrucous, villous, papil- lary tumors with numerous thornlike elevations; and cauliliowerlike growths with a dendritic arrangement of the proliferating tissues. Sev- eral dift'ereiit foi'ms may be combined in the same tumor. Expansive and Infiltrating Growth. — A tumor, as it grows, pushes aside or infiltrates the surrounding tissue, the former being known as exjnnisivc, the latter as infiltrating growili. The increase in the size of a tumor is due to the proliferation of its constituent parts alone, and not to the transformation of the infiltrated tissue into tumor cells and their proliferation to form tumor masses, as was formerly con- 760 GENERAL PART sidered to be the case. A tumor growing by expansion has sharp bound- aries, may easily be separated from the surrounding tissues, and has a distinct capsule formed by the thickening and reactive proliferation of the surrounding tissues; while an infiltrating tumor has more or less indistinct boundaries and is intimately attached to the surrounding tissue. Sometimes a growth which is expansive in the beginning later becomes infiltrating. A tumor is always nourished by blood vessels, which enter it from the surrounding tissues. In slowly growing tumors the blood supply is usually sufficient to nourish the entire tumor, while in rapidly growing tumors it is often insufficient, and parts of the tumor may become necrotic during its later development. Frequently the necrosis is pre- ceded by fatty and mucoid degeneration. Often tumors, especially those with long pedicles, become oedematous as the result of venous stasis. When stasis occurs, fluids may be pressed from the cut surface of the tumor as from a sponge. It then resembles closely myxomatous tissue. RegTessive Changes. — Regressive changes occur when the infiltrat- ing growth invades and occludes the blood vessels. The regressive changes lead to the formation of cavities in the interior of tumors, of ulcers upon the surface, and not infrequently to contraction of the connective tissues. Clinical Significance. — The clinical significance of tumors rests in the first place upon the harm they do, which may be the direct result of their enlargement and other properties of tumor tissue. In expansive growths the amount of harm done the organism depends entirely upon the importance of the structure or of the organ pressed upon or dis- placed. For example, pressure upon large vessels causes circulatory disturbances; upon nerves and the spinal cord, irritation or paralysis; upon the brain, severe symptoms or death; while a tumor upon the sur- face of the body, even if very large, may cause but slight inconvenience. Infiltrating growths do much more harm, as they press upon the infil- trated tissue, which is destroyed (e. g., destruction of an entire viscus and replacement by tumor masses, erosion of large vessels). The harmful effects of tumors may also be due to recurrences, metas- tases, and the so-called cachexia which they induce. Recurrence of Tumors. — Recurrences occur after removal only when part of the tumor tissues has been left. Naturally this is much more frequent when tumors infiltrate the surrounding tissues than when they are circumscribed and encapsulated. The recurrences may de- velop in the area from which the tumor was removed, or, if the cells have been carried by the lymph stream, in surrounding structures. Metastatic Growths. — By metastatic tumors are understood those developing secondary to the primary growth in distant parts of the FORM, GROWTH, A\D CLINICAL SIGNIFICANCE OF TUMORS 761 l)()(ly. They develop from tnnior tissue (cells, groups of cells, or pieces of tuiiior tissue) which has been carried by the lymphatic vessels and blood vessels to distant parts, after one or the other of these has been invaded by the infiltrating growth. The cells carried by the lymph stream are arrested in the adjacent lymph nodes and develop into sec- ondary tnmoi's. If the tnmor cells pass into blood vesseLs, as is fre- (juently the case in advanced carcinomas and sarcomas, or into the thoracic duct from some of tlie smallci" lymphatic vessels, they are dis- tributed and deposited in difl'crent i)arts of the body in the form of emboli (luematogenous metastases). If the tumor invades the veins of the systemic circulation, tumor masses may be carried l)y the ])I()()d stream into the lungs. If the em- boli are small enough to pass thi'ough the capillaries of the lung (G yu, in width), they are carried to the left heart, and from here into the arterial system, to lodge where there is a hypera^mia or where the capil- laries are very narrow (liver, kidney, more rarely other viscera, bone, skin). Embolism of one of the larger branches of the pulmonary artery may cause inmiediate death. If the tumor tissue gains access to the ])ortal vein, it will first be deposited in the liver. It cannot be estimated how many tumor cells die in the lymph and blood stream or fail to develop after they are deposited. It is not to be doubted that degen- erating non-viable cells as well as viable cells are carried in the emboli, and that all of them are not able to form metastases. ]\Iore rarely the following varieties of extension occur l)y way of the lymphatic and ])lood vessels: (1) Continucms extension by growth of the tinnor ele- ments within the lumen of the vessel (e. g., a carcinoma grows for some distance in a lymphatic vessel to an adjacent node, extension of car- cinomas of the stomach and intestines into radicles of the portal vein, and of a sarcoma or hypernephroma of the kidney through the renal vt'iii into the inferior vena cava, and from here into the right heai't) ; (12) retrograde extension, the tumoi- tissue developing against the cur- rent of the vessel involved. This may be the case if there is a marked v(Mious stasis and the pulsation transmitted to the veins is more power- ful than the blood current (Ribbert). The occlusion of one of the principal lymphatic channels may so change the direction of the lymph stream that tumor cells may be car- I'ied in a direction opposite to that in which the stream normally flows ill vessels entering into the collateral circulation. A continuous growth within the lymphatics extending to adjacent nodes is more frequent than the retrograde embolism above mentioned. In serous cavities tumor cells may be disseminated upon the surfaces of the peritoneum, pleura, and pericardium by the movements of the viscera. Tumor cells may also be transplanted into an operation-wound 49 762 GENERAL PART during the removal of malignant growths (inoculation metastases or recurrences). The structure of the secondary growth is always the same as that of the primary tumor. The formation of metastatic growths is peculiar to tumors with an infiltrating growth. Tumors with an expansive growth do not invade lymphatic and blood vessels. According to Ribbert, the clinically sig- nificant but not sharp division of tumors into the benign and malignant is based upon this difference in growth, and not alone upon the char- acteristics of the tumor cells. Benign tumors, as a rule, grow slowly by expansion without forming metastases, and becomes dangerous only when they attain great size or interfere with the function of some of the important organs. Malignant tumors form metastatic growths giv- ing rise to regional or general metastatic growths, and as they infiltrate tissues they destroy the tissues or organs involved. The more closely the cells composing a tumor approach an embryonal type, the more rapid the growth of the tumor and the more frequent the infiltrating growth will be. General Constitutional Effects of Tumors. — Tumors may produce gen- eral constitutional effects which consist most frequently of a marked falling off in the nutrition of the body — the so-called cachexia of tumors. This cachexia is most pronounced in malignant tumors when accom- panied by metastatic growths, but may also occur in benign growths if they are multiple (e. g., multiple lipomas) or if they attain an extraor- dinary size (e. g., fibromyoma of the uterus, large fibrolipoma of the skin). There are a number of different causes of cachexia, such as interference with the function of the viscus involved, interference with the general functional activity and nutrition of the body, pain, loss of sleep, and a number of other things. Fever and the absorption of the products of decomposition from the tumor and of putrefactive products from ulcerated tumors are important factors in causing ca- chexia. Finally, regressive changes in a tumor may give rise to danger- ous complications, such as aspiration pneumonia in carcinoma of the mouth or peritonitis after perforation of a carcinoma of the stomach. CHAPTEE IV THE GENERAL DIAGNOSIS OP TUMORS The diagnosis of a tumor — that is, determining whether the lesion is a true tumor (differentiating it from hyperplasias, inflammatory infil- trations, infectious granulomas and cysts) and determining the character of the tumor — is based upon the following: THE GENERAL DIAGNOSIS OF TUMOllS 7G3 I. The previous and present history. The time at Avhicli the tvniior l)e<,^an to develoj), the determining cause, the mode of jirowth, and tin; way in which the tumor has extended. The local and general subjective symptoms are also of importance. II. Upon the physical findings (A) the h)cal, (B) the general, com- bined with (C) consideration of what varieties of tumors are most fre- quent in the area or organ involved, and (D) special diagnostic methods. A. In the local examination the position and peculiarities of the tumor should first be determined by inspection and palpation. Inspection should determine : 1. The position and extent of the tumor in relation to anatomical structures (region of the body, contour of the bone, nniscles, tendons) ; 2. The form (round, oval, irregular, fiat, hemispherical, nodular, pedunculated, fungous, cauliflowerlike, papillary) ; 3. The size (compared with "well-known objects such as a pea, cherry, walnut, hen's egg, child's head, or accurate measurements of its trans- verse and longitudinal diameters) ; 4. The surface; (a) Covered with skin or mucous membrane (of normal appearance, permeated with dilated vessels, hyperfemic, pigmented, tense and shin- ing, transparent) ; (h) Sloughing, ulcerated (secreting, bleeding slightly, covered with crusts) ; (i) Edges of the ulcer (forming an elevated wall or flat, sharply cut, excavated, or eroded, firmly attached to underlying tissues or under- mined, hard, or soft) ; (ii) Floor of the ulcer (flat, depressed, craterlike, or filled with growths, necrotic, uneven, smooth, or fissured) ; (iii) Surrounding tissue (normal, raised by tumor masses or invaded by secondary nodules) ; (iv) The margins (sharply defined or indistinct, circmuscribed, or diffuse). Palpation should determine : 1. The relation of the tumor to the tissues covering it (whether the skin covering it may be raised in folds as the healthy surrounding skin, whether the skin or mucous membrane covering the tumor can be dis- placed over it, whether muscle lies between the skin and the tumor. The latter is to be determined by lifting the muscle up — for example, by lifting the sterno-cleido-mastoid — or by testing the function of the nnisele — for example, by testing the rigidity of the abdominal muscles, by elevation of the arm to prove w^hether a tumor is beneath the deltoid). 2. The characteristics of the surface of the tumor. It may be de- termined Avhen the examination is made concerning the displaceability 764 GENERAL PART of the tissues covering the tumor whether its surface is flat and smooth, nodular, lobulated, or irregular. 3. The boundaries of a tumor, whether they are distinct or indis- tinct, whether sharply defined against the surrounding tissues or whether they disappear indistinctly into the deeper parts — for example, below the jaw, at the mastoid process — or gradually fuse with the normal tissue. 4. The position of the tumor and its anatomical relations (after pal- pation of adjacent tendons, muscles, bones, and viscera). 5. The relation of the tumor to surrounding and subjacent tissues (whether it can be moved here and there with the skin and soft tissues, or is situated deeply upon bone, or is firmly attached to tendons or fascia ; whether it moves with tendons, muscles, or with the liver during respiration) . 6. The consistency of the tumor. The most important characteristic to be determined is whether the tumor is soft or hard. (a) Only the experienced, not the beginner, can detect the finer dif- ferences, such as the difference between the hardness of cartilage and bone, and between the elastic consistency of a lipoma, and the sensation imparted by a soft or hard fibroma. (&) Fluctuation, Hard as well as soft tumors may fluctuate, de- pending upon whether the capsule surrounding the fluid or liquefied masses of tumor tissue is tense or relaxed. A hard, fluctuating tumor is elastic. In soft tumors the capsule must be made tense by pressure before fluctuation can be elicited. In firmly attached or slightly movable tumors fluctuation is elicited in the same way as in abscesses. The index finger of each hand should be placed upon the tumor opposite each other, first at a small, later at a greater, distance from each other. The fingers should be laid flat upon the tumor, and only in examining soft tumors should any great amount of pressure be exerted. The left index finger (inactive finger) is then held quiet and motionless, while pressure is made with the right (active finger) which is then quickly removed. The inactive finger will be elevated by the displaced fluid if the tumor fluctuates. If the tumor is movable it is best to grasp it between the index finger and thumb of each hand. If pressure is then made with both fingers of the right hand, those of the left will be raised if fluid is present. Some tumors (lipoma, myxoma) very frequently impart the sensa- tion of indistinct or pseudo-fluctuation. [Mistakes are not infrequently made even by experts in determining fluctuation. I myself have made the diagnosis of fluid in a case of fatty tumor in the infraspinous fossa covered by the infraspinatus muscle.] THE (JK-NEllAL DlAC.NDSlrf OF TLMORS 705 (r) The ooiulilion found in dermoid cysts and the so-eaHed fteeal tumors (liard faral masses), in whieli the (h'i)i'('ssion made l)y tlie liny;er remains and only disappears when pressure is iiuuU' upon the opposite side of the tumor, is spoken of as a dougJty or kneadablc consistency. {il) Pulsation is best elicited by placinj; the lumd tiat upon the tumor without exerting pressure (in certain ha^nangiomas in the same way as in aneurysms). If pressure is made upon the pi-incipal artery supi)lyinji the tumor, pulsations cease. ((') A tumor is spoken of as compressible when it diminishes in size under pressure and enlarges again when the pressure is removed (haem- angiomas and lymphangiomas). (/) Thrills are often felt in pulsating tumors when the hand is placed upon them {vide hydatid fremitus in echinococcus cysts). {g) Tiunors covered by a thin shell of bone, when palpated, impart a parchmentlike sensation or crepitation. B. The general examination begins with: 1. The palpation of neighboring lymph nodes, which in many malig- nant tumors are enlarged and indurated, then follows: 2. The examination of other similar growths, if present (multiple tumors), and the search for metastatic growths of the skin, large viscera, and bones (by percussion or palpation). 3. The special examination of diti'erent viscera and systems; for ex- ample, examination of the urine (for albumin, blood, also for sugar in supposed pancreatic tumor), of the fa?ces (for blood, and mucus in tumors of the intestine), of the gastric juice (in tumors of the stomach), of the function of the kidneys (the solids of the urine are estimated by determining the freezing points of the urine discharged from each kid- ney), of the nervous functions (in supposed tumors of the brain, spinal cord, and peripheral nerves), of the blood (to determine the relative proportion of the cells in diseases of the blood-forming organs, the spleen, lymph glands, and bone marrow). ■4. The critical examination of the general condition (cardiac func- tion, anajmia, digestion, physical and mental characteristics). C. What tumors or tumorlike formations occur most frequently in the area or organ involved? The an.swer to this question often makes a definite diagnosis possible, even after the results of a most accurate examination have been insufficient. A few examples will render this statement clear. A hard, indistinctly fluctuating, round tumor which is slightly mov- able upon the subjacent tissues and has no connection wnth tendons is situated just beneath the skin in the palm of the hand. A tumor with similar characteristics situated about the eye would be diagnosed at once as a dermoid cyst, as they frequently occur here. Not so, however, in 766 GENERAL PART the palm of the hand. Dermoid cysts do not occur here, while epithelial cysts (which never occur about the eye) do. In considering the diagnosis of some tumors, their connection with a nerve may be definitely established. The characteristics of the tumor alone, which is round, of average hardness, and not adherent to the skin or underlying tissues, will suggest the variety. The few varieties of the tumors, however, which develop upon the peripheral nerves limit the differential diagnosis to a few new growths, and one has only to deter- mine whether the tumor has grown slowly or rapidly to decide whether it is a fibroma or sarcoma. In making the diagnosis of the character of a tumor of the breast, the position is very important. A number of tumors and tumorlike hyperplasias develop in the breast which do not occur in other parts of the body. A lobulated, nodu- lar, soft tumor, lying beneath nor- mal skin and displaceable upon the underlying tissue is not to be diagnosed, as it might be in the back, as a lipoma. The relation of the tumor to the breast must first be determined. Often the entire breast or parts of it may be hypertrophied and cystic (mastitis chronica cystica), a con- dition which might easily be mistaken for a subcu- taneous lipoma. Tumors of similar characteristics occur even #^B W in the male breast and J^B 'M surrounding tissues. A similar lesion of the male breast may be a tumor or a condition known as gyntecomastia, in which the breast undergoes a hyperplasia of all its com- ponent parts (which may even be unilateral) and resembles the female breast (Fig. 282). Car- cinoma of the breast has some special characteristics, such as very evi- dent infiltration of the gland, retraction of the nipple, etc. Frequently Fig. 282.- -Gyn.ecomastia (Right Side), Male Patient Eighteen Years Old. TIIK GK.NERAL DIAGNOSIS OF TIMORS 767 a defiiiitf diaj;:nosis of carcinoma of the breast can l)c made much earlier than that of carcinoma of other parts. jMyelop:enous and periosteal sarcomas, chondromas, and osteomas are the most common tumors of bone. In spite of this a fiat or nodular, resistant, not sharply defined tumor which is attached to the bone, is covered by normal skin, and has grown rapidly cannot be diagnosed as a sarcoma without considering some other lesions. One should think of the enlargement associated with chronic suppurative and tuberculous osteo- myelitis, and especially of a periosteal gunmia, which occurs most com- monly upon the diai)hysis of the tibia, and search for other evidences or remains of the infectious diseases above mentioned should be made. Any number of such examples might be cited. Those already men- tioned show conclusively that an accurate knowledge of special pathol- ogy, vast experience in diagnosis, the ability to weigh po.ssibilities, and an extended clinical experience are recpiired before the diagnosis of tumors can be made correctly and with certainty. Even the mast expert diagnosticians are frequently unable to make a positive diagnosis, being unable to decide between a number of pos- sibilities. 13. Special diagnostic aids. Aspiration, exploratory incision and ex- cision with microscopical examination, X-ray pictures and special meth- ods in abdominal tumors are diagnostic aids. 1. Puncture and aspiration of a swelling is important when it is dif- ficult or impossible to determine its consistency (indistinct fluctuation). By inserting a needle or canula, it is possible to determine whether fluid is present or not, and if present the character of the same (serous, ha»morrhagic, purulent, mucoid, or fluid from echinococcus cysts). 2. The exploratory incision is sufficient in many cases to enable the surgeon to make a definite diagnosis as to the character of the tumor by the macroscopic appearance of its cut surface (e. g., lipoma or sar- coma, fibroma or carcinoma of the mammary gland). The harpooning of pieces of tumor tissue, which was employed extensively in preantiseptic times, is no longer practiced. Ilari)ooning consisted of inserting an instrument provided in barbs (similar to a harpoon) and removing small pieces of tissue from the tumor, which could be used for micro- scopic examination (Middeldorpf 's harpoon). Excision of pieces of tissue for microscopic examination is often resorted to. Small pieces of tissue are removed for microscopic exami- nation in cases in Avhich it is probable that a tumor is malignant, but the symptoms are not pronounced enough to make a positive diagnosis possible. It is of most value when tumors are first beginning to develop (e. g., to diagnose between psoriasis, syphilis, and beginning carcinoma of the tongue, between carcinoma and papilloma of the larynx, in sus- 768 GENERAL PART pected carcinoma of the uterus). A small wedge-shaped piece of tissue is removed from the surface of the tumor, and the resulting wound is touched with a thermocautery to control the hemorrhage. In tumors of the larynx a good view of the tumor should first be had with the laryngoscope before the tissue is removed with forceps, in order to be certain that the tissue is removed from the tumor and not from the diseased area adjacent to it. In many cases pieces which are separated and cast off from the tumor may be used for examination (e. g., tissue expectorated in tumors of the mediastinum and lungs, vomited in carcinoma of the stomach, passed in the urine in tumors of the bladder, in the fgeces in carcinoma of the rectum). X-ray pictures are of value in many cases. Hard tumors and those consisting of bone (osteoma, osteosarcoma), or containing pieces of bone (teratoma) may often be recognized in pictures by their nodular form and differentiated from inflammatory infiltrations and hyperostoses. The appearance of the bone from which the tumor develops depends upon whether or not it is destroyed by the new growth. Exostoses are attached by broad or thin pedicles to the surface of the bone. A perios- teal sarcoma surrounds the bone which in the beginning at least is still normal, the contour of which can be seen through the shadow of the tumor. Small central tumors can be differentiated from inflammatory processes only when the cortical layer of bone covering them has become thinned. As a rule, bone surrounding inflammatory processes becomes thickened and sclerotic. Often it can be seen that the tumor has rup- tured through the thinned and expanded parts of the cortex at a num- ber of points. Tumors of the mediastinum can often be diagnosed by an X-ray examination. In the examination of abdominal tumors a number of different diag- nostic methods are employed to determine the position of the tumor and its relation to neighboring organs. For example, the stomach may be distended Avith an effervescing powder, the colon with air or w^ater in order to determine the relation of the tumor to these organs, whether it is in front or behind or whether the tumor changes its position as the organs are distended. EXAMPLE OF THE METHOD EMPLOYED IN MAKING THE DIAGNOSIS OF A TUMOR LIPOMA I. Anamnesis : Symmetrical, gradual growth for a number of years, no cause, no trouble, only discomfort because of size, general condition of patient unchanged. THE GENERAL I)IA(Jx\OSIS OF TUMORS 769 11. Status: (A) The local exaiuinalion by inspection: 1. Position antl extent. A tumor is present upon the back of the patient, in the right scapular region, covering alniost the entire bone. 2. Its form is almost oval; in profile hemispherical, with an indis- tinct tonguelike process upon the medial side. 3. Its size is a little larger than the head of a newl)orn child. 4. Its surface is covered by normal skin. 5. Its boundaries are sharp and distinct except along the lower part. By palpation : 1. The skin may be raised in folds from the surface of the tumor, but the skin is thinner than that of the area adjacent. [In doing this an irregular wi'inkling is produced by the trabecular of connective tissue which divide the lobules of the tumor.] In some areas the skin covering the tumor is less movable. 2. The surface of the tumor is smooth throughout. At the margins distinct, round projections may be felt, and upon the medial side a large process. Both may be made visible by rendering the skin tense. 3. The boundaries of the tumor are sharply defined and distinct from the surrounding structures except along the lower margin. 4. The position of the tumor corresponds to the right scapula. Its lower part disappears beneath the latissimus dorsi, the border of which may be distinctly palpated. If the muscle is made to contract by pressing the arm against the side of the chest, the lower part of the tumor becomes harder and its lower boundary still more indistinct. 5. The tumor is but loosely attached to underlying structures (fas- cia), as it can be easily displaced in all directions. 6. Its consistency is soft. If the tumor is grasped with four fingers, indistinct or pseudo-fluctuation may be elicited. (B) The general examination reveals no enlargement of the regional lymph nodes. Another tumor about as large as a walnut witli similar characteristics is situated upon the outer side of the left thigh. The general appearance of the patient is good. (C) The part involved (the back in the region of the shoulder) is a common site for subcutaneous lipomas. The findings correspond to such a tumor. Other tumors occurring in this region, such as a sarcoma, may be excluded because of the slow growth ; atheromas because of their round form and small size. (D) Special diagnostic aids, such as puncture and aspiration, are not necessary. Diagnosis : Circumscribed subcutaneous lipomas over the right scap- ula and on outer surfaces of left thigh. 770 GENERAL PART SARCOMA I. Anamnesis : For one half year an enlargement in the region of the right scapula has been noticed. For two months the growth has been rapid, accompanied by pain and limitation of motion of the arm. For two weeks marked general weakness, attacks of coughing, and pain upon breathing in left side of thorax have been present. II. Status: (A) Local examination by inspection: 1. Size and extent. A tumor in the region of the right scapula, in- volving the area below the spine, extending about 4 cm. below it. 2. Its form is that of a round, flat swelling. 3. Its size corresponds to that of a child's head. 4. Its surface is covered in the upper half by skin which appears normal, while that covering the lower half is traversed by dilated veins. 5. The boundaries of the tumor are ill-defined. By palpation : 1. The relations of the tumor to structures covering it differ. The skin covering the upper part of the tumor may be raised in folds, and is of the same thickness as the surrounding skin. In the lower part the skin is so firmly attached to the surface of the tumor that it cannot be raised in folds. 2. The surface of the tumor is smooth with superficial furrows. 3. Its boundaries can be distinctly made out in the lower part only. 4. The position of the tumor corresponds to the right scapula. Above the boundary becomes indistinct at the spine of the scapula; medially and laterally it fuses with the neighboring muscles; beloAV it extends two fingers' breadth beyond the angle of the scapula. There is no muscle between the tumor and the skin, at least muscle cannot be recog- nized during active movements. The tumor is attached to the scapula, following its movements. 5. It is also firmly attached to the underlying bone, as it cannot be displaced over the scapula. 6. The consistency of the tumor is hard, and only at a small point in the lower part where it is attached to the skin can fluctuation be elicited. (B) The general examination reveals no enlargement of the axillary lymph nodes. Similar growths are not present upon any other part of the body. A general physical examination reveals some involvement of the left lung. There is a left pleuritic effusion and the expectoration is bloody. Aspiration reveals an effusion which is bloody in character. The sallow appearance of the patient and the great weakness are striking. (C) The area involved is the favorite site for lipomas (see previous example), but a lipoma does not become attached to bone. Exostoses, THE GENERAL DIAGNOSIS OF TFMORS 771 <'ii('li()ii(lroin;is, and sarcoiiiJis two the most ('(inimdii of the otlicr varieties of tumors develo])inerative removal of all parts of a tumor is the most cer- tain therapeutic measure. It is usually indicated in the treatment of all tumors, excepting, of course, benign tumors giving rise to no trouble where the operation would be severe or mutilating and the cosmetic GENERAL DISCUSSION OF THE TREATMENT OF TUMORS 773 results bad. Small tniiiors of the skin may be exeised by an oval ex- seetion of the skin, and the resulting wound sutured. In the face, plastic operations ai-e often required to close the defect following the removal of tumors of the skin, a.s immediate closure without such a procedure often leads to distortion of the parts and deformity. The operative removal of malignant tumors is possible only when the diagnosis is made early and the growth is just beginning. Even then the excision nnist be carried into healthy tissues, especially in cases of carcinoma, and the neighboring lymph nodes must be exposed and removed even when thei'c are no macroscopic changes. A malignant tumor may be inoperable: (1) Because of the size of and extent of the primary growth; (2) because of metastases into the lymph nodes; (3) because of other metastases (disseminated, lymph- ogenous nodules in the surrounding skin and ha'matogenous metas- tases). Inoperable Tumors. — For example, a carcinoma of the breast is inop- erable if the tumor is tlrndy attached to the chest wall, or, even if the tumor is small, w^hen the supraclavicular as well as the axillary lymph nodes are involved; when there are small, disseminated nodules in the surrounding skin, or metastases in the viscera (lung, liver) or in the bones (neck of the femur with spontaneous fracture, in the vertebra leading to pain, kyphosis, etc.). Cauterization and its Indications. — Cauterization (with a thermo- cautery or caustics, in pedunculated fibromas of the mucous membrane with the loop of a galvano-eautery) is to be recommended for the re- moval of small, benign tumors, such as warts and pedunculated fibromas of the skin and mucous membranes only. It is to be discarded in the treatment of other forms of tumors, as the removal is not complete, and when there is a possibility of malignancy. Experience has shown that the irritation following cauterization hastens considerably the growth of malignant tumors. Besides, hideous, often deforming, scars remain after cauterization. Ligation. — The ligation of the pedicle of pedunculated tumors (warts, pendulous fibroma) is performed by lay people and physicians Avho fear the knife. The object of ligation is to produce a necrosis and subsequent sloughing of the tumor. The great disadvantage of this procedure is that parts of the tumor, from w^hich the growth recurs, often remain. The operations to be emploj^d in the treatment of dif- ferent varieties of tumors are described in their respective chapters. Light Therapy: Indications and Contra-indications. — Eight therapy is a modern method of treatment. The eft'oi'ts which have been made to remove tumors by bloodless methods, and the discovery that the X-rays, radium, and Finsen rays produced inflammatory changes in the skin I 774 GENERAL PART often resulting in necrosis, led to a number of experiments dealing with the effect of the above-mentioned rays upon tumors. X-rays in particular seem to have some special action, as it has been demonstrated that warts, telangiectases, and carcinomas of the skin which have been exposed to the rays often disappear completely. This is apparently due to the degeneration of the tumor cells (von Mikulicz and Fittig, Pusey, Hyde, Bevan, Perthes, von Bruns). In the treatment of superficial tumors the so-called soft (low vacuum) tulje is employed. The diseased area is exposed, the tube being at a distance of 10 cm., from five to fifteen minutes, some days intervening between exposures, or from five to ten minutes for a number of succes- sive days. The healthy surrounding skin should be protected by a lead plate while the treatment is being given. If the tumor is deeply situated a hard (high vacuum) tube should be employed, the rays from which penetrate more deeply. If the rays have the proper penetration the bones, when looked at through a fluoroscope, should cast a gray, not a black shadow. According to our present knowledge, the treatment should be continued only until an erythema of the normal skin, with or without vesicle formation, develops. Usually this occurs after two weeks. If the dosage is higher (harder tube or continued for a longer time) alterations in the vessels of the normal skin (degeneration of the intima and muscularis, Gassmann) which often lead to necrosis develop, and the rays are then no longer suited for the treatment of tumors (Perthes). Chronic " Roentgen-ray ulcers," which may occasionally become transformed into carcinomas, may develop after long and im- proper exposures. In the treatment of benign tumors a trial with the X-rays is always permissible. In the treatment of malignant tumors the X-rays should be considered only for the small, flat carcinomas of the skin, espe- cially those occurring upon the face, which pursue a chronic course and rarely form metastases. It should be kept in mind, however, that even in th&se cases, while there may be apparent healing, the growth may be extending more deeply beneath the scar, so that soon after superficial healing regressive changes may occur, leading to the forma- tion of a deep ulcer which may even penetrate to bone. The simplicity, rapidity, and safety of the operative treatment are in marked contrast to the slowness and uncertainty of this method. X-ray treatment of other operable malignant tumors, such as deep carcinomas and sarcomas, should be discarded. It can never replace the operative treatment, as the destruction and absorption are limited to the superficial parts of the tumor and occur but slowly during the course of weeks and months. In the treatment of malignant tumors, delay of complete removal merely favors the formation of metastases. GENERAL DISCUSSION OF THE TREATMENT OF TUMORS 775 For cxainpk', ^'"— * -1,' / ■ ' - : x^i:^^^- - " ~ - -^ / '~ ■*".-< m- -^ "^ ^ ' ^•'^ . ^^ " • ^ ^^-•^•^•.^>'> -^ ^ -^ " ^ — « ^ * i - . ^ -^ -:- V^ >'>>cV a spina bifida occulta. In many forms (keloid, elephantiasis nervorum) there is a distinct, even li e red i t a ry , predisposi- tion. Some fibromas de- velop fi'oni inllammatoiy proliferations. It is not possible to make a sharp di.stinction between fil)i'omas and the two other forms of tissue l)roliferation. Ch ronic iuflammatortf (jroictlis of the skin and subcuta- neous tissue and COIigcn- Fig. 283. — Hard Fibroma with Few Vessels. ital hypertrophies (par- tial giant growth) lead to the formation of tumorlike, elephantous masses. If these are sharply circumscribed and distinguished from tlie surrounding structures by a more independent growth — for example, if they contain lobulated or pedunculated parts — they are to be re- garded as lobulated elepliantiasis and classified with fibromas. It is often diffieult to differentiate between a fibroma and a fibrosarcoma, which Jiiay develop from the former. If the tumor is rich in cells with large, oval nuclei undergoing rapid division and with a large amount of cytoplasm, and there is but little intercellular substance, the tumor sliould ])e regarded as a fibrosarcoma. The vascularity of fibromas varies greatly. If the blood vessels, which are represented by spaces of different size lined by endothelium, are present in large numbers (e. g., in many nasal and pharyngeal polypi) the tumor may be designated as a fibroma teleangiectaticum, or, if it contains large sinuses, as a fibroma cavernosum. The fibroma hjm])ha)i(jicctati(um is provided with numerous dilated lymphatic vessels. Regressive Changes. — A number of regressive changes may occur in fibromas. The vessels may be occluded by the pressure of neighboring k 780 DIFFERENT VARIETIES OF TUMORS structures or as the result of torsion of the pedicle, and the tumor may then undergo necrosis. As the result of liquefaction of the intercellu- lar substance, areas containing mucoid tissue (fibroma myxomatodes) and cavities (fibroma cysticum) de- velop. Mixed forms of these tumors are frequent, fibrolipomas occurring in the subcutaneous and subserous tissues, fibromyomas in the uterus. Fibromas are com- mon, occurring upon different parts of the body, some parts be- ing more frequently involved than others. Eight varieties may be differentiated, de- pending upon the tissues involved. I. Fibromas of the skin appear in five different forms : (a) The soft wart (flesh wart, verruca carnea) occurs as a small, round, usually pigmented formation with a broad base and smooth or wrinkled surface. It is either con- genital or develops in childhood from small congenital pigmented moles, and may become transformed into the larger lobulated and peduncu- lated soft fibroma. They develop most frequently, when single, upon the face and neck. If associated with a general fibro- matosis of the nerves, they may be disseminated over the entire surface of the body, alternating with numerous flat, wartlike naevi and larger fibromas. According to Soldan, histologically they are soft fibromas rich in cells, and develop from the connective-tissue cells of the cutaneous nerves. They can be easily differentiated from ordinary warts, which are so frequent upon the hands of children. The ordinary warts differ from Fig. 284. — Fibromata Molltjsca of the Skin and Sarcoma of the Left Ax- illary Fossa. FIBROMAS 781 tliose (loscril)O(l abovo : (1) Tii that they ai'O transforahle to different |)arts of tlie same individual, as (lie experiments of Jaihissohn and Lanz liave sliown ; (2) they arc the resnlt of the hypertrophy of the papillae and the skin covering tliem and depending npon tlie condition of the latter; their surfaces are smooth, rough, or fissured. 1'liere are some other forms of congenital Avarts or pa{)ill()iiias which belong to the libro-epithelial tumors. (h) The tnuUipIr, pdiiilcss ttiniors of (lie skin, Avhich are some- times nodular, sometimes ])eduncnlated, are designated as fibromata mol- litsca. They vary in si/e, and, according to von Recklinghausen, develop from the cutaneous nerves, belonging therefore to the neurofibromas. Not infrecjuently they contain the most delicate plexiform neuromas {vidf p. 793). Fig. 285. — I>ot!itlati:d Elephantiasis (Elephantiasis Nervorum). (c) Under the term JohnJaled clephaniiasis are grouped a number of different fibrous growtlis of tlie skin which resemble each other in that they are composed of long, pendulous growths, folds, flaps, or 782 DIFFERENT VARIETIES OF TUMORS masses. Part of these growths belong to the lymphangiomas and ha^m angiomas (elephantiasis lymph- and ha^mangiectatica) ; part are soft fibromas which, like the nodular soft fibromas of the skin, develop from the connective tissue of cutaneous nerves, but they also contain numerous lymphatic and blood vessels (von Esmarch and Kulenkampff). The nerve form of elephantiasis may be congenital or develop in early childhood from soft fibromas. The tumors occur most frequently upon the face and scalp, upon the neck, and about the region of the shoulder. They are covered by thin, wrinkled skin which is often pig- mented and covered with hair. There are frequently found associated with the fibrous growths occurring in this form of elephantiasis, other tumors which belong to the neurofibromas, such as the soft wart, fibromata mollusca, the plexi- form neuromas in the base of the lobulated growths, and finally fibromas of the larger nerves; changes which von Bruns has placed in one group and to which he has given the name of elephantiasis 7iervorum. Almost all of these forms are associated with congenital changes in the skin, indicated by small and large, usually flat, light-brown pigmented areas. Just as a soft wart may become transformed into a larger fibroma and these into lobulated formations, so, according to Soldan, each pigmented mole at any time may become trans- formed into a soft wart or into multi- ple fibromas of the .'-kin. The cell col- umns of these pig- mented na3vi with al- veolar arrangement are, according to the researches of this in- vestigator, neither of epithelial nor of en- dothelial origin, but are derived from the connective tissues of the nerves of the cutis. These histo- logical findings cor- respond perfectly to the clinical picture as the flat, more rarely, ver- rucous nasvi, soft warts, fibromas of the skin, and deeper nerves are frequently associated. Independent growths developing from inflammatory hyperplasias, / Vie,. 2SG. — Fibroma Pendtlu.m. FIBROMAS 783 wliit'li iive secoiulaiy to repeated attacks of erysipelas, and infections with filaris sanguinis hominis, do not belong to lobidated elephantiasis. ((]) The hard fibroma of the shin is less frequently of congenital origin than is the soft tibronia. It appears as a small, hard nodule or as a slowly growing fungoid, pendulous tumor with a long, thin pedicle. \ Fig. 287. — Fungiform, H.\rd Fiurom.a. of the Skin with Section of the Same. Tlie latter form may develop at any period of life. It occurs most fre- • luently upon the back, the inner side of the arms and thighs. There are also transitional forms to the soft fibroma. Upon section the tumor is sharply defined against the subcutaneous fat, and its surface is cov- ered by a thin layer of subepithelial connective tissue. Diagnosis. — The diagnosis of fibromas of the skin is not difficult, notwithstanding the great number of different forms tliat are met with. If it is found upon section or microscopic examination that the epi- 784 DIFFERENT VARIETIES OF TUMORS thelium has proliferated to form part of the tumor, it should be placed in the fibro-epithelial group (Ribbert). Growths occurring in this form of elephantiasis, which become smaller under pressure, are either closely related to or be- long to lymphangiomas and haemangiomas. Treatment. — These growths should be ex- ■ „/ cised when they become '"'*"*' V so large or are so situ- T^ „oo T, o, T. T. ated that they cause r iG. 288. — h iBROMA of the Skin with Broad Base as It Appears upon Section. trouble. If the growtllS in elephantiasis are ex- tensive, partial excision at a number of different sittings is indicated. In the congenital forms the proliferated connective tissues and the subcutaneous nerves must be carefully removed in order to prevent recurrence. The defects resulting from operations upon both the con- genital and acquired forms of elephantiasis should be repaired by skin grafting or plastic operations. (e) Keloids form a special group of fibromas of the skin. They are hard tumors, relatively rich in cells, and are composed of thick bundles of connective-tissue fibrils which frequently become transformed into homogeneous, collagenic trabeculae. Sometimes they occur as painless, red, indurated thickenings of the skin, sometimes as nodular new growths of considerable size, and sometimes in the forms of tumors sending out- growths into the .adjacent healthy tissues. The growth involves only the reticular layer of the cutis. It never extends to the deeper structures (Fig. 289). A keloid is therefore always displaceable with the skin, and may be raised from the under- lying structures. The surface of a keloid is red and shining and is covered by a layer of epidermis which contains no papillas and is not cornified, and by a thin layer of vascular connective tissues. The tis- sues composing a keloid gradually fuse with the healthy surrounding tissues, and the boundaries of such a growth are therefore never sharp and distinct. The neighboring tissues are pushed aside and separated by the expansive growth of these tumors. They contain neither elastic libers, hair, nor sebaceous glands. Cicatricial and Spontaneous Keloids. — The majority of keloids de- velop within a cicatrix. They increase gradually in size, often for a number of months, and then remain stationary or in rare cases disap- pear spontaneously. They develop most commonly in scars resulting FIBROMAS 785 from burns ol" the third degree and from cauterization, but also in sup- purating wounds and wounds healing by primary union, from chronic ulcers, vaccination scars, and from contusions of the skin. Since Ali- bert's description (1814) the keloids following wounds have been spoken -^ ^■^ * ^ , i ft mm i^ Fig. 289. — a, Keloid w hich Developed upon the Fore.^km of a Child Eight Ye.^rs of Age after a Scald, b, Section Through the Same. of as cicatricial keloids and difterentiated from spontaneous keloids. Histologically they are alike, and the spontaneous development of the latter is probably only apparent, as they develop after some insignificant Avound or injury of the cutis in which there has been no separation of the epidermis. TJie Hypcrtrophicd Scar and Differences Between It and a Keloid. — The hypertrophied scar, which appears as red, frequently very pain- ful, hard, fiat, or irregular tuniorlike growth at the site of a former injury, is not to be regarded as a keloid. It is not strictly speaking a new growth, but is the result of excessive scar formation in the most 786 DIFFERENT VARIETIES OF TUMORS superficial layers of the cutis. A hypertrophied sear develops most fre- quently from infected wounds. Wavy, loose, connective-tissue bundles without deposits of collagen (Goldmann), normal connective-tissue cells, frequently also cellular infiltrations and isolated hair follicles are Fig. 290. — Kkloid Developing in a Laparotomy Wound (Young Woman, Twenty Years Old). found in a hypertrophied scar, and these histological findings enable one to differentiate between such a scar and a keloid. A hypertrophied scar also differs from a keloid in that the scar tissue slowly undergoes the normal changes and eventually almost, if not completely, disappears. Positions in which Keloids are Most Common. — The position of the keloid is naturally determined by the site of the injury. There are, however, parts of the body in which keloids are especially prone to develop — for example, they follow more frequently injuries to the lobe FIBROMAS 787 of the ear, breast, face, and vaccination scars of the nppor arm, than they do injuries of the skin of the pahii of tlie hand and the sole of the foot. Keloids are most frequent in people of middle age. Recurrence after Extirpation. — The great tendency to recur is the most important characteristic of keloids. Even after complete extir- ])ali()n a new keloid may develop Avithin some weeks within the resulting cicatrix. It malccs no dinVi-cncc wlx^ther the wound has been sutured, Fig. 291. — A Keloid which Developed in a Sutured Wound of the Arm after the Excision of a Keloid which Developed in a Vaccination Scar. closed by a plastic operation, covered by skin grafts, or has healed by secondary intention. Small nodules will even develop from the stitch holes of a sutured wound (Figs. 290 and 291). Only in rare cases is 788 DIFFERENT VARIETIES OF TUMORS there no recurrence after extirpation. Von Bergmann observed a case in which there was no recurrence after seventeen years. In spite of the fact that they recur, keloids do not belong to the malignant tumors, as they do not form metastases. Multiple Keloids. — I'he development of multiple growths is another important characteristic of keloids. A person with a keloid may develop other similar growths at the site of any injury, provided the injury has involved the cutis (Lauenstein). There are cases, however, in which extensive injuries and op- eration-wounds of parts of the body some dis- tance from the site of a keloid heal normally. The different results fol- lowing wounds indicate that there is a predispo- sition to keloid formation which in one case may be general, in another case local. The fact that heredity is a factor in some cases also speaks for a special predisposition. Causes of Keloid For- mation. — Negroes are pe- culiarly liable to develop keloids. Nothing is known of the essential cause of keloid formation. The theory advanced by Goldmann that absence of the connective-tissue bundles of the cutis, resulting from injury, is the cause, is not a satisfactory explanation. Diagnosis. — The diagnosis of keloids is not difficult. They may be confused with large, irregular, hypertrophied scars (e. g., after burns and cauterization). Treatment. — The great tendency to recur must always be consid- ered before treatment is instituted. Excision is not to be advised, espe- cially if recurrences have already developed. Goldmann believes that recurrence may be prevented if the wound following excision of a keloid is immediately covered by large epidermal grafts. According to the experience of the author proliferation of the granulation tissue is pre- vented by the firmly agglutinating epithelium. Recurrences cannot be Fig. 292. — Recttrkence after Excision of a Sponta- NEOtTS Keloid. FIBROMAS 789 prevented with certainty either by this procedure, suturing of the wound, or by plastic operations. A number of different chemical agents have been used in the treat- ment of keloids. Thiosinamin, first introduced by Ilebra in 1892, is tlu' best agent. It is frccpiently used in the form of a fifteen per cent al- coholic solution or as a ten per cent acpieous glycerin sohition, as recom- mended by Duchuix. The solution should be injected directly into the keloid. After a number of injec- tions of 1 c.c. the keloid becomes smaller. If the keloids or hyper- trophied scars are very large the in- jections nnist be continued for a number of months. The injections are quite ^- painful to a number of pa- /^ tients. This method, which at least causes a reduction in the size of the keloid, is to be preferred to excision. Fibrolysin (Merck) soluble in water is a double salt of thiosinamin and sodium ^'<^- 293.-Another^Recurrence after Four salicylate. [Hyde and Ormsby have removed a number of keloids with the X-ray. This should be to-day the treatment of choice.] II. Fibromas of the subcutaneous tissues are much less common than those of the skin. They may occur upon almost any part of the body at any period of life, and growing slowly may attain considerable size. The skin covering them is of normal appearance, and may be raised from the tumor. These tumors are encapsulated and may be displaced upon the underlying fascia. They first give rise to symptoms by pres- sure upon nerves. The diagnosis is based upon the slow growth, hard consistency, and encapsulation. Extirpation is not difficult. III. Fibromas of the mucous membranes occur most frecpiently in the nose. They are usually nndtiple. The pedunculated or lobulated nasal polypi are composed of loose or firm fibrous tissue which contains large vessels, and are covered by a stratified epithelium and a thin layer of subnuicous tissue. It is often difficult to distinguish between them and polypoid, inflammatory growths of mucous membranes. 790 DIFFERENT VARIETIES OF TUMORS ^^^t^ ,-,— -^''" ^ 'F*** Similar but smaller multiple tumors are found in the larynx; more rarely in the gastro-intestinal canal, the urethra, and bile passages. Small, circumscribed, smooth fibromas may also be found in the mouth cavity (on the tongue, in the floor of the mouth, and upon the gums). Laryngeal and nasal polypi should be grasped with special forceps and torn away. Sometimes it is necessary to split the nose or larynx in order to remove these tumors. IV. Fibromas of the fasciae and aponeuroses are hard, nodular, pain- less growths. They may be single or multiple. These tumors develop most frequently in the abdominal wall (d&smoid of the abdominal ^ wall), taking their ori- gin most often from the posterior sheath of the rectus muscle, more rarely from the ante- rior sheath, from the aponeuroses of the oblique muscles, from the transversalis fascia and the linea alba. They grow slowly, be- coming as large as or larger than a fist, and separate the adjacent muscles. Their growth is hastened by pregnancy. The muscle from the fascia of which the fibroma develops undergoes in j)laces a pressure atrophy as the tumor extends along the intramuscular connective-tissue bundles (Fig. 294). In isolated cases a number of these tumors have been found in the abdominal wall, one developing after another. Recurrence may occur after excision, but it is rare {vide Pfeiffer). These tumors, as a rule, develop only in women who have borne chil- dren, and it is probable that trauma (slight laceration of the aponeu- rosis) is the etiological factor in their development. The diagnosis is based upon the position of the tumor in the abdomi- nal wall, its hardness, slow growth, and round form. It is important to determine the relation of the tumor to the muscles by palpation and by rendering the muscles tense. After removal of the tumor, the defect in the muscles should be sutured in order to prevent a hernia. Fibromas of the neck form another clinical group of tumors arising from fascia" and aponeuroses. They develop in the posterior part of the neck from the cervical aponeurosis, in the anterior part from the sheath of the vessels, at the sides from the intermuscular connective Fig. 294. — Fibroma of the Internal Oblique Muscle of THE Abdomen in a Female Patient T"m;NTY Years of Age (Natural Size). FIBROMAS 791 tissnos. Thoy may tako their origin from tlio periosteum of the ver- tebra' ami from the dura mater of the cervical pari of llie spinal coi-d (de Quervain). V. Fibromas of the periosteum are most eommoii upon the maxilhi and mandible and at the base of the skull. They are found almost always in young people and very rarely develop on other bonas. They belong to the hard form of fibromas, and often contain many large vessels, fre(iuently cavernous tissue. Occasionally they contain bone, as they de- velop from periosteum. Epulidcs. — Fibromas of the jaw, together with different forms of sarcomas, form part of the clinical group of tumors known as epulidcs (epulis, from iiri, meaning upon, and ovAis, meaning gum), therefore those tumors which are situated upon the gums. Developing from the periosteum of the alveolar processes, they grow between the teeth as small nodules covered with mucous membrane. They give rise to symp- toms only when they have attained considerable size or ulcerate and Fig. 295. — FiBRors Nasopharync.eal Polyp which has Invaded the Antrum of HiGHMORE. bleed. Lobulated and round forms of periosteal fibromas occur upon other parts of the jaw, especially upon the upper. Central fibromas are most eonnnon in the jaw bones, developing from the connective tis- sue of the bone marroAv, from the blood ve.'-'sels or nerves, perhaps also from displaced tooth-buds (Blauel). The bone gradually undergoes a 792 DIFFERENT VARIETIES OF TUMORS pressure atrophy and becomes expanded as these tumors grow. Finally they may rupture through the thin shell of bone covering them. A tumor of the upper jaw may then grow into the antrum of Highmore. Fihromas of the Vault of Pharynx. — The hard fibromas which are found in the vault of the pharynx and develop from the periosteum of the basilar part of the occipital and adjacent bones are known as fibrous nasopharyngeal polypi. They are covered by the epithelium of the epipharynx and grow in the directions in which there is the least resistance. These tumors are most common in the male sex be- tween the fifteenth and twenty -fifth years. First they occlude the pos- terior nares. After they have filled the nasopharyngeal space, they ex- tend into the pterygopalatine fossa. The surrounding bone undergoes a pressure atrophy, so that finally tumor masses invade the acces- sory sinusas of the nose, the sphe- noidal sinus, and the skull cavity (Figs. 295 and 296 j. If the tu- mor ulcerates, severe hgemorrhages from the fairly large vessels may occur. These tumors are not infrequently mistaken for malignant tumors which develop from the base of the skull or upper jaw and extend in much the same way. It is often necessary to jjerform a preliminary operation (temporary resection of the upper jaw) in order to render these tumors accessible, so that a radical removal may be performed and recurrences prevented. VI. Of the glandular organs, the breast is the most frequent seat of fibromas. Fibromas occurring in this organ frequently contain glandular elements (vide Adenoma). Part of the fibromas, fibroade- nomas, and fibrolipomas occurring in the kidney are the r&sult of de- velopmental disturbances. These tumors are most frequently situated in the pyramids, enclosing renal tubules, at the hihis, and beneath the capsule, and may attain considerable size. VII. Fibromas of the nerves (fibromata nervorum), or less correctly speaking, neurofibromas, are fairly common tumors. They develop from the connective tissue, the ends and perineurium of nerves, and are traversed by nerve fibers which have been separated by the growths but Fig. 296. — The S-vnie TriiOE Shotttntg Ix- VASIOX OF THE SkX.'LL CA-vaXY. FIBROMAS 793 have not ])r()liferate(l. I'sually tlirsc tiuiiors are multiple, often l)eing present in large numbers. They develop most frecjuently upon the delicate cutaneous nerves. Their relation to soft fibromas of the skin and elephantiasis nervorum has already been discussed {vide Fibromas of the Skin, p. 781). Fibromas developing upon the larger nerves and nerve trunks, in- cluding the sympathetic nerves and the roots of cranial and spinal nerves, lead to the formation of flasklike or spindle-shaped swellings; sometimes to the formation of large tumors or nodular thickenings which may be distributed over a considerable extent of the nerves involved. The plexiform neuroma is a nodular, fibrous degeneration of a par- ticular nerve, usually of one of the subcutaneous nerves. As it develops, the nerve involved becomes transformed into a thickened, nodular, Avreathlike, twisted, tortuous, circumscribed mass. Plexiform neuromas may also develop in the terminal filaments of cutaneous nerves, and often lie concealed beneath soft fibromas of the skin and lobulated growths occurring in elephantiasis. The plexiform neuroma, if not present at birth, begins to develop in early childhood. Tumors of the larger nerves grow slowly and ap- pear in middle age. Even these larger tu- mors have some rela- tion to congenital changes in the nerves, ^ for they are often ap- parently merely a late manifestation of those ^ changes which are comprised under the term elephantiasis nervorum. The cause of the formation of fibromas of the nerves, likewise of all the forms of ele- phantiasis of nerves, must be sought in some disturbance of normal development as a result of which, perhaps, there is an irregu- lar distribution and arrangement of the connective-tissue elements of the nerves permitting of independent growth (Ribbert). The following facts may be cited to support this theory: (1) These tumors develop in early childhood; (2) they are multiple; (3) an heredi- 51 Fig. 297. — Nerves Dissected Free from a Subcutaneous Plexiform Neuroma Removed from the Occipital Re- gion OF A Child Four Years Old. 794 DIFFERENT VARIETIES OP TUMORS tary history may be elicited or a congenital predisposition shown as different forms of elephantiasis nervorum (either neurofibromas, soft fibromas of the skin, soft warts or pigmented naevi) may be demon- strated in different members of the same family. The clinical significance of fibromas of nerves varies. The fibroma molluseum, and even fibromas of larger nerves, may give rise to no symptoms. The most frequent symptom is pain, which radiates along the nerve from the tumor toward the periphery. It is increased by move- ments and pressure. However, slight functional disturbances, very rarely sensory and motor paralyses, may develop. Frequently these tumors compress adjacent nerves or parts of the brain and spinal cord (fibromas at the point of origin of cranial and spinal nerves). Isolated fibromas of nerves do not recur after extirpation. Some- times there is a tendency to progressive development of tumors upon all the nerves of the body (von Blingner). In twelve per cent of the cases of general fibromastosis of the nerves, sarcomas (fibrosarcoma and myxosarcoma) develop from one of the nodules, which, according to Garre, should be called secondary malignant neuromas to dis- tinguish them from the pri- mary sarcomas developing in nerves. The diagnosis of fibro- mas of nerve is not diffi- cult when they are multiple and the larger nerves are involved. Where there are isolated nodules situated upon deep nerves, one is often in doubt whether the enlargement is a lipoma, a lymph gland, etc., which is pressing upon an adjacent nerve and giving rise to a radiating pain. Other changes, such as light- brown, flat, pigmented areas, which may be local- ized or distributed over the entire surface of the body, are frequently associated with these fibromas and are of considerable importance as a diagnostic aid. Fig. 298. — Plexiform Neuroma of the Subcittane- ous Nerves op the Thorax in a Boy Eight Years OF Age. (The tumor, about as large as a small plate, was flat and covered by normal skin, which, however, was somewliat adherent to it. Surface of tumor somewhat nodular. Pain upon pressure. Tumor well encapsulated and not attached to underlying structures. Many flat, pigmented moles in the skin adjacent to the tumor.) FIBROMAS 795 Treatment. — The treatment consists of r§ion of the part of the nerve involved, when the growth is limited enough to render this possible. In plexiform neuromas tlie skin covering them, which has undergone an t'lephantiasislike hyper- plasia, should also be re- moved. Recurrences de- velop from thickened nerves which are left be- hind. VIII. Fibromas of the peritoneum develop from tlie subserous tissue of the mesentery, mesocolon, and omentum, and from the r e t r o p e r i t o n e a 1 tissues. They grow slowly, form- ing hard, somewhat nod- ular tumors, and produce different symptoms de- pending upon their rela- tion to the viscera. These tumors often con- tract firm adliesions with the intestines or become so closely related to the blood vessels of the intestines that it is often necassary to resect some length of the intes- tinal loops in removing them. LiTEKATURE. — Adrain. Ueber Neiirofibromatose und ihre Komplikation. Beitr. z. klin. Chir., Bd. 31, 1901, p. 1. — v. Bergmann. Demonstration eines vor 17 Jahren wegen eines grossen Keloides operierten Patienten. Verhandl. d. Berl. med. Gesellsch., 1903, I, p. 206.— F. Brum. Das Rankenneurom. Beitr. z. klin. Chir., Bd. 8, 1892, p. 1. — V. Biingner. Ueber allgem. mult. Neurofibrome des periph. Nervensystems und Sympathikus. Chir. Kongr.-Verhandl., 1897, II, p. 298. — Courvoisier. Die Xeurome. Eine klin. Monographie. Basel, 1886. — v. Esmarch and Kulenkampff. Die elephant iastischen Formen. Hamburg, 1885. — Garre. Ueber sek. malign. Neurome. Beitr. z. klin. Chir., Bd. 9, 1892. p. 465. — Kiimmel. Nasenrachenfibrome. Im Handb. d. prakt. Chir., Bd. 1, 2. Aufl. — Lam. Leontiasis mit generalisiertem Fibr. moll. Deutsche Zeitschr. f. Chir., Bd. 58, 1901, p. 580: — Experim. Beitrage zur Geschwulst- lehre. Deutsche med. Wochenschr., 1899, p. 313. — Ledderhose. Die chir. Erkrank- iingen der Bauchdecken. Deutsche Chir., 1890. — Lewaiulowski. Ueber Thiosinamin vmd seine Anwendung. Therap. d. Gegenwart. 1903. — Lexer. Operation eines Mesen- terialfibromes mit ausgedehnter Resektion des Dinmdarmes. Berlin klin. Wochenschr., 1900, No. 1. — Olshausen. Ueber Bauchwandtumeren, spez. iib. Desmoide. Zeitschr. f. Geburtsh. u. Gynak., Bd. 41, 1899, p. 271. — Pfeijfer Die Desmoide der Bauchdecken Fig. 299. — Large Fibuoma (25 cm. ix Diameter) Removed from the Mesentery of a Male Pa- tient Forty-one Years of Age. During the op- eration it was necessary to resect about two feet of the small intestine which were adherent to the tumor. (Lexer.) 796 DIFFERENT VARIETIES OF TUMORS u. ihre Prognose. Beitr. z. klin. Chir., Bd. 44, 1904, p. 334. — de Quervain. Ueber die Fibrome des Halses. Arch. f. klin. Chir., Bd. 58, 1899, p. 1. — v. Recklinghausen. Ueber die multiplen Fibrome der Haut und ihre Beziehung zu der mult. Neuromen. Berlin, 1882. — Soldan. Ueber die Beziehungen der Pigmentmaler zur Neurofibromatose. Arch. f. khn. Chir., Bd. 59, p. 261, 1899.— TFiZms. Zur Pathogenese des Keloid. Beitr. z. klin. Chir., Bd. 23, 1899, p. 149. CHAPT^^R II LIPOMAS Lipomas are tumors in which is reproduced the structure of normal fatty tissue, and they are therefore composed of more or less lobulated, yellowish masses. They may be single or multiple, and in the latter case they are often symmetrically placed. Lipomas are decidedly benign and do not recur after complete extirpation. They are rarely congenital, developing most frequently in individuals from thirty to fifty years of age and in the female sex. Macroscopic and Microscopic Appearance. — Lipomas, excepting the small, multiple, symmetrical forms which sometimes develop within a few months, grow very slowly. They develop from large cells which in earlier life are fat free, and become transformed into fat cells by the deposition and coalescence of fat droplets within their cytoplasm. Usu- ally the cells found in a lipoma are larger than those occurring in normal fatty tissue; Groups of these fat cells, held together by a capil- lary network, form a small fat lobule which, using a favorite compari- son, bears the same relation to its nutrient artery that grapes do to the lateral branches of the stem. The lobules, however, are not separate and distinct as in normal fatty tissue, but are united by connective-tissue trabecular into large lobes and fingerlike processes. The surface of the tumor is always provided with a thin connective-tissue capsule, sending trabeeulae into deep furrows between the different lobes, which are often the size of a hen's egg. Even when non-lobulated lipomas, which are rare, are cross-sectioned, thin connective-tissue tral^eculae may be seen passing from the capsule into the depths of the tumor. The capsule of a lipoma is usually but loosely attached to the sur- rounding tissue. If, however, the tumor is exposed to irritation (rub- bing of the clothing, pressure during work, etc.), the capsule becomes thickened and contracts adhesions with the skin and underlying tissues. The capsule then becomes fused with the subcutaneous fat and extir- pation is rendered difficult. Independent of General Nutrition. — A lipoma does not decrease in size when a patient emaciates (Virchow). The complete independence of the growth is best shown by this fact. LIPOMAS 797 Blood Supply. — The few and relatively small vessels supplying a lipoma develop from the subjacent tissues and pass into the tumor with the interlobular eoiHiective tissue. Fre- quently but two or three arteries are found even ill the hirL;(^ lii)()iiias. Method of Growth. — The sur round in Fig. 301. — Section of a Subcutaneous Fibrolipo.m.a. of the Gluteal Region. The skin and a thin layer of subcutaneous fat pass over the surface of the encapsulated tumor. through the femoral and inguinal canals or the linea alba and prepares the Avav for hernia. 798 DIFFERENT VARIETIES OF TUMORS A lipoma, which is usually soft, may become hard if the fibrous tissue is increased in amount (soft and hard lipomas). Depending upon whether the fatty or fibrous tissue predominates, one speaks of a lipo- fibroma or a fibrolipoma. If there is a marked development of blood vessels (proliferation and dilatation), the tumor is spoken of as an angiolipoma. If the fibrous tissue has become transformed into mucoid tissue, or if there are smooth muscle fibers in the tumor, it is described as a myxoUpoma or myolipoma. Regressive Changes. — Calcification, occasionally ossification of the septa, oedematous changes and liquefaction resulting in the formation of oillike masses (oil cysts) occur, especially in the larger tumors. Nutritional disturb- ances resulting in ne- crosis of part of the tumor and the skin covering it, with sub- sequent erosion of ves- sels and putrefactive changes may also de- velop in the larger growths. Origin and Causes of Lipoma. — ]\Iany li- pomas, especially those occurring as hetero- plastic tumors in vis- cera and tissue nor- mally containing no fat, and as congenital tumors situated over defects in the skull and vertebrae (enceph- alocele, spina bifida occulta) , develop from displaced germinal tis- sues. A hereditary influence has been observed in rare eases only (Blasehko). Grosch, Kottnitz, Payr, and others have suggested that the multiple, symmetrical lipomas are of trophoneurotic origin, and the first has attempted to show that certain tumors are prone to develop upon certain parts of the body because of anatomical conditions and structural peculiarities. After an exhaustive study concerning the dis- FiG. 302. — Subcutaneous Lipoma of the Arm. LIPOMAS 799 tribiitidii of lipomas upon the sia-faco ol" the body, (Irosch came to the i'oui'liisi(»n that lipomas arc most pommoii in those areas where there are the fewest glands, and least eommoii wheiv the ^daiuls are most nu- merous, that therefore lipomas are most eonnuon in those areas where the least fat is secreted. It has been freipiently su|j:- i^ested that there is a causal re- lationship between a sinirlo ti-auma and the development of lipomas. This re- lationship has not l)een demonstrated. It eaiinot be de- nied, however, that long-continued irri- tation, as, for exam- ple, when the part of the body is exposed to frequent pressure, may be an etiological factor. Most Common Sites for the Development of Lipomas. — According to the statistics of Grosch and Stoll, lipomas de- velop most frequently in the subcutaneous connective tissues of the shoulder and back. They are less common upon the front and back of the neck, in the breast, and in the gluteal region, and are liut rarely encountered upon the face, scalp, scrotum, and labia. Subcutaneous Lipoma. — Subcutaneous lipomas sometimes appear as small, flat, at other times as nodular, lobulated growths, the size of a fist or a man's head. Sometimes a lipoma becomes so heavy during its later growth that its broad base is drawn out, forming a relatively narrow pedicle (lipoma pendulum). An wdema then often develops as the result of stasis, and when the tumor is incised fluid may be pressed out as from a wet sponge. The skin covering a lipoma is of normal appearance, movable, and may be raised in folds. It may feel thick or thin. dei)ending upon the amount of subcutaneous fat. If the skin is made tense, the shallow depressions between the difl'ereut lobules of the tumor may be distinctly seen, especially if the tumor is immediately adjacent to the skin. Fig. 303. -Subcutaneous Iuhma ix the Re- GIOX OF THE Hip. soo DIFFERENT VARIETIES OF TUMORS A lipoma may cause pain by pressure upon nerves. Multiple, symmet- rical lipomas are frequently painful because of their relation to the con- nective tissues of the cutaneous nerves. Lipomas may be so situated or become so large that they cause considerable discomfort. Usually, however, they give rise to but few symptoms, and it is not at all uncommon to see a patient who has carried an enormous lipoma about for a number of years. Fig. 305.— -Stjbctttaneous Lipoma which has DEEN Growing Gradually for Fifteen Yejars. The skin covering the tumor is very OBdematous. Fig. 304. — Subcutaneous and Partly Intermuscular Lipoma of the Back. Fascial and Aponeurotic Lipomas. — As compared with subcutaneous lipomas, those de- veloping within fascifB and apo- neuroses and intermuscular con- nective tissue are not common. These different forms are prone to develop in particular regions of the body, and a knowledge of the most common sites aids considerably in making a diag- nosis. The small, round, rarely lob- ulated lipomas occurring about the head are most common in LIPOMAS 801 tlie frontal region, and are often refern-d to as pericranial lipomas. They lie beneath the aponeurosis or muscular fibers of the occipito- frontalis, and are (juite firmly attached to the latter. They may pro- duce a pressure atrophy of the periosteum and external plate of the subjacent bone. In this way a depression is made in the bone in which they lie, and they resemble closely in some cases dermoid cysts (von Bergmann). Lipomas in the palm of the hand develop most frcfpiently be- neath the palmar fascia. They then extend between the metacarpal bones to reach the dor- sal surface of the hand (Steinheil). Occasion- ally lipomas develop upon the fingers, espe- cially upon the palmar surface, being either subcutaneous or at- tached to the bone. Subfascial lipomas also occur in the neck, back, and abdominal wall. They send off large processes between the muscles. Intermus- cular lipomas may be encountered in the back, beneath the pec- toralis major, upon the extremities, and in the abdominal wall. Some of the lipomas of the cheek, developing from the sucking pad, and of the tongue are inter- muscular forms ; others develop from the submucosa. Lipomas Developing within the Abdominal Cavity. — The abdominal cavity is another but not frequent site for the development of lipomas. A portion of omentum which has been retained in a hernial sac for a number of years may proliferate to form a lipomalike mass (omental lipoma). The appendices epiploica* at times become so large that they resemble a tumor, and they may become detached, forming free bodies in the peritoneal ca\nty. Small submucous lipomas occur in the stom- ach. The largest fatty tumors develop from the retroperitoneal tissues from which growths weighing from twenty to fifty pounds have been removed, sometimes successfully (statistics of Heinricius). Lipomas 306 802 DIFFERENT VARIETIES OF TUMORS of the mesentery are situated either at its root or along its intestinal attachment. Subserous lipomas, developing from the properitoneal fat and extending into the femoral and inguinal canals and through the foramina in the linea alba, dilate these openings and draw a funnel- shaped process of peritoneum after them. [Rose and Linhart have emphasized the relationship between hernia and subserous lipomas. Un- doubtedly they are an etiological factor in a number of cases. They dilate the canal and draw the peritoneum, which forms the sac after them. Often in operating for a small hernia of the linea alba in the early stages a small subserous lipoma will be found, unassociated as yet with any definite sac] Lipomas of the Different Viscera. — Lipomas are rare in the different viscera, being most common in the kidney. The small tumors which develop in the latter never become larger than a walnut, and are usu- ally situated in the cortex. They often contain smooth muscle fibers. These tumors are very rare in other organs, such as the lungs, liver, heart, uterus, and breast. Small lipomas developing from the pia mater are occasionally found at the base of the brain. Lipoma Arhorescens. — Lipoma arborescens is a particular form re- sulting from the proliferation of synovial villi and associated with the formation of clublike processes. This form of lipoma is associated with different chronic inflammatory processes in the joints, especially of the knee joint, where it was first observed by Joh. Miiller. It is occasionally found in chronically inflamed tendon sheaths, especially in those of the hand (Stieda, Schmolk, Haeckel). It should be mentioned that lipomas occasionally develop in the orbit, spermatic cord, tongue, and retromammary tissues. Diagnosis. — The diagnosis of superficial lipomas is rarely difficult. It is based upon the position of the tumor, its slow growth and well- defined boundaries, mobility, lobulated structure, pseudo-fluctuation and consistency, which is sometimes soft, sometimes hard. Usually the painful lipomas are symmetrical, flat, and somewhat nodular, and may be easily differentiated from the round, spindle-shaped fibromas devel- oping upon the nerves. If the surface of the tumor cannot be pal- pated and its boundaries cannot be definitely defined, the diagnosis of a benign tumor may be made, but frequently nothing definite can be said concerning the variety. In doubtful cases, cystic formations (der- moids, echinococcus cysts, hygromas) and tuberculous abscesses may be excluded by aspiration. A lipoma of the forehead differs from a peri- osteal gumma by being inore mobile. Large lipomas of the peritoneal cavity may be regarded, because of their hardness, as fibromas or fibro- sarcomas, the soft form as an ascites or an encapsulated tuberculous abscess. It is often difftcult to differentiate between a retromammary LIPOMAS 803 iipouia and a lipoma within the Invast ])r(tp('i', hclwccn a lii)oina l)o malli the pai'otid ^land and one witliin it. Technic of Removal. — Tsually llie ronoral of a fnlli/ honor is not dirticult. ri'hc tumor sliould be seized between tlie tliuiiib and index I Fig. 307. — 1)iifisk Symmkihu .\i, Lii'om.\s. finger of the left hand and the skin made tense. An incision is then made down to the capsule and often the tumor fairly pops out. If any difficulty is encountered the tumor may be seized with sharp hooks or retractors and pulled from its bed, the dissection being completed with 804 DIFFERENT VARIETIES OF TUMORS the fingers, thick septa being divided with scissors.] In the excision of large tumors a sufficient portion of the thinned or oedematous skin covering the tumor should also be removed. Diffuse Lipomas. — Clinically, a diffuse lijjoma is differentiated from the circumscribed, encapsulated form. These diffuse lipomas may be congenital, being associated with partial giant growths of the extremi- ties, or may occur as multiple, symmetrical growths in middle-aged people. They surround the neck as broad nodular growths (the so- called fatty neck of Madelung) and occur upon the trunk and extremi- ties as transverse and oblique masses (Fig. 307). These diffuse lipomas, described by Billroth as lipomatosis regionaria, are not tumors strictly speaking, but are merely localized accumulations of fat, secondary to an excessive development of fat in the individual. [They usually develop in people who drink large quantities of beer and eat to excess, and differ from true lipomas in that they decrease in size when beer is withdrawn and the patient is compelled to take exer- cise.] They bear the same relation to polysarcia and obesity that lobu- lated fibroma formation does to elephantiasis (Virchow) . The subcutaneous fat is chiefly involved by these growths, but they may extend deeper, passing in betw^een the muscles. Sometimes it is necessary to remove these growths, especially when they occur in the neck, as they may press upon the trachea and interfere with breathing. A complete operation can never be performed, however, as the growths are not encapsulated. The tumors do not recur even after incomplete removal. Repair of the sutured wound is often delayed by the discharge of a serous fluid, containing fat, which continues for some time. This fluid may even seep out through the stitchholes. Literature. — Blaschko. Erbliche Lipombildung. Virchows Arch., Bd. 124, 1891, p. 175. — Ehrmann. Ueber multiple symmetrische Xanthelasmen und Lipome. Beitr. z. klin. Chir., Bd. 4, 1889, p. 341. — Grosch. Studien iiber das Lipom. Deutsche Zeitschr. f. Chir., Bd. 26, 1887, p. 397. — Haeckel. Lipoma arborescens der Sehnenscheiden. Zentralbl. f. Chir., 1888, p. 297. — Heinricius. Ueber retroperitoneale Lipome. Deutsche Zeitschr. f. Chir., Bd. 56, 1900, p. 579 and Arch f. klin. Chir., Bd. 72, 1904, p. 172.— Kottnitz. LTeber symmetrisches Auftreten von Lipomen. Deutsche Zeitschr. f. Chir., Bd. 38, 1894, p. 75. — Lunger. Zur Kasuistik der multiplen symmetrischen Lii^ome. Arch. f. klin. Chir., Bd. 46, 1893, p. Sm.— Madelung. Ueber denn Fetthals. Arch. f. klin. Chir., Bd. 37, 1888, p. 106; — Exstirpation eines vom Mesenterium ausgehenden Lipoma oedematosum myxomatodes mit partieller Resektion des Diinndarmes. Berl. klin. Wochenschrift, 1881, p. 75. — Hellmut Muller. Ueber die Lipome und lipomatosen Mischgeschwulste der Niere. Virchows Arch., Bd. 145, 1896, p. 339. — Payr. Beitr. z. Lehre von den multiplen und symmetrischen Lipomen. Wien. klin. Wochenschr., 1895, p. 733.— Preyss. Ueber die Operation der diffusen Lipome des Halses. Beitr. z. klin. Chir., Bd. 22, 1898, p. 469.— Schmolk. Zwei Falle von Lipoma arborescens genu. Deutsche Zeitschr. f. Chir., Bd. 23, 1886, p. 273.— Steinheil. Ueber Lipome der Hand CHONDROMAS 805 und Finger. Beitr. z. klin. Chir., Bd. 7, 18U1, p. 60.5. — Stiedn. Lipoma arborescens. Beitr. z. klin. Chir., Bd. 16, 1896, p. 285.— Stall. Beitr. z. Kasuistik der Lipome. Beitr. z. klin. Chir., Bd. 8, 1892, p. 597. CHAPTER III CHONDROMAS Tumors "which are composed of cartilage are called chondromas. Those chondromas occurring in parts which normally contain no carti- lage were called enchondromas by Virchow to differentiate them from ecchondromas, which develop in parts normally containing cartilage. Enchondroma is therefore synonymous with heterologous chondroma. Hyperplastic cartilaginous growths are known as ecchondroses, but it is often impossible to make a sharp distinction between tumorlike and hyperplastic growths of cartilage. Appearance and Histolo^. — Chondromas are nodular, soft, or hard tumors of opalescent appearance resembling normal cartilage. They are often multiple and may appear in great numbers. Usually they Fig. 308. — Multiple Enchondromas op THE Bones of the Hand. Fig. 309. — Enchoxdrom.v of the Thumb. develop slowly, but sometimes begin to grow rapidly and become quite large. These tumors are most connnon in young people. Histologically they differ from normal cartilage, as the cells fre- quently do not possess a capsule, are less regular in shape, being oval, 806 DIFFERENT VARIETIES OF TUMORS roimd, fusiform, and stellate, and are not arranged according to any definite plan. The ground substance consists of hyaline, elastic, or fibrous cartilage. The different nodules composing the tumor are held together by vascular connective tissue, which may even penetrate into the cartilage. Fibrous, myxomatous, osteal, and angiomatous tissue may develop at the same time that the cartilage does, and mixed Fig. 310. — Roentgen-ray Picture of A Cortical, Enchondroma. Fig. 311. — Enchondroma of the Second Meta- carpal Bone as It Appears Externally and UPON Section. tumors, such as fibrochondromas, chondromyxomas, and osteochondromas are formed. As a result of the excessive proliferation of the cartilage cells the tumor may become transformed into a sarcoma (chondro-sar- coma, or if bone is also present into an osteochondro-sarcoma). Method of Growth. — The growth of chondromas is sometimes expan- sive, sometimes infiltrating. Depending upon the character of their growth, these tumors are sometimes benign, sometimes malignant. If the tumor is surrounded by a layer of tissue resembling perichondrium, it merely displaces the neighboring structures as it grows. In the soft, cellular forms a capsule is frequently wanting, and then the cartilage cells grow into the spaces of the adjacent tissues, invade the veins and lymphatic vessels, and are carried to the lungs and lymphatic nodes. A continuous growth extending from a chondroma of the vertebra through the large veins to the heart has been observed (Ernst). Changes Occurring in Chondromas. — Ossification (ossifying chon- droma) is the most important of the changes which a chondroma may undergo. It is preceded by vascularization, as in normal bone forma- CHONDROMAS 807 tion, and finally the cai'tilayinons tunioi- is transfornicd into a ])()ny tumor, tlu' only indication of its carlilaginons oi'i^in hcin^- a. thin cover- ing- oi* cartiiaue. JiCf/nssnw changrs, sucli as calcification, myxomatous soi'tcuinj^r, and cyst formaticm, are conniion in chondromas. Tlu^y are usually sec- ondary to nutritional changes in tlu; tumor tissue. If myxomatous softeninii; occurs, a. choiidfoma vnj.ronKihxIcs develops; if cyst forma- tion a choudvoma cusHcidh. Occasionally ulc(M'a1iou of the skin, the result of ])ressure, is observ(>d. Putrefaction of the tumor may follow ulceration. Most Common Sites of Chondromas. — Chondromas are most connnon in the bony system. Enchondromas developing in bone may be congenital; f re(iuently they develop during the first two decades of life. They occur most frequently upon the phalanges, metacarpal and metatarsal bones as single or nmlti})le tumors. A favorite locality for enchondromas is the fin- gers, where they form characteristic, shapeless, nodular masses. These tu- mors develop more frequently from the metaphysis than from the diaphysis (Nasse), from the interior than from the surface of bone. The bone sur- rounding one of these tumors under- goes pressure atrophy and a cortical enchondroma produces deep depres- sions in the surface of the bone in- volved, while a central enchondroma gradually destroys the bone as it grows, so that finally it is covered only by a thin shell of bone or periosteum. In the bone which is not destroyed small islands of cartilage may be found. In the long, hollow bones the metaphysis is the favorite site for the de- velopment of cortical and intraostcal chondromas. The phalanges when involved become considerably enlai'ged. These tumors may interfere with the growth of long bones, and when involved they become shortened and deformed, changes resembling closely those associated with rickets. In rare eases chondromas develop upon one side of the body only, and then the growth changes are unilateral (Oilier, A. Wettek). A central enchondroma may produce such an osteoporosis that a spontaneous fracture occurs. If the tmnor has previously given rise to no symp- toms and caused no enlargement of bone, it is often difficult to deter- Fi(i. 312. — Cystic Enchondroma of the ScAI'lI.A OF AN AnUI.T. 808 DIFFERENT VARIETIES OF TUMORS mine whether the fraetnre was secondary to the tumor or whether the tumor developed in the callus. Cystic softening of the central tumors, which are usually fibrochondromas, occasionally follows an injury and leads to the formation of large multilocular or coalescent cysts, the contents of which consist of a bro^vnish fluid containing disintegrated ^ blood and cholesterin. "' ^ Often some of the orig- /' inal tumor tissue is found in these cysts, and the diagnosis as to their na- ture may be based upon this finding (VirchoAV, Schlange, Fritz Konig, and others). If no tu- mor tissue is present, islands of hyaline car- tilage at some distance from the epiphyseal car- tilage, and cartilaginous exostoses in the walls of the cysts indicate their origin and enable one to distinguish between them and the cysts (p. 749) occurring in osteitis de- formans (Lexer). Of the bones of the trunk those of the pelvis and the scapula are most often involved, being fre- quently the site for the development of very large tumors. Chondromas develop but rarely upon the ribs and skull bones, only occasionally upon the vertebrae, clavicle, sternum, and hyoid bone. In many cases multiple cartilaginous exostoses are associated with enchondromas (Virchow, von Recklinghausen, Nasse, Lawen (Figs. 310 and 316). Enchondromas are the result of some interference with normal bone formation, consisting either of a defect in the skeletal anlage, or of pathological changes occurring in bone during intra- or extrauterine life. The cause of the changes in normal bone formation is unknown. It is to be regarded as certain, however, that chondromas develop from germinal cartilaginous tissue which has been displaced from the epiphys- eal zone (Virchow) into the bone marrow of the diaphysis. It is prob- FiG. 313. — Cystic Enchondroma of the Upper Met- APHYSIS OF THE HuMERUS OF A ChILD NiNE YeARS OF Age, Healed by Curetting Out the Tumor Tissue. Bony trabeculae are still pre.sent between the nodules and cysts of the tumor. CHONDROMAS 809 ahk' that a inimbcr of those tumors oi'inosis of cartilaj;iiious exostoses is based upon their position and relation to the bone, their slow growth, luu'dness, and well-de(ined borders. The clinical ])icture of ]nulti])le cai'tilai;inous ex- ostoses is characteristic, and the diaj^nosis, as a. rule, should be made without difficulties. Sinule tumors nuiy be confused with periosteal fibronuis and chondromas unl(>ss on(» nud\es use of X-ray i)ictures. Fibrous Exostoses. — Frc^piently fibrous exostoses cannot be ditK'er- entiated from cii-cumscribed growths of bone not at all related to true tumors etiologically. Held lion to Inflammation and Trauma. — luHanunation and traumatism often stimu- late the periosteum to the for- mation of lai-ge, rapidly grow- ing, bony growths (llonsell). Sometimes tumorlike processes develop from the callus follow- ing a fracture and extend be- tween the neighboring muscles, developing apparently from separated and displaced frag- ments of periosteum. Other ex- ostoses develop where circum- scribed areas of periosteum are subjected to constant pressure (subungual exostoses of the great toe, exostoses upon inner side of great toe in hallux valgus), and still others de- velop where tendons or mus- cles are inserted. They appear as roughened areas, bony pro- jections and crests. Of the bones of the skull, the frontal and parietal are most frequently involved, the exostoses occurring as single or multi])le, nipple or buttonlike, spinous and pedunculated tumors cov- ered by a thin layer of periosteum. They may be situated upon the \ \ Fio. 319. — Carth.aginous Exostosis ox the Mk.dial Sidk of the Uppkr Metaphysis of THE TiHiA IN Genu Vai-gum Rhachiticum. 816 DIFFERENT VARIETIES OF TUMORS internal or external plate of these bones or upon both plates, opposite each other. The exostoses rarely become larger than a walnut. One of the larger forms is represented in Fig. 322. Only a part of the exostoses of the orbit and the different cavities of the face develop from periosteum, as the osteomas of the frontal and sphenoidal sinus develop from foetal rests displaced from the cartilagi- nous anlage of the ethmoid (Arnold). If these tumors fill the cavity Fig. 320. — Multii'll; Cahtilaginous Exostoses of the Metaphysis of the Femur and Tibia with a Chondroma of the Upper Metaphysis of the Fibula on the Right Side. in which they lie, they are called "' encapsulated hony bodies " (Cru- veilhier). If, as a result of suppuration and necrosis, their pedicle is destroyed and the connection with the wall of the cavity is lost, they are called " dead osteomas " (Tillmanns). These exostoses grow slowly, and gradually produce a pressure atrophy of the walls of the cavity in which they lie, extending to neighboring cavities or the surface; for OSTEOMAS 817 example, from the fi-ontnl sinus to the roi-clicjul or into the orl^it, from the sphenoidal simis into the (u-anial cavity. Osteomas of the Jaws. — In the .jaws, not ineludino- tlie eneapsulated osteomas of Ihe antrum of IIi;^hmore, there are found ])erios1cal nodular exostoses Avhieli often attain eonsidei*- a])le size and central tumors surround- in^' tooth buds. Oidy a ])art of the latter are pure osteomas; the i-emain- der are odontomas, usually composed of dentine and developing from nor- mal or displaced teeth. Sifniptinns. — The symptoms dep(Mid U[)on the position of the tumor and the direction in Avliich it extends. Growiuij from the under surface of the skull or from the vertebra\ they may give ri.se to serious symptoms from irritation or compression of the brain and spinal cord. A tumor developing in the frontal siiuis, by occluding the communication be- tween the accessory sinus and the nose, may lead to sinus inflamma- FiG. 321. — Subungual Exostosis. Fig. 322. — Enormous Exostosis of the Temporal Bone, Part op which Projects into THE Skull Cavity. Sclerosis of the bones of the skull, (vou ^'olkmall^.) 818 DIFFERENT VARIETIES OF TUMORS tion. Tumors may also be so situated as to press upon important nerves (optic and trigeminal) or to cause ugly deformities of the face. Diag)iosis.—Th.e diagnosis, because of the slow, painless growth and the circumscribed form of the tumor, or of the symmetrical expansion of the bone in osteomas of the accessory sinuses, is usually not difficult. In the beginning they may resemble clinically central sarcomas. When an empyema of the frontal or maxillary sinuses develops second- ary to the tumor, the inflammatory symptoms may be most prominent. The deep shadow which an osteoma casts in X-ray pictures aids, in doubtful cases, in making the diagnosis. The bony growths occurring in leontiasis ossea do not have sharp, distinct outlines. Treatment. — The treatment consists of complete removal of the oste- oma when possible. Recurrences may develop from pieces of the tumor which are left behind. Myelogenous Enostoses. — True (myelogenous) enostoses of the long, hollow bones are exceedingly uncommon (Virchow, Bennecke). Those developing in the skull bones from the diploe and extending outward and inward cannot be differentiated from exostoses which develop on the surface and later perforate the bones (von Bergmann). Bony Growths in Soft Tissues. — Bony growths also occur in the soft tissues. Even in these cases it is often difficult to distinguish between osteomas proper and inflammatory hyperplastic growths of connective tissue which have secondarily undergone calcification and ossification. Part of the small nodular osteomas of the brain, of the flat growths in the dura mater (falx cerebri), of the circumscribed foci occurring in the lungs, of the multiple small nodules and cords upon the inner surface of the trachea, and of the bony deposits in the cavernous tissue of the penis (penis bones) develop from displaced cartilaginous rests. This is especially true of the osteomas of the lung and trachea which develop from the cartilaginous anlage of the respiratory passages. Myositis Ossificans. — The ossification of muscle gives rise to an im- portant and peculiar clinical picture. Although the disease may be conveniently discussed in this chapter, the pathological changes are not exactly similar to those resulting in the formation of osteomas in soft tissues. This disease may be progressive, aff'ecting in succession a number of different muscles (myositis ossificans progressiva), or limited to one muscle {myositis ossificans cimcumscripta) , the changes following a trauma. In myositis ossificans progressiva a number of different muscles gradually change into bone. In some of the cases the changes begin in the periosteum (Virchow) leading to the formation of exostoses at the point of attachment of the muscle, and then extend to the connective OSTEOMAS 819 tissue of the muscles and to the fascia. In other cases the disease begins in the bellies of the muscles (Lexer, von Zoege-Manteuffel, Stempel) and extends in both directions to their points of attachment. The new bone which is formed may become attached to the bones at the point of attachment of the muscles or may remain free. Histological CJiangcs in Myosiiis Ossificans. — Histological examina- tions made in the early stages of the disease (Lexer, Stempel) have revealed germinal tissue rich in cells which infiltrates the intermuscular con- nective tissues (perimysium externum and internum), causing a pressure atrophy of the nuiscle fibers and bundles which are replaced by a firm connective tissue or bone, repeating in its development either the periosteal or endochondral type of bone formation. In the begin- ning of the cellular growths, round-cell infiltration, a change indicative of in- flannnation, may be observed. These changes have some relation to the clinical picture, but cannot be re- garded as either the cause or the result of the process. The proliferation extends from the perimysium to the tissues sur- rounding the tendons and to the fascia?, and both become ossified. Up to the present time about fifty cases of this disease have been observed. It begins in early life, rarely after the twentieth year, and is about three times more frequent in the male than in the female. There are no data concerning heredity. Muscles Most Frequently Involved and Clinical Course. — The disease usu- ally begins in the muscles of the neck and back. Suddenly the muscles or groups of muscles involved swell and become painful. The swelling is sometimes accompanied by fever and a slight reddish or bluish discoloration of the skin covering the muscles. The pain following motion and pressure gradually subsides, and the swollen muscles, of a doughy consistency at first, become smaller and indurated. This stage has been called by Miinchmeyer the stage of connective-tissue indura- FiG. 323. — Progressive Ossifying Myositis from a Photograph Owned by Professor Helfer- ICH. 820 DIFFERENT VARIETIES OF TUMORS tion. In some cases the pathological changes do not progress farther. In the majority of cases, however, the changes progress, and corallike, scalloped cords and plates of bone develop throughout the muscle pri- marily involved and extend to adjacent muscles. These not only de- stroy the function of the muscles involved, but fix the extremities in uncomfortable and useless positions, as the newly formed bone bridges over the joints, uniting bone with bone. A number of years may intervene between attacks, in each of which new muscles are involved. Finally the entire musculature of the trunk, different muscles of the extremity, and the muscles of mastication may become ossified. The patient then becomes transformed into a motion- less mass (ossified man). Deglutition and respiration gradually become more and more difficult, and finally after a number of years the patient dies of exhaustion or of aspiration pneumonia. Cause of the Disease. — There has been a great deal of discussion as to the cause of the disease. The name myositis ossificans has been given it because of the inflammatory symptoms in the muscles at the beginning of the disease. It is well established that a very cellular germinal tissue develops in the intermuscular spaces which becomes transformed into dense connective tissue and bone. It has been sug- gested that the disease is the result of a congenital anomaly of develop- ment in the skeletal system, or, as Stempel thinks, is due to the im- perfect differentiation of the mesenchyme, as a result of which the muscles acquire the property of forming bone. In some cases mal- formations of the fingers and toes (microdactylism, anchylosis of the phalanges, absence of the terminal phalanges and muscles) have been present at the same time (Virchow, Helferich), supporting the view that the disease is a congenital anomaly of development. The diagnosis of the disease may be difficult at the beginning. Treatment. — Treatment has no influence whatever upon the course of the disease. The patient should be made as comfortable as possible, and pieces of bone which interfere with motion or render the patient uncomfortable (especially bone about the jaw interfering with masti- cation and about the joints) should be removed. Myositis Ossificans Circumscripta. — Myositis ossificans circumscripta is not a progressive lesion. It follows repeated traumatisms or a single severe injury, and remains limited to the muscle primarily involved, in w^hich histological changes (similar to those described above in myo- sitis ossificans progressiva) occur. The bony plates and cords which develop lie firmly imbedded in the connective tissues of the muscle or become fused with the bone at its points of attachment. The so-called rider's bone develops in the adductor muscles, more rarely in the pectineus and gracilis, after injuries received during OSTEOMAS 821 horseback riding; the so-called exercise bone develops in the deltoid muscle after injuries caused by the rifle coming forcibly in contact with the muscle during drill. The turner's bone, which develops in the brachialis anticus, is a rarity. The development of bone in these cases is i)robably due to some congenital anomaly in the connective tissues of the muscle, as the result of which they acquire the property of forming bone when injured or irritated. The ossification of muscle following a single trauma (myositis ossifi- cans traumatica) gradually develops in the course of months. The brachialis anticus and quadriceps extensor muscles are most frequently involved. Lymph cysts may also develop in the connective tissues sur- rounding the piece of bone (Wolter). Myositis ossificans traumatica follows severe contusions, dislocations, and fractures, and cannot be sepa- rated from those bony growths which extend from an exuberant callus into the soft tissues. The bone probably develops in these cases from separated and displaced fragments of periosteum. The position of the bone in a nmsclc which is exposed to repeated traumas or has been severely contused suggests at once the diagnosis. The findings may be readily verified by an X-ray picture. [Gouty deposits in muscles and about joints are sometimes confusing.] Although cases have been observed in which the bone disappeared spontaneously and in which massage has been helpful, extirpation with subsequent suture of the wound in the muscle is to be recommended if there are symptoms. Literature. — v. Bcrgmann. Geschwiilste tier Schadelknocken. Handb. d. prakt. Chir., 2. Aufl., Bd. 1, p. 123.— Bennecke. Exostose der Tibia. Zentralbl. f. Chir., 1904, p. 500. — Bornhaupt. Ein Fall von linksseitigem Stirnhohlenosteom. Arch, f. klin. Chir., Bd. 26, 1881, p. 589. — Busse and Blecher. Ueber Myositis ossificans. Deutsche Zeitschr. f. Chir., Bd. 73, 1904, p. 388. — Chiari. Zur Lehre von den multiplen Exostosen (inehr als 1,000 Exostosen und ein Spindolzellensarkoni am Hianerus). Prager rned. Woehenschr., 1892, No. 35. — Eckert. Zur Keinitnis der Osteorne des Unterkiefcrs. Beitr. z. klin. Chir., Bd. 23, 1899, p. 674. — Fehleisen. Zur Kasuistik der Exostosis bursata. Arch. f. klin. Chir., Bd. 33, 1886, p. 152. — Honsell. Ueber trau- matische Exostosen. Beitr. z. klin. Chir., Bd. 22, 1898, p. 277. — Lexer. Das Stadium der bindegewebigen Induration bei Myositis ossificans progressiva. Arch. f. klin. Chir., Bd. 50, 1895, p. 1. — Nadler. Myositis ossificans traum. mit spontanem Zuriickgang der Muskelverknocherung. Deutsche Zeitschr. f. Chir., Bd. 74, 1904, p. 427. — Nasse. Ueber multiple kartilaginare Exostosen und multiple Enchondrome. v. Volkmanns Samml. klin. Vortriige, No. 124, 1895. — Reich. Ein Beitrag zur Lehre iiber die multiplen Exostosen. Deutsche Zeitschr. f. Chir., Bd. 43, 1896, p. 128. — Riethus, Exost. bursata mit freien Knorpelkorpern. Beitr. z. klin. Chir., Bd. 37, 1903, p. 639. — Rothschild. Ueber Myositis ossificans traumatica. Beitr. z. klin. Chir., Bd. 28, 1900, p. 1. — Schuler. Ueber traumatische Exostosen. Beitr. z. klin. Chir., Bd. 33, 1902, p. 556. — Stark. Ueber multiple kartilaginare Exostosen und deren klinische Bedeutung. Beitr. z. klin. Chir., Bd. 34, 1902, p. 508. — Stempel. Die sogenannte Myositis ossificans pro- gressiva. Mitteil. aus d. Grenzgeb., Bd. 3, 1898. — Virchow. Ueber Myositis ossi- 822 DIFFERENT VARIETIES OF TUMORS ficans progressiva. Verhandl. der Berl. med. Gesellsch., 1894, I, p. 172 and II, p. 142 and 1900, I, p. 151. — Walter. Ueber Myositis ossificans traumatica mit Bildung von Lymphzys' en. Deutsche Zeitschr. f. Chir., Bd. 64, 1902, p. 351. — v. Zoege-Manteuffel. Demonstration eines Skelettes mit Myositis ossificans. Chir.-Kongr, Verhandl., 1896, I, p. 43. CHAPTER V ANGIOMAS HiEMANGIOMAS The tumors composed of abnormally arranged, tortuous, and dilated vessels are classified as angiomas. The term angioma, however, should be applied to those tumors only in which there is an actual new forma- tion of vessels or a proliferation of the vessel walls, aneurysms and varicose veins being thus excluded. Angiomas composed of blood vessels (hgemangiomas) are distinguished from those composed of lymphatic vessels (lymphangiomas). Three forms of ha?mangioma are distinguished: Hsemangioma sim- plex, cavernosum, and racemosum. Hsemangioma Simplex. — The ha?mangioma simplex is also known as a telangiectasis. This term, however^ does not fully describe the nature of the tumor, as there is not only " a dilatation of the vessels," but an actual new formation of vessels as well. During the removal of such a growth small, dark-red, spurting lobules may be seen at the edge of the tumor. These are held together by connective tissue, and may extend close to the epidermis or be covered by a thin layer of the cutis and reach into the surrounding fatty tissues, muscle, and fascia?. Not infrequently these growths are surrounded by a delicate connective- tissue capsule which is united with the neighboring structures only at the points where the vessels enter and leave the growth. The tumor is composed of dilated, interlacing capillaries and small vessels, the walls of which contain flat or cubical endothelium and cir- cularly arranged connective-tissue bundles. If both the endothelium and connective tissue have proliferated (angioma simplex hyperplasti- cum of Virchow) and the himina of the vessels have become narrow as a result, it is often difficult to differentiate the vessels from sweat and sebaceous glands, both of which may be found in these tumors. The transformation of the vessels into solid cords consisting of pro- liferated endothelium forms a transitional stage to the ha?mangio-endo- theliomas. Angiomas are not infrequently combined with other forms of tumors ANGIOMAS 823 of the eonneetive-tissno urotip, foniiiiiji' angiolipomas, angiofibromas, angiosai'coiiias, etc. Siinple lufiiianuioiiiiis ciilai'gc in tlic following way: the processes devek)piiig from the vessels extend like buds into the surrounding tis- sue's, and by a con- liiuious new forma- tion and dihitation of the capillaries the adjacent tissues become c o m p 1 e t e 1 y infiltrated. This method of growth, which resembles the infiltrating growth of malignant tumors, leads to the destruc- tion of the infiltrated tissue, even if it is bone. They never form metastases, however, and do not enlarge in this way if encapsulated. The growth, sometimes slow, at other times rapid, is frequently interrupted for long intervals or ceases permanently after a short time. Secondary changes following inflammation may cause complete involution. Simple ha-mangiomas are the result of developmental anomalies. According to Ribbert, the area supplied by a small artery develops from the beginning without any connection with surrounding tissues, or loses its connection during subsequent growth and develops independently. The facts emphasized by Virchow that angiomas are commonly situated about the lips, cheeks, eyelids, and the root of the nose, the position of earlier fu'tal clefts, and that they are frequently congenital and often multiple support this theory. Simple luemangiomas develop most commonly in the skin and sub- cutaneous tissues. Although any part of the body may be involved, two thirds of these tumors occur in the skin of the face. Cut(i)icous Angionnis. — The cutaneous angiomas may be present at birth, appearing as light-red or dark-red, well-defined, round, or scal- loped blotches or elevations, or they may develop during the first few weeks or months of life from small, scarcely noticeable points (resem- bling a flea bite) from which little delicate vessels radiate (nrt'\'us vas- culosus, 'flammeus, port-wine mark). Some of these nivvi grow very Fn. 324. — HEMANGIOMA Simplex Cutis. 824 DIFFERENT VARIETIES OF TUMORS rapidly, extendmg' within half a year over the entire half of the face; others enlarge slowly, their growth corresponding to that of the body. Not infrequently the veins of the surrounding tissues become dilated. If the tumor also extends into the deeper tissues, nodular, polypoid, and lobulated masses of dark-red color covered by a delicate skin de- velop which resemble the changes (vide p. 793) found in elephantiasis (elephantiasis ha^mangiectatica) . Suhciitaneous Angiomas. — The subcutaneous appear later than the cutaneous angiomas, remaining concealed beneath the skin until the lat- ter becomes thin enough to allow the bluish shimmer to show through. A distinct swelling produced by filling of the vessels, when the patient cries, or the principal vessels are pressed upon and the circulation inter- fered with, and the extension of the growth to the epidermis leading to the formation of red blotches and elevations as in cutaneous angiomas indicate the presence of these tumors. If both the skin and subcutaneous tissues are involved, pads and folds form upon the fiat surface of the angioma from which, especially upon the lips, lids, and nose, large, purple, blackberrylike, lobulated, and pedunculated tumors may develop (Fig. 326). These tumors contain parts which are transitional to the cavernous angiomas. A simple angioma occurring upon the lips may produce a macrocheilia similar to that caused by a lymphangioma. The upper lip, which is more fre- quently involved, then hangs down as an irregular bluish fold over the mouth, while the lower lip when involved projects out- ward like a snout. The tumor enlarges when the patient stoops, cries, or becomes excited. It has been said of Emperor Leopold, that when angry his lip, the seat of such a growth, hung down to his chin. Angiomas of the eyelid, which may be primary in these struc- tures or extend to them from the temporal and naso-frontal regions, should be mentioned, as they may invade the orbit and threaten the integrity of the eye. Fig. 325. -Simple Cliaakwl,^ a,\d Subcuta- neous HEMANGIOMA. ANGIOMAS 825 .Siini)]o anjiionias of the sealp, aeeordiiii;- to Ilciiu'cko, coinpriso thirty- lliice per cent oi' the anjjionias of the liead. Thj-y oeeui- most frequently in the frontal reirion, developing' alxuit llic uKilx'lIa. at the intu'r ex- tremity of the eyebrow, and over the fontanelles. Clunifjcs Wliicli May Occur in an Angioma. — The most impor- tant ehanires which may occur in a simple angioma are inMannna- tion, ha'morrhages, and sponta- neous involution. It has often been observed that not only the small, but also the larger flat an- giomas may completely or par- tially disappear following the obliteration of the vessels com- posing them. Frequently inflammation, which develops after an injury of the thin, easily vulnerable skin, pre- cedes and favors subsequent ul- ceration, cicatrization, and oblit- eration of the vessels. It has occasionally been attempted to cure angiomas in children by in- fecting them. IRvmorrhages are not frecpient. AYhen they occur they are apt to be profuse, but may easily be controlled by a bandage exert- ing mild pressure. Simple angiomas are also found in rare cases in fat, especially in that of the orbit, in muscles, the breast, in bone, the brain, and spinal cord. The small, macular, and wartlike hanuangiomas, never becoming larger than a pea, which occur as multiple growths upon the surface of the body associated with soft and pigmented warts, form a special group. They develop usually in old age. Haemangioma Cavernosum. — The ca.vernous angioma (ha^mangioma cavernosum) resembles in structure the corpus cavernosum, being com- posed of retiform blood spaces. Fre(|uently transitional stages to the cavernous luvmangioma are found in the simi)le ha'mangioma, from Miiich they may develop. The irregular cavities, filled with blood and connnunicating with each other, are surrounded by a network of fibrous tissue containing elastic fibers. The thickness of the network varies in different parts of the tumor. These tumors are nourished by a single artery and discharge their blood into dilated veins. Thrombosis of the 53 Fig. 32(j. — Simple LoBfLATED Hemangioma. 826 DIFFERENT VARIETIES OF TUMORS blood spaces leads to localized connective-tissue changes. If the thrombi become calcified, phleboliths are formed. Single spaces may become closed and transformed into blood cysts in this way. These tumors may be well encapsulated or the capsule may be entirely or partly absent, and then the tumor extends without any sharp line of demarca- tion into the surrounding tissues. The growth, as in simple angiomas, may be partly expansive, partly infiltrating, slow but continuous, or rapid after remaining stationary for some time. An encapsulated tumor frequently ceases to grow. Involution may be complete after thrombosis and cicatricial contraction of parts of the tumor. The fact that these tumors are frequently congenital and multiple indicates that they, like simple angiomas, are the result of some develop- mental anomaly, the exact nature of which is unknown. Fig. 327. — Cavernous Hemangioma of the Subcuta- neous Fat (After Extirpation). Fig. 328. — Cavernous Hem- angioma of the Ear. Most Common Sites for Development. — These tumors develop most frequently in the skin and subcutaneous tissues, being most common in the cheeks, eyelids, lips, and scalp. Other parts of the body are more rarely involved and with about the same frequency. These tumors, which may be present at birth, or develop shortly after, more rarely in later life, assume a number of different forms. Cavernous angiomas of the skin are characterized by the formation of dark-blue, bluish- black, nipplelike, and nodular growths, or of large, blackberrylike, lobu- lated masses covered by a delicate epidermis; cavernous angiomas of the subcutaneous tissues by the formation of a flat swelling, covered by slightly bluish, discolored, otherwise normal skin, or by skin the seat of a simple hemangioma or nipplelike growths, such as are asso- ciated with cavernous haemangiomas of the skin. If both occur together, folds in skin, such as are found in elephantiasis (elephantiasis caver- nosa), may develop. Cavernous haemangiomas of the cheeks, eyelids, and ANGIOMAS 827 lips soon extend to the mucous membranes, forming bluish nodules and lobulated growths. Cavernous angiomas of the face frequently assume rapid growth, extending from the cheek to the nnicous membranes of the mouth cavity and lips, finally involving the entire half of the face and head. If they occur in the scalp, the spongy tissue composing the tumor may grow through the bones and become connected by means of dilated emissary and larger veins with the venous sinuses. Excruciating pain may be produced if the tumor presses upon nerves, especially upon the branches of the trigeminal nerve. A cavernous angioma of the orbit may dis- place the bulb of the eye and threaten its integrity. It should be mentioned that these tumors occur in the tongue and occasionally in the different muscles (nniscles of the calf, rectus ab- dominis, sterno-cleido-mastt)id, and masseter). Of the abdominal viscera, the liver is most fretjuently the seat of cavernous tumors, occurring as small, multiple growths which are acci- dentally found during post-mortem examinations. Sometimes they ap- pear as large, occasionally pedunculated, tumors, especially in children. Cavernous tumors may also occur in the spleen, bone marrow, uterus, and intestines, but are very rare. Hemorrhage, following rupture of nodules covered by thin skin, may be quite profuse, but is easily controlled by a bandage exerting mild pressure and by cauterization. Diagnosis. — The diagnosis of ha^mangiomas, the simple as well as the cavernous, is based upon their peculiar color and form and upon the fact that they can be emptied by pressure, but refill when the pres- sure is removed. The soft tumor masses, nodular if thrombi or phlebo- liths are present, become smaller and less discolored when pressure is exerted, but rapidly fill Avith blood, assuming their original form and color as soon as the pressure is released. In tumors of the dependent portions of the body the increase in size is very noticeable when pres- sure is exerted upon the veins passing from the tumor, or when the patient stands up. After compression of a subcutaneous angioma of the scalp, the pits and fissures in the bone through which the dilated, anastomosing veins pass to the interior of the skull may be easily felt. Only the deep-lying, calcified, or mixed tumors (lipoangioma) do not decrease in size upon pressure. Cavernous lui'mangionuis may pulsate if nourished by large arteries. The clinical picture of angiomas is char- acteristic, and the diagnosis usually not difficult. Sometimes it is dif- ficult to difVei-entinte the isolated, subcutaneous forms from other tu- mors, especially when thei-e is no involvement of the skin. It is not difficult to exclude plexiform angiomas, aneurysms, and varicose veins if the symptoms are pronounced. 828 DIFFERENT VARIETIES OF TUMORS Treatment. — There are a number of methods which may be employed in the treatment of simple and cavernous angiomas. Superficial and deep angiomas, when encapsulated, should be excised. If the tumor is situated upon the extremities, hgemorrhage should be controlled during the operation by elastic constriction ; if situated upon other parts of the body, by digital compression or special instruments. If the tumor is not encapsulated and extends into the deeper tissues, the greater part of it should be rapidly removed with a sharp spoon (von Bergmann), for after the large blood spaces are destroyed there is but little haemorrhage from the small arteries entering the tumor tissue. Large defects should be skin-grafted or closed by plastic oper- ations. Deep angiomas of the face extending through the cheek to the mu- cous membrane, and angiomas which perforate the bones of the skull should not be excised. In treating angiomas in young children, the bloodless methods are always to be preferred when they can be em- ployed. In the treatment of superficial birthmarks, a single applica- tion of fuming nitric acid is a simple and effective method. The eschar produced by this acid extends deeply enough, and when it is cast off a delicate scar remains. The skin surrounding the angioma should be protected from the acid by adhesive plaster or some other device. Puncturing with the actual cautery (ignipuncture) is often success- fully employed in the treatment of elevated nodular ngevi, which should never be excised when occurring in weak children. It may be necessary to repeat ignipuncture a number of times, as the tumor cannot be destroyed by one application without leaving unsightly deformities, and it recurs from the tissue which is not destroyed unless the treatment is repeated after an interval. The scars resulting from this treatment are large and unsightly, and therefore this method cannot be employed for angiomas of the face. Aseptic dressings should be applied after sepa- ration of the eschar to prevent secondary infection, for infections devel- oping in haemangiomas of the cheek or scalp may easily extend to the meninges. Payr, after making small incisions in the skin, has inserted small pieces of magnesium into the tumor in all directions. As the metal is being absorbed the blood coagulates, the large dilated vessels become occluded, and even deep extensive tumors sometimes disappear. This method is especially suited for the treatment of inoperable hsem- angiomas of the skull and face. The injection of chemicals sometimes cause a gradual obliteration of the vessels and reduction in the size of the tumor. Alcohol has been recommended by Schwa I be. From fifteen to sixty drops of seventy or eighty per cent alcohol are injected at first into the margins, later directly into the tumor, some days intervening between each injection. ANGIOMAS 829 The injections should not be iiiach' wlioio tlie skin is thin, as it may become necrotic, favorinjjc ha'morrhaucs and ini'ection. [Repeated injec- tions of small quantities (1 to 2 c.c.) of boilinji: water with a hypo- dermic needle and syringe directly into the angioma offers one of the best methods of treatment.] Some of the flat and superficial ha^mangiomas have been successfully treated by the X-rays (vide p. 774). The Cirsoid Aneurysm. — The cirsoid angioma (cirsoid aneurysm, an- gioma arteriale racemosum of Virehow) consists of thickened, dilated, tortuous pulsating vessels, the ''^^ arteries supplying the tumor emptying directly into large blood spaces without the in- tervention of capillaries. The dilatation of the vessels may be fusiform or saccular. Fre- quently the afferent artery is thickened for a considerable extent as the result of pro- liferation of its walls, while the efferent veins, communi- cating as they do directly with the artery, are trans- formed into large, pulsating cords. For this reason this form of angioma is fre([uently referred to as a phlebarteriec- tasia. Cirsoid angiomas develop most frequently from sim- ple, congenital ha^mangiomas. They also develop after fre- quently repeated mechanical injuries (e. g., after pulling the ears, Konig) after injuries of the hand received while rowing, after a single trauma, and even without any apparent cause. It is probable that this form of new growth is the result of some congenital defect in the arterial anlage, as a result of which the tissues composing the artery may be stimulated to proliferation by a number of different influences. Most Common Sites. — Cirsoid angiomas occur most frequently in the scalp and face, more rarely in the extremities, the arm (hand and fore- arm) being next most frequently involved. Fig. 329. — Cirsoid Axkuhys.m of iHi; Face which WAS xoT Improved by Ligation of the Ex- ternal Carotid Artery and Other Large Branches Supplying it and by the Injec- tion OF Alcohol. 830 DIFFERENT VARIETIES OF TUMORS The snperficial, tortuous, anglewormlike strands and masses are cov- ered by a thin, cyanotic skin which is freciuently adherent at a number of different points. When they occur in the face, the skin covering the tumor is fre- quently the seat of a simple angioma, or is raised to form a flat swelling, Fig. 330. — Cirsoid Aneurysm of the Hand and Forearm (Englebrecht's Preparation). which gradually disappears into the surrounding tissues. The vessels composing the tumor pulsate, the pulsations being transmitted to the skin. Rhythmical impulses and thrills may be felt when the angioma is palpated ; loud blowing and buzz- ing bruits, transmitted to com- municating vessels, may be heard when the tumor is auscultated. In angiomas of the extremities these signs disappear when pres- sure is made upon the principal arteries. This does not always occur in the face, because the anastomosing arteries are more numerous ; frequently, however, a slowing and strengthening of the pulse can be noticed, ap- parently the result of the di- version of the blood, into the general circulation following the exclusion of so large a circula- tory area. Clinical Course and Regressive Changes. — These tumors develop quite rapidly at first; later more slowly, growth often being in- terrupted by long intervals. When they occur upon the head the patient often complains of headache and dizziness; throbbing of the head and ringing in tlie ears, preventing sleep; excruciating pain Fig. 331. — Racemose H.iomangioma of the Scalp (von Langenbeck's Collection). ANGIOMAS 831 caused l)y pressure upon the nerves, and functional disturbances, the result of adhesions between the tumor and adjacent nerves and niusck's. Necrosis of tlie atrophic skin coverinj; these j^rrowths is a serious matter, as chronic uk-ei's favorinjj;- luemori'lia^c and infection then (h'velop. Even the terniinal phalanges of the fingers may become ne- crotic when the tumor involv(>s the hand. I)i may be mixed with I blood. The cysts do S»j not communicate with neighboring lymphat- ics, and do not be- come smaller on pres- sure. Their inner sur- faces are lined with endothelium, and the walls consist of thick fibrous tissue ar- ranged in the form of a cavernous mesh- work. These tumors de- velop in the lateral regions of the neck, posterior to the sterno-cleido-mastoid, about the angle of the jaw, or in the supraclavicular fossa, and extend as they enlarge to the posterior part of the neck and toward the median line. ':-m ~-~ii('J^f' ^ Fig. 335.— C ANGIOMAS 835 A 'i» , ft A larp;f>, oystie lyiiiphanjiioma may extend from the jaw to the clavicle, from the metliaii line in front to tlie same line posteriorly (Fiji. -i'-H)). The new growths, depending upon tlie amount of fluid they contain, may be elastic and tiuetuating, covered by skin which is tense but not adherent, or relaxed and soft. When the walls of the cysts are relaxed, irregularities produced by ledgelike projections and thickenings may be palpated. As they enlarge, cystic lymphangiomas may exert pressure upon the trachea, oesophagus, and large vessels, and become dangerous. This is especially so when they enlarge sud- denly as the result of intiammation, which may end in suppuration. Cystic lymphangiomas occur more rarely in the cheeks, axil- lary fossa, groin, and upon ^' ~ the flexor surfaces of the extremities. These tumors are occasionally found upon the anterior surface of the sa- crum and in the root ^ of the mesentery. The latter contain cliyle. The diagnosis of the nature of multilocular cysts, occurring where lymphangiomas are common, is not difficult. It is often extremely diffi- cult to make an accurate diagnosis of the small unilocular forms, as one has also to consider branchial and blood cysts when they occur in the neck, echinococcus cysts and lipomas when they occur in the cheek. Varicosities of the lymphatic vessels, developing in areas with a rich lymphatic supply, give rise to much the same clinical picture as do multilocular lymphangiomas. These tumors occurring about the sacrum, must be differentiated from dermoid cysts and teratoid tumors; at the root of the mesentery, from a number of different kinds of cysts. Origin of Lymphangiomas.— Lymphangiomas are almost exclusively of congenital origin. They are the result of a disturbance in embryonic development, being frequently associated with other anomalies, such as myeloceles, encephaloceles, etc. Not only the lymphatic vessels, but also the fatty and fibrous tissues and the smooth musculature of the walls of the larger lymphatics, participate in these growths (Ribbert). FlG. 336. — C'om;k.mtai., Cystic Lymphangioma (Cystic Ht- GROMA OF THE Neck). Cured b}- extirpation. 836 DIFFERENT VARIETIES OF TUMORS Changes Which May Occur in Lymphangiomas.— Lymphangiomas are benign growths, notwitlistanding the fact that they frequently are not encapsulated and may be so situated or become so large that they threaten life. Inflammation may be followed by cicatricial contraction and spontaneous cure. It may also lead to the most serious conse- quences, such as exhausting lymph fistulas or the extension of the in- flammation along the lymphatic vessels communicating with the tumor, causing phlegmon of the orbit, mediastinitis, meningitis, etc., depending upon the position of the growth. Indications for Treatment and Technic. — Encapsulated cystic tumors should be extirpated. If the skin is adherent to the tumor it should be removed at the same time. If one proceeds slowly and cautiously, fre- quently the entire tumor with all its processes may be removed by blunt dissection (sponges and tissue forceps) without rupturing it. Separa- tion of adherent nerves offers the greatest difficulties. Cavernous por- tions of a tumor can never be com- pletely removed. Fig. 3.37. — Specimen Removed from Patient Represented in Fig. 336. After removal of the tumor the wound should be accurately sutured and a compression dressing applied, the accumulation of lymph and the development of lymph fistula3 being prevented in this way. Incision of the cyst and tamponade, recommended by Wolfler, should not be employed, as Nasse has shown that there is danger of infection which may persist indefinitely if this method is employed. The simple and cavernous lymphangiomas cannot be radically re- moved, and even partial removal by cuneiform excision, as recommended ANGIOMAS 837 in the troatment of maerotjlossia and niacrocheilia, is not without clan- ger, as lymph fistuhe and proi^ressive inHaniination may develop. In the treatment of these cases, especially in children, one must be content with less efficient but less dangerous methods, such as the injection of alcohol, tincture of iodin, and one per cent solution of zinc chlorid. If frequently repeated they cause at least a cicatricial contraction of parts of the tumor and a decrease in size. Cauterization should be discarded, as it has the same disadvantages as the incomplete operation. Literature. — v. Brumunn. Ueber Chyluszysten des Mesenterium. Arch. f. kiln. Chir., Bd. 3o, 1887, p. 2U1. — Emjclbrecht. Angioma arteriale raccmosuni. Arch. f. kliii. Chir., B<1. 5.5, 18U7, p. 347. — Fr. Fischer. Krankheiten der Lyinphgef;i.s.se, Lymph- ilrii-seii und Blutgefiisse. Deutsch Chir., lUOl, Rankenangiom, p. 222. — Heine. Ueber Angioma arteriale racemosum. Vierteljahrsschr. f. prakt. Heilkunde, 1869. — Hilde- hrand. Ueber multiple kaverniise Angiome. Deutsche Zeitschr. f. Chir., Bd. 30, 1880, p. 91. — Honsell. Ueber Alkoholinjektionen bei inoperablen Angiomen. Beitr. z. kUn. Chir., Bd. 32, 1902, p. 251. — Katholicki. Ein Fall von Lymphangiom des Vorderarmos. Chir. Kongr.-Yerhandl., 1903, I, p. 61 and Disku.ss., p. 125, Payr, v. Bramann. — A. Kruse. Ueber das Chylangioma cavernosum. Virch. Arch., Bd. 125, 1891, p. 488. — Kiittner. Ueber die intermittierende Entziind. d. Lj-mphangiome. Beitr. z. klin. Chir., Bd. 18, 1897, p. 728. — Laewen. Ueber genuine diffuse Phlebar- teriektasie a. d. ob. Extremitiit. Deutsche Zeitschr. f. Chir., Bd. 68, 1903, p. 364. — Lieblein. Ueber einen durch Alkoholinjektionen geheilten Fall von Angioma racemo- sum des Kopfes. Beitr. z. klin. Chir., Bd. 20, 1898, p. 27. — E. Mailer. Zur Kasuistik der Lymphangiome. Beitr. z. klin. Chir., Bd. 1, 1885, p. 498. — H.MUllcr. Ein Fall von arteriellem Rankenangiom des Kopfes. Beitr. z. klin. Chir., Bd. 8, 1892, p. 79. — W . Midler. Zur Technik der Operation grosserer Hiimangiome und Lymphangiome. Beitr. z. klin. Chir., Bd. 37, 1903, p. 565. — Muskatcllo. Ueber das primare Angiom der willkiirlichen Muskeln. Virch. Arch., Bd. 135, 1894, p. 277. — Xarath. Ueber retroperitoneale Lymphzysten. Chir. Kongr.-Verhandl., 1895, II, p. 396. — Nasse. Ueber Lymphangiome. Arch. f. klin. Chir., Bd. 38, 1889, p. 614. — Payr. Ueber Verwendung von Magnesium zur Behandlung von Blutgefasserkrankungen. Deutsche Zeitschr. f. Chir., Bd. 63, 1901, p. 503. — Ranke. Zur Anatomic der serosen Wang- enzysten. Arch. f. kUn. Chir., Bd. 22, 1878, p. 707. — Ribbert. Wachstum und Gene.se der Angiome. Virch. Arch., Bd. 151, 1898, p. 381. — Riethus. Ueber primare Muskelangiome. Beitr. z. klin. Chir., Bd. 42, 1904, p. 454. — Ritschl. Ueber Lymph- angiome der quergestreiften Muskeln. Beitr. z. kUn. Chir., Bd. 15, 1896, p. 99. — RotUjans. Aneurysma cirsoides. In Hildebrand's Jahresber., 1897, p. 346. — Sachs. Die von den Lymphgefassen ausgehenden Xeubildungen am Auge. Ziegler's Beitr. z. pathol. Anat., Bd. 5, 1889, p. 99. — Samter. Ueber Lymphangiome der Mund- hohle. Arch. f. klin. Chir., Bd. 41, 1891, p. 829. — Strauch. Intramuskulares kavernoses Angiom (Masseter). Deutsche Zeitschr. f. Chir., Bd. 62, 1902, p. 323.— Suckstorff. Lymphangiom des Rachens mit Bildung krupposer Membranen. Beitr. z. klin. Chir., Bd. 27, 1900, p. 185. — Sutter. Beitr. zu der Frage von den primtiren Muskelangiomen. Deutsche Zeitschr. f. Chir., Bd. 76, 1905, p. 368. — Tavel. Ueber die schubweise auftre- tende entzimdliche Schwellung der Lymphangiome. Zentralbl. f. Chir., 1899, p. 817. — Weichselbaum. Chylangioma cavernosum des Mesenterivuns. Virch. Arch.. Bd. 64, 1875, p. 145. — Wegncr. Ueber Lymphangiome. Arch. f. klin. Chir., Bd. 20, 1877, p. 641. 838 DIFFERENT VARIETIES OF TUMORS CHAPTER VI SARCOMAS ^,-r,^;^'m 'W 'Mm ■X-h Definition and Nature. — Sarcomas (from the Greek o-ap^, meaning flesh) are malignant tumors Avhich are derived from mesoblastic tissues. They are composed of immature, unripe elements, while the benign con- nective-tissue tumors, such as the fibromas, chondromas, and osteomas described in the preceding chapters, are composed of mature, fully devel- oped elements. In sarcomas the cellular elements predominate over the intercellular substance, the former proliferating rapidly and without re- straint. Sarcomas are closely related to embryonal tissues and to granu- lation tissue developing in wounds and in chronic inflammatory processes (especially the infectious granulomas) . The cells composing the latter, however, complete their cycle of development forming adult connective tissues if favorable condi- tions are provided, while the cells composing a sar- coma maintain their em- bryonal characteristics. They have lost their abil- ity to form tissues of an adult type (Borst) and proliferate without re- straint at the expense of the organism. These tu- mors form the malignant group of the connective-tissue tumors corre- sponding to carcinomas, malignant tumors arising in epithelial tissue. Classification. — Sarcomas differ in histological characteristics and in their clinical courses. Frequently it is impossible to determine the clin- ical peculiarities of a sarcoma by histological findings; therefore it is difficult to make a classification in which both the histological picture and the clinical course are taken into consideration. Eibbert's classification seems to be the best. He distinguishes between sarcomas composed: 1. Of cells of any of the connective tissues; 2. Of cells resembling lymph corpuscles; 3. Of mucoid tissues; 4. Of pigment cells. 5S^'-^^ ■J?r^-.. i Fig. 338. — Fibrosarcoma. SARCOMAS 839 Characteristics Common to all Sarcomas. — Thore are certain charac- teristics common to all sarcomas wliich may be more marked in some than in others. Sarcoma^ consist principally of cellular elements, the intercellular tissue, if present, beint,^ greatly reduced in amount. The intercellular substance may be fibrillar, cartilaginous, bony, or mucoid, depending upon the origin of the tumor. Reiiuiants of the infiltrated and degenerat- ing tissues may also be found between the cells. Blood vessels, the develop- ment of which varies in different tumors, form the third constituent part of sarcomas. As in granu- lation tissue, the newly formed capillaries form the framework for the proliferating groups and columns of cells. Among the thin-walled vessels, ar- teries and veins cannot be differentiated from each other. The vessels consist of spaces or clefts in the tumor tissues. In some cases the endothelium lining the vessels rests directly upon the tumor cells, while in other cases the connective- tissue stroma of the tumor forms a fairly well-defined wall. If these spaces, surrounded by stroma, become filled with cells, structures histo- logically resembling alveoli (alveolar sarcoma) are produced. If the vessels are numerous and the proliferation of the tissues im- mediately adjacent to them is marked, transitional stages to the peri- theliomas, in wliich the proliferation begins in the perivascular endo- thelial cells, are found. This is especially true if the columns of cells surrounding the vessels do not become fused with each other, 1)ut remain separated by intercellular substance, lymph, or blood. These tumors are called angiosarcomas or, better, telangiectatic or cavernous sarcomas (Borst), as these terms can also be used for peritheliomas. Mode of Growth, — The growth is usually expansive in the beginning, the adjacent displaced tissues forming a thin capsule. If operated upon at this stage, the tumor can sometimes be easily enucleated. Many sarcomas from the first, and all later on, infiltrate the surrounding tis- sue, replacing the normal structures. The increase in size of these tumors is due to the proliferation of the cells composing them, and not Fig. 339. — Large Spindle-Ckll Sarcoma. g40 DIFFERENT VARIETIES OF TUMORS to tlie tranf3formntion of surroTinding elements into tumor tissue. Pro- liferation of the surrounding tissues is indicative of reactive growth and not of transformation into tumor tissue. The infiltrated tissues gradually undergo pressure atrophy. Pressure upon the larger vessels may cause necrosis. Even bone is disintegrated by the tumor cells. Cartilage resists their growi;h for a long time. Regressive Changes. — A number of regressive changes, such as fatty and parenchyniat(ms degeneration of the cells, necrosis of large areas, haemorrhages, thrombosis of the large vessels, hyaline degeneration and obliteration of the blood v^^^JS};3^^?v7r^ vessels and death of the '-<.■.^:;'■';^^•;X.^;*JO^^^^^^^^ tissues surrounding them, 1^^ \^'r^: may occur m any sarcoma. Softened areas and blood cysts then develop, and upon section yellowish, gelatinous, and heemor- ; r-'^'^v-'^' rhagie foci may be seen ■ " ■ '' upon a surface which, in . ^ ■•; ' the beginning, is of a gray- ''*^J^^' "rV^ _ -' . ' ••. '■ V'-- ^^^^ ^^ ^^^ color through- ' ^iif' , 1 '-';- '' , ' "" . ■/ out. Necrosis of the infil- p^g^''. ^ _.. trated skin leads to the %rj<>7'' t * /■•■- formation of deep ulcers ' ' ' ' in which putrefactive in- L .- - '--. • - > fiammation may easily de- FiG. 340. — Round-Cell Sarcoma of the Skin. velop. It is interesting to note that these tumors oc- casionally become smaller following an attack of erysipelas (Busch), the cells undergoing a fatty degeneration and being absorbed (Spronck, Borstj. X-rays have a similar effect upon the tumor cells. Metastases. — The malignancy of sarcomas is indicated especially by the formation of metastases. The tendency to the formation of metas- tatic growths is least marked in the encapsulated tumors and in the relatively highly develofjed fibrosarcomas; it is most marked in the cellular, rapidly growing, infiltrating forms, especially in the round- cell sarcomas. Secondary nodules may develop by way of the lymph stream in tissues adjacent to the tumor or in regional lymph nodes. Metastases by way of the lymphatics are not, however, the rule as in carcinoma. In sarcomas metastases by way of the blood stream are more common, as the cells invade the vessels of the surrounding tis- sues or those of the tumor itself. A progressive, intravascular growth then develops, or, as more frequently happens, a small group of SARCOMAS 841 cells or sinj;le colls arc soparatod and carried away in the blood stream to he dejxxsited in the Iniijis, liver, sph'cn, hone niai-row, tlu; kidneys, and in other viseei-a jind tissues. The nictastatie "growths repeat the structure of the primary tumor, l)ut i>roliferate still more rapidly. Fever and Angemia Associated with Sarcomas. — The effect of the sar- coma upon the organism is often indicated by an irregular fever, due to the absorpti(m of pyroj^enic substances from the tumor (haemorrhages, products of decomposition), and by a progressive antemia, which always suggests the formation of ucnci-al inetastatic growths. Age at Which Sarcoma Develops. — Sarcomas occur most commonly in middle-aged people, more rarely in the young and old. Congenital .sarcomas are relatively common. It is striking that they are most common in powerful, healthy men. As a rule, the primary tumor is single, but primary multiple tumors have been observed. Cause of Sarcoma Formation. — The essential cause of sarcoma for- mation has not been determined. There are a number of objections which may be raised against the parasitic theory. There are a number of facts which seem to jus- tify the theory that these tumors arise from rests, displaced during embryonal or later life, such as: their congenital oc- currence ; the pres- ence of sarcoma tis- sue in (teratoid) mixed tumors, which certainly develop from tissue displaced during embryo n a 1 life ; the development of tumors from dis- placed adrenal rests, f r o m unde^scended and displaced testi- FiG. 341. — Soft, ^'A.scuLAK Sakco-m.v of the Left Half of THE Face, Developing Apparently from the Bulb of the Eye. Tlie growi;h has extended into the ncse, pharynx and mouth. cles, and from con- genital tumors, such as neurofibromas and soft warts; likewise, the development of bone and cartilage in sarcomas of the soft tissues and 54 842 DIFFERENT VARIETIES OF TUMORS the occasional clevelopnient of sarcoma tissue in any of the benign connective-tissue tumors. Germinal tissue apparently may be displaced in later and as well as in embryonal life, during growth, in inflamma- tory^ and regenerative processes (Ribbert). A sarcoma developing in a callus following a fracture may be cited as an example of a tumor developing from tissues displaced during regenerative processes. According to clinical experience, it is highly probable that the trauma is only the exciting cause in such a case, Fig. 342. — Sarcom.^ Tisstte (aj which has Invaded Muscle (6). stimulating a tumor to more rapid growth, which has previously ex- isted, but has given rise to no symptoms. In the example cited above it is more probable that a tumor existed before the fracture than that a tumor developed from the callus. (a; SARCOMAS DEVELOPING FROM THE DIFFERENT CONNECTIVE TISSUES Sarcomas, which develop from any of the connective tissues, may contain but little interstitial substance and resemble closely histologic- ally embryonal connective tissues. Some of these tumors contain car- tilage and bone, indicating that they have developed from the skeleton (chondro- and osteosarcoma). SARCOMAS 843 FIBROSARCOMAS Sarcomas arising from fibrous tissues are most commonly composed of spindle cells (sarcoma fiisocellulare) , less frequently of round cells (sarcoma globocellu- lare), small and large cells with many tran- sitional forms being found. Besides the soft, medullary forms, which usually are very malignant, there are the firm, less ma- lignant forms contain- ing relatively large amounts of intercellu- lar tissue. The dif- ferences in consist- ency and appearance depend usually upon the number of blood vessels, the amount of blood pigment, upon hiemorrhages and re- gressive changes. Sometimes the cut sur- face has a homogeneoiLs, grayish red or dark red appearance; at other times it is dotted with htpmorrhagic foci and cysts. Histology of Fibrosarcoma. — The spindle cells have nuclei centrally situated, and each end of the cells is provided with a long process. The large cells are, as a rule, irregular in shape, being round or fusiform, oval or serrated. Often they are arranged in a fasciculated manner. The intercellular fibrilla? are most abundant in the fibrosarcomas, which can only be differentiated from fibromas by their cells of unequal size, rich in cytoplasm and containing large nuclei. Spindle-cdl sarcomas usually are firm, hard tumors. They are less malignant than round-cell sarcomas, causing less local disturbance, growing le.ss rapidly, and forming metastases, which are less extensive, later. The spindle-cell sarcoma composed of large cells are, however, almost as malignant as the round-cell varieties. Eound-ccll sarcomas are composed either of small, round cells with little cytoplasm, or of large epitheliallike cells, rich in protoplasm and containing vesicular nuclei. If the cells lie imbedded in a well-developed Fig. 343. — Round-Cell S.\rcoma of the Cheek. 844 DIFFERENT VARIETIES OF TUMORS stroma (alveolar sarcoma) the tumor may resemble a carcinoma very closely histologically. Round-cell sarcomas are characterized by a rapid, infiltrating growth. They are more frequently soft than hard. Usually a single type of cell is found only in spindle-cell sarcomas. In other forms of sarcoma, while one type of cell predominates, a num- ber of other types are also found. Irregular, atypical, mitotic figures and multinuclear cells, the cytoplasm of which is not capable of divi- sion, are indicative of defective processes of growth. Fig. 344. — Sarcoma of the Skin of the Thigh in a Woman Sixty Years of Age (Small-Cell, Variety). Giant-cells, which resemble closely osteoclasts, are found in addition to the round and spindle cells in fibrosarcomas, especially in those developing from bone. The giant-cell sarcomas, composed principally of si)in(ll(! cells, develop from the periosteum of the jaw (epulis) or iroiii the Mian-ovv of long, hollow bones (vide p. 853). They form a relatively benign group of tumors. Clinical Course. — The clinical course of the sarcomas arising from fibrous tissue depends upon the position of the tumor and its degree of SARCOMAS 845 nialignaney. The dia<»:noRi.s is often tlifficnlt, ospccially when llie tumor is just l)»\i:'iiiniii<_; let develop. Sarcomas of the Skin. — Sarvoinas of the skin appeal- as i-apidly <;rovv- intr, round, well-delined nodules and masses, or as pedunculated, fun- u FlU. 345. llliKOSAHCOMA OF THE Al'ONEUKOSlS OF THE OcCIPITO-FhoXTAI.IS (Man Fifty Yeaks of Age). giform, and nodular tumors, vaiying in consistency. They liave a bluish-red color, as they contain a large number of vessels, and, in the beginning at least, are covered by epi- dei'inis. Later the skin becomes infil- trated, and large, deep ulcers may foi'm, or the surface of the tumor, which bleeds easily and pro- fusely, may be cov- ered by crusts. Sar- comas of the skin often develop from warts and papillo- mas. Frequently they are multiple from the beginning. So long as they are not large and do not extend deeply, they move with the skin. Rapid growth indi- cates m a 1 i g n a n c y . The nodular surface of the tumor, or the fissured , irregular ulcer may resemble Fig. 34G.- -Mui.tiple Sarcomas of the Skin in a. Ma.n Forty Years of Age (Small-Cell Variety). M6 DIFFERENT VARIETIES OF TUMORS NN *^. closely the changes foimd in carcinoma. The absence of indurated lymphatic enlare<^ments enables one to exclude the latter. It is often difficult to distinguish the multiple sarcomas from mycosis fungoides. a peculiar disease, the etiolog%' and ^xaet nature of ^\"hich are iin- Sarcomas of Subcutaneous Tis- sues. — Sarcomas developing in the subcutaneous tissues appear as round nodules with slightly un- even, tuberculated surfaces. In the beginning they are sharply defined against the surrounding tissues, but later infiltrate them, become adherent to the skin, and ulcerate through it. They may de- velop from fibromas of the nerves. The diagno.sis is based principally upon the rapid growth. They may be easily differentiated from fibromas. but with difficulty from rapidly developing subcutaneous giunnias. A positive diagncsis at times can be made only by examining pieces of tissue, or after ulceration, when the products characteristic of syphilitic lesions are wantinsr. •< • V * •••*>:/ % -^ Fig. 347. — Fibrosarcoma with Glvxt-Cells (Epin.is). -4.. Fig. 348. — Vert Vascular Sarcoma of the Ski.v. The tumor has broken through the skin which surrounds it like a collar. Fig. 349. — Rouxd-Celi. Sarcoma of the Skxn^ SARCOMAS 847 Sarcomas of Mucous Membrane. — Sarcomas of the mucous mcmhrane may be composed ol* cither rouiul or spindle cells. They usually grow rapidly. They appear as nodular tumors with broad bases, more rarely as pedunculated or poorly defined thickeninus, varying in consistency. After destruction of the nnicous membrane, which is apt to occur eai'ly, craterlike ulcers form. They develop from the subnuicosa, more rarely from the intermuscular and submucous connect- ive tissues, and occur in the stomach, intestines, and sometimes in the tongue and trachea. Sar- comas of the mucous membranes are much less frequent than are carci- nomas, with which they liave many clinical symp- toms in connnon. Mucous membrane Fig. 350. — Section of a Pe- dunculated Sarcoma of THE Skin (Vascular Spin- dle-Cell Sarcoma) of the Finger. The cutis does not extend beyond the pedicle. Mu.scle Sarcoma Fig. 351. — Ulcerated Round-Cell Sarcoma of the Stomach (Woman Twenty-three Years of Age. Resection of Right Half of Stomach, Recov- ery). Intermuscular Sarcomas. — Intermuscular sarcomas are most com- monly composed of large cells and grow rapidly. They may form enor- mous tumors entirely surrounding the bones of the part involved. The diagnosis is often difficult when the tumor is seen in its early stages, as one has to exclude a gunnna developing in the muscle. The diagnosis may be difficult even in the advanced stages, as it may be impossible to deternn'ne whethei- the tumor has developed from soft tissues or bone. Be- sides the very cellular, soft, malignant tumors, there are also hard, fibrous, intermuscular tumors which grow slowly and are partially encapsulated. 848 DIFFERENT VARIETIES OF TUMORS Both of these forms are also represented in sarcomas developing from fascia and the connective-tissue sheaths of blood vessels. The latter especially give rise to early symptoms by pressure upon nerves and blood vessels. Sarcomas of the Periosteum. — The sarcomas developing from the peri- osteum — in rare cases they are multiple (Nasse) — are fibrosarcomas or Fig. 352. — Small Round-Cell Sarcoma of the Hand, Developing from the Fascia. Amputation was soon followed by symptoms indicating involvement of the lungs. A piece of tissue was expectorated, which resembled histologically the prim^ary tumor. (From Prof. Bevan's Surgical Clinic.) spindle-cell sarcomas, through which are distributed giant cells. They are common, appearing as nodular, hard tumors upon the alveolar processes of the jaws. A tumor of this character may be attached by a broad base or a rather narrow pedicle. Such a tumor is called an epulis. It is often difficult to differentiate between these tumors and fibromas which occur upon the jaws. These firm periosteal sarcomas also occur on other bones, especially on the ends of long, hollow bones. Spindle-cell sarcomas also occur in the dura, forming a part of the tumors known as fungus duras matris. The fibrosarcomas developing from bone marrow contain a large number of giant cells and are rela- tively benign. Their position and clinical symptoms correspond to those of myeloid sarcomas. SARCOMAS 849 Tlic nodular, encapsulated tumors developing from the synovial sheaths of tlie tlexor tendons of the fingers have a similar structure, and are, likewise, not very malignant. Their red or yellowish-brown color is due to the deposition of blood pigment following haemorrhages caused by trauma. Sarcomas of Nerves. — If a sarcoma develops from the connective tis- sues of a nerve, a nodular, fusiform thickening or a tumor which is encapsulated at first forms upon the nerves. These tumors grow more rapidly than fibromas. They press upon the nerves, giving rise to con- siderable pain, and may finally infiltrate the surrounding soft tissues. Occasionally a sarcoma develops from a sim- ple fibroma which may have existed for some time. Retroperitoneal Sarcomas. — Sarcomas of this group develop in the posterior abdom- inal wall and in the mesentery, forming large growths with nodular surfaces. They form nuich more extensive growths and develop more rapidly than retroperitoneal fibromas. Fibrosarcomas of the different organs (mammary, thyroid, and parotid glands, tes- ticle, kidney, uterus, etc.) rapidly destroy the parenchyma of the organ involved. The se- rous membranes (pleura, peritoneum) are but rarely primarily involved. P^iG. 3.53. — Soft, Small, Spin- dle-Cell Sarcoma of the Fascia Lata. Fig. 354. — Central Giant-Cell Sarcoma of the Upper Jaw (Resection Prepar.\tion). The different forms of primary sarcoma of the lymph nodes, except- ing the lymphosarcomas, are exceptionally rare. Diagnosis. — Usually one mu.st be content with making a general diag- nosis of sarcoma, differentiating it from other forms of malignant 850 DIFFERENT VARIETIES OF TUMORS growths. Sometim&s the diagnosis as to the histological structure of the tumor can be based upon the position of the tumor; for example, peri- osteal giant-cell sarcomas are common upon the alveolar processes of the jaws. Often it is impossible to ditferentiate between a lympho- sarcoma, a chondrosarcoma, and a myxosarcoma. The color of a melano- sarcoma, the consistency and position of an osteosarcoma enable one, as a rule, to make a positive diagnosis as to the character of the tumor. Fig. 355. — Gi.^js't-Ckll Sarcoma of the Mammary Gland (mostly Large Cells). It is often exceedingly difficult to make a diagnosis between a sarcoma and a deep inflammatory mass, especially a gumma. In these cases an exploratory incision is a much more rapid diagnostic method than anti- syphilitic treatment. Treatment. — The treatment of a sarcoma consists of as early and complete renjoval as possible, if there are no demonstrable metastatic growths. If the tumor is so situated that an amputation is possible, it should be performed if there are no contra-indications. SARCOMAS 851 CHONDRO- AND OSTEOSARCOMAS Chondro- and osteosarcomas develop from the skeleton ; more rarely from the soft tissues. Chondrosarcomas are closely related o-onetically to chondromas, from which they may develop, and occur in the same regions. They are char- acterized, like the chondromas, by the formation of a hyaline ground substance. They dili'er from the chondroma in that they are more cellu- lar, being composed of groups or colunnis of round, fusiform, or poly- morphous cells, surrounded by small or large islands of cartilaginous sub- tance. "Within this ground substance lie isolated groups of cartilage cells, usually without a capsule. Appearance of Cut Surface. — The cut surface of a chondrosarcoma does not have the homogeneous appearance of the cut surface of the chon- droma. The cartilaginous parts appear as opal, bluish areas in the soft, reddish, sarcomatous tissue. Calcification of the cartilage is indicated by the development of white areas in the tumor, ossification by its hardness (chondro-osteosarcomas). Softening with subsequent liquefaction may lead to the formation of large cystic cavities. Chondrosarcomas grow rapidly, often attaining enormous size, infiltrating the soft tissues, and destroying bone. Not infrequently thoy form metastases, as the prolifera- tion of the cells is so rapid that there is scarcely time for p^v,> the formation of Osteosarcomas, comas, or ossify are much more chondrosarcomas, speaking, one means by osteosarcoma a tumor contains bone or its cedents, and not a fibrosa P,-. ■ v.-!s.'v:;-:-.-'-^;%*^' • .1?; coma developing from It is not always possible to make a sharp distinction, as a fibrosarcoma developing from the periosteum may contain fig. 356.— Pekiostkai a of the bone formed by the reactive ^'^^-^- Sarcomatous tK.uewitlig.ant-cells and osteoblasts mav be seen between newly formed growth Ot the latter. calcified (a) and osteoid (6) lameUa;. Osteosarcomas develop most frequently in the ends of long hollow bones, in the bones of the pelvis, the scapula, the clavicle, the sternum, the bones of the skull, the short, hollow bones, the vertebrae, the os calcis, and the patella. They 852 DIFFERENT VARIETIES OF TUMORS develop most frequently during the period of growth and are divided into periosteal (peripheral) and myelogenous (central) tumors. Periosteal sarcomas (Fig. 356) are composed mostly of spindle cells, but also contain round- and giant-cells. The cells lie in a stroma, which resem- bles bone, and sometimes is arranged in regular lamellee, and at other times has no definite arrangement whatever. If the tumor contains only deli- cate, non-calcified, osteoid lamellae, it is spoken of as an osteoid sarcoma. These tumors are closely related to those less malignant tumors which are composed of broad, non-calcified lamellae of a cartilaginous ground sub- stance, between which are found irregular cells, which have been called osteoid chondromas by Virehow. The formation of bone is rarely evenly distributed throughout the whole of the tumor. It is much more advanced in the older, central parts of the tu- FiG. 358. — Cystic O teosarcoma of the Sternum. Fig. 357.— Periosteal Osteosarcoma ™0r than in the cellular, and therefore OF THE Lower End of the Femur softer, peripheral parts. Areas com- "wiTH A Radiating Arrangement ^ j ^ .• it ^ i, OF THE Trabecul.^. OF BoNE. P^^^^ ^f tissuc rcsemblmg bone alter- nate with those composed of osteoid or chondroid tissue. The lamellae, which frequently contain and are surrounded by osteoblasts, either form a spongy framework in which the sarcoma cells and the vessels supplying the marrow lie, or are arranged so that after maceration (Fig. 357) they appear as needles and projections radiating in all directions or irregularly grouped. Periosteal sarcomas appear in the beginning as circumscribed nod- ules, varying in consistency and covered by a layer of periosteum. They are most common in long, hollow bones, beginning as a rule about SARCOMAS 853 the motnpliysis. During later j^rowth siu'h a tumor may involve the entire bone, whieh then becomes transformed into a shapeless, nodular mass resemblinj; a eliib. If the tumor grows slowly, forming considerable bone, only the superficial part of the cortex is destroyed and the base of the tumor is surrounded by osteophytes. If the tumor grows rapidly and perforates its capsule, it invades muscles, tendons, and Fig. 359. — Myelogenous S.\rco- MA of the Lower End op THE FeMUK, which H.\S EX- TENDED Along the Surface of the Bone After Rupture through the Epii'hysis. Fig. 360. — Osteoid Sarcoma of the Patella (Sag- ittal Section through the Knee Joint). ligaments, and passes along the Haversian canals to the medullary cav- ity, destroying the cortex. The tumor can be differentiated from the bone marrowy by its lighter color. In advanced cases, therefore, it is often difficult to determine whether the tumor originated in the peri- osteum or bone marrow. The articular cartilage resists for the longest time the invasion of the tumor, but the joint capsule may be early involved at its line of attachment to the bone, and the tumor may ex- tend to the joint cavity in this way. The clinical picture of the periosteal sarcoma resembles very closely that of th(^ myelogenous. The periosteal has no bony shell surround- ing it. wliicli is ])resent in the beginning of the myelogenous forms. Myeloid Sarcomas. — The myelogenous osteosarcomas, or myeloid sar- comas, occur most frequently in the spongy ends of long, hollow bones 854 DIFFERENT VARIETIES OF TUMORS (especially in young people), being situated in the metaphysis close to the epiphyseal cartilage more frequently than in the epiphysis. They may, however, develop in any other of the bones. The mandible, carpal, and tarsal bones, the bones of the skull, the vertebree, and pelvic bones are most frequently involved after the long bones. Multiple myeloid sarcomas have been observed, especially in association with osteitis deformans (p. 749). Histology. — They are composed of round and spindle cells or large cells of different shapes, and contain giant cells more frequently than the periosteal forms. Generally the for- mation of bone is less marked than the cellular proliferation. These tumors are exceedingly vascular and may pulsate. They are often spoken of as l)one aneurysms. Thrills may be elicited upon palpation and bruits upon aus- cultation. Hfemorrhages within the tumor tissue are relatively common, and pigment is deposited in the tissues which assume a yellow- ish or reddish brown color. Softening with subsequent liquefaction leads to the formation of cysts, the walls of which contain trabeculse of bone. Mode of Growth. — Generally these tumors have an expansive growth for some time, and are therefore . rela- tively benign, being the least malignant of all sarcomas. This is especially true of the tumors composed of spindle cells with a fibrous or osteal ground substance, and containing large numbers of giant cells. As the tumor grows the bone be- comes expanded, but not, as in inflammatory processes, as the result of a thickening of the cortex. The cortex gradually undergoes a pres- sure atrophy from within as the tumor enlarges, and is not replaced by new bone formed from the periosteum. The bone surrounding a central tumor is gradually destroyed, and spontaneous or pathological fractures may occur. Some- FlG. 361. — Osteosarcoma OF THE Fibula. Fig. 362. — Myelogenous Giant-Cell Sahcoma of the Lower End of THE Radius (Woman Thirty - five Years of Age. Resection Preparation. No Recurrence After Four Years). SARCOMAS 855 tiiiios, ospofially in .snrcoiii.is of the jaw, tho thin, yioklin<; sliell of hone iiiipai-ts a " ]>ai-cliiiirntlike eraekh; " (I)upuytren) to tlie pal- pating? finder. If the periosteal hone formation is not as rapid as the bone al)sorption, the bony capsule surround- ing the tumor is sooner or later ruptured, and the tumor then extends to the soft tissues and invades tiie joint and surrounding bone. In- filtrating growth then predominates, resulting in the rapid formation of metastases. Malignant Transfor- mation. — The transition from a relatively benign to a malignant stage does not progress with the same rapidity in all eases. The soft, cellu- lar forms (the so-called medullary forms) rup- ture through their cap- sule and assume an in- filtrating growth much earlier than the firm forms (containing large numbers of giant-cells), which, even after exten- sion to the ,^oft tissues, may preserve for a long time their tendency to limitation and expansive growth. Symptoms. — Usually the first symptoms are pain and rapidly devel- oping enlargement of the bone involved. In mj-eloid sarcomas of the bones of the extremities, spontaneous frac tures and a serous exudate into the neighboring joint may develop early Fig. 363. — Centhal Osteos.\rcom.\ or the Femxjr with Rupture into the Soft Tissues and Knee Joint. 856 DIFFERENT VARIETIES OF TUMORS / If the pain and enlargement of the bone have not been marked, it is often difticnlt to interpret correctly the clinical significance of the frac- tnre or of the accumulation of fluid in the joint. The more rapid the growth, the earlier the func- tional disturbances, result- ing from the displacement and infiltration of the mus- cles and nerves and from pressure upon the large veins, develop. The symp- toms depend upon the po- sition of the tumor (for example, a tu- mor growing into the cranial cavity from the sur- rounding bones produces symp- toms of cerebral compression ; a tu- mor developing; from the bones of the thorax, symp- toms of lung com- pression). Deep ulcers, which bleed profusely and easily become infected, follow infiltra- tion of the skin. Diagnosis. — The diagnosis in advanced cases is based upon the pres- ence of a large, rapidly growing tumor which is firmly attached to the bone involved by a broad base. The boundaries of the tumor cannot be sharply defined, as in the advanced cases the tumor has already con- tracted adhesions Avith the surrounding muscles. Sometimes it can be demonstrated that the function of the muscle is interfered with or lost, indicating that it has been infiltrated by tumor tissue. In the large and rapidly growing tumors, symptoms of metastatic lung foci, accom- panied by those of a pleuritic effusion, are frequently present. It is often impossible to determine by the position and consistency of the tumor whether it developed primarily from the periosteum or medulla, or even from the soft tissues, whether it is an osteo-, chondro-, or fibrosarcoma. This, however, is of little practical importance. Mye- logenous are more common than periosteal forms, and often cause spon- FiG. 364. -Osteosarcoma of the Upper End of the Humerus IN A Patient Nineteen Years of Age. SARCOMAS 857 taneous fraetnros. Tlie early diairnosis is diffienlt. The symmetrical enlarjiement of the bone, accompanied by an acute hydrops of the neiirhborint; joint, may suggest some chronic inflammatory process, such as tuberculosis or syphilis. Sarcomas fretiuently develop in parts of the bone where chronic inflammatory processes (such as tuberculosis and syphilis) are common, and are often accompanied by some fever. The small periosteal sarcomas resemble quite closely fibromas, chondromas, and osteomas, being nodular and hard. A spontaneous fracture favors the diagnosis of sarcoma, but even when a spontaneous fracture is present a positive diagnosis cannot always be made. A sarcoma can- not be excluded even when the lesions are multiple, but the prob- abilities are that when lesions are primarily multiple the tumors are not malignant. In all cases care- ful clinical observations are necessary, but they should not be extended over too long a period. If the skin over a rap- idly growing tumor be- comes red, the diagnosis must be made between a suppurative osteomye- litis and a gumma, for a tuberculous lesion, even after rupture into the soft tissues, does not in- crease rapidly in size, and a sarcoma, although containing a large num- ber of vessels and some- times causing fever, does not produce an inflam- matory redneas of the skin covering it. If, dur- ing the period of obser- vation, potassium iodid has been administered without results, chronic suppurative osteomye- litis is the only diagnosis that can be made. If, on the other hand, 55 Fig. 365. — Preparation from THE Same Case Seen from Beiuxd. (Removal of the shoulder girdle.) 858 DIFFERENT VARIETIES OF TUMORS there is no inflammatory redness of the skin, a diagnosis of tumor may be made, and it may be regarded as a myelogenous form if a bony cap- sule can be demonstrated, either by palpation or the X-ray. Rapid growth spealvs for a sarcoma and against benign tumors (fibroma, chon- droma, echinococcus cysts of bone). It should, however, be clearly understood that many sar- comas have a relatively slow growth. If there is any sus- picion that the lesion is of a sarcomatous nature, clinical- observations should not be prolonged for more than one or two weeks. [In these cases an exploratory incision should be made early, and if the macroscopic appearances are characteristic enough to justify a diagnosis of sar- coma, the lesion should be removed. If the lesion is not sufficiently characteris- tic, tissue should be removed and examined microscopical- ly, and then if the lesion is malignant, operative meas- ures, unless there are contra- indications, should be advised at once.] X-ray pictures frequently aid in making a diagnosis. Exostoses may be easily rec- ognized, as they are conical or pedunculated, and their sharp outlines become con- tinuous with those of the bone. In pictures of peri- osteal sarcomas, on the other hand, one sees irregular, cloudy shadows, the density of which depends upon the amount of bone the tumor contains. The boundaries of the tumor gradually become continuous with the outlines of the bone, which are indistinct at the points where the growth has reached the periosteum. In myelogenous sarcomas a faint shadow, sur- FiG. .366. — Soft, Sfixdle-Celiv Sarcoma of the Upi'er Epiphysis of the Humerus Removed FHOM A GiHL Fourteen Years Old. SARCOMAS 859 rounded by a thin, expanded cortieal layer of l)one, may be seen when the bone surrounding- the tumor has undergone pressure atrophy. The bright shadows merely indicate destruction of bone, and may be found in abscesses and eysts as well as in tumoi's (sarcoma, chondroma). A delicate bony capsule, however, speaks against intlannuatory foci of all kinds, even against tuberculosis, at least as it occurs in long, hollow bones, and the symmetrical shadows with indistinct boundaries against chondromas and cysts. Similar findings enable one to make a positive diagnosis in spontaneous fractures. If a central gumma is considered, the differential diagnosis can be easily made, as the gumma is always associated with irregular hyperostoses developing from the cortex. The diagnosis is most difficult when a rapidly growing, soft, peri- osteal or myelogenous sarcoma invades an adjacent joint. As the tumor invades the joint capsule and para-articular tissues, a doughy swelling develops and the joint becomes fusiform in shape, suggesting a tuber- culous or ha-mophiliac lesion, the latter especially, as aspiration reveals blood. The X-ray findings are, as a rule, not definite enough to enable one to make a positive diagnosis. If a careful examination is made, a tumor attached to the bone near the joint may be palpated. Soon, how- ever, the tumor extends beyond the joint, and the extremity enlarges as the result of circulatory disturbances. The enlargement is in marked contrast to the atrophy associated with tuberculosis of joints (Fig. 363). In children the soft, myelogenous tumors, developing in the metaph- ysis, often cause a separation of the epiphysis. In these cases a diagnosis of suppurative osteomyelitis may be made, especially if the soft tumor masses fluctuate and there is fever. It may be very difficult at times to differentiate between a tumor of this character and an aneurysm if the tumor develops adjacent to a large blood vessel (e. g., in the axillary fossa or popliteal space), for a telangiectatic sarcoma which pulsates may form. Illustrative Cases to Demonstrate Difficulties in Diagnosis. — A few examples may be cited to illustrate how difficult it is at times to make a correct diagnosis. A boy ten years of age fell ill with a swelling of the entire left arm. When first seen the arm was cedematous and the subcutaneous veins dilated. The cause of the venous stasis was a thickening of the left clavicle. This thickening, which gradually fused with the deeper struc- tures, was covered by normal skin. The diagnasis rested between a chronic suppurative osteomyelitis and a sarcoma of the clavicle. After two weeks' observation the skin over the thickened area became slightly reddened and made the diagnosis of osteomyelitis positive. A focus of granulation tissue which communicated through a cloaca with the 860 DIFFERENT VARIETIES OF TUMORS interior of the bone was situated beneath the reddened skin. The path- ology corresponded to that of the sclerotizing form of suppurative osteo- myelitis. Permanent healing occurred after the newly formed bone was chiseled away and the granulation tissue removed. A boy fifteen years of age fell ill with a painful swelling of the upper articular end of the left tibia. For two weeks the swelling had rapidly increased in size, especially anteriorly just below the tuberosity, where it was firmly attached to the skin. The temperature was about 98.8° F. X-ray pictures were negative. The diagnosis rested between a periosteal sarcoma and a superficial suppurating focus. The ex- ploratory incision revealed a soft periosteal sarcoma. Three weeks before examination a slightly painful, poorly defined swelling developed in the middle of the right leg over the fibula, in a man forty-five years of age. The skin was slightly adherent to the h^rd swelling, the contour of which became continuous with the fibula. Was the lesion a sarcoma, a suppurative osteomyelitis, or a gumma of the fibula? The X-ray pictures revealed an irregularly thickened fibula surrounded by a faint shadow cast by the mass. The thickening was not distinct enough to warrant a diagnosis of a gumma. After a week the skin over the swelling became reddened. A sarcoma could be ex- cluded with certainty and a tentative diagnosis of a chronic suppura- tive osteomyelitis could be made. Just as an operation was about to be performed a round, white scar the size of a nickel, such as remains after the healing of a syphilitic ulcer, was found upon the other leg. The swelling disappeared completely under antisyphilitic treatment. A woman thirty-five years of age suffered for a week with a swelling of the right wrist joint, which was supposed to be the result of a sprain. The joint was immobilized for two weeks, and when the dressings were removed the exudate had disappeared. Some slight thickening of the lower end of the radius which suggested some inflammatory lesion, such as tuberculosis or suppurative osteomyelitis, or a sarcoma could then be palpated. The X-ray pictures revealed a bright shadow surrounded by a thin layer of bone; therefore a suppurating focus could be ex- cluded. The complete destruction of the spongy bone of the metaphysis and of the epiphysis spoke against tuberculosis. The operation revealed a myelogenous giant-cell sarcoma about to rupture into the joint. The resected portion of the bone is reproduced in Fig. 362. The patient is well, and no recurrences have developed four years after the operation. An emaciated man, twenty years of age, developed a painful swell- ing of the right knee so(m after a fall. The joint was greatly swollen, and the normal outlines of the joint were lost as the capsule was filled with an exudate. The swelling was of a doughy consistency ; fluctuation SARCOMAS 861 and patcllai- l)alottcnient pould bo elicited oidy when eoiisidei-a])le pres- sure was made. The entire eliiiieal picture resembled closely tiiat of tuberculosis. Aspii-ation i-eveali-tl (hii'k blood. It was possible, there- fore, tliat the lesion miiiht have been due to luemophilia, and the patient irave a histoiy su«i'^estive of this disease. Tlie joint was th<'i'efore im- mobilized for two weeks. After this time a soft swelling- attached to the boiu' could be demonstrated, which extended upward above the eomlyle of the fennir. X-ray pictures at this time Avere negative. A diagnosis of sarcoma of the femur with rupture into the joint was maile, which was verified b.y operation (amputation of the thigh). A soft myelogenous sarcoma which was very vascuhir and cystic had rup- tured through the cortex at the point of attachment of the capsular liga- ment, and had first extended into the joint and later upward along the bone. For other examples see chapter dealing with diagnosis of suppura- tive, tuberculous, and syphilitic lesions of bone. Significance of Glandular Enlargement. — The glandular enlargements which occur in many cases of sarcoma of bone (Nasse) are not of much value in making an early diagnosis. The enlargements are frequently caused by the absorption of decomposition products from the tumor, and in the beginning they cannot be differentiated from intiammatory hyperplasias. Prognosis. — The prognosis of sarcomas developing from bone is usu- ally bad. Even the more benign forms gradually lead to a destruction of bone and the formation of metastases. Indications for Treatment.— There is no ciuestion that sarcomas de- veloping from bone or cartilage should be completely removed when there are no metastatic growths, unless they are so large or are so situated that removal is impossible. The extent of the operation that is necessary varies, as all of these tumors are not of the same degree of malignancy. The indication as to the extent of the operation that should be performed is dependent to a certain degree upon the character of the cells composing the tumor, as it is well known that giant-cell sar- comas represent the most benign, small, round-cell sarcomas the most malignant form of this class of tumors. The character and rapidity of the growth also determine, to some extent, the character of the opera- tion. Well encapsulated tumors with an expansive growth — especially giant-cell sarcomas, which may be recognized by their brownish-red color — may be removed by blunt dissection with a periosteal elevator or shelled out with a sharp spoon. Experience has shown that even after such a conservative procedure as this the dangers of recurrence are not great. Usually, even in the treatment of encapsulated tumors, it is to be recommended that a part of the surrounding bone, the parent tissue S62 DIFFERENT VARIETIES OF TUMORS of tlie tumor, be removed. The part of the bone involved should be com- pletely removed with a chisel, bone-cutting forceps, or saw, if the bony capsule is thin. If the tumor is situated upon one side of the bone, or is surrounded by a thick layer of the same, it may be completely removed and the continuity of the bone still be preserved by an osteal bridge. Extensive resections of bone have given good results even in the treatment of central and periosteal sarcomas which have ruptured through their capsules. Of course the results following resection have only been good when the operation was performed before the tumor involved the soft tissues (von Bergmann, von Bramann, von Mikulicz, Nasse, and others). In the other forms of sarcoma nodules develop very early in the part of the bone adjacent to the primary focus after resection (Konig). The resected end of the bones may be approximated and held in apposition by silver wire or strong catgut sutures or a piece of dead bone may be placed between them. Of course the frag- ments should be immobilized until union is complete. If the tumor has already infiltrated the soft tissues, or if it is a soft, rapidly growing one, an amputation should be performed if it is situated upon an ex- tremity; if the tumor occurs upon the trunk, neck, or head, it and the tissues adjacent should be removed — for example, if the sarcoma is in the orbit, the eye should be removed. In the treatment of large tumors of the thorax it is often necessary to open the abdominal and thoracic cavities. Nasse has determined, in examining tissues from a number of osteo- sarcomas, that the cells frequently extend early in the clinical course of these growths along the blood vessels of the muscles. This imposes upon the surgeon not only the duty of operating as soon as possible, but also of removing all those muscles attached to the bone involved, even to their points of origin — that is, above the adjacent joint. There- fore this rule has been formulated, that in sarcomas of the forearm or leg a high amputation of the arm and thigh respectively should be performed; in sarcoma of the humerus the entire upper extremity in- cluding the shoulder girdle should be removed ; in sarcoma of the femur a disarticulation at the hip should be performed with the removal of all the muscles passing from the pelvis to the femur. [After operations for sarcoma the mixed toxins of prodigiosus and erysipelas (Coley) should be iLsed as an insurance against recurrence.] The prognosis of sarcomas developing from bone is bad. Reinhardt estimates that permanent recoveries occur in only 18 per cent of the cases. These unfavorable results are much more often due to metas- tases, especially in the lungs, than to local recurrences. The metastases often develop so rapidly after the operation that it is probable the cells SARCOMAS 863 had already l)0('n d('])<)sit('d, ])ut that tlic foci vvoi-c not larjjjc onough to give I'isc to syiiiptoiiis or G9. — Lymphosarcoma of the Neck and Left Axillary Fossa. the most radical procedures are unsatisfactory, as recurrences rapidly develop. Hodgkin's disease (malignant lymphoma) differs from lymphosar- coma, especially in its clinical course. In this disease also there is a proliferation of lymphatic tissue, espe- cially of the lymphatic nodes. The histological changes resemble very closely those found in Ixiiipliosarcoma, except that there is no tendency to disintegration. Clinical Differences between Hodgkin's Disease and LympJiosarcoma. — As the disease progresses two distinct clinical differences between it SARCOMAS 867 and lymphosarfionin iti.iy Ix' noted:- (1) Tii Ilod^kin's disease the changes arc limited to tlie lymph nodes, and th(> prolit'eratint;- lymphatic tissue does not break through the capsules of tlie nodes and involve ncijj^hbor- ing structures. (2) In Ilodgkin's disease there is a progressive and suc- cessive involvement of dilTd'ent chains of lymph nodes, including the spleen, and in I'arc cases the bone nian-ow. The development of foci in the liver, lungs, kidneys, and bone mar- row would seem to indicate that malignant lymphoma is closely related Fig. 370. — Lymphosarcoma of the Neck. Rapid recurrence following operation. (From Professor Bevan's Surgical Clinic.) to true tumors. It cannot, however, be demonstrated that these new foci are of metastatic origin, as it is possible that they may have devel- oped from preexisting lymphatic nodules. 868 DIFFEREXT VARIETIES OF TUMORS Lymphatic lenlapiiiia may resemble malignant lymphoma quite closely, as in this disease there is also a progressive enlargement of the lymph nodes with the formation of so-called heteroplastic nodules in different organs. A blood examination enables one to differentiate be- tween the two very easily, as in lymphatic leukaemia the leucocytes are greatly increased, reaching 150,000 or more per cubic millimeter, and there is a great preponderance of lymphocytes which constitute from ninety to ninety-nine per cent of all the cells, while in malignant lymph- oma the number of leucocytes is normal or only slightly increased. Clinical Course and Appearance of Lymph Nodes. — Aleuksemic ma- lignant lymphoma (Hodgkin's disease, pseudoleukaemia) develops most frequently in young and vigorous people. The disease begins with a gradual painless enlargement of the lymphatic nodes, the cervical group being most frequently, the axillary and inguinal less often, primarily affected. The separate nodes enlarge to form soft tumors, if there is connective-tissue induration to form hard ones, the size of a walnut or apple, and the entire chain of nodes becomes transformed into a nodular mass. The nodes are homogeneous and grayish-red in color upon section, the distinction between cortex and medulla being lost. There is no tendency to regressive changes or to break through the cap- sule of the lymph nodes and invade surrounding tissues; therefore the separate nodes can be palpated beneath the normal skin and displaced upon each other. The growth is, as a rule, intermittent, periods of rapid growth alter- nating Avith periods during which the nodes remain stationary. When the proliferative changes extend to neighboring nodes, and the lymphatic tissues of the pharjmx, gastrointestinal tract, spleen, and thymus gland become involved, general symptoms may develop. These consist of an intermittent fever, increasing ancemia, and weakness. Digestive dis- turbances (vomiting, diarrhea), secondary to involvement of the lym- phatic tissue of the gastrointestinal tract, and interference with respira- tion and deglutition, secondary to proliferation of lymphatic tissue of the pharynx, may rapidly increase in severity and cause death, which in severe cases may occur in a few months. Diagnosis. — The diagnosis is difficult so long as a single chain of lymph nodes is affected. An examination of the blood, with the absence of the characteristic changes of leukaemia, and the fact that the separate nodes may be palpated and moved freely beneath the skin and upon each other enable one to exclude lymphatic leukaemia and lymphosar- coma respectively. Lymph nodes the seat of gummatous lesions are hard and soon contract adhesions with the surrounding tissues and skin, lead- ing to the formation of quite characteristic ulcers. The differential diag- nosis between malignant lymphoma and tuberculous lymph nodes, espe- SARCOMAS 869 cially when the latter are small and their characteristic changes but little pronounced, is often very difficult. Tuberculous lymph nodes are more common in the young and are more frequently bilateral. Regressive changes are common in tubercu- lous nodes, leading to the formation of abscesses and fistula?. The ex- tent of the regressive changes varies, but, as a rule, the diagnosis can be made even before the nodes have contracted adhesions with surround- FiG. 371. — Malignant Lymphoma in a Woman Thirty Years of Age. (After Dietrich.) ing tissues or have broken down to form tuberculous abscesses. There are, however, rare forms of tuberculosis of lymph nodes in which the entire lymphatic system is involved and in which softening does not occur. These hyperplastic forms of tuberculosis resemble very closely malignant lymphoma. In these cases a differential diagnosis based upon clinical data alone is impossible, and the tuberculous nature of the 870 DIFFERENT VARIETIES OF TUMORS lesions can be determined only by an accurate microscopical examination (demonstration of bacilli and giant-cells). [Crowder has reported an exceedingij^ interesting case of generalized tuberculous lymphadenitis with the clinical and anatomical picture of Hodgkin 's disease. In discussing this case he says : ' ' The great number of terms applied to the condition designated as pseudoleukemia, based upon the somewhat varied clinical course, as well as a limited variation in the gross and minute pathological changes and the greatly differing interpretation of these changes by different observers, are evidences of the heterogeneity of the class to which the name refers. The etiology is for the most part admittedly unknown; it is also admittedly various. The symptom complex determines the disease as the disease is now understood. AYhy, then, exclude those cases in which the tubercle ba- cillus is known to be the cause? A disease of known origin is not to be singled out and classed as a different disease, but as an etiological division of the heterogeneous class."] It should not be considered, however, that there is any relation between hyperplastic tuberculosis of lymph nodes and Hodgkin 's disease (Dietrich, Borst), even if cases have been reported in which the changes occurring in malignant lymphoma have been associated with tuber- culosis of the lymph nodes and viscera (Ricker and others). Treatment. — Xo attempt should be made at radical removal of the lymph nodes, even in the beginning of the disease, as there is a great tendency for the disease to recur and progress in other chains of lymph nodes. The internal administration of gradually increasing doses of arsenic in the form of Fowler's solution was recommended by Billroth, and in some cases it apparently has a favorable action. Decrease in the size of the lymph nodes and improvement of the general condition have been noted after daily injection of 3 or 4 minims of Fowler's solu- tion into the enlarged lymph nodes (Czerny, von Winiwarter), after the injection of 3 or 4 minims of a one per cent solution of sodium arsenate into the subcutaneous tissues (von Ziemssen), and the use of the X-raj^s. Permanent recoveries after any line of treatment are apparently excep- tionally rare. [A number of these cases have been much improved by the X-ray. The tumors grow smaller, and even disappear entirely. The treatment should not be pushed too rapidly, as with the breaking down and absorption of the tumor masses severe and even fatal toxemia may occur.] LiTERATLTUE. — Coenen. IJeber ein LjTnphosarkom der Thymus. Arch. f. klin. Chir., B(l. 73, 1004, p. 44.3. — Dudrich. Ueber die Beziehungen der malignen Lymphome zvir Tubfrkiilose. Beitr. z. klin. Chir., Bd. 16, 1896, p. 377.~Fr. Fischer. Krankheiten der Lyinphgefasse, Lymphdriisen und Blutgefasse. Deutsche Chir., 1901. — Richer. Ueber die Beziehungen zwischen Lymphosarkom und Tuberkulose. Arch. f. klin. Chir., Bd. SAR(X)MAS 871 !}(), IS'.t,"), i>. 573. — SUrnbcnj. riiivcrscllc I'iimilrerkr:inkun{j:('n dos lyinj)li;ier- ganges in Sarkoin. Zi-itschr. f. llcilk., Bd. 2."), I'.KM, p. 2G9. Myelomas and Chloromas. — Myelomas and chloromas, which are rare and jx'culiar I'oriiis of tumors, should be classified with lymphosarcomas. Multiple myelomas are rare. They appear as small, nodular, circum- scribed, soft, grayisli red ui-owths, especially in the red mari-ow of diffeivnt bones. Tliey ai'e rei^arded by some as lymphosarconuis, by otheivs as localized hyperphisias of bone marrow. They have no tend- en('y to infiltrate surrounding tissues oi- to foi'iii metastases, but remain limited to the bones primarily involved. 'I'lie b(me adjacent to a mye- loma is, however, gradually destroyed and deformities of the spine, defects in the skull bones, and spontaneous fractures may occur. The disease is most connnon in old people. Often it runs a rapid course with intermittent fever and symptoms of a severe primary anjemia, and terminates fatally. It has frecpiently been demonstrated that a peculiar product known as Bence- Jones 's albumose appears in the nrine in multiple myelogenous osteosarcomas and myelomas. Tlie reaction has been regarded as almost ])athognonionic. Askanazy has, however, found the substance in the urine in a case of lymphatic lenk;emia. He has come to the conclusion that Bence- Jones 's albumose is indicative of som(^ lesion of tbe bone nuirrow, most frecpiently of multiple myelomas, but also occasionally of other diffuse changes, such as occur in lymphatic leukannia. LiTEUATURK. — Hoffmann. Heber Myelomatose, Leukamio iind Ilodgkiiiischc Kraiikh. Arch. f. klin. Chir., Bd. 70, 190(5, ]). \^SA.—W^elamL Studien iiber das priniiir multipel auftrctende Lyniphosarkom der Knochen. Virch. Arch., Bd. 166, 1901, p. 103. — Winkler. Das Myeloni in anatomischer und klin. Beziehung. Virch. Arch., Bd. 161, 1900, p. .'SOS. — Yellinck. Zur klin. Diagnose und path. Anatomie des nuiltiplen Myeloins. Virch. Arch., Bd. 177, 1904, p. 96. — v. VereUly. Ueber das Myeloni. Beitr. z. klin. Chir., Bd. 48, 1906, p. 614. Chloromas are also rare. They appear as multiple new growths com- posed of lymphadenoid tissue. They are most connnon in children and young people, developing as firm, more rarely soft, tumors from the the periosteum of the bones of the skull and face (especially from the squamous and petrous portions of the temporal bone, the maxilla and orbits (both orbits usually being involved), also from the sternum, ribs, vertebrae, and long, hollow bones. They resemble quite closely very malignant sarcomas, in that they grow rapidly and form metastases in lymph nodes and the different viscera, but differ from sarcomas in that 872 DIFFERENT VARIETIES OF TUMORS the tumors have a bright green, yellowish, or grayish-green color, which is also reproduced in the metastatic growth. According to von Reck- linghausen, the color is due to pigment formed by the cells; according to Chiari and Huber, to the fat contained in the tumors. Literature. — Risel. Zur Kenntnis des Chloroms. Deutsch. Arch. f. klin. Med., Bd. 72, 1902, p. 31. — Rosenblath. Ueber Chlorom und Leukamie. Ibid., p. 1. (c) SARCOMAS COMPOSED OF MYXOMATOUS TISSUE Myxomas and Myxosarcomas. — These tumors are composed of soft, often indistinctly fluctuating, gelatinous masses of tissue. Their sur- faces upon section appear yellow or grayish-red and transparent. A tenacious fluid containing mucin and permeated by delicate fibers may be removed from the cut surfaces of such a tumor. The tissue composing these tumors closely resembles, histologically, embrvonal connective tissue from which white fibrous tissue and fat Fig. 372. — Myxosarcoma, a, Myxomatous tissue; b, columns of cells; c, fibrous tissue. (After Ziegler.) are formed. It has its prototype in Wharton's jeWy and the vitreous humor. Histology. — The structure of these tumors is quite characteristic, polymorphous, stellate cells, provided with long processes, being found within a homogeneous, slightly granular or fibrillated ground substance, which is traversed by a relatively large number of blood vessels. Single giant-cells may be found in some parts of the tumor. No tumor is ever composed of myxomatous tissue alone. It is usually SARCOMAS 873 ) found in eonibinntion with other kinds of tumor tissue, espeeiidly with i'.il, cjirtihiye, fibrous, and sarconiatt)Ms tissue. For tliis reason the tumors are ealled lipomyxomas, ehondromyxomas, fibroniyxomas, and u'.yxosareomas. If tlie tumor contains a haro-e nuiidier of bk)od vessels it is called a myxoma teleangiectati- eum or cavernosum ; if the tissues uiidei'^'o I icjuef action and cyst for- mation the tumor is described as a myxoma cysticum. Some connective-tissue tumors (fibroma of the nasal nnicous mem- brane, pendulous fibroma or lipoma of the surface of the body) may be- come (edematous as the result of interference with their cii-culatiou and resemble myxoiaatous tissue, but these tumors should never be classified with myxomas. The deli- cate but distinct fibrillar ground substance, together with the micro- scopic mucin reaction (acetic acid), are the important characteristics of myxomas. .Mucoid degeneration may occur in large tumors, such as chondromas, osteomas, fibromas, sar- comas, but in these cases there is, strictly speaking, no formation of myxomatous tissue. In order to sig- nify this difference between the two forms, a fil)roma, chondroma, or other tumor which has undei'gone secondary nmcoid degeneration is called a fibroma- or chondroma- myxomatodes, etc., while a tumor which is composed of both myxomatous or fibrous tissue is called a myxofibroma or fibrom.yxoma. Origin, Distribution, and Clinical Course. — These tumors are fre- quently of congenital origin. This indicates that they are the result of developmental disturbances occurring in embryonal life. Congenital tumors of this character have been observed in the cheeks by Zahn, in the remains of the umbilical cord by O. Weber, Kaufmann, and von Winckel, and in the mesentery by Borst. The displaced embryonal myxomatous tissues do not always form myxomatous tissue only, but fi])rous and sarcomatous tissues as well. 56 Fig. 373.- -^Iyxosarcoma of the F.\scia Lata. S74 DIFFERENT VARIETIES OF TUMORS ]\r\xomas form nodular or lobiilated tumors with well-developed con- iieetive-tissiKj septa. These tumors often attain considerable size. They are most common in young or middle-aged people, and their rate of growth varies. Some of these tumors have an expansive growth for a Fig. 374. — Myxosarcoma of the Fascia of the Arm. long time or permanently. The cellular tumor of a sarcomatous nature grows rapidly, breaks through its capsule, infiltrates the surrounding structure and skin, which ulcerates, and forms metastases. Some of these tumors are benign and some are malignant; depending upon their character, they are spoken of as myxomas or myxosarcomas. These tumors may develop in a number of different tissues and or- gans, occurring most commonly in the cutaneous and subcutaneous, inter- muscular and retroperito- neal connective tissues and fat, in bursas and fascia, the periosteum and bone marrow, the membranes of the brain and spinal cord, the connective tissues of the nervous system and different organs (mam- mary gland, ovary, tes- ticle, and spermatic cord, kidneys, liver, and lung). They are most frequently found in the thigh, developing from the skin, the subcutaneous and intermuscular connective tissues, the fascia and the bunsae about the knee joint, less frequently upon the arm and in the gluteal region. They occur, when they develop upon the external genitalia, the neck, face, and scalp, as subcutaneous tumors. In the orbit they develop from the retrobulbar fat or the optic nerve. Myxo- FiG. 375. — Myxoma of thi; Radial Xerve ix a Man Thirty-five Years of Age. Resection followed by nerve suture. Healing with complete return of func- tion. Xo rccurrcncr- after five j^ears. SARCOMAS 875 mas ol' tlie jxTiplKral nerves, like fibroinas, may occur as multiple tuinors. When developing upon the nerves, they separate the nerve fibers and cause fusifoi-iii thickonintrs of the nerve trunks. In children these tumoi'S inay develop from the remains of the umbilical cord. I\lyxiillaries and in the larger vessels of the viscera, especially in the liver. The metastases developing in a melanoma may be very extensive, appearing as closely grouped nodules, not only in one, but in many or all of the organs (lungs, liver, spleen, kidneys, brain, heart, intestinal wall, serous membranes, bone marrow, skin). Besides there may be an extensive discoloration of the skin and mucous membranes (melanosis). The amount of pigment contained in the metastatic growths varies. Adjacent to dark, black foci, may be areas and nodules Avhich contain little or no pigment. A rapid proliferation of the cells is associated with a decrease in the amount of pigment formed. The pigment set free when regressive changes occur in a melanoma may gain access to the blood stream. Part of the pigment is deposited in the different organs, and part is dissolved to be excreted in the urine (melanuria), which then assumes a dark color. Clinical Course. — The clinical course of melanomas depends upon their rapidity of growth and upon the number of meta.stases which form. Non-()j)erated cases die in a short time of anaemia, metastases and general infections developing from ulcerating and infected tumors. Kecurrences are very frequent after operation. The early development of metastases after an operation indicates that emboli had lodged in the tlifferent viscera before the operation was performed. A fatal termi- nation may at lea-st be delayed by the removal of the tumor, and some- times the first metastases develop years afterwards (Dobbertin). A permanent cure can be expected only when the operation is performed ygiy early. Diagnosis. — The diagnosis of melanomas in the early stages may offer some difficulties. A melanoma should never be mistaken for a benign tumor, as the former grows rapidly. A vascular sarcoma with exten- sive ha?morrhages may resemble a melanoma macroseopically, but a microscopic examination enables one to differentiate between the two. 882 DIFFERExNT VARIETIES OF TUMORS Indication for Treatment. — The indication for treatment, taking into consideration the malignancy of these tumors, is to remove the growth as early and thoroughly as possible. The regional lymphatic nodes should be removed, even if not enlarged. [It should be remembered that melanomas form early and extensive lymphatic metastases, differ- ing in this respect from other forms of sarcomas, and that if the opera- tion is to be at all successful the lymphatic nodes draining the primary tumor must be radically removed.] In a melanoma of the bulb of the eye, the contents of the orbit should be removed, even if the growth is still confined to the eye. In a melanoma of the skin, excision should be carried wide of the tumor into healthy tissues and down to muscle. If the tumor occurs upon the extremity, amputation at some distance from the growth should be per- formed, unless there are contraindications. Naevi. — The classification of n^pvi is still a mooted question. Von Recklinghausen and Ziegler regard them as pigmented forms of lymph- FlG. 382. N^VUS PiGMENTOSUS PiLOSUS. angiomas. Unna and others regard them as epithelial tumors. Borst classifies them as melanotic fibromas. Following Ribbert's example, we will classify them under melanomas. There are several reasons justify- ing this classification. In the first place, melanomas frequently develop .SARCOMAS 883 frdiii |)i<^iii('iit<'(l iiii'vi, Jiiid till' f;i('t that liotli may i)c pi^nin'iilt-fl itidi- cali's tlial flirrr is a cfrtaiii rclalioiisliip Itclwccii llic two. j'i^iiiciilcd iia'vi iiia\' apprar in a imiiihci- ol' dirrci-cut Tonus, between wliicli tliciT may be a number of ti-aiisitioiis. Naevi Spili. — The flat mevi (na'vi spili) appear as sharply defined, irrt'iiuiar, collfc-lxown oi" black areas in the skin, varyinir in si/.i- i'roin Fig. 3S3. — X.f.vis PiriMKNTosis ^'^;lua■<•nsx• the head of a pin to a saneer. They are covered by a smooth epidermis and do not extiMid above the level of the skin. They are very similar in gross appearance and in structure to lentigines and freckles, the latter developing upon the face and the doi'sum of the hands after exposure to the sun's rays. The flat, smooth luevi may be associated with ('le])liantiasis of the nerves, and may then be distributed with con- siderable regularity over the entii-e surface of the body (ride p. 794). Naevi Prominentes. — The elevated na'vi (na?vi prominentes) are like- wise shari)ly defined. They occur as deeply pigmented, beetlike, soft growths, which often become very large. In some cases they may ex- tend over the entire trunk. Their surfaces may be either smooth and shining, or covered with shallow furrows, corresponding to folds in the skin, or with a thick hair and warty growths. The following forms are differentiated, depending: upon the character of the surface of the na'vus: (a) Haiiy moles (na^vi pilosi, Fig. 382) are covered by a thick S84 DIFFERENT VARIETIES OF TUMORS growth of short dark hair, which is sometimes soft, at other times stiff. The hair, together with the brown discoloration of the mole, is suggest- ive of an animal's hide. (6) Warty najvi (na^vi verrucosi, papilloma- tosi) are covered, by Avarty growths. They appear either as small, soft, or if cornification is marked, as hard, round or peduncu- lated nodules, or as long, thorny papilla (Fig. 383). The papillomatous growths often develop later upon a. preexisting nasvus. Origin of Pigmented Ncevi. — Pigmented mevi are of congenital origin, or appear shortly after birth. They en- large slightly and slowly until the full growth of the indi- vidual is attained, and then they remain of the same size and form. Warty growths may, however, develop upon a navus in later life (Fig. 384). They may occur upon any part of the surface of the body, frequently being mul- tiple (Fig. 385). They cause no symptoms. In many cases nasvi occur along the course of cutaneous nerves, hav- ing a unilateral or symmetrical distribution (nerve naevi, neuropathic papilloma, occurring especially in the face and neck), or in the folds and growths of skin covering plexiform neuromas and superficial neuro- fibromas. Flat naivi are also frequently associated with soft warts and fibj-omas of the skin, being distributed over the entire surface of the body. All these facts seem to indicate that naevi have some relation to nerves. Their relation to cutaneous nerves and neurofibromas is not clear. Sol dan regards naevi as fibromas of the most delicate cuta- neous nerves, but his findings have not as yet been verified. Histology of Ncevi. — Histologically, the elevated na^vi are composed of the proliferated connective tissue of the cutis, especially of the pa- pillae, which are no longer well defined against the subcutaneous tissues. The epidermis is also involved in the growth, so that pigmented ncevi are closely related to fibroepithelial tumors. Fig. 384. — Congenital Hairy N^vus. In the up- per parts of the jijbvus papillary growths, which have been developing for some years, may be seen. » 'tm^ >.^ : # •^^ I'LATI-: 1 1. Vi.xr I'i(iMi;.\Ti.ii N.Kvrs. (ii) ( irmips of ii.T- viis cells jiliil clii-d- iiijitoiiliori's ill I lie (■()iiiiL'c(ive I issue. (//) (Iroups of ](!.<;- IIU'Ill cells williill Mild Ijelie.'il ll I lie e{>i- (lerillis. ■*^fi s^{. 2. Ar.vKdLAR JIki.a- NO.MA OK TIIK SkIX. 3. I\Iixi:t) Tr.Moii oi'' Tino I'akdtiii Cil.ANI). (a) ('iirtiliii;o. {h) Stroiii;i ix'sein- liliii<^ lilirous tissue. (r/) ('uliiiuiis (if opitlielijil cells with j;l;iii(llike struclure ■•mil hyaline con- lellts. (r) Infers till ill siibsliinco resoni- MiiiLT ii sarcoma. SARCOMAS 885 pi'oliforated con- 'I'lie piu'iiicnt lit's in line, ui-iinihii-, hi'owni.sh masses in t\\v cyVni (Irieal cells (if tin- sti'atuin irci-iniiiativuin and in tlic lar^o cliroinato pliores tlistribuU'd throuiiliout the coriuni. AVitliin tin nectivo tissues of the cutis are found groups and cohunns of round or oval cells, the so-called invvus cell clusters. These cells, together with the piy:- uient cells, are the most important constituents of Ihe flat na'vi. Accord- inj:: to von Recklinghausen, Ziegler, and Borst, the so-called noevus cells are the proliferated endothelium of the lymphatic vessels; according- to Kibbert, they are imperfectly differ- entiated chromatophores surrounded by a fine fibrillar network. Soldan regards them as connective-tissue cells. ]\Iarchand, Orth, Unna and his school believe that these cells are of epithelial origin, while Krompecher believes that they are derived from the basal cells of the epidermis. These groups of cells often occur in columns, or are radially arranged, passing toward the surface of the na>vus. In the deeper parts the groups of na^vus cells are closer to- gether than they are near the epi- dermis, upon the cells of which they may rest. Diag n as is. — T he diagnosis of pigmented nwvi may be made without any difficulty. The pro- jecting forms often suggest that a plexiform neuroma may be pres- ent in the deeper tissues {vide p. 79-1). Treatment. — Nan'i are removed especially for cosmetic purposes, and then, as a rule, only when they occur upon the face and neck. In removing a na'vus the skin surrounding it shoidd be cii'cuniscribed and then dissected awav from the subcutaneous tissues. If the defect is Fig. 385. — A Young Woman Eighteen Years of Age with Multiple N^vi AND AN Elevated, Hairy Verrucous N^vus which Involves the Left Cheek, Scalp, and Neck. 8S6 DIFFERENT VARIETIES OF TUMORS so largo that the wound cannot be closed by sutures, it should be cov- ered by skin grafts. Pedunculated flaps should not be used unless it is absolutely necessary, for they leave disfiguring scars and large secondary defects. Epidermal strips should not be used in skin-grafting these defects, as disfiguring tumorlike masses of scar tissue may form which are less desirable than the naeviLS. If a single, large, non-pedunculated cutis flap is used a beautiful result may be obtained. Particular care should be exercised in excising a nsevus of the eyelid and in grafting the defect. If the na^vi are very widely distributed, excision should be limited to those upon the face or upon areas uncovered by clothing. The development of nodular growths upon a nasvus is the second indication for operation. Every na?vus is potentially a malignant tumor — a melanoma. If the development of nodules or rapid growth arouses suspicion of malignancy, thorough removal should not be delayed. Xanthomas. — The growths occurring in the skin known as xantho- mas or xanthelasmas consist of small, sulphur-yellow or brown, circum- scribed areas (xanthoma planum), and nodular elevations (xanthoma tuberosum). They occur most frequently in the skin, especially upon the ej'elids, but also in other parts. They are also found upon the mucous membranes of the respiratory passages, mouth, and oesophagus. These growths are often multiple, occasionally congenital. The acquired forms are most common in old age. These growths contain cell nests which resemble those found in naevi. They differ from these, however, in that they contain a granular, yellow pigment and fat droplets. The cells containing fat droplets resemble closely those found in proliferating fatty tissue (Borst). Literature. — Aschenbach. Ein Fall von orbitalem Melanosarkom. Virchows Arch., Bel. 143, 1806, p. 324. — Borst. Die Lehre von den Geschwiilsten. Wiesbaden, 1902, pp. 043 and 960. — Dobbertln. Beitrag zur Kasuistik der Geschwiilste. Zieglers Beitrjige zur path. Anat., Bd. 28, 1900, p. 42; — Melanosarkom des Kleinhirnes und des Riickenmarks. Ibid., p. 52. — Just. Ueber die Verbreitung der melanot. Geschwiilste. im Lymphgefassystem. I.-D., Strassburg, 1888. — Krompecher. Der Basalzellenkrebs. Jena, 1903, p. 100 (Xasvi). — Joh. Kroner. Ein ausgedehnter Fall von Papilloma neuropathicum. I.-D., Wiirzburg, 1890. — Lanz. Experim. Beitrag zur Frage der Uebertragbarkcit melanot. Geschwiilste. Kochers Festschrift. Wiesbaden, 1891. — Martens. Ein Beitrag zur Entwicklung des Melanosarkoms der Chorioidea bei ange- borencr Melanosis sclerae. Virchows Arch., Bd. 138, 1894, p. 111. — Putiata-Kersch- haumer. Das Sarkom des Auges. Wiesbaden, 1900. — Ribbert. Das Melanosarkom. Zieglers Beitr. zur path. Anat., Bd. 21, 1897, p. 471 ;— Geschwulstlehre. Bonn, 1904. — Soldan. Ueber die Beziehungen der Pigmentmaler zur Neurofibromatose. Arch. f. klin. (Jhir., Bd. 59, 1899, p. 261.— Unna. Die Histopathologic der Haut., 1894;— Naevi und Naevokarzinome. Berl. klin. Wochenschr., 1893. — Wagner. 19 Falle von Melano- sarkom. Miinch. med. Wochenschr., 1887, p. 14. — Wiener. Ueber ein Melanosarkom des Rekfurns und die melanot. Geschwiilste im allgemeinen. Zieglers Beitr. zur path. Anat., Bd. 25, 1899, p. 322. — Williams. Beitriige zur Histologic und Histogenese des Utcrussarkoms. Zeitschr. f. Heilk., Bd. 15, 1894, p. 141. LEIOMYOMAS 887 B. TUMORS COMPOSED OF MUSCLE 'I'liiiiors coiiiitosi'd mostly ol imisclc lihcfs i\re enlled iiiyoiiuis. A h Kinij/onKi ('(tiiipdscd of siiiooth iiiiisclc iilxTs is dilTci'i'iil i;itc(l rrnm a ihiihdnnijjonKi coiiiposcd of striiitcd iimsclc lihcfs. ("IIAITKU I Li:i().M VOMAS The loiomyoiiia is an os]KH'i:dly benign tiiinoi-. It is encapsulated and rarely has an infiltratin«i' growth or forms metastases. They oeenr as ronntl tumors with a smooth or nodninr surface, most frequently in tlu» uterus, less often in the ^ i i.i H ■ ,; ., \ ..1 ■nil-; I'TKliT.s. (t, Trniis- •isc sci'lion (it hiuKlle of iiuisclo fibers. tissue bundles is even more jjroiiounecd than in fibromas. Histology. — Upon histo- logical examination, longitu- dinal, obli(|ue, and transverse bundles of smooth nuiscle libers with rodlike nuclei may be seen. The nmsele fibers liave blunt, rounded ends aiul may be easily dilTerentiated from the i)ointed connective-tissue ii])ers found in iibromas. Between the bundles of nmsele libei's lie varying amounts of tibrons tissue which carries the blood vessels. The fibrous tissue may eiieirele the bundles of smooth muscle fibers or run parallel with them. The tumor is either sui-ronnded by a thin capsule, being sharply de- limited from the surrounding tissues, or bundles of muscle fibers extend into the surrounding tissues, and then the tumor is firmly attached. Consistency. — If tliere is but little fibrous tissue, the tumor is soft and succulent; if, however, it is well develoix'd, the tumor has 888 DIFFERENT VARIETIES OF TUMORS the consistency of a fibroma (fibromj^oma). A large ninnber of di- lated vessels may also be present, and the tumor is then called a fihrotnyoma teleangiectaticum. IMalignant myomas are very cellular. They resemble spindle-cell sarcomas, as they grow rapidly, infiltrate surrounding tissues, and may form metastases. It cannot be posi- tively determined in these malignant myomas whether the sarcoma de- velops from the fibrous tissues of the tumor or from the muscle fibers proper. Regressive Changes. — In the large tumors all the regressive changes may be found which follow an insufficient blood supply. Large cavities filled with detritus, areas that have undergone hyaline degeneration or have become calcified, and in pedunculated myomas an oedematous infil- tration, the result of venous stasis following torsion or kinking of the pedicle, may be seen. Origin of Leiomyo- mas. — Nothing but con- jectures, based upon the occasional finding of glandular elements in myomas of the ute- rus and intestinal wall, can be made concern- ing the genesis of leio- myomas. Apparently all myomas, certainly the adenomyomas con- taining epithelial tu- bules, are the result of developmental disturb- ances. Pieces of mus- cle become separated from their normal con- nections early in em- bryonal life, which assume an independent growth and form tumors later (Ribbert). Most Common Sites for Development.— Leiomyomas are most common in the uterus. A large number may develop in the fundus, being pres- ent in early life as small growths. They may be situated beneath the iiiucous or serous membrane (submucous or subserous fibromyomas) or in the utci-inc wall f intr;nnui"il fibromyomas). The submucous and Fig. 387. — Uterus with Subserous Myoma Removed FROM A Patient Thirty-nine Years of Age, Frontal Section. LEIOMYOMAS 889 siihsci'oiis I'oriiis .-ire ri'('(|iiciil ly pcdiiiiciiljilcd. Tlicy fonn nnuid or liciiiisplicric.'il ciicnpsiihilcd liiimns of [ii iin r coiisislciicy lliiiii llic iitci'ine iinisciihiliirc, aiul c'luso ;i iiiimhci- ol' (litrciciit syiiiploins (scvci't! iiiciioi-- rluiyia or metrorrhagia being- the most proiiiiiu'iit j. Fibromyomas of Fl(5. 3SS. FlUUOMVOMA l)l'' TlIK PoSTKKIDK ^\'AI.^ OK TIIK RecTUM Ri'.MOVED BY ReSKCTION OK TIIK Ri;cri'.M (Male Patient 'rmurv-Kivi': Ykahs of Auk). (Lexer.) the uterus interfere Avith pregnancy and labor, and may also beeome infected and undergo putrefactive changes. The ligaments and tubes are most frequently involved after the uterus. Adenomyomas. — It is important in discussing the genesis of myomas of tlie uterus to note that von Recklinghausen has demonstrated tubules and cavities lined with cubical, cylindrical, and ciliated epithelium within the tumor tissue in some cases. These adenomyomas are usually small, poorly defined, subserous tumors, occurring most frecpiently upon the posterior surface of the uterus at the junction of the tubes with the uterus, in the broad and round ligaments. It is supposed that some of these tumors develop from displaced nuicous glands, some from the Wolffian body or duct, and some from IMiiller's duct, pieces of muscle being displaced with the epithelium. 57 g90 DIFFERENT VARIETIES OF TUMORS Leiomyomas of the Intestines, (Esophagus, Urinanj Passages, etc. — Leiomyomas are found less frequently in the gastrointestinal tract, de- veloping from the musculature. ]\Iyomas developing in different parts of the oesophagus usually remain small and cause no symptoms. Myomas of the stomach, of the small and large intestine and rectum grow slowly. They may become as large as a man's head. These tumors may be sessile or pedunculated. Sometimes they grow into the lumen of the bowel, while at other times they develop upon the outer side. They may give rise to a number of Fig. 389. — MALiG>fANT Leiomyom.a. of the Bladder. (Maie patient, sixty years of age.) The subserous myoma which wa.s attached to the bladder wall by a broad base had developed into the abdominal cavity. It was necessary to resect the wall of the bladder during the removal of the tumor. No recurrence after four years. (Lexer.) Dotted line indicates the outline of the bladder. different symptoms (intestinal obstruction, intussusception, hemorrhage after ulceration of the mucous membrane). The finding of pancreas tissue in a myoma of the stomach (Cohen) indicates that these tumors, like adenomyomas of the uterus, develop from a congenital anlage. Ma- lignant myomas are very rare. Myomas of the urinary tract are not very common. Up to the pres- LEIOMYOMAS 891 ent time only seventeen eases have been described. They develop from the musculature and may grow into the cavity of the bladder or exter- nally (Fig. 389), attaining considerable size. Biittner found a large myoma in the urethra. Small myomas which were attached to the fibrous capsule have been found in the kidneys. Pure myomas are rarely found in the prostate. Usually a part or all of the gland becomes hypertrophied, all of the elements ))t'ing involved. ]\Iyomas occasionally occur in the mammary glands and testicle. Myo- mas of the skin occur upon the trunk and extremities. They appear as snuill multiple nodules of firm consistency which project above the surface. These tumors, covered by normal skin, never become larger than a hazel- nut. They frecjuently give rise to severe pain. They develop from the musculature of the cutaneous blood vessels or hair follicles. Clinically they cannot be differentiated from fil)romas of the cutaneous nerves. Diagnosis. — The diagnosis of leiomyomas occurring in the uterus is easily made. Leiomyomas developing in other organs are so rare that if a slowly growing tumor is found, the diagnosis of a fibroma, or, if rapidly growing, of a sarcoma is iisually made. Only when it can be demon- strated that a large round abdominal tumor is connected with the stom- ach, intestinal, or bladder wall, should a myoma be thought of. ]\Iyomas of the skin may easily be mistaken for fibromas, as they are so painful. In these cases a myoma should be thought of if the changes so fre- quently associated with fibromas of the nerves (pigmented naevi and soft warts) are wanting. Treatment. — An attempt should be made in the treatment to remove the tumor completely. If the tumors are scattered throughout the uterus, a hysterectomy should be performed. Encapsulated tumors may be enucleated. If the tumor is not encapsulated the dissection should be free, removing the muscle from which the tumor develops. RHABDOMYOMAS The rhabdomyomas are rare tumors which are composed of striated nuiscle fibers and a vascular intercellular connective tissue. Sometimes these tumors are benign, sometimes malignant. If other varieties of tissue are found in the growth they are classified as mixed tumors. Gross Appearance and Histology. — ]\lacroscopically they appear as nodular, usually well-defined, growths of varying consistency. They may attain considera])le size. The interlacing of the fibers cannot be so easily seen in the grayi.sh-red or gray tissue as in leiomyomas. IVIicroscopically no completely developed striated nuiscle fibers are found, but embryonal types of cells and fibers in different stages of de- velopment. The latter appear as hollow, tubular, or solid, multinucleated 892 DIFFERENT VARIETIES OF TUMORS bands of considerable length and different thicknesses in which both the transverse and longitudinal striations may be distinctly seen. The cellu- lar forms contain spindle cells with long threadlike processes, parts of which have transverse striations, and irregular round or oval cells, often of considerable size, with one or many nuclei. All of these forms of cells frequently contain glycogen (Marchand), which may be distinctly seen, upon the addition of tincture of iodin, as large brown globules. On the fibers with transverse striation there may be indications of a poorly developed sarcolemma. The structure of different rhabdomyomas differs, as in some cases the round or spindle cells predominate, in other cases the muscle fibers. The more the cells and fibers are grouped and interlaced, the more these tumors resemble histologically leiomyomas and fibromas. Origin of Rhabdomyomas. — In discussing the origin of rhabdomyo- mas it is important to note that many mixed tumors, which undoubtedly b / Fig. 390. — Rhabdomyoma of the Temporal Region, b, b, Muscle cells cut parallel to their long axes in which fusiform enlargements and transverse striations may be seen, g, g, Round cells with processes; h, round cell without processes. The dark deposits repre- sent drops of glycogen. (From Ribbert.) are the result of developmental disturbances, contain striated muscle fibers, and that only the embryonal forms of these fibers are found in pure myomas. Rhabdomyomas are of congenital origin or develop in early life, and as they occur in organs which do not contain striated fibers, one seems justified in concluding that these tumors develop from germinal muscle tissue which was separated from normal physiological connections and displaced during embryonal life (Ribbert). It has also been suggested that the smooth muscle fibers composing a leio- myoma become transformed into striated fibers, thus forming a rhabdo- myoma, and that normal, fully developed muscle might proliferate to form this type of tumor. There are a number of objections which may be raised against both of these suggestions (Borst and Ribbert). LEIOMYOMAS 893 Most Common Sites for Development. — IJlinlKlomyoniiis ocfur most fr('(|U(Mitly ill i\w kidney, wliidi is ur;i(lii;illy dcsl roNcd ;is the Imiior onhirucs, so that iiiially a few reiiinaiits only are left. Tlie tiiiiior may reaeli the size of a ehikl's head and send out iioduhir and polypoid j)rocesses into the ])elvis of the ki(hiey. Occasionally rhabdomyomas appear as ])oly])oid tumors in tiie pelvis of the kidney, in the hiadder, and as nodular lirowths in the testicles. Of the other organs the uterus and heart are tlie most important sites for the development of these tumors. Rhabdomyomas of the uterus appear as polypoid p:ro\vths pro- jeetiny: into the vagina. They occur in the heart as congenital, multiple, usually small grayish-red nodules. Single tumors have been described in a number of different parts — in the o'sophagus, stomacli, parotid gland, prostate, in the muscles of the extremities, and about the but- tocks and hips, in the tongue, orbit, temporal regions, etc. Mode of Growth. — According to Ri])bert, these tumors enlarge as the result of the proliferation of the young spindle and round cells, which later become transformed into striated muscle fibers. The growth is fre([ueiitly expansive and slow, but it may be infiltrating in character. Then the tumor enlarges rapidly, the surrounding structures are in- vaded and metastases form. It is not known in these cases whether the tumor is to be regarded as a pui-e malignant rhabdomyoma or as a fibrosarcoma containing striated muscle fibers. The latter is frequently the case in mixed tumors, but it should not be forgotten that the young, non-striated, muscular elements may be easily mistaken for sarcoma cells. Diagnosis. — The clinical peculiarities of these tumors are not suf- ficiently marked to enable one to make a positive diagnosis. The diag- nosis is limited to determining whether the growth is benign or malig- nant, and then, depending upon the form, position, and rapidity of growth of the tumor, one can make a tentative diagnosis of a fibroma or of sarcoma, or, if it occurs in the genital tract, of a mixed tumor. The operation which should be performed depends upon the extent, position, and character of the tumor. Literature. — Becker. Beitrag zur Koiiiitnis dor wahron Muskelgeschwiilste des Hcxlens. Virchows Arch., Bd. 16.3, 1901, p. 244.— Biiitmr. Eiii Fall von Myoni der weiblichon I'rethra. Zeitschr. f. Geburtshilfe, Bil. 28. 1894, p. 13G.— Cohen. Beitnige zur Histologic iind Histogenesc der Myoine des Intents und iles Magens. Ibid., Bd. 158, 1800, p. 524. — Fujinama. Ein Rhahdomyosarkom mit hyaliner Degeneration (Zylindroin) im willkiirlichen Mii.skel. Ibid., Bd. 160, 1000. p. 203.— //fss. Ein Fall von multiplen Derinatomyomen an der Xase. Ibid., Bd. 120, 1800, p. 321. — Lexer. Myome des Mastdarmes. Arch. f. klin. Chir., Bd. 68, 1902, S. 241 ;— Myosarkom der Blase. Zentralbl. f. Chir., 1904, p. 22.— Marchand. Ueber einen Fall von Myo- sarcoma striocellulare der Xiere. Virchows Arch., Bd. 73, 1878, p. 280: — Ueber eine GeschwTilst aus quergestreiften Muskelfasern mit ungewohnlichem Gehalt an Glykogen. 894 DIFFERENT VARIETIES OF TUMORS C. TUMORS COMPOSED OF NERVE ELEMENTS CHAPTER I NEUROMAS PiBROMAS, myxomas, and sarcomas of nerves, which have also been called false neuromas, should not be classified with this group of tumors. Only those tumors composed of nervous elements belong here. They are exceedingly rare, developing apparently only from the sympathetic nerves upon which they appear as round or nodular growths resembling fibromas. Sometimes they attain considerable size, becoming as large as a man's head. Histology. — They are composed of interlacing bundles of nerve fibers, the majority of which are non-medullated, the smaller part medullated. Between these fibers are found varying numbers of gan- glion cells, which sometimes appear as poorly developed, round cells, at other times they give off axis cylinders. Neurilemma, interfibrillar connective tissue, and a few vessels are also found in these tumors. The terms ganglio-neuroma or neuroma ganglio-cellulare have been applied to these tumors, indicating that they contain both nerve fibers and gan- glion cells. The few cases (Knauss, M. B. Schmidt, Beneke, and Kredel) that have been observed have occurred mostly in small children. They appear as large tumors developing in the place of or near the sym- pathetic ganglia, or as small, multiple tumors of the skin developing supposedly from the sympathetic nerves, which contain a few ganglion cells, supplying the blood vessels (Knauss). The retroperitoneal tumor described by Beneke was benign, and caused symptoms only by its posi- tion and size. Symptoms, Diagnosis, and Treatment. — The clinical peculiarities of these tumors are not striking enough to enable one to make a positive diagnosis. Nothing definite is known concerning the origin of ganglio-neuromas. Their early, even congenital, occurrence and the presence of incom- pletely developed nervous elements indicate that they are the result of some disturbance in the development of the sympathetic nervous system (Ribbert, Borst). Surgical treatment should be instituted when these tumors are accessible. GLIOMAS 895 Amputation Neuromas. — The siiiall nodul.ir tliiekenings which de- V('h)p upon injured iiltvcs are called tniumalic m iinntxis, although they are not true tumors, strictly speakiufj. They are found especially upon the nerves in amputation stumps (so-called amputation neuromas), upon the central end of completely divided nerves or the sides of incompletely divided ones. They develop as the result of mechanical irritation of the nerves which lie immediately bencvith the skin, that become caught in a scar or lie upon the edge of a bone (e. g., along the jaw and supraorbital ridge after saber cuts). There is a proliferation of the connective tissues of the nerve and a regeneration of medullated and non-medullated nerve fibers, which grow out for a short distance and then bend back to interlace with other ])roliferating fibers. The nodules, which form, never exceed in size twice the diameter of the nerve involved, and merely represent an excessive regenerative growth of the injured nerve. Diagnosis and Treatment. — The diagnosis can be easily made. Small, hard nodules, which are painful upon pressure, lie beneath the skin in connection with the scar or immediately adjacent to it. They may be easily removed. Precaution should be taken against their development when amputations are performed. The nerves to be divided should be drawn out from the w'ound and cut short so that they may retract some distance beyond the cut surfaces. Literature. — Bcneke. Ueber gangliose Neurome. Zieglers Beitrage zur path. Anatoniie, Bd. 30, 1901, p. 1. — Bcneke und Kredel. Ueber Ganglionneuronie und andere Geschwulste des peripheren Nervensystems. Deutsche Zeitschr. f. Chir., Bd. 67, 1902, p. 239. — Biissc. Ein grosses Neuroma gangliocellulare des Nervus sympathicus. Vir- chows Archiv, Bd. 151, 1898, p. 66 of the Supplement. — Goldmann. Beitrag zur Lehre von den Neuromen. Beitr. z. klin. Chir., Bd. 10, 1893, p. 13. — Knauss. Zur Kenntnis der echten Neurome. Virchows Arch., Bd. 153, 1898, p. 29. — M. B. Schmidt. Ueber ein ganglienzellenhaltiges wahres Neurom des Sympathikus. Virchows Archiv, Bd. 155, 1899, p. 557. CHAPTER II GLIOMAS Tumors developing from neuroglia, the stroma of the central nervous system, are called gliomas. They are composed of glia cells varying in their degree of development. They occur in the brain, spinal cord, and the eye, the last having histological peculiarities. Peculiarities of Gliomas. — ( iliomas of the brain occur as tumors, vary- ing in size from a cherry to a fist, within the white and gray substance. 896 DIFFERENT VARIETIES OF TUMORS At times they infiltrate an entire hemisphere, the tumor gradually fusing with the surrounding tissues. It is frequently impossible to determine the boundaries of the tumor, as it may be of about the same color and consistenc}^ as the surrounding nervous tissue. Frequently such a tumor can be recognized macroscopically by the flattening of the convolutions covering it, or upon section by small, scattered, hemorrhagic foci, ne- crotic areas or cavities resulting from softening and liquefaction. Gli- omas occur most frequently in early childhood. Sometimes they appear as multiple, small, hard nodules upon the inner surface of the ventricle. They usually grow very slowly. The cellular forms grow rapidly, infil- trate and destroy the surrounding tissues; only rarely are the latter displaced by the growth. Gliomas do not develop above the surface of the brain. Symptoms. — The symptoms are those of a brain tumor, and depend upon the position of the growth and the increase in intracranial pres- sure. Large haemorrhages into the tumor are common, and apoplecti- form seizures are frequent. Varieties. — Gliomas of the Spinal Cord. — Gliomas of the spinal cord are most common in childhood. They frequently surround the central canal. They grow slowly, forming long, conelike growths, or transform a considerable extent of the cord into a gray mass, so that upon section only a narrow peripheral layer of normal tissue can be seen. Occa- sionally the growth extends through this peripheral layer and reaches the pia mater (Pels-Leusden). Cyst formation is frequent in gliomas of the cord. This is partty the result of dilatation of the central canal. and partly of softening of the tumor tissue. The symptoms are those of a spinal tumor. When cyst formation is marked, the symptoms may resemble those of syringomyelia. The prognosis of gliomas of the brain and spinal cord depends upon their position. They have an infiltrating growth, and are therefore closely related to malignant growths, although they grow slowly and seldom form metastases. Gliomas of the Eye. — Gliomas of the eye develop from the retina. They appear as nodular gray and white tumors, and grow into the vitre- ous humor. They grow rapidly, extending through the cornea exter- nally, through the sclera into the orbit, or pass along the optic nerve to the cranial cavity. These tumors occur in children, not infrequently being bilateral. Some are of congenital origin. They destroy the eye affected, and frequently recur after enucleation of the eye. They are as malignant as sarcomas. Histolo^.— Histologically, gliomas of the brain and spinal cord are composed of glia cells and a thick network of interlacing fibrillse, part of which are the processes of the glia cells. The fewer the cells in GLIOMAS 897 proportion to the mniihcr ol' lihrilhi'. tin- liarder tlu- tumor. Tlif luiin- ber of blood vessels in these growths varies. Small or hir^re, round or slitlike cavities lined with colunniar cells are occasionally found. The latter are derivatives of the ependymal epithelium from wh'ich the glia cells develop. IT proliferating; ganglion and nerve cells are also present, the tumor is called a iieuroglioma ganglionare (Ziegler). If mast of the cells are fusiform in shape and the fibriihe are not very pronounced, the tumor might easily be mistaken for a sarcoma. Gliomas of the eye contain large numbers of round or oval cells with processes, and only occasionally an intercellular fibrillar substance. They also frequently contain cylindrical cells, radially arranged to form a lumen producing roscttelike formations. It has been suggested that these tumors develop from the neuroepithelium of the external layer of the retina (therefore they are called neuroepitheliomas by "Winter- steiner). Origin of Gliomas.— ]*robal)ly all gliomas must be regarded as the result of some disturbances in embryological development of the brain, spinal cord, or eye. Congenital occurrence, development in early age, association wdth malformation of the brain and spinal cord, the bilateral occurrence of glioma of the eye, and their development in many mem- bers of the same family support this theory (Ribbert). Diagnosis and Treatment. — A positive diagnosis of a glioma can be made when both eyes are affected. In other cases a glioma may be easily confused with a sarcoma. Usually one must be content in making a diagnosis of a tumor without being more specific. Treatment is successful only in gliomas of the eye, and in these cases the contents of the orbit should be removed early. Gliomas of the brain and spinal cord are very fretiuently so situated, or are so exten- sive that complete removal is impossible. Literature. — L. Bruns. Gehirntumoren. Enzyklop. Jahrb. von Eulenburg, Btl. 5, 1895, p. 159. — Grceff. Gliom. in Orths Lehrb. tier path. Anat. Path, des Auges, p. 400. — Pels-Leusden. Ueber einen eigentiimlichen Fall von Gliom des Riickenniarkes niit Uebergreifen auf die weichen Haute des Riickenmarkes und Gehims. Zieglers Beitr. zur path. Anat., Bd. 23, 1898, p. 69. — Saxer. Ueber Syringomyelie. Zusanunen- fassendes Referat iiber die seit 1892 erschienenen Arbeiten. Zentralbl. fiir allg. Path, u. path. Anat., Bd. 9, 1898, pp. 6 and 49: — Ependjnnepithel, Gliome und epithcliale Gcschwiilste des Zcntralncrvensystems. Zieglers Beitr. zur path. Anat., Bd. 32, 1902, ]). 276. — Strobe. L^eber Entstehung und Bau der Gehirngliome. Ibid., Bd. 18, 1895, p. 405. — Wintersteiner. Ueber das Neuroepithelioma retinae. Leipzig-Wien, 1897. S9S DIFFERENT VARIETIES OF TUMORS D. TUMORS DEVELOPING FROM EPITHELIUM CHAPTER I PIBROEPITHELIAL TUMORS In fibroepithelial growths there is a proliferation of both the epi- thelium and connective tissue, although they may vary in their degree of development, while in carcinomas the connective tissues play a subor- dinate role, forming merely the framework of the tumor which supports the cells and blood vessels. The structural relationship between epithelium and connective tis- sue in fibroepithelial tumors finds its prototype in normal tissue. In the group of papillomas the same relation exists between epithelium and connective tissue as in the skin and mucous membranes. The structure of an adenoma resembles that of a gland, and the structure of epithelial cysts resembles in a number of ways the structure of skin and mucous membrane. (a) PAPILLOMAS Papillomas occur upon the free surface of the skin and mucous mem- branes. They are usually small tumors, rarely becoming larger than a walnut or hen's egg, have an expansive growth, and result from a hyper- plasia of the epithelium with a corresponding new growth of the con- nective tissue and blood vessels. Long, branched papilla, covered from summit to base with epithelial masses, extend down into the connective- tissue framework of the tumors. If the papilla are surrounded by connective tissue and are held together, the new gro\\i;h resembles a round nodule or a wart. If the papillge and their branches are sepa- rated, deep-fissured, blackberry-, grape-, and villouslike tumors are formed which may be attached to the skin or mucous membrane by a broad base or thin pedicle. ]\Iarked cornification of the epithelium pro- duces another variety of papilloma of the skin. In benign tumors the proliferation never extends below the subepithelial tissues. Clinical Appearance. — Papillomas appear as single or multiple tu- mors, often being closely grouped, with broad bases or short pedicles. As a rule, they grow slowly. Sometimes they bleed profusely after injuries in which the base or pedicle is torn. After incomplete removal (ligation of pedicle, cauterization with weak caustics), they may begin to enlarge and grow rapidly. Usually, after growing slowly for some time, they remain stationary. FIBROEPITHELIAL TUMORS 899 Varieties. — I'dpillonins of llic >s7.///. — 'I'lu; (■pithdiuiii covcriiiji pjipil- loiiiiis of the skid bccoiiics coniincd. They are, therefore, harder than piipillonias of the iinicous iiiciiibranes. 'i'hese tumors deveh)p most fre- ([uently upon the sealp of old people, but tliey also oceur in the axil- lary fossa, the injjuinal rej>ions, in the folds below the breasts, on the back and perineum, about the anus, and upon oilier parts of the body ex])osed to eouliininl iri-itation by sweat, rubbing', and uncleanliness. -.- — ^- - -y About the temporal re' vessel should be caught by a transfixion suture, or tlie bU'eding point shoukl be touched with the actual cautery. Multiple Adenomas of the Intestines. — IMultiple adenomas of the in- testine give rise to a peculiar, often severe clinical picture. The nuicous ineiiibrane of the rectum, which is chiefly affected, also that of the large intestine, and more rai'cly that of the small intestine immediately adja- cent, is beset with numerous, closely set, small and large polypi (poly- ])osis recti et intestini crassi). The symptoms of these multii)le tumors, which occur in children and young adults, begin with an intestinal catarrh Avhich resists treatment. The discharge of blood-stained masses of nuicus is suggestive of multiple tumors of the intestinal mucous mcMnbrane. A history of hert'dity can frequently be elicited. Profus(> liA'morrhages occur in rapid succession, producing a marked ana'inia. Occlusion of the bowel by the larger tumors, invagination of intestinal loops as the result of continual traction (e. g., invagination of the colon into the rectum), and finally the development of carcinoma (adenocarcinoma) are some of the complications. Twelve of the eight- een cases collected by Rotter died. The diagnosis is made certain by an examination of the rectum. Similar adenomatous polyps occur in the uterine mucous membrane and in young children about the umbilicus. The latter develop from remains of the vitelline duct. These adenomas are to be regarded as the result of developmental disturbances, originating from pieces of nuicous membrane which have been displaced and have become independent of the surrounding tissues. Treatment. — In the treatment an attempt should be made to remove all the tumors which are accessible through the rectum. It will be necessary to perform a laparotomy in order to remove the adenomas situated in the higher intestinal loops. If the tumors have broad bases it will be necessary to circiumscribe them and remove a portion of the wall of the stomach or intestine adjacent to them, closing the defect in the ordinary way. If the tumor has a long pedicle, all that is necessary after exposing the tumor is to ligate it close to the mucous membrane. In polyposis of the large intestine the results following even repeated operations are only temporary, because of the extent of the pathological changes. LiTERATUKE. — Port. Multiple PoIyiK'nbildimg iin Tiactus intcstiniilis. Deutsche Zeitschr. f. Chir., Bd. 42, 189G, p. 181. — Rotter. Verletzungen unci Erkrankungen des Mastdarmes und des Afters. Handb. d. prakt. Chir., 2. Aufl., Bd. 3, p. 669. — Schwab. Ueber multiple Polypenwucherungen im Kolon und Rektum. Beitr. z. klin. Chir., 90S DIFFERENT VARIETIES OF TUMORS Bd. IS, 1897, p. 353. — Smoler. Ueber Adenome des Diinn- und Dickdarmes. z. klin. Chir., Bd. 36, 1902, p. 139. Beitr. ADENOMAS OF THE GLANDULAR ORGANS Adenomas of the Salivary Glands. — These tumors are usually benign, being circumscribed and encapsulated. Sometimes they invade blood vessels and form metastases, in this way resembling clinically a malig- nant groAvth, although they resemble closely the structure of the organ from which they develop and would be classified histologically as benign tumors. The relative amounts of epithelial and connective tissues dif- fer in the different tumors, and therefore the histological pictures of different adenomas vary a great deal. If the connective tissue predomi- nates, the tumor is hard and of about the same consistency throughout, resembling a fibroma; therefore the term fibroadenoma. If the con- nective tissue is very cellular, the tumor is spoken of as an adeno- sarcoma; if mucoid, as an adenomyxofibroma (cystosarcoma phyllodes, myxofibroma intracanaliculare). The epithelial cells, which are usually arranged in a single layer, may be cylindrical, cubical, flat, or very irregular, and may form tubules which rasemble ducts (tubular ade- noma) or alveoli (alveolar adenoma). If the tubules or alveoli be- come transformed into cysts, a cystadenoma develops. If branched papillary growths develop 'mw^ '■■■■■■ "-''" '■' '" r^\ in the tubules or cysts, an adenoma or cystadenoma papilliferum (papilloma, fibroma intracanaliculare) is formed. Adenomas of the Mam- mary Gland. — Adenomas of the mammary gland appear as round, slowly growing nodules of different sizes and consistency. They may occur as multiple tumors in one or both breasts, are well encapsulated and be- nign, but recur after incom- plete removal from pieces which are left behind. Be- cause of their encapsulation they can be easily differentiated from dif- fuse hyperplasia of the breast. Adenomas of the breast are frequent in young women, but extremely rare in men. They may attain con- siderable size, especially the cystic forms. Finally, the skin covering 'A.:' ',^i^t P'ifJ. 400. — < 1 -I I )i:XOMA OF THE PaROTID GlaND. FIBROEPITHELIAL TUMORS 909 these timioi-s, wliicli had hecn niu-liantred and perfectly iintvahle, under- goes a j»re.ssiire atrophy and becomes necrotic. The tnnior is then ex- posed and develops al)<»ve tlie level of tlie skin. Tlie simple tubular and alveolar adenomas are haid, rich in connective tissue, and upon section liave a homo<.a'neous, j;rayish red color r (fibroadenomas). ]f l,V''f t<«r^,.>V7 ' ' '- ^^ i. ^/ ' ' .■:. ' - 'A they develop frojii lar^'e tubules reseiii- blino; ducts of the iihuid, larjre tortu- ous si)aces and cj'sls form, which can be seen upon section. The tumor is then spoken of as a cyst adenoma. If connec ive- tissue processes. earryin S 1 . 1 1 1 1 e Cl j^^jj Arr.\ngf.ment of Epithei-ium, at other Points k Tc- with pedunculated, bular Arrangement.) papillary, villous, or grapelike g-rowths are formed (cystadenoma papillare, papilliferum, or, depending upon the character of the stroma, tibroma or myxoma intra- canaliculare, sarcoma arborescens, phyllodes). Mastitis Chronica Cystica. — A disease of the breast occurring fre- quently, especially in old women, and characterized by the formation of multiple cysts in one or both breasts, is regarded by Schimmelbusch as multiple cystadenomas : by Konig, because of its clinical course, as a chronic inflammation (mastitis chronica cystica). Upon section, small and large, brownish cysts are seen in the tissue of the breast, which is usually enlarged. Adenomas of the Thyroid Gland. — Adenomas of the thyroid gland are nodular and circumscribed, differing from the diffuse or local hyper- plasias which occur in the ma.jority of goiters. The adenomas occurring in this gland gradually enlarge and may become as large as an apple. They may be congenital and are frequently multiple. Occasionally an adenoma of the thyroid becomes malignant, producing a pressure atrophy of the wall of a vein and invading its lumen. Cells are then carried by the blood stream and develop in different viscera and tissues. Slowly developing, secondary nodules then appear in the lungs and {a, Alveo- 910 DIFFERENT VARIETIES OF TUMORS bones where the cells find conditions most favorable for development. Gradually the bone involved undergoes pressure atrophy and spontane- ous fractures may occur. [It has not been satisfactorily explained why adenomas and carcinomas of the thyroid gland are followed so frequently by the formation of secondary growths in bone. It should be remem- bered in this connection that carcinomas of the breast and prostate and hypernephromas are also frequently associated with secondary deposits in bone.] Hypernephromas.- — Adenomas of the adrenal glands (strumae supra- renales, hypernephromas) appear as circumscribed nodules, the char- acter of which may be easily recognized by the bright yel- low color. These tumors, re- sembling histologically the cor- tex of the adrenal glands, de- velop from misplaced adrenal tissue. They occur in the ad- renal gland and kidney (being probably the most' frequent tumor occurring in the latter organ) ; more rarely in the broad ligament, in the epididy- mis, and on the under surface of the liver. Developing from adrenal rests lying in the cor- tex, they may form large tu- mors in the kidney and destroy almost all of the normal kidney tissue. If they rupture through their capsule, these tumors in- vade the renal vein and lead to the formation of extensive metastases. Adenomas of the Kidney. — Adenomas of the kidney occur as single or multiple encap- sulated grayish white tumors which rarely become malignant. They never become larger than a cherry, and are composed either of tubules or cysts filled with papil- lary ingrowths. Adenomas of the Liver.— Adenomas of the liver are composed of solid or hollow cell columns. They occur as round, soft, light brown nodules, or at times as large pedunculated tumors in the margin of the liver (von Fig. 402. — MAnciNANr Hypernephroma of the Kidney. (Woman thirty-five years of age.) a, Upper half of kidney not involved by the growth; h, tumor. FIBllOKriTlIKLLvL TlMUllS 911 Berginanii). Tliesc tumors are nncoiniiiou. IMany have a tendency to an infiltratiny; and malignant jirowth, as they invade the radieles of the portal and hepatic veins and form metastatic f»:rowths. Accoi-ding to Kihbert, the development of multiple tumors which are histologically Fig. 403. — Skctkin fuom a Hypkrnki'iiko.ma. (From Professor Bevan's Svirgical Clinic.) adenomas is best explained in this way. In spite of the tendency of these tumors to invade the vessels, metastases ( in the lungs, lymph nodes, and bones) are relatively rare. ORIGIN OF ADENOMAS Adenomas develop from germinal tissue which lias been displaced and encapsulated in the parenchyma of the organs in which they de- velop, forming independent centers of growth. The hypernephroma, which develops from adrenal tissue displaced into the cortex of the kidney, is the most striking example of this. The diagnosis and treat- ment of adenomas of the different organs belong to special surgery. The cystic growtlis which occur in a number of organs and are prob- ably due to developmental disturbances should be mentioned before clos- ing the chapter upon adenomas. The cysts or cystadenomas which occur so frequently in the ovaries should be mentioned first. These growths appear as large unilocular 912 DIFFERENT VARIETIES OF TUMORS or nuiltilociilar cysts in one or both ovaries. The cysts are lined with cylindrical epithelial cells which in some cases have proliferated to form papillary growths. The epithelium may have a glandlike arrange- ment. If the villous or papillary growths break through the cyst wall, the peritoneum becomes involved and the pelvis and the lower part of the abdominal cavity may become filled with papillary growths. In congenital cystic disease of the kidney and liver these viscera are completely filled with small and large cysts (multilocular cystadenomas) . Literature. — Beer. Ueber Nebennierenkeime in der Leber. Zeitschr. f . Heilkunde, Bd. 25, 1904, p. 381. — v. Bergmann. Zur Kasuistik der Leberchirurgie. Chir.-Kongr. Verhandl., 1893, II, p. 218. — Buday. Beitrage z. Zystenbildung in den suprarenalen Nierengeschwulsten. Zieglers Beitr. z. path. Anat., Bd. 24, 1898, p. 501. — Dobbertin. Beitrag z. Kasuistik der Geschwiilste. Ibid., Bd. 28, 1900, p. 42. — Gierke. Ueber Knochentumoren mit Schilddriisenbau. Virchow's Arch., Bd. 170, 1902, p. 464. — Goebel. Ueber eine Geschwulst von schilddriisenartigem Bau im Femur. Deutsche Zeitschr. f. Chir., Bd. 47, 1898, p. 348. — Hildebrand. Beitrag zur Nierenchirurgie. Deutsche Zeitschr. f. Chir., Bd. 40, 1895, p. 90; — Weiterer Beitrag zur pathol. Anatomie der Nierengeschwiilste. Arph. f. khn. Chir., Bd. 48, 1894, p. 343; — LTeber den Bau gewisser Nierentumoren, ihre Beziehung zu den Nierenadenomen und zur Nebenniere, nebst Mitteilungen, iiber den Glykogenbefund in diesen, sowie in anderen Geschwiilsten. Arch. f. khn. Chir., Bd. 47, 1894, p. 225. — Hoist. Ueber doppelseitige primare Neben- nierentumoren. I.-D., Leipzig, 1904. — Morris Wolff. Beitrag zur Kenntnis der Tumoren der Mamma. I -D., Rostock, 1899. — Rehberg. Untersuchungen iiber die Adenome der Nieren und ihre Entwicklung. I.-D., Freiburg, 1902. — Sasse. Ueber Zysten und zystische Tumoren der Mamma. Arch. f. klin. Chir., Bd. 54, 1897, p, 1. — Schitnmelbusch. Das Fibroadenom der Mamma. Ibid., Bd. 44, 1892, p. 102; — - Das Zystadenom der Mamma. Ibid., Bd. 44, 1892, p. 117. — Sudeck. Ueber die Struktur der Nierenadenome. Ihre Stellung zu den Strumae suprarenales aberratae. Virchows Arch., Bd. 133, 1893, p. 405; — Zur Lehre von den aberrierten Nebennierenge- schvvulsten in der Niere. Ibid., Bd. 136, 1894, p. 293. (c) EPITHELIAL CYSTS This group comprises tumors the majority of which develop in the beginning as cysts. They are composed of epithelium and connective tis- sue. According to Ribbert, they may be classified with the fibroepithelial tumors, although many are closely related to the mixed tumors. DERMOIDS OR DERMOID CYSTS Tlicse tumors usually occur singly, appearing in the first few years of life. They are spherical or hemispherical in shape, depending upon the tension and pressure exerted by the soft tissues covering them. Wall Lining and Contents.— The walls of these cysts are fairly thick and resistant. TJie outer surface is smooth, while the inner surface is rough, of a whitish color and covered with numerous fine and short, or thick and long liairs. The inner layer of the cyst wall is quite like FIBROi:riTllELlAL TUMORS 913 skin, as it contains t'pitk'rniis, papilla', hair, sebaceous and sweat glands. The outer layer, consisting of firm connective tissue, the inner part of which forms the connective tissue of the papilla', is loosely attached to the surrounding tissue, and therefore the majority of these cysts can be easily enucleated without rupturing the wall. When occurring about the head, they may be firmly attached to the periosteum. The epithelial lining in many dermoids is incomplete. Where the lining is incomplete the epithelium is replaced by connective tissue rich in large polynuclear giant cells. The areas of different sizes, in which the epithelium is not present, are brown in color, smooth, and round (Fritz Konig). The giant cells frequently contain hair and fat crystals, and are to be re- garded as foreign body giant cells. The contents of a dermoid cyst are a cheesy, yellowish-white mass, consisting of desquamated cells, the secre- tion of the sebaceous and sweat glands, numerous drops of fat, fat crystals, and cholesterin plates. Sometimes the contents are of a watery or serous character, or, after a hsemorrhage, of a reddish brown color. Dermoid cysts occur in definite positions and are the result of de- velopmental defects. They are found where, during embryonal life, there were clefts, furrows, or depressions of the surface of the body which later close, or where there were invaginations of the ectoderm. During the process of development cutaneous germinal tissue becomes buried beneath the skin and gradually develops to form cysts. There- fore these tiuiiors usually occur in childhood and lie more frequently just beneath the skin than at a deeper level. Dermoids of the Head and Neck. — Dermoids of the head and neck are the most connuon. Dermoids about the eye develop from pieces of ectoderm which are displaced during the invagination of the ectoderm to form the lens or during the fusion of tlie maxillary with the naso- frontal process. They occur most commonly: (1) Along the supraor])ital ridge, at the outer canthus of the eye, about the glabella, at the root of the nose, or at the outer extremity of the orlntal ridge; (2) within the orbit. The dermoids occurring along the orbital ridge appear as round growths, varying in size from that of a pea to that of a walnut. Tho.se occurring in the orbit produce an exophthalmos. They are covered by normal skin, which may be easily displaced over the tumor, and lie directl.y beneath the skin or beneath the galea aponeurotica, the frontal portion of the oecipito-frontalis, or the orbicularis oculi. When der- moids are deeply situated they sometimes produce changes in the bones about the orbit or in the other skull bones over which they are situated. When the dermoid lies directly upon the bone, a shallow depression with raised edges may be formed. Sometimes the depression may ex- tend through the bone, and then the tumor comes in contact with the dura mater or the contents of the orbit. Occasionally a dermoid lying 914 DIFFERENT VARIETIES OF TUMORS outside of tlie orbit communicates by a narrow process with another cyst lying within the orbit. These cysts, communicating with each other (Zwerschsackdermoide of Kronlein) are not formed by the fusion of two separate cysts, but during the development of the cranial and facial bones the preexisting cyst is surrounded by the bone and a part of the cyst is con- stricted to form the intermediate portion between the two parts. When the bone is fully developed a part of the cyst lies without, a part within the orbit. Dermoids also oc- cur at other points in the head, where, dur- ing development, the ectoderm can be in- vaginated easily. They occur about the anterior and posterior fontanelles, about the ear, just in front of the tragus, or over the mastoid process (developing from the aural anlage and the first branchial cleft). They also occur, but very rarely, on the face, on the dorsum and about the point of the nose, developing from the median nasal furrow (von Bramann, Lannelongue), in the cheek, at the side of the al^e nasi, developing from the naso-orbital cleft (von Bramann), in the middle of the cheek, developing from the transverse cleft of the cheek between the maxillary and mandibular processes (Lannelongue, Verneuil, Lexer). It is striking that dermoids occur much more frequently about some of the embryonal clefts than others. Dermoids never occur about those clefts, fusion of the edges of which is easily prevented giving rise to a number of different developmental disturbances, such as lateral labial fissure, harelip, or cleft palate. Von Bramann believes that the piece of ectoderm forming the dermoid anlage is most frequently constricted off about those fissures, which are closed very early by the fusion of their borders. At the time of the closing of these clefts the proamnion is Fig. 404. — Dermoid Cyst at the Outer End of the Supra- orbital Ridge. FIBROEPITIIELIAL TUMORS 915 closely related to the head, and there is more cliaiiec for the di.si)iace- iiieiit of i)ie('es of ectoderm diiiiiij^- the closure of the cleft or the in- vajiiiiatioii of tlic ectoderm to form the lens, caused by adhesions with the proamnion, tlian after formation of the true amnion. Dermoids do not develop about the clefts that close later for the reason above given. Dermoids of the neck occur most frecjuently in the lateral re<^ions just below the subnuixiilary glands. When they occur in this position they are covcped by the platysnui and reach from the inner border of the steriio-cleido-mastoid to the digastric muscle. When they attain considerable size they develop posteriorly beneath the sterno-cleido-nias- toid muscle. Dermoids occurring in the position above mentioned de- velop from the second branchial cleft. IMore rarely these cysts lie in the median line of the neck directly beneath the skin, sometimes above, at other times below the larynx, or in the jugulum (fusion of the branchial clefts, sinus cervicalis). The dermoids occurring in the floor of the mouth usually lie between the genioglossus muscles, extend toward the tongue, and elevate the mucous membrane of the floor of the mouth. In rare cases these tumors, resulting from imperfect fusion of the halves of the upper branchial arches, form on the outer side of the myelo- hyoid muscle, and then they are covered only by the skin of the sub- mental region. Dermoids Occurring in Other Parts. — The following positions in which dermoids also occur should be mentioned: (1) Dermoids of the chest, situated in the anterior or posterior mediastinum, which, like those oc- curring in the abdominal wall about the navel or in the omentum and mesentery, are formed from pieces of ectoderm invaginated during the closure of the thorax and abdominal wall. (2) Dermoids of the pelvic connective tissues, of which those not connected with the ovary or con- stricted off from it develop from ectoderm invaginated from the peri- neum. (3) Cysts of the retroperitoneal connective tissue, which, like those occuri'ing along the spernuitic cord (Wrede), develop from the ectodermal remains of the Wolffian duct. (4) The extremely rare der- moids of the scrotum, penis, and raphe, which are formed during the formation of the perineum or the fusion of the anlage of the external genitalia. (5) Dermoid cysts occurring in the saci-al or coccygeal re- gions, which are relatively frequent upon the dorsum of the sacrum and coccyx, and often become transformed as the result of infection or traumatism into fistuhe which resist treatment. [Some of these cysts appear as funnel-shaped invaginations of the skin, and, as they contain hair, they are called pilonidal cysts.] Dermoids occurring in front of the sacrum and coccyx are formed during the development of the peri- neum or the formation of the cloaca. (6) Intracranial dermoids are situated at the base of the brain betw-een the dura mater and bone or 916 DIFFERENT VARIETIES OF TUMORS within the pia mater. Dermoids of the vertebral column, associated with spina bifida, and of the pharynx are extremely rare. Dermoids of the testicle and ovary are rarely simple. The majority are complicated dermoids, cjsts containing a number of different tissut^s, and should be classed with the teratoid tumors (vide p. 980). Epidermoids. — In the histological examination of many dermoids it is found that the lining of the wall of the cyst is not composed of tli'- cutis, but of many layers of flat epithelium containing papillae and tin- stratum ]\Ialpighii, but no hair or sweat glands. These tumors ai<_^ called epidermoids and are probably formed by the invagination of gc^r- minal cutaneous tissue containing no glandular or hair anlage. Perhaps the difference between dermoids and epidermoids depends upon the time at which the tissue was displaced. It is quite conceivable that the germinal tissue displaced early would be more apt to form fully di- veloped skin than that displaced later. In the post-embryonal trans- plantation of skin epithelial cysts and not dermoids develop. According to Frank (p. 989), some of the atheromas, those lying subcutaneously, belong to the class of epidermoids, as they develop from germinal tissue displaced during the formation of the hair follicles and sebaceous and sweat glands. Suppuration and Fistula Formation. — The formation of a fistula fol- lowing a trauma or inflammation is the most important of the changes which may occur in a dermoid. Fistula formation occurs most fre- quently in dermoids situated about the coccyx, occasionally in those situated about the nose. It is indicated by the protrusion of a small tuft of hair. Suppuration of the cyst follows infections secondary to injuries, occasionally haematogenous infections. In rare cases a carci- noma develops in the cj^st wall (H. Wolff and others). Diagnosis. — The diagnosis is easily made. It is based upon a num- ber of characteristics common to dermoids. The position of the tumor and its early appearance, even before puberty, are of the greatest diag- nostic significance. Besides, the cysts are sharply circumscribed and smooth, and but slightly adherent to the surrounding tissues, being, therefore, freely movable. They are covered by normal skin, which can be easily displaced over the tumor. Their consistency differs, depending upon their contents. Frequently an indistinct or decided fluctuation can be elicited; often these tumors have a doughy consistency. Dermoids of the head and face can usually be easily differentiated from atheromas, which are attached to the skin at the point at which the duct escapes and therefore move with it. Cysts occurring at the root of the nose, about the glabella, and at the inner canthus of the eye may be easily confused with nasofrontal and nasoethmoidal en- cephalcceles, if they lie in a depression in the bone and give the im- FIBROEPITIIELIAL TUMORS 917 prcssion of coniinimicating with the cranial cavity. In making the ditlf'erential diagnosis it is important to note whether there are symptoms of intracranial pressure and whether the tumor decreases in size under pressure. Both of these characteristics are often present in encephalo- celes. It is scarcely possible to differentiate retrobulbar orbital der- moids from other varieties of tumors. Dermoids occurring in the lateral regions of the neck and the branchial cysts, which are genetically the same, may, in spite of the definite positions in which they occur, be confused with tuberculous abscesses and lipomas. Examination should be made for swollen adjacent lymph nodes, as these would be indicative of tuberculosis. The smooth surface of the cyst may prevent mistaking it for a lipoma, which is usually lobulated. Aspiration is uncertain. Dermoid cysts in the floor of the mouth usually have a median position, dift'ering in this way from ranula?, which usually are situated more to the sides of the floor of the mouth cavity. Treatment. — Dermoid cysts should be enucleated. Enucleation is dif- ficult only when the wall has been partially destroyed by suppuration. If during the removal of the cyst any of the wall is left, the tumor rapidly recurs. Simple incision, permitting of the escape of the con- tents of the cyst, is not sufficient. Only in very large retroperitoneal, thoracic, and sacrococcygeal cysts should one be content with this line of treatment, as a destruction of the sac cannot be expected after drainage. Literature. — Aschoff. Zysten. Lubarsch u. Ostertags Ergebnisse, 2. Jahrg. Wiesbaden, 1897, p. 456. — v. Bramann. Ueber die Dermoide der Xase. Arch. f. kliu. Chir., Bd. 40, 1890, p. 101. — Franke. Die Epidermoide (sog. Epithelzysten). Deutsche Zeitschr. f. Chir., Bd. 40, 1895, p. 197; — Ueber das Atherom, besonderc mit Bczug auf seine Entstehung (das Epidermoid). Arch. f. klin. Chir., Bd. 34, 1887, p. 507. — Klapp. Zur Kasuistik der Dermoide des Mundbodens. Beitr. z. khn. Chir., Bd. 19, 1897, p. 608. — Fritz Konig. Beitrage zur Anatomie der Dermoide imd Atherom- zysten. Arch. f. klin.- Chir., Bd. 48, 1894, p. 164. — Kroiilein. Dermoide der Orbita. Beitr. z. khn. Chir., Bd. 4, 1889, p. 149. — Laiinelongue et Achard. Traite deskystes con- gcnitaux. Paris, 1886. — Lannelongue et Menard. Affections congenitales. Paris, 1891, T. 1. — Langner. Die angeborenen Geschwiilste der Steissbeingegend und des Beckenbindegewebes. I.-D., Berhn, 1902. — Lexer. Ueber teratoide Geschwiilste in der Bauchhohle und deren Operation. Arch. f. klin. Chir., Bd. 61, 1900, p. 648. — de Quervain. Ueber die Dermoide des Beckenbindegewebes. Arch. f. klin. Chir., Bd. 57, 1898, p. 129. — Sanger. Dermoidzysten des Beckenbindegewebs. Arch. f. Gynakol., Bd. 37, 1895. p. 100. — Heinr. Wolff. Karzinom auf dem Boden des Dermoids. Arch. f. klin. Chir.. Bd. 62. 1900. p. 731. — Wrede. Die Dermoide des Samenstranges. Beitr. z. klin. Chir., Bd. 48, 1906, p. 273. TRAUMATIC EPITHELIAL CYSTS Not infrequently small, roiuid cysts, which never become larger tlian a cherry, are found in the palm of the hand and upon the flexor sur- 918 DIFFERENT VARIETIES OF TUMORS faces of the fingers. These cysts, resting upon the palmar fascia or upon the sheaths of the flexor tendons, may be displaced quite easily. The skin, in Avhich small scars indicating the nature and origin of the cyst may be seen, is slightly adherent to it. The walls of the cysts are composed of loose connective tissue, more or less firmly fused with surrounding structures, and are lined by squamous epithelium. The contents are similar to those found in dermoids. Etiology. — These cysts develop from small pieces of skin which have been displaced by trauma — therefore have been called traumatic epi- thelial cells (Garre) — or originate from appendages of the skin (hair follicles, sebaceous and sweat glands) which have been displaced and car- ried into the tissues by some penetrating foreign body (Pels-Leusden). An epithelial cyst is represented in Fig. 405. It was situated in the palm of the hand and developed six months after a gunshot wound. A small, flattened, lead bullet is encapsulated in the subcutaneous tis- sues. The capsule does not sur- round the foreign body closely, be- ing separated from it by a cheesy I ^^^ S mass. Upon one side a piece of Fig. 405. — Traumatic Epithelial Cyst of THE Palm of the Hand, a, Germinal cutaneous tissue ; h, bullet ; c, cheesj' con- tents of cj'st; d, connective- tissue capsule with epithelial lining. Fig. 406. — Traumatic Epithelial Cyst of the Index Finger. thickened epidermis (a), which was carried into the deeper tissues by the bullet, surrounds it like a hood. This epidermis forms part of the cyst wall. Wiemann has also demonstrated foreign bodies in two epithelial cysts. Experimental Production. — Similar cysts may be produced experi- mentally. After a piece of skin has been transplanted into the sub- cutaneous tissues or into the abdominal cavity it becomes encapsulated by connective tissue, which, however, cannot become united with the FIBROEPITIIELIAL TUMORS 919 epitlielial snrfaoo of the transplanted epidermis. A small space, which bec'oiiK's lilli'd and distended Avitli desquamated epithelium, remains be- tween the epithelium and eonnc^ctive tissue, and the walls of the space become lined witli epithelium formed by the proliferation of the epi- thelium of the transphmted skin. Till' treatment consists of complete extirpation. Literature. — Garrc. Ueber traumatische Epithclzysten der Finger. Beitr. z. klin. Chir., Bd. 11, IS'.U, p. 524. — Peis-Leusden. Ueber ahnornie Epithelisierung und traiiiuati.sfhe Kpithelzy.sten. Deutsche mod. Wochenschrift, 19U."), p. loTS. — Weyner. Boitrag zur Lehre von den trauniatischen Epithclzysten. Deutsche Zcitschr. f. Chir., Bd. 50, 189!), p. 201. — Wiemtnui. Epidermoide (Epithelzysten) niit Einschluss von Frenidkorpern. Zentralhl. f. Chir., 1902, p. 578. — Wijrz. Ueber traumatische Epithel- zysten. Beitr. z. klin Chir., Bd. 18, 1897, p. 753. CHOLESTEATOMAS Cholesteatomas are tumors which are closely related to dermoids and epidermoids. Their walls are alike, but their contents differ. Contents. — The contents of these tumors consist of white, pearllike, glisteninu' masses, which are concentrically arranged. These masses are dry and upon section become broken up into fine lamella. They con- sist of cornified, firndy compressed epidermal scales, and contain large amounts of fatty detritus and cholesterin; for this reason the term cholesteatoma has been applied to them. The walls are composed of a stratified epithelium. Transitional stages between the flattened epithe- lium and the cornified masses may be seen in any part of the tumor. Sebaceous and sweat glands and hair are but rarely found. External to the epithelium is a layer of loose connective tissue. Clinical Course. — These tumors grow slowly without producing sjTnp- toms for a long time, and finally may become as large as a hen's egg or larger. If the wall undergoes necrosis as a result of the pressure of the contents, the latter extend along the spaces of the surrounding con- nective tissues. Finally even bone may undergo atrophy following pres- sure produced by these masses. Most Common Sites for Development. — The most frequent and most important situations for cholesteatomas are the middle ear, the pia mater, and the urethra. They develop most frecjuently in the tympanum and the antrum, varying in size from that of a cherry seed to that of a hen's egg. They may gradually produce a, pressure atrophy of the bone and give rise to dangerous symptoms. These growths almost always cause, after a time, an otitis media and extend, when the bone is perforated, into the cranial cavity. Some of these tumors develop from ectoderm which has been displaced into the mastoid cells or the tympanum during the develop- 920 DIFFERENT VARIETIES OF TUMORS ment of the ear (von Mikulicz and Klister), and some follow chronic inflammations, the squamous epithelium of the external auditory meatus growing through the perforation of the menibrana tympani to rephice the cylindrical epithelium destroyed by suppuration. The secretion of the epithelium then becomes inspissated to form with the desquamated cells the cholesteatomatous masses (pseudocholesteatoma of von Troltsch, Fig. 407. — Cholesteatoma of the Skull Bones, which has Invaded the Orbit. Part of tumor which has invaded the orbit; b, external table elevated by tumor mass; c, layer of bone, remains of external table. Habermann, Korner). It is possible that the epithelium of the middle ear undergoes a metaplasia in some cases, for cases have been observed in which a perforation of the membrana tympani, permitting of the ingrowth of squamous epithelium, could be positively excluded (Borst). In chronic inflammations of the middle ear similar masses are found (otitis chronica desquamativa), but the epidermoidal sac is wanting in all these false cholesteatomas (Kiimmel). Cholesteatomas of the pia mater appear as round or nodular tumors, which grow very slowly. They usually occur at diiferent points about the base of the brain; more rarely within the ventricles. The capsule of the tumor, which is lined by a number of layers of flattened epi- thelium, is fused Math the pia mater. Bostrom regards these tumors as FIBROEPITHELIAL Tl'MORS 921 epidennoids, and believes that tlioy develop from frerininal ectodermal tissue displaced into the anlafte of the pia mater about the fourth or fifth week of embryonal life. Borst and others r(>^ai'd them as endo- theliomas. A few cases of cliolesteatoma of the bones of the face and skull liave been observed. They have been found in the frontal, occipital, and parietal bones (Bleeher), in the temporal bone, the pteryj^oid plates of the sphenoid, in the bones of the orbit (Lexei-), and in the mandible (von ilikulicz), appearing as sh)wly cjrowino; tumors which ^fratlually destroyed the bone. Not infrecpiently tliese tumors are epi- dural. Borchardt has removed such a tumor f;-om the posterior cranial fossa. Cholesteatomas of the urinary passa«:es are not true tumors, but the products of degeneration of flat epitlielium, the occurrence of which in these passatifes is abnormal. These cornified masses occur in the urethra, back of strictures, in the bladder, the pelvis of the kidney, and in the ureter ( Briichanow ) . Diagnosis. — A positive diagnosis of cholesteatoma can be made only when the eliaraeteristie masses are discharged. In making the diagnosis tile symptoms pi'odueed by tl:e pressure of the tumor should also be considered, but it is impossilile to differentiate cholesteatonuis from other tum(»rs, unless the characteristic masses are discharged. Treatment. — The treatment consists of removal of the cornified masses, and, in the true cholesteatomas, of the capsule also. Literature. — Borchardt. Cholesteatom der hinteren Schadelgrube. Chir.-Kon- grcss Verhandl., 1905, II, p. 496. — Bostrum. Die pialen Epidermoide, Dermoide und Lipome und duralen Dermoide. Zentralhl. f. allg. Path., Bd. 8, 1807, p. 1. — Briich- anow. l>her einen Fall von sag. Cholesteatonibildung in der Haml)lase. Prag. med. Wochenschr., Bd. 23, 1898, p. 52.). — Haug. Ueber das Cholesteatom der Mittelohrraimie. Zentralhl. f. allg. Path., Bd. 6, 1895, p. 124:.— Hahermann Zur Entstehung des Chole- steatoms des Mittelohrs. Arch. f. Ohrenheilkunde, Bd. 27, 1889, p. 42. — Kiimmel. Die Verletzungen und chirurgischen Erkrankungen des Ohres. Handb. d. prakt. Chir., 2. Aufl., Bd. 1, p. 404. — Unterberger. Ein echtes Cholesteatom der Sehiidelknochen. Deutsche Zeitschr. f. Cliir., Bd. 81, 1900, p. 90. ADAMANTINOMAS AND FOLLICULAR CYSTS OF THE JAW Adamantinomas are benign tumors of the jaw which occasionally occur in young people. They grow very slowly and may become as large as an apple or a fist. These tumors usually lie encapsulated within the bone and gradually expand the latter, so that finally the tumor is covered only by a shell of bone. If the tumor is cystic, a " parchment crackling " can be elicited when the thin shell of bone covering it is palpated. Adamantinomas of the maxilla may grow int(j the antrum of Ilighmore and comj^letely fill it. 59 922 DIFFERENT VARIETIES OF TUMORS Histology. — Upon section these tnmors differ very much. They ap- pear either as homogeneous, yellow, resistant masses, the consistency of which is very much like that of a fibroma, or as small or large cysts (therefore the terms " Multilocular cystomas of the jaw, epithelioma adamautinosum cystieum "). The entire mass may be enucleated from the expanded bone, unless the latter has O^ 23456 become so thinned that it is fractured dur- 23456 ing the enucleation (Fig. 408). Fig. 408. — Multilocular Cystoma of the Mandible (Adamantinoma). a, Condyle; h, symphysis. Microscopically the solid tumors consist of a connective-tissue stroma throughout which are scattered interlacing, narrow, and wide columns of epithelial cells. If these are abundant the tumor is very similar, histo- logically, to a carcinoma, but differs from a carcinoma in that it is encapsulated. Cylindrical epithelial cells are found at the periphery of these columns, while the cells occupying the center are either flat, ar- ranged concentrically, or are stellate and branched. If the epithelial masses undergo regressive changes, small cavities form within the cell columns, which later enlarge. The cysts are usu- ally lined with but a single layer of cylindrical epithelium, and resemble, histologically, cystadenomas. The histological picture is still different if papillary growths develop into the cavity or if the stroma between the columns of epithelial cells becomes ossified. Origin of Adamantinomas. — The form and arrangement of the epi- thelium indicate that these tumors arise from the enamel organ; there- fore the term adamantinoma. They develop from the remains of the epithelium of the enamel organ (debris paradentaires, Malassez), which lie about the teeth and can even be demonstrated under normal condi- tions. Perhaps the hyperaemia associated with inflammation may be the exciting cause of these growths. FIBROEPITIIKLIAL TIMORS 923 Diagnosis. — It is difficult to make a positive diai2:nosis. Small, solid tumors may be mistaken for osteomas; cystic tumors for simple cysts of the jaw, or if it is not known that the tumor has existed for some time, for soft, central sarcomas. Treatment. — The treatment consists of free exposure of the tumor and enucleation. The jaw should be resected in order to prevent recur- rence if a cystic tumor has caused a pressure necrosis of the jaw and rendered it fragile (Fig. 408). Follicular Cysts. — Follicular cysts of the jaw are simple cysts which develop from misplaced or supernumerar>' tooth buds. The position of these cysts varies. They may occur upon any part of the jaw (e. g., the ramus of the lower jaw, in the orbit). They are found chiefly in young people. When they occur in adults they develop about the wisdom teeth only, and most frequently in the mandible. They grow slowly, without causing pain, producing a local- ized expansion of the bone. They are found more rarely in the maxilla, and then easily extend into the antrum. These cysts have smooth walls, which are lined by an epithelial mem- brane derived from the tooth bud, and contain a rudimentary or fully developed tooth. The fluid contents of the cyst are seromucous in char- acter and rich in clio- lesterin. Follicular cysts are common, and the diag- nosis is not so difficult. But it should be remem- bered that the thinned and expanded cortical layer of bone may con- ceal a central sarcoma or a cvstic adamantinoma. and that the antrum of Ilighmore may be dilated as the result of chronic inflammation. The indications for treatment are to remove the cortical layer of bone, to expose the cyst, and then to remove the cyst wall. Periosteal Cysts.— Periosteal cysts of the jaws are to be differentiated from both of these forms of true cysts, above mentioned, which develop within the bone. Periosteal cysts are inflammatory growths. They fre- quently develop after a periostitis involving the root of the tooth. After Fig. 409. — .\d.\m.\ntiv' nia. 924 DIFFERENT VARIETIES OF TUMORS the destruction of the bone surrounding the diseased root, a cloudy, mucoid fluid containing cholesterin collects beneath the periosteum and produces a flat, fluctuating swelling on the outer surface of the jaw, which usually is situated about the molar or bicuspid teeth. Such a swelling may even rupture into the antrum of Highmore. It is questionable whether these cysts are produced by inflammation alone. The finding of epithelium in the walls of these cysts (Charcot, Malassez) suggests that the displacement of epithelium has something to do with their development. It may be that displaced epithelium is essential to the formation of the cyst, and that the inflammation acts as the exciting cause. Periosteal cysts are painful, grow quite rapidly, are situated just beneath the periosteum, and occur at any age. When these facts are taken into consideration, periosteal may be easily differentiated from central cysts. Free incision permitting of the discharge of the fluid, curettage of the depressed area in the jaw, with removal of the diseased root, and subsequent tamponade, are followed by a permanent cure after some days. If the cyst is large it is best to remove a large piece of the ex- ternal wall. Literature. — Becker. Zur Lehre von den gutartigen zentralen Epithelialge- schwiilsten der Kieferknochen. Arch. f. klin. Chir., Bd. 47, 1894, p. 52. — E. Bennecke. Beitrag zur Kenntnis der zentralen eiaithelialen Kiefergeschwiilste. Deutsche Zeitschr. f. Chir., Bd. 42, 1896, p. 424. — Goebel. Ueber Kiefertumoren, deren Entstehung auf das Zahnsystem zuriickrufiihren ist. Sammelreferat. Zentralbl. f. Path., Bd. 8, 1897, p. 128. — Haasler. Die Histogenese der Kiefergeschwiilste. Arch. f. klin. Chir., Bd. 53, 1896, p. 749. — Kruse. Ueber die Entwicklung zystischer Geschwiilste im Unterkiefer. Virchow's Arch., Bd. 124, 1891, p. 137. — Malassez. Sur le role des debris epitheliaux paradentaires. Arch, de physiol., 1885. — Nasse. Paradentares zentrales. Adeno- kystom des Unterkiefers. Chir.-Kongr. Verhandl., 1890, I, p. 129. . EPITHELIAL CYSTS DEVELOPING FROM NORMAL EMBRYONAL ANLAGE Cysts may develop from persisting, noninvoluted remains of differ- ent embryonal fissures and canals of ectodermal and entodermal origin. The most important of these cysts occur in the neck, the floor of the mouth, and in the abdomen, the last developing from the urachus and the vitelline duct. Branchial Cysts. — The epithelial cysts occurring in the neck are divided, depending upon their position and origin, into the lateral and median ; the former developing from the branchial clefts, the latter from the thyreoglossal duct. These cysts are closely related genetically to the lateral and median cervical fistulas. Branchial cysts usually develop in the young. They may even be FlBROEnTlIi:LlAL TUMORS 925 0()ni:('nital. They form ]>;iinl('ss swelliiius, wliieli ^i-ow slowly. Often the hciiiiiniiiii' of the I'lihiriioiiieut is not noted. They (Icvciop in the reuion Itelweeii the .jaw, tlic iiuiei' boi'dcr of the sli'i-no-clcido-niastoid nnisele, and tlie hyoid bone. Externally they are covered by the pla- tysnia. They extend inward to tlu> digastric nnisele. They may bt-eomc larger than a tist, and then thry extend downward almost to tlic clavicle and backwai'd beneath the stenio-clcido-mastoid mnscle into the poste- rior ti'iangle of the neck. The swell ini>' prodnced by such a cyst is Hat or hemispherical, has faii'ly well-detincd bonndai'ies, a siiidoth sur- face, and, depending- ni)on the character of the contents, a doughy or fluctiiatingf consistency. The skin covering: it is normal and can be raised from it, but the tumor proper can be displaced but little, as it is adherent to the deeper tissues. The firm, smooth wall of the cyst has either a white lining like that of a. dermoid, or a iirayish red lining, M'hich is often very granular, resembling mucous mend)rane. The con- tents are cheesy, mucoid, or serous, with a number of transitional forms. The symptoms are entirely dependent upon the size and posi- tion of the cyst. l^ranchial cysts usually develop from remains of the second bran- chial cleft; exceptionally, from the first or third (Fritz Konig). CJenet- ically they are clasely related to congenital branchial fistula^ the in- ternal oritice of which usually communicates with the supratonsillar fossa, when the fistula is complete; the external orifice emptying upon the skin anterior to the sterno-cleido-mastoid muscle at any level of the neck. The epithelial lining of these cysts, like that of the fistuhe, diiVers in character. The inner part of branchial fistula^ is of entodermal origin and is lined either with ciliated epithelium or with squamous epithelium provided with lymphadenoid tissue or follicles (like pha- ryngeal mucous membrane), while the outer part is derived from ecto- derm, and is lined with squamous epithelium containing papilla^ and often glands of the skin. There are branchial fistula?, however, which are lined throughout with cylindrical epithelium, having developed en- tirely, from the entodermal portion of the cleft. The lining and contents of branchial cysts ditifer, depending upon whether the epithelium from which the cysts develop is derived from the entodermal or ectodermal portion of the cleft. Cysts lined with skin or epidermis have cheesy contents, like a dermoid, and do not differ from dermoids or epidermoids (p. 916) of a doughy consistency. Cysts derived from the entoderm have seromueous contents and fluc- tuate distinctly. The inner surface of these cysts often resembles closely a granular tuberculous membrane, but the granulations are firm and cannot be wiped away as in the tuberculous membrane, for they are 926 DIFFERENT VARIETIES OF TUMORS produced by uiinierous lymphatic follicles situated just beneath the mu- cous membrane. Occasionally, different forms of epithelium are found in different parts of the cyst, or if the cysts are multilocular, the smaller compartments may be lined by different kinds of epithelium. The outer layers of the wall of the cyst may, like those of a branchial fistula, contain lymphadenoid tissue, striated muscle fibers, or cartilage {vide Plate II). Thyreoglossal Cysts. — Cysts developing from remains of the thyreo- glossal duct never become as large as branchial cysts. They lie in the median line of the neck in front of the hyoid bone, between it and the larynx, or below the larynx in the region of the jugulum. They form round, sharply defined, fluctuating tumors, which may be easily displaced, and are covered by normal skin. Although they are freely movable, it can always be noted upon palpation that they are attached to the deeper tissues, and often the cordlike attachment can be traced to the hyoid bone. This cord, which may so often be palpated, is the remains of the thyreoglossal duct. If the duct remains patent and ruptures upon the surface of the neck, a median cervical fistula forms. The lining of the cysts and fistulae developing from remains of the thyreoglossal duct differ. If they develop from the lower part of the duet they will be lined vv'ith ciliated epithelium; if from the upper part (ductus lingualis), with mucous membrane like that of the mouth. The walls of the cysts may contain mucous follicles. Some of the difficulties in making a diagnosis of branchial cysts have already been mentioned in discussing dermoids. The large, dis- tinctly fluctuating cysts may resemble congenital, cystic lymphangiomas so closely that a definite diagnosis can be made only by microscopic examination. In median cysts the cord, which may often be palpated and extends to the hyoid bone, is of great diagnostic significance. Der- moid cysts are superficial and freely movable. Tuberculous abscesses are usually associated with enlargement of the neighboring lymph nodes. Branchial cysts may be most easily confused with small, non-lobulated lipomas occurring in front of the hyoid bone. The ductus lingualis, a part of the thyreoglossal duct extending from the foramen caecum to the hyoid bone, has a genetic relationship to small cysts occurring about the foramen coecum and cysts, known as ranula, which develop in the floor of the mouth. Some ranula are lined with ciliated epithelium and develop from Bochdalek's tubules, which are evaginations of the ductus lingualis. Cysts of the Urachus.— Cysts of the uraehus, which are not frequent, develop from the embryonal canal connecting the bladder with the allantois. The urachus usually undergoes complete involution and be- PLATE II /:' .$ ■N;5---->V 'ii^^.^ 1^ ::^.. ^%. \ W,i A^.S .v^^-«^*.--C' >' Lateral RKoxcniAL Fistula. (rt) Remnants of ciliated epithelium. (6) Lympli follicle. (c) Lonjjfitudinal musculature of the fistula. fij}Hoi:i'1tiii;lial tlmors 927 comes closed to form the superior true ligament of the bladder. If the canal remains open, a urachal fistula is formed, from which urine is discharged. If the canal becomes onl}^ partially closed, small cysts, the size of a bean, or a very large cyst which contains yellowish fluid, devel()i)s. Cysts of the Vitelline Duct. — Cysts may also develop from the vitel- line duct, which up to the eighth Aveek of embrj'onal life extends be- tween the intestines and the yolk sac. Vitelline cysts, like cysts of the in-achus, are rare. If the duct remains patent, a congenital fistula, from which nnicus and intestinal contents are discharged, persists after the cord separates. If the umbilical end of the duct closes and the intestinal end remains open, a blind sac (iNIeckel's diverticulum), which empties into the ileum, persists. If the intestinal end closes, and the umbilical end, from which the mucous membrane protrudes, remains open, an umbilico-vitelline diverticulum is formed. If both extremi- ties become closed, but the intermediate part of the duct remains patent, a vitelline cyst (enterocystoma) forms as the secretion is poured out. The walls of the cysts, like those of the fistula? and diverticula, are composed of regularly and irregularly arranged bundles of smooth mus- cle fibers. They are lined with epithelium which corresponds histo- logically to either the adult or embryonal types of intestinal epithelium. These c.ysts are found within the abdominal wall at the level of the innbilicus, and in front of the peritoneum, or within the abdominal cavit3\ AVhen they occur within the abdominal cavity they are some- times adherent to the parietal peritoneum ; at other times to intestinal loops or are situated within the mesentery. The occasional occurrence of multiple cystomas suggests that some of these tumors may develop from displaced portions of germinal tissue, which later forms the in- testines (Borst). In the treatment of congenital epithelial cysts the cyst wall should be completely enucleated. This may be difficult, as the cyst may have contracted adhesions with the surrounding tissues at different points. LiTERATUKE. — Hildcbraiul. 1. Ueber angel)orene epitheliale Zysten unci Fisteln de.s Halses. 2. Ueber angeborene zystische Geschwiilstc dor Steissgegend. Arch. f. klin. Chip., Bd. 49, 1895, p. 167. — Fr. Konig. Ueber Fistula colli congenita. Arch, f. klin. Chir., Bd. 51, 1896, p. 578. — Lexer. Ueber die Behandlung der I^rachusfistel. Arch. f. klin. Chir., Bd. 57, 1898, p. 7.3; — Magenschleimhaut im persist ierenden Dotter- gang. Arch. f. klin. Chir., Bd. 59, 1899, p. 859.— A^asse. Ein Fall von Enterokystom. Arch. f. klin. Chir., Bd. 45, 1893, p. 700. — v. Recklinghausen. Urachuszyste. Deutsche med. Wochenschr., 1902, No. 34, Vereinsbeilage, p. 266. — Roth. Ueber Missbildungen im Bereich des Ductus omphalo-mesentericus. Virchows Arch., Bd. 86. 1881, p. 371. — Sultan. Zur Kenntnis der Halszysten und -fisteln. Deutsche Zeitschr. f. Chir., Bd. 48, 1898, p. 113. 928 DIFFERENT VARIETIES OF TUMORS CHAPTER II CARCINOMAS Malignant epithelial 'new growths are grouped under the term car- cinoma or cancer. They are characterized by an infiltrating growth, destroying the tissues which are invaded. Relation Between Parenchyma and Stroma. — The relation between the parenchyma and stroma varies in different tumors and in different fields of the same tumor. The epithelial cells composing the parenchyma differ morphologically and in their arrangement, depending upon whether they have developed from the skin, mucous membranes, glandular viscera, embrj^onal epithelial rests, from preexisting fibroepithelial tumors, or from epithelial cysts. In spite of the rapid multiplication of the cells in a carcinoma, they preserve the characteristics of the parent cells; for example, the cells of a carcinoma arising in skin become cornified; the cells composing carcinomas arising in the gastrointestinal tract, liver, and thyroid gland secrete mucus, bile, and colloid respectively. The stroma, or connective-tissue framework, consists of netlike tra- becular varying in thickness and firmness. The stroma consists partly of newly formed connective tissue, partly of the tissues which have been invaded. It may therefore contain, besides old connective tissue, muscle, the parenchyma of the viscera involved, bone, etc. Scirrhus and Medullary Forms. — If the stroma predominates the car- cinoma is hard and resistant and tends to undergo cicatricial contrac- tion. If the parenchyma predominates over the stroma the tumor is soft. The first form, which is called scirrhus, never becomes as large as the latter, which is called a medullary carcinoma. The intermediate form is usually called the carcinoma simplex. Clinical Appearance. — A carcinoma may appear in a number of dif- ferent forms, which depend more upon the tissues in which the car- cinoma originates than upon the arrangement of the cells composing it; for example, carcinomas developing within the viscera are usually nodular, while those developing in the skin or mucous membranes tend to form tuberculated, cauliflowerlike, papillary, or polypoid growths, associated with a flat infiltration of the surrounding tissues and the formation of deep, craterlike ulcers. Histogenesis. — There is no single conception among authorities con- cerning the histogenesis of carcinoma. After Virchow's teaching con- cerning the connective-tissue origin of carcinoma had been disproven by the brilliant researches of Thiersch, Waldeyer, Hauser, and others, Koster demonstrated that some of the tumors regarded as carcinomas CAUCLNOMAS 920 dovclopefl from the oTKlotholium of blood vessels, and were, therefore, really of a connective-tissue nature. For this reason these tunioi-s have been separated from carcinomas, sometimes being classified with sareoimis, at otlier times being regarded as a separate group {endo- thclionKia). Kibbert has ascribed to the connective tissue a very signifi- cant role in the development of carcinomas. According to him, the proliferation of the connective tissues is the cause, which leads to the irregular, atj^pical proliferation of the epithelial cells and the invasion of the tissues. Squamous-cell Carcinoma. — It is the generally accepted view that in a S(iuaiiious-cell carcinoma the proliferation begins in the germinal layer of the epidermis. At the point at which the carcinoma develops the cells multiply rapidly, preserving their embryonal characteristics and possessing irregular — the so-called pathological — karyokinetic figures, which may be easily explained upon the basis of excessive growth. The proliferating cells extend in all directions, raising and casting off the normal cells and sending down conelike processes into the deeper tissues and toward all sides, piercing the basement membrane, which normally separates the epithelial cells from the underlying struc- tures. By the continued budding of these conelike proces.ses, which are usually solid, a number of new processes are sent out into the tis- sues, so that eventually the point at which the carcinoma develops and its numerous processes resemble the roots of a plant. Naturally in microscopical si-ctions the columns of cells which have been cut trans- versely or obliquely appear as separate islands of epithelium or as alve- oli. True alveolar formation occurs if a group of cells becomes con- stricted off from the epithelial process; but this is rare, as usually the groups of cells which appear as separate would be found to be connected A\itli the large epithelial downgrowths if serial sections were made. llauser and Petersen have succeeded in demonstrating clearly the method of growth by means of reconstruction in wax, using Born's method, which has been employed so extensively in reconstructing em- bryos. They have shown by this method that growth begins simul- taneously at a number of points closely adjacent to each other. According to the opinions of many authorities the cells of glands — for example, in carcinomas of the skin — the cells of the hair follicles, and of the sebaceous glands, and perhaps even of the sweat glands are involved in the growth (Borst). According to Ribbert, these observa- tions are incorrect, the histological picture having been wrongly inter- preted, as the epithelial cells surround the glands and appear to de- velop from them, Avhile in reality they do not. Changes in Connective Tissue. — While the proliferating epithelial cells are invading the cutis and subcutaneous tissues, and are produc- 930 DIFFERENT VARIETIES OF TUMORS ing a pressure atrophy of the normal tissues, the connective tissues do not remain inactive. Proliferative changes occur in the connective tis- sues, similar to those in mild inflammation, which lead to the formation of a fibrillar connective tissue rich in blood vessels. Atrophy and pro- liferation occur about the invading epithelial processes, which become surrounded with remains of the tissues that have been invaded and by those newly formed. When a carcinoma invades the skin, mucous mem- brane, or viscus, the preexisting stroma forms- part of the stroma of the tumor, while the stroma of the part of the tumor which develops above the surface of the skin, muc6us membrane, or viscus is always newly formed. A reactive proliferation occurs in all tissues invaded by carcinoma (especially in bene), as is demonstrated by the study of metastases. According to Hauser, the growth relations in carcinomas composed of cylindrical cells, M'hich may develop from any mucous membrane or embryonal rest composed of cylindrical cells, are the same as those de- scribed above in squamous-cell carcinoma. In cylindrical-cell carcinoma the epithelial processes are not solid, but are provided with a lumen and resemble, histologically, a gland. Carcinomas developing from glandular epithelium grow in much the same way as described in the preceding paragraph. Sometimes the epi- thelial downgrowths have a lumen, at other times they do not. The normal glands are surrounded and compressed by the carcinomatous tissue, which spreads out in all directions. The view generally accepted at the present time concerning the de- velopment of carcinoma is especially combated by Ribbert. According to him, carcinomas develop because of the weakness of the tissues in proximity to the cells, which are then no longer able to offer resistance to . the downgrowth of proliferating epithelium, as they normally do. As a result of this weakness of the subepithelial connective tissues the cells break through the basement membrane and invade the surrounding tissues. Borst admits that not infrequently groups of epithelial cells become separated or displaced as a result of the inflammatory proliferation of connective tissues, and that the epithelium may develop, but in his opin- ion the initiative to the proliferative processes lies in the epithelium. This is the opinion of the majority of pathologists at the present time. Mode of Growth. — There is considerable difference of opinion among autliorities fis to the way in which carcinomas grow. Ribbert, Borst, and others believe that a carcinoma begins in small, limited, epithelial area, and that the cells of this area proliferate and invade the surrounding normal epithelial and glandular tissue, which are thus destroyed, while Hauser, Beneke, and others think that the normal cells bounding the CARCINOMAS Uijl ai'on in wliicli the fai-cinonia develops l)eeoino transfoi-iiied into earci- noiiia eells and lliat tlie tniiior enlai-.ufs hy i)ei'i|)lieial apposition. 'I'liis theory of the transfoi'ni:inatinic crusts, may imperceptibly develop into carcinoma. If the epithelium is retained for some time (this occurs especially in basal-cell or cerium carcinomas), a superficial, platelike nodule forms in which fre(iuently small cysts with clear contents may be recognized. The cysts are produced by a retention of secretion in, and subsequent dilatation of the glandlike down- growths of cells found in basal-cell carcinomas, and those developing from sweat and sebaceous glands. The form and clinical course of superficial carcinomas are char- acteristic as long as the tumor remains superficdal and extends within the cutis. The borders of the ulcer are but little indurated, and the ulcer can be moved with the skin so long as the cells do not invade the deeper tissues. Invasion of the deeper tissue, which is usually ac- companied by considerable pain, occurs only after the lesion has persisted a number of years. When the crust, consisting of dried secre- tion and carcinoma cells, is re- moved, the stroma, which carries the blood vessels and is easily in- jured, bleeds. The floor of the ulcer is red and but slightly fissured, as it does not extend deeply into the subjacent tissues. As the growth invades the surrounding tissues a firm, wall-like, but narrow, border is formed which is covered by the raised, undermined epithelium, and is rather shari)ly defined against the floor of the ulcer. / "^^--^f f^ \ /f \ Fio. 410. — SiTEHFiciAi, Carcinoma of the Skin. 942 DIFFEREXT V.^PJETIES OF TUMORS As ulceration occurs tlie borders of the ulcer acquire a serpiginous or jagged outline and frequently appear undermined, as the carcinoma cells undergo more rapid regressive changes than the epithelium of the border of the ulcer. If the carcinoma cells in the center of the ulcer degenerate com- pletely, the proliferation of the stroma, followed by cicatricial con- traction, becomes marked and radiating folds are formed which extend into the normal skin (Fig. 416), causing distortion of the eyelids and lips. [" These superficial carci- nomas, frequently called ' rodent ulcers ' by Amer- ican and English sur- geons, may heal over at certain periods of the year. An old man pre- sents himself in a clinic and states that an ulcer upon the face, undoubt- edly of carcinomatous na- ture, becomes raw in cold weather and heals at cer- tain periods of the year, being covered by a deli- cate bluish epithelium. The raised border sur- rounding such a scar still indicates the nature of the lesion. These ulcers may heal spontaneoasly. but the temporary healing is often attributed to some ointment which may have been applied shortly be- fore the spontaneous but temporary healing occurred. " The spontaneous healing is only temporary. Another ulcer soon forms which extends more quickly, and then it may be seen that the carcinoma cells were invading deeper ti.ssues, even when the ulcer was apparently healing. Xo structures seem to resist the ravages of the disease, and most museums contain evidences of the hideous results of rodent ulcer upon the face, destroying the contents of the orbit and the bones of the nose, and laying bare the nasopharynx. Bands of fibrous tissue long resist the ulceration, and. although the vessels may be dis- sected out they are seldom if ever laid open. All this time the general health is not affected, there is little or no pain, unless the eyeball or Fig. 417. — Superficial Carcixoma of tele Xose of Tex Years' Staxtjixg. CARCINOMAS 943 nerve trunks are involved, and the lymphatic nodes remain quite un- complicated."— Allbutt's " System of [Medicine," Vol. IX, p. 843.] Lupuslike Carcinoma. — ^Von Bergmann has described a peculiar form of superficial carcinoma occurring in the skin of the temporal regions wliich he has doscril)ed as lupuslike carcinoma. It begins with the for- mation of small nodules in the skin. These disappear without ulcer- ating, leaving a scar uncovered by hair. New nodules later develop about the scar, finally encircling the latter. After the disappearance of these nodules with resulting scar formation, new nodules develop about the periphery, so that finally a large area of skin is involved. These superficial carcinomas, which occur most frequently upon the face and scalp (cheeks, eyelids, nose, temporal regions, forehead, or exter- nal eai-). may persist for a number of years before they extend deeper. Eventually such a growth may transform the deeper tissues into a fri- able, ulcerating mass, and rup- ture into the cavities of the face or destroy the bones of the skull and expose the dura mater. Konig describes a superficial carcinoma occurring in a woman ninety years of age, which in- volved only one half of the face after persisting for twenty-five years, and another case (repre- sented in Fig. 417) occurring in a man which pursued a clinical course of ten years' duration be- fore it produced a complete de- struction of the nose. A superficial carcinoma of the skin grows very slowly, usually in the form of a superficial ulcer with slightly elevated, serpigi- nous, or undermined borders, with a slightly fissured, uneven base which bleeds easily when the crust covering it is removed. Such a carcinoma has a great tendency to cicatricial contraction, scar formation, and apparent healing. If neglected a superficial carcinoma finally involves the deeper tissues. Metastases. — The adjacent lymph nodes are involved late, usually not before the lesion has involved the deeper tissues. When the lymph nodes are involved thev become enlarged and indurated. Fit-.. 41.>. .-^i ,r,i.,i-..w. l.A.-AI. L L-.L (.'i.i.Ll- XOAfA OF THE SkIN' (COMPANION TO FiG. 415). Regarded for some time as a sj-phi- litic, later as a tuberculous, lesion. 944 DIFFERENT VARIETIES OF TUMORS Ha?matogenoiis metastases occur in neglected cases only. Diagnosis. — The diagnosis of superficial carcinomas of the skin is usually easily made when the characteristics above mentioned are kept in mind. The chronicity of the ulcer, the absence of a dusky margin, and a serpiginous outline at once distinguish a rodent ulcer from the ulcer of tertiary syphilis. The resemblance between an ulcerated gumma and a superficial carcinoma may be very close, and it is often difficult to distinguish between the two without a microscopic examination. A rodent ulcer in a syphilitic subject may be curiously modified. A tuberculous ulcer has flat, irregular borders which are often un- dermined for some distance, and a distinctly reddish or yellowish floor containing caseated masses and tubercles. Single, isolated syphilitic and tuberculous ulcers are the exception. They are usually associated with other lesions closely adjacent or upon other parts of the body, while single lesions are the rule in carcinomas. Superficial ulcers developing from adenomas of the sweat glands and following seborrhea never have indurated, thickened borders. Treatment. — Thorough excision, carried into healthy tissues, is the only successful treatment, as rapid, safe, and permanent healing cannot be secured by any of the other procedures which have been recom- mended, such as cauterization with the hot iron, different caustic solutions and pastes, and the use of Rontgen and radium rays. If the excision is properly performed, the carcinoma recurs in a very few cases (in 4.5 per cent, according to Borrmann). Extensive and deep recurrences follow so frequently the apparent healing, which may also occur after the use of the dry aseptic dressing (von Bergmann), produced by the agents above mentioned, that a word of warning should be spoken. Lexer has seen a number of cases in which the carcinoma became inoperable after having been treated for a number of months with Rontgen and radium rays. The defect resulting from the excision of the ulcer, which should be carried well into the healthy tissues, should be repaired by a plastic operation. Defects upon the forehead and body should be covered with epidermal strips. The surface of bone, when invaded, should be chis- eled away. The eye should be enucleated as soon as a carcinoma de- veloping upon the lid invades the orbit and the bulb. Diseased or suspicious lymph nodes, together with the connective tissue and fat surrounding them, should be radically removed. Often the enlargement of the regional lymph node is of an inflammatory nature, being due to the absorption of infectious materials from the ulcer. Sometimes the nodes are tuberculous. Carcinomas of the face may finally extend deeply, destroying the bone and exposing the dura mater or invading the ethmoid. They theii CARCIXUMAS 945 become inopi'ral)!^. Ctiustic j);istt's (zinc cliloridj, the use of the actual cautciy and of compresses of hydroi^en peroxid solution are indicated to retard the extension of the disease and overcome the odor associated witli putrefaction. (2) DEEP CARCINOMAS OF THE SKIN Origin. — These carcinomas develop from small, round nodules which, when situated in the deeper tissues, originate in the glands of the skin (sebaceous glands, hair follicles, perhaps also sweat glands) or from superficial carciuonuis which have existed for a long time. They have the chai-acteristics of new growths, which are often almost completely wanting in the superficial carcinomas of the skin. They occur most fre(pient]y upon the face, involving the nose, the eyelids, and the muco- cutaneous border of the lips. When the lips are involved, the clinical picture resembles very closely that of carcinonui of the mucous mem- branes. These tumors are rarely found on other parts of the body. Appearance and Clinical Course. — They rapidly invade the surround- ing tissues and degenerate to form ulcers, the bases of which are indu- rated and fused with the underlying tissues (fascia, bone, etc.). Fissures, spaces, and craterlikc depressions, covered by crusts and degenerated epithelium, and in which easily bleeding carcinoma tissue may be found, are present in the floor of these ulcers. Plugs of carcinoma tissue may be expressed from the ulcer if lateral digital pre&sure is made. The edges of the ulcer are raised and definitely infiltrated. They are hard to the touch, and the induration may extend to the tissues beneath. The edges of the ulcer are pinkish in color and often marked by dilated capillaries. The discharge is seroha?morrhagic in character and filled with the decompos- ing products of cellular debris. If the ulcer is large, the secretion has a peculiar and offensive odor. Severe hsemorrhages may follow the ulceration of large arteries in the deeper parts of the new growth. Nodular or wartlike projections may develop in the floor of such an ulcer later in the clinical course, and project above the level of the surrounding skin, forming a transitional stage to the papillaiy form of carcinoma of the skin. Metastases. — The regional lymphatic nodes become extensively in- volved and transformed into large nodular tumors early in the course of the di.sease. Ha?matogenous metastases are not rare. Treatment. — The course of this form of carcinoma is so rapid that the diagnosis must be made early if the treatment is to be eft'ectual. Any wart or scar occurring in old people, which begins to enlarge rap- idly and ulcerate, or rapidly developing and ulcerating warts or papil- lomas, which form upon an inflammatory base (for example, the warts 946 DIFFERENT VARIETIES OF TUMORS developing npon the chronic eczema occurring in chimney sweeps), should arouse suspicion of malignancy, even when the definite character- istics of carcinoma are wanting. Eemoval of the growth by excision is the only treatment that should be considered. The excision should be carried well into healthy tissue, and the regional lymph nodes should be removed. It is frequently neces- sary to resect the bone adjacent to the gro-wi^h. The same methods should be employed in the treatment of inoper- able cases as have already been described in discussing superficial car- cinomas of the skin. (3) PAPILLARY CARCINOMAS OF THE SKIN Appearance and Clinical Course. — These carcinomas are characterized by the early growth of the tumor tissue above the level of the skin. They usually develop from small nodules, wartlike growths, or from carcinomatous ulcers, and usually appear as firm pedunculated or sessile tumors with hard infil- trated bases, overhang- ing borders, and nodular, fungoid, cauliflowerlike or papillomatous surfaces in which deep depressions may be seen and which are frequently covered by horny masses or crusts composed of dried secre- tion. The skin usually stops abruptly at the margin of such a growth. Fig. 419. — ^Nodxtlar Carcinoma which Developed upon a Varicose Ulcer of the Leg. Tlie fibula has been partially destroyed by the growth. TARCINOMAS 947 Upon sectidii, loii^' briiiiclicd pjipillni y uruwtlis iii'c seen (Icvclopiii"^ rroni the carciiioiiiatoiis masses, wliicli in the hi-LiitiiiiiiL;-, at least, do not extend far into the subjacent tissues. Carcinomas of the skin of tlie extremities (Fi^^. 4"2()) and of the penis, and carcinomas developin^^ in the nnieous memlirane of the ^huKs and inner hiyer of the prepuce produce the same clinical Fig. 420. — C.\uliflowf,rlike CARriNOMA of the R.\(k ok tuk II.\nd aviiicii DE^^:LOPED IN A Scar One and a H.^lf Years After an Injury. (Male patient sixty years of age.) pictiu'C. Carcinomas of the skin of the face assume this picture more rarely. This form of carcinoma develops most frequently from fibroepithelial growths and in scars and ulcers; occasionally from atheromas and der- moid cysts. Rapid enlargement of a wartlike growth should arouse suspicion of malignancy. When a papillary carcinoma develops upon an old ulcer, small, hard nodules tirst appear within the Habby granulations, and then infiltration and induration of its edges (juickly follow. Metastases. — The adjacent lymph nodes rapidly become involved. General metastases may occur. Treatment. — If early and extensive excision is performed, recovery without metastases may occur. In papillary carcinomas of the extrem- ity which have invaded and passed through the fascia, amputation may afford the only hope of permanent cure. Excision carried well into healthy tissues shoidd be attempted only when the gi-owth is still lim- ited and is not adherent to the underlying tissues (tendons, bone). The penis should always be amputated when a carcinoma involves this organ. The other rules for the treatment are the same as described in dis- cussing other forms of carcinoma of the skin. 948 DIFFERENT VARIETIES OF TUMORS (b) CARCINOMAS OF THE MUCOUS MEMBRANES Clinical Forms. — Carcinomas of the mucous membranes appear in a number of different forms; sometimes developing as pedunculated or sessile, nodular tumors, sometimes as fungous, caulifiowerlike, papillom- atous, or villous growths, sometimes as superficial or deep ulcers, and finally as diffuse infiltrations. They are very different morphologically. The difference depending mostly upon whether the tumor develops from mucous membranes cov- ered with squamous or cylindrical epithelium, or whether it develops from glands within the mucous membranes. 8q\iamous-cell Carcinomas. — Squamous-cell carcinomas with cornifi- cation, similar to those of the skin, occur most frequently upon the tongue and lips. The lower lip is more frequently involved than the upper lip. They also occur in all parts of the mouth cavity (cheeks, floor of the mouth, soft palate, tonsils), in the larynx, the oesophagus, the cardiac end of the stomach, in the vagina, the cervix of the uterus, upon the mucous portions of the labia, the prepuce, and the glans penis. Fig. 421. — Carcinoma of the Neck, Secondary to a Carcinoma of the Lip. Involve- ment of the skin following extension from Ijmiph nodes. (From Professor Bevan's Surgical Clinic.) Carcinomas, the cells of which become cornified, may also develop from the transitional epithelium of the urinary passages. In the rare cases in which the S(iuamous-cell carcinomas develop in mucous membrane covered with cylindrical epithelium (gall bladder, stomach, trachea), it must be supposed that they develop from dis- CARCINOMAS 949 plaecd ('iiil)ryonal tissue c()iisistiii the sun-oundiiig tissues are solid. The division of glanduhir carcinoiiiiis into tlie adenomatous and solid varie- ties is therefore ,justi(ial)le. Colloid Carcinomas. — The colloid careinonias (nnicoid) in whieh there is the formation of considerable mucus is another variety of this form of carcinoma. The cells composing a colloid carcinoma ai'e filled with mucus, and appear as large, round, swollen structures, which, because of the lat- eral position of their nuclei, have been called the " seal-rinp; cells " (Kibbert). The mucous masses Avhich are secreted either fill the alveoli or separate the cells from the thin connective-tissue bands of the stroma. A colloid carcinoma is composed of a soft, glassy, translucent tissue from which a viscous sub- stance is discharged when the tumor is sectioned or scraped with a knife. Most Common Sites for Development. — The cylin- drical and glandular car- cinomas of the mucous membranes occur most frequently in the gastro- intestinal tract, most commonly at the pylorus and on the lesser curva- ture of the stomach, in the ctveum, at the hepatic and splenic flexures of the colon, and in the rectum. These tumors may also develop in the nasal mucous membrane, re- spiratory passages, the gall bladder, the cervix and the body of the uterus; also from the epithelial remains of the branchial clefts (branchi- ogenic carcinoma) and from mixed tumors. Ulcers of the nuicous mem- brane (ulcer of the stomach) and fibroepithelial tumors (multiple in- testinal polypi) form with about equal frequency the base from which these carcinomas develop. Clinical Course. — These carcinomas begin as hard, nodular, infiltrated areas beneath the mucous membrane, apparently at first well delimited. Regressive changes soon occur, resulting in the formation of superficial and deep ulcers which in the intestine and at the pylorus are sur- rounded by hard raised borders, and usually tend to surround the lumen 61 LAKCIMOMA OF THE Rectum. 954 DIFFERENT VARIETIES OF TUMORS of the bowel or pylorus re- spectively. If the nodular, cauliflowerlike, or papillary growths predominate, the lumen may be completely occluded. The cicatrizing form of carcinomatous ul- cer encircling the bowel may also produce a stenosis of the bowel, sometimes so reducing the lumen that it is impossible to pass a probe or a grooved direc- tor through it. Ulceration, haemorrhage, and putrefac- tive changes develop espe- cially rapidly in carcino- mas of the gastrointestinal tract, as they are exposed to the continual irritation of the intestinal contents. They are asso- ciated, depending upon the position of the tumor, with the vomiting of blood, the discharge of blood-stained mucus, and the usual svmptoms Fig. 42!). — ('(ii.i.niij ( '.vi;i im i.\i.\ c.i- im. rti.cTUM. Section of specimen represented in Fig. 431. Fig. 430. — Nodular and Papillomatous Carcinoma of the Rectum (6). a, Multiple Papillom.\s. Resection Preparation. CARCINOMAS 955 of intestinal catarrh caused hy the passage of putrefying masses over the mucous membrane. 'Many of these tumors infiltrate rapidly and extensively the walls of the stomach and intestines without ulcerating. The part involved then be- comes transformed for a considerable extent into a rigid, tubelike struc- ture, the walls of which are thickened and lined by a nodular mucous membrane which cannot be displaced upon the subjacent tissue. The de- velopment of snuill nodules and fine strands in the serosa indi- cate lymphatic involvement. If a carcinoma involving the stomach or intestine extends through their walls and rup- tures into the peritoneal cavity, a general or local putrefactive peritonitis follows, depending upon whether or not adhesions have formed. An intestinal loop or a part of the stomach in- volved by a carcinoma may con- tract adhesions with a neighbor- ing viscus, and then the latter I)ecomes involved. Adhesions may be contracted with an in- testinal loop or some hollow viscus, such as the bladder, and when ulceration and perforation occur a communication is estab- lished between the two. Colloid carcinomas are found most frequently in the rectum, but thej' also occur in the stom- ach and cgeeum (Fig. 431). They form large growths, invade wide areas, and have a tendency to progress- ive infiltration of the intestinal wall, the mesentery, omentum, the appendices epiploicre, and the entire peritoneum. Importance of Early Diagnosis. — It is essential that an early diag- nosis be made in these cases, in order that efficient treatment may be instituted. This is often difficult, as the physical signs and symptoms are not pronounced, and the latter, even when marked, frequently re- semble closely those occurring in other diseases. Therefore it is fre- quently the case that a positive diagnasis is made when the carcinoma is too far advanced for radical removal. ^^-^ Fig. 4.31. — Colloid Carcinoma of the Rectum Removed from a Young Woman Twenty- three Years of Age. 956 DIFFERENT VARIETIES OF TUMORS Carcinomas developing in the mouth, are naturally noted early. They are, however, often mistaken for syphilitic lesions, as they are frequently Fig. 432. — Nodular, Circular Carcinoma of the C^cum, the Center of which is Ulcerated. The carcinoma was situated close to the ileocsecal valve. Removed from a man thirty-five years of age. Three years have elapsed since operation with no recurrence. surrounded by or associated with leucoplakia. If a piece of tissue is excised for microscopic examination, it should be large enough to per- mit of a positive di- agnosis and should be taken from the proper part of the lesion. Symptoms. — The symptoms depend up- on the position of the tumor and upon inter- ference with the func- tion of the organ in- volved. A carcinoma of the larynx causes hoarseness ; of the stomach, vomiting and chronic gastritis ; of the intestines, symp- toms of stenosis and chronic ileus; of the rectum, haemorrhage and the discharge of blood-stained mucus. A Fig. 433.— Ulcerated Superficial Carcinoma of the tumor of the bladder Is RECTU.M. a, Craterlike margin; h, ulcer. associated with haemor- CARCINOMAS 957 vha^o and tlio rotontion of urine; while a tumor of the antrum of IIi<;lim()i-e may he associated with the symi)toms of an empyem^, of the antrum, foHowini;' the aecumuhition and suhsc(|iient infection of the secretion of the nnicous membi-ane. The symptoms produced by a car- cinoma developin<>- in any of the organs or parts above mentioned may be confused with those associated with relatively harmless lesions. If the tumor is visible and palpable, the diagnosis can usually be easily nuide, as the form of the ulcer, the induration of its ed^es, the appearance of its floor, the character of the secretion, and, when far advanced, the infiltration of adjacent tissues and the involvement of re»;ional lymph nodi's are (piite characteristic. In carcinomas involving Fic. 434. — Sectiox through Carcinoma Rkpresented in Fig. 433. a, Mucous mombrane at margin of the ulcer; b, tumor tissue. the gastrointestinal tract it is often necessary to perform an exploratory laparotomy before a positive diagnosis can be made. If a tumor can be palpated through the abdominal wall, tlie diagnosis may be made, but in the majority of these cases the tumor has then extended so far that radical removal is impossible. It is advisable, when the symptoms indi- cate a carcinoma of the gastrointestinal ti"act, to perform an exploratory laparotomy, in order that an early and positive diagnosis may be made. Treatment. — If the diagnosis is made early enough to permit of oi)erative procedures, the tiunor and the lymph nodes which di-ain it should be removed. (c) CARCINOMAS OF GLANDULAR ORGANS Histology. — Carcinomas developing in the various glands correspond more or less closely, histologically, to the glands in which they occur, and therefore ditt'ei- wi(U'ly in their structure. Usually an adenomatous can be ditt'erentiated from a solid type, depending upon wliether the cells are arranged in the form of gland tubules or solid processes. The epithelial cells may be cylindrical, cubical, or polymorphous, and ar- ranged in a single layer or stratified. The secretion of the cells differ, 958 DIFFERENT VARIETIES OP TUMORS depending' npon the origin of the tumor. The cylindrical cells in a carcinoma of the thyroid may secrete colloid, while those found in a primary carcinoma of the liver may secrete bile. The cylindrical cells found in carcinoma of the breast may, like those found in adenocarci- noma of the gastrointestinal tract, secrete mucus. If the gland tubules become dilated as the result of the accumula- tion of the secretion, small and large cysts may be formed which com- municate with each other. The epithelium lining these cysts may proliferate to form large papillary growths which completely fill the cavity of the cyst (papillary eystocarcinomas of the breast and ovary). Mucoid degeneration leads to the formation of a colloid carcinoma (e. g\, in the breast), just as in cylindrical-cell carcinomas. Predisposing Causes. — Chronic inflammation, contusions, and benign growths (e. g., fibroadenomas of the breast) are regarded by many as predisposing causes. The etiological relations, however, between the lesions above mentioned and malignant growths are based upon clinical observations confined almost entirely to the female breast. Appearance of These Growths. — The clinical appearance of the carci- nomas occurring in the different glands are very similar. They differ in consistency, the scirrhus forms being hard, the medullary forms soft. The tumors develop as round nodules which invade the normal tissues in all di- rections and replace them. The nodules become fused with the adjacent tissues'. The carcinoma extends, when it reaches the surface of an organ, to the adjacent struc- tures (e. g., a carcinoma of the prostate may extend into the bladder and rectum). When it reaches and invades the mucous membrane or skin regressive changes soon oc- cur, resulting in the for- FiG. 43.5. — Carcinoma of the Breast (Scirrhus). mation of deep ulcerS and nodular growths. The female breast affords the best examples of carcinomas develop- mg m glands. Usually the nodule, which develops without symptoms, is accidentally noticed. It appears as an indurated area, the size of a cherry, within the substance of the breast. The boundaries of the nodule are indistinct, and it is firmly adherent to the surrounding tis- C ARC I. NOMAS 959 sue. If the tumor lii>s bcucjitli the nipple or close to it, the latter will be somewhat rctractt'd and iiioi-e ditficult to tinitely (^xcluded before an opinion can be given. Causes of Carcinoma. — Nothing definite is known concerning the caiLse of carcinoma. The principal theories have already been discussed in the general discnssion of tumors. The fact that carcinomas not infrequently develop from wounds and scars, from benign new growths and chronically inflamed tissues is used by the defendants of Virchow's theory of chronic irritation to show that the latter may produce changes in the cells which result in nnre- stricted proliferation. Congenital carcinomas and the development of a carcinoma from demonstrable embryonal rests, both of which are rare, also the occurrence of a s(|uamous-cell cai'cinoma in nuicous membranes composed of columnar cells have been used to substantiate Cohnheim's theory that tunuM's deveh)ped from displaced embryonal rests. According to Eibbert, the general cause of carcinoma formation is the displacement of small islands of epithelium from their normal con- 962 DIFFERENT VARIETIES OF TUMORS nections, the displacement following the proliferation of the connective tissue, which may be caused b}" a number of different agents. The parasitic theory concerning the origin of carcinoma has won many friends. This theory rests partly upon an analogy between dis- eases which are undoubtedly of an infectious origin and carcinomas, and partly upon clinical observations that carcinomas occur most fre- quently upon parts exposed to irritation (e. g., about the orifices of the body, in narrow or tortuous parts of the gastrointestinal tract) , in ulcers or chronically inflamed tissues, in man and wife or many members of the same family. These facts observed clinically may be most easily explained by assuming an infectious origin. But the structures which have been regarded as parasites have been proven by later investigations to have been inclusions of epithelial cells or leucocytes. The peculiar and differ- ent appearance of the cell-inclusions are dependent upon the extent of the regressive changes in the latter. The microorganisms which have been found and cultivated cannot be regarded as the cause of carcinoma. Besides, the histology of certain forms of carcinoma and the way in which they develop are important arguments against the parasitic theory. Heredity. — The question of heredity is still unsettled, as it is dif- ficult to estimate the value and accuracy of statistics regarding it. Clin- ically, it is quite striking that many members of the same family may apparently inherit the tendency to carcinoma formation and that the same organ may be primarily involved. Literature. — Ausfijhrliche Literaturangaben bei Borst. Die Lehre von den Geschwiilsten. Wiesbaden, 1902, II, p. 966. — v. Bergmann. Das lupusahnliche Karzinom. Handb. der prakt. Chir., 2. Aufl., Bd. 1, p. 47. — Borrmann. Das Wachstum und die Verbeitungsweise des Magenkarzinoms. Kitteil. aus d. Grenzgeb., Bd. 1, Suppl., 1901; — Die Entstehung und das Wachstum des Hautkarzinoms, nebst Bemerk- ungen ijber die Entstehung der Geschwulste im allgemeinen. Zeitschr. f. Krebsforsh., Bd. 2, 1904; — Statistik und Kasuistik iiber 290 histol. untersuchte Hautkarzinome. Deutsche Zeitschr. f. Chir., Bd. 76, 1905, p. 404. — Coenen. Zur Kasuistik und Histologie des Hautkrebses. Arch. f. klin. Chir., Bd. 78, 1905, p. 801. — Hauser. Das Zylinder- epithelkarzinom des Magens und des Dickdarms. Jena, 1890. — Heimann. Die Ver- breitungsweise der Krebserkrankung. Arch. f. khn. Chir., Bd. 57, 1898, p. 911. — ■ Krompecher. Der Basalzellenkrebs. Jena, 1903. — Kilttner. Welche Aussichten bietet die Operation des Mammakarzinoras beit vergrosserten Supraklavikulardriisen? Beitr. z. klin. Chir., Bd. 36, 1902, p. 531.— Milner. Gibt es "Impfkarzinome"? Arch. f. klin. Chir., Bd. 74, 1904, p. 669. — Fr. Muller. Stoffwechseluntersuchungen bei Krebs- kranken. Zeitschr. f. klin. Med., Bd. 16, 1889, p. 496. — Orth. Die Morphologie der Krebse und die parasitiire Theorie. Berl. klin. Wochenschr., 1905, p. 281. — Petersen.^ Beitrage zur Lehre vom Karzinom. Beitr. z. klin. Chir., Bd. 32, 1902, p. 543; — Ueber Heilungsvorgange im Karzinom (Riesenzellen). Ibid., Bd. 34, 1902, p. 682. — • Ribbert. Geschwulstlehre. Bonn, 1904, p. 459; — Die Entstehung des Karzinoms. Boim, 1905; — Beitr. zur Entstehung d. Geschwiilste. Bonn, 1906. — v. Volkmann. Ueber den primaren Krebs der Extremitaten. v. Volkmann's Samml. klin. Vortr., 1889, Nos. 334-335. KNDOTHKLIAL THMOKS 963 E. P]NDOTHP]LIAL TUMORS ENDOTHELIOMAS Von Kpcklino-lianson (18G2) was lirst to i'('eo<;ni/.e that emlotlielial cells eoinposi'cl the proliferating' i)art of these tniuoi-s. This fact lias been especially emphasized hy Koster. The classification of these tumors, in spite of the amount of investigation that has been devoted to them, is still a mooted ciuestion. Nature of Endothelium. — The intimate relationship between endo- thelium and connective tissue (His) does not permit one to draw a sharp-and-fast line of distinction between these tumors and sarcomas. Histologically, endotheliomas resemble some epitheliomas so closely, especially those in which there is the foi-mation of gland tubides, that it is impossible to give any opinion accei)table to all pathologists as to the nature of the cells (e. g., Ki-ompecher's carcinoma basocellulare, p. !);iS; mixed tumors of the salivary glands, p. 971; cholesteatomas, cylin- dromas). Besides, there is no uniformity of opinion am(mg embryolo- gists and histologists as to the classification of endothelium, the latter, being regarded by some as connective tissue, by others as epithelium. Clinically these tumors have certain peculiarities. It is impossible to make a positive clinical diagnosis of an endo- thelioma. The microscope nmst decide the nature of the tumor. Even an experienced pathologist may have great difficulty in making a micro- scopic diagnosis and differentiating a tumor of this character from cer- tain forms of carcinoma, sarcoma, and adenoma. It is customary to divide these tumors into hjtnphangio-endotlieUo- mas, luttnangio-oKlothelionKis, and into special forms, such as peritheli- omas, and ciKlotJidloriiiis of flie dura mater (psammomas). Lymphangio-endotheliomas. — Lymphangio-endotheliomas develop from the endothelium lining the tissue spaces and lymphatic vessels. These tumors are composed of colunnis of cells which coi'respond to the course of the lymphatics. The cells, which have a tul)ular or solid arrange- ment, are flat, cubical, or columnar. The three varieties may be found in different parts of the tumor oi- coml)ined in the same field. The cell columns are enlarged at the nodal points, and the cells composing them may be concentrically arranged. According to Borst the cell columns, which diff'er in size, have a delicate linear arrangement and are lined by two layers or a single layer of cells, resembling very closely the histo- logical picture presented by proliferating lymphatic vessels. These tubules may dilate to form cysts. If papillary grcnvtlis then develop, 964 DIFFERENT VARIETIES OF TUMORS Fig. 437. — Lymphangio-endothelioma of the Skin. the tninor may be mistaken for a cavernous or cystic lymphangioma or for a papillary c.ystadenoma (e. g., of the sweat glands). Stroma. — The character of the connective-tissue stroma varies. It may be very cellular, mucoid, or fibrous. Probably a metaplasia of the ^__________ stroma into cartilage, oc- casionally even into bone, occurs, the presence of cartilage and bone in mixed tumors of the pa- rotid and related forms of endotheliomas being explained in this way (p. 974). Most Common Sites for Development. — Lymph- angio - endotJieliomas of the skin and subcutane- ous tissues, especially of the face, appear as cir- cumscribed, encapsulated nodules or non-encapsu- lated growths which are sometimes regarded as sarcomas, sometimes, es- peciall.y when ulcerated, as carcinomas of the skin. They grow slowly, but rarely forming metastases, and therefore are to be regarded as rela- tively benign tumors. According to Tanaka, the lymph nodes when in- volved are of a soft, fluctuating consistency, and are not adherent to the surrounding tissues. Similar tumors, which have been regarded as lymphangio-endotheli- omas, occur in the different viscera, in the membranes of the central nervous system, in the bones, the ovary and testicle, and in the salivary glands. The latter are sometimes regarded as mixed tumors (Wilms), and sometimes as fibroepithelial growths (Ribbert). As a result the group of endotheliomas has been considerably reduced. These tumors are usually encapsulated. Endotheliomas of Pleura and Peritoneum. — Endotheliomas of the pleura and peritoneum are rare. They produce a diffuse, thick infiltra- tion of the membrane involved, and frequently form metastases. Endo- theliomas of the pleura may also produce large nodular tumors which invade the lung. Depending upon the view held concerning the origin and nature of the cells covering the serous membranes, these tumors are classified as endotheliomas or carcinomas. ENDOTHELIAL TUMORS 965 Jlccmnnqio-cndothcliomas. — lla"niaii<^i()-t'ii(l(»tli('li()iMas develop from the endothelium of blood vessels. The proliferating eai)illaries and small vessels which compose thase tumors are lined or filled with tall, actively proliferating endothelial cells. They appear upon microscopic examination as glandlike tubules or solid cell cohunns which branch repeatedly and communicate with each other. If the proliferating endothelium is cubical or cylindrical, the tumor can only be differentiated from a new growth developing from a gland by the presence of blood in the lumina of the vessels. Ila^numgio-endotheliomas usually grow slowly, are circumscribed, and have but little tendency to invade the surrounding tissues and form metastases. They have been observed in the dift'erent viscera and in the bones, occurring in the latter also as multiple growths (Fritz Konig, Xarath). These tumors resemble upon section hii'mangiomas or very vascular, soft sarcomas. Endotheliomas occurring in bone produce a pressure atrophy and expansion of the cortex. They are so vascidar that they often give rise to symptoms resembling those of an aneurysm. X-^5%^SS?^ Fig. 438. — H.emangio-endothelioma of the Kidney, a, Blood vessels containing blood; h, blood vessels filled with proliferating endothelial cells. (From Ziegler's General Pathologj-.) Peritheliomas. — Peritheliomas are a variety of htpmangio-endotheli- omas; sometimes they are regarded as lymphangio-endotheliomas. These tumors may develop from the adventitial cells of the blood vessels, which apparently are very similar to endothelial cells, or from the endothelium of the perivascular lymphatics. The tumor tissue is 966 DIFFERENT VARIETIES OF TUMORS composed of dilated capillaries, wliicli are surroiinded by a wide zone of cells of different forms. The cell mantles, or, more correctly, the cell cylinders, containing the blood vessels are very sharply differentiated from the poorly developed connective-tissue stroma. The vessels surrounded by the cells have a cirsoid arrangement, branch frequently, and give rise to a very characteristic histological pic- FiG. 439. — Perithelioma of the Thyroid Gland, a, Section through a vessel; b, peri- vascular cylindrical cells with many mitoses; c, granular masses and cells between the cell columns. (From Ziegler's General Pathologj'.) ture. The latter is so characteristic that Waldeyer has called these tumors plexiform angiosarcomas; Kolaczek, angiosarcomas. It seems best to avoid the use of these terms, however, as the tumors might then be confused with very vascular sarcomas, which might also be called angiosarcomas, or, better, telangiectatic or cavernous sarcomas (Borst). Sarcomas in which the proliferation of perivascular cells is pro- nounced resemble pei'ithcliomas very closely, when the cell cylinders are fused. If hyaline degeneration occurs and the vessels become oblit- erated, the tumor resembles a cylindroma. Peritheliomas are found mo.st frequently in the brain and in the membranes surrounding it. They appear as circumscribed nodul&s or as diffuse, even multiple, infiltrations. They are also found in the sub- cutaneous tissue, especially in the subcutaneous tissues of the cheeks and lower lip, in the bones, muscles, and different viscera, The encapsulated ENDOTHELIAL TUMORS 967 tumors (Icvclopinu I'roMi tlic cjiiotid trlimtl niid sitii;i1f»l ;it the bifurca- tion of the coiiiiiiou cMiotid are usually peritheliomas. Peritheliomas are n-latively benign tumors. PsunnnoiiHis. — Tumors of the dura mater form a special class of endo- theliomas. They contain small calcium granules which resemble sand, such as normally occurs in the pineal gland and upon the inner surface of the dura. The term psanunoma was api)lied to the.se tumors by Virehow. These tumors develop from the endothelial cells covering the inner surface of the dura, and appear as grayish red, circumscribed, firm, Fin. 440. — PsAMMOMA of the Dura Sitiated upon the Po.sterior Surface of the Right Petrous Bone and Producing a Depression in the Flocculus, the Corkesponi>- iNG Superior Cerebellar Peduncle and the Pons. The trunk of the fifth ner\-e (a) run.s through the tumor mass (6). The facial and auchtorj' nerves lie upon the outer side of the tumor and are fu.sed with its capsule. The only symptoms produced by this tumor, which was almost as large as a walnut, was severe trifacial neuralgia. Tlie patient, a woman .seventy-three years of age, died following the removal of the Ga.sserian ganglion and the tumor was found during the post-mortem examination. (Lexer.) hemispherical tumors. They are attached to the dura by a broad base or short pedicle, and produce a depression in the surface of the brain, being separated from the latter ])y a vascular capsule. They usually occur as single, more rarely as multiple growths, and are found more 968 DIFFERENT VARIETIES OF TUMORS frequently upon the upper than upon the lower surface of the brain. These tumors differ in size. Only the larger tumors, the size of a walnut or apple, produce symptoms, which, of course, are those of a brain tumor. The smaller tumors, often no larger than a pinhead, produce no symptoms and are usually accidentally discovered during post-mor- tem examinations. Usually they groAV slowly. The cellular forms may develop relatively rapidly and rujDture through the dura mater and bone. These tumors do not form metastases. The dangers associated with them depend altogether upon the position of the tumor. The relation between the parenchyma and stroma varies in differ- ent tumors. The 'cells composing the former are flat or polymorphous and are arranged in groups or columns. These groups or columns are surrounded by connective-tissue trabeculte which contain few or many cells. Among the endothelial elements, which under the micro- scope appear in well-defined alveoli or columns, may be seen varying numbers of stratified bodies composed of cells concentrically arranged. These undergo calcifica- tion and become trans- formed in the white bodies resembling grains of sand. Connective -tissue bundles ma}^ also undergo hyaline degeneration and calcifi- cation. Similar tumors also oc- cur within the orbit, devel- oping in the dural sheath of the optic nerve (Rib- bert). They are also found in the pia mater, the pineal gland, and the choroid plexus. Multiple tumors of this character are occa- sionally found in the peri- toneum (Borst). Cylindromas. — The cylindromas, first described by Billroth in 1856, and regarded by Koster as endothelial growths with hyaline degen- eration of tlie cell columns, are classified by many authors with endo- theliomas. The small, glassy, hyaline bodies of round, bulbous, cordlike or cylin- drical form witli numerous branches and bulbous expansions, which may be easily isolated from the cut surface of a fresh tumor, are character- ENDOTHELIAL TUMORS 969 istie. Tlie histolofjical picture is (luitc cliaraeteristic, as tliese ^'lasslikf bodies are surrouiidtMl by a broad mantle of cells. If there are no cell rests or fibrilhe within the bodies above mentioned, they appear as liimina of larjre vessels. A similar histological picture may be produced in a number of dif- ferent forms of tumors by hyaline detreneration of the cells or by secre- tion poured out from them. For these reasons a number of patholo- gists (Ziegler, Orth, Lubarsch) are unwilling to place cylindromas in a separate and distinct class. A similar histological picture is presented by vascular sarcomas after hyaline degeneration of the cells and obliteration of the lumina of the vesseLs, by adenomas and carcinomas after the secretion of a hyaline ma- terial and its accumulation in the glandliUe tubules, or between the celLs forming a solid colunui. One can, therefore, speak of a sarcoma, car- cinoma, or adenoma cylindromatosum. The changes above described occur most fre([uently in endotheliomas and peritheliomas. Borst regards these two forms as true cylindromas. Ribbert also places them in a separate group, but regards them not as endothelial new growths, but as fibroepithelial tumors, believing that they develop from mucous or closely allied glands. These tumors have a slow growth, are encapsulated, and often may be recognized upon gross examination by the cavities containing hyaline masses. They rarely invade the surrounding tissues, and are rarely fol- lowed by metastases. They may be regarded as benign tumors. The hyaline changes occur partly within the endothelial, or, according to Eibbert, epithelial cell columns, partly within the connective-tissue stroma lying between them. These tumors develop most frequently in the orbit, the salivary glands, the palate, the floor of the mouth, the antrum of Highmore, and the nose. Sometimes they are found in the skin, the membranes of the brain and cord, in the peritoneum, in muscles and bone. They have no characteristics which make a positive clinical diagnosis possible. Developing in the salivary glands or palate, they resemble closel}', clinically, encapsulated adenomas or mixed tumors. If they ex- tend from the orbit into the nose, the antrum of Highmore, or the frontal sinus, they may resemble a carcinoma or sarcoma. Treatment. — The treatment of all the tumors of the endothelial group consists of removal. If they are encapsulated they may be enucleated. If they have no capsule and have invaded the neighboring tissues, they should be treated as nuilignant tumore. LiTERATDRE. — Billroth. Untersuchungen iiber die Entwicklung der Blutgefasse nebst Beobachtungen aus der Berliner Klinik. Berlin, 18.^6. Die Zylindergeschwulst, p. 55. — Borst. Die Lehre von den (Jeschwulsten. Wiesbaden, VM2, U, p. 9.53. — 62 970 DIFFERENT VARIETIES OF TUMORS Burkhardt. Sarkome und Endotheliome nach ihrem path.-anat. unci klin. Veilialten. Beitr. z. kliu. Chir., Bd. 36, 1902, p. 1. — Hildehrand. Ueber Resektion des Penis wegen eines Endothelioma intravasculare. Deutsche Zeitschr. f. Chir., Bd. 48, 1898, p. 209. — ■ Hinsberg. Die klinische Bedeutung der EndotheHome der Gesichtshaut. Beitr. z. kUn. Chir., Bd. 24, 1899, p. 275. — Fritz Konig. Ueber multiple Angiosarkome. Arch. f. klin. Chir., Bd. 59, 1899, p. 600. — Koster. Kankroid mit hyaliner Degeneration (Cylindroma Billroths). Virch. Arch., Bd. 40, 1867, p. ^68.— Mulert. Ein Fall von multiplen Eiidotheliomen der Kopfhaut. I.-D., Rostock, 1897. — Narath. Pulsierendes Angio- endotheliom des Fusses. Chir.-Kongr. Verhandl., 1895, II, p. 427. — Nasse. Die Geschwlilste der Spiecheldriisen und verwandte Tumoren des Kopfes. Arch. f. kUn. Chir., Bd. 44, 1892, p. 233. — v. Recklinghausen, v. Grafes Archiv fiir Ophthalmologie, Bd. 10, Abt. 2, 1864, p. 62.—Ribbert. Geschwulstlehre. Bonn, 1904.— Tanaka. Ueber die klinische Diagnose von Endotheliomen und ihre eigentiimliche Metastasenbildung. Deutsche Zeitschr. f. Chir., Bd. 51, 1899, p. 209.— Volkmann. Ueber endotheliale GeschwiiLste, zugleich ein Beitrag zu den Speicheldriisen- und Gaumentumoren. Deutsch. Zeitschr. f. Chir., Bd. 41, 1895, p. 1. F. MIXED TUMORS Definition. — By the term mixed tumor is usually understood a tumor which is composed of different tissues. They are distinguished from the combined forms of connective-tissue tumors, such as fibrolipomas, osteochondrosarcomas, lymphangiofibromas, etc., and also from the fibro- epithelial growths in which the epithelium resembles mucous membrane, skin, or glandular epithelium. Mixed tumors form a distinct group which vary a great deal in their histological characteristics. As there are so many transitional forms, a division into other groups is necessary. If the classification is based upon the structure, which is sometimes simple, sometimes com- plicated, and at other times highly organized, the three following forms may be differentiated: 1. Simple mixed tumors of different organs. 2. Teratoid tumors with two varieties: (a) Complicated dermoid cysts of the ovary and testicle (cystic embryomas of Wilms). (h) Teratoid mixed tumors (embryoid tumors of Wilms). 3. Teratomas. CHAPTER I SIMPLE MIXED TUMORS Nature and Origin. — These tumors, varying so much in structure, have attracted tlie attention of a number of investigators, but even at SIMPLE AlIXi;i) TIMORS 971 the present time tlioiv is no luiiforniity of opinion concernin<^ their nature and origin. Some pathologists believe that they are the result of metaplasia or of a tumorlike metamorphosis of adult tissues; while others think that they develop from displaced pieces of germinal tissue, supporting Cohnheim's theory concerning the cause of tumor formation. The latter view appears to Wilms to be the more plausible. Accord- ing to him these tumors develop from undili'erentiated germinal tissue which was displaced very early in fa'tal life and is potentially able to reproduce any of the tissue normally found in the pai't from which it was displaced. The group of simple mixed tumors comprises tvnnors of the salivary glands, breast, and of the urogenital system. Some of these tumors are well known clinically. Within this group of simple tumors are some which are relatively complicated. It is impossible to make a sharp distinction between them and fibroepithelial growths on the one hand and teratoid tumors on the other. Mixed Tumors of Salivary Glands. — Mixed tumors of the salivary glands are found most frequently in the parotitl, more rarely in the other salivary glands. They appear as well- circumscribed growths which may develop at any age, being most com- mon in the second and third decennia. These tumors grow very slow- ly, cases having been observed in Avhich the growth has existed from twenty to f o r t y - f i v e years without enlarging to any great extent. Occasionally, however, they assume rapid growth and reach con- siderable size (as large as a man's head). Usu- ally they are encapsu- lated and sharply de- fined against the sur- rounding tissue, are displaceable upon the subjacent tissues, and covered by normal skin, which may, however, be tense and thin if the tumor is lariie. The surface of such a tumor is usually nodular, the nodules Fig. 442. — Mixed Tumor of thk Pahotiu Gland. 972 DIFFERENT VARIETIES OF TUMORS being large. The consistency is usually hard, but frequently in some parts of the tumor soft, even pseudo-fluctuating areas may be found between the firm, resistant parts. The completely encapsulated growths lie between the lobules or upon the surface of the parotid gland, in which they produce, a bed by their expansive growth. At times a tumor is attached to the gland by a pedicle. Occasionally multiple tumors are found within the salivary glands. Position. — If the tumors develop in the anterior part of the parotid gland, they lie just in front of the ear, between the zygoma, the ante- rior border of the masseter muscle and mandible, while if they develop from the lower and posterior part of the gland they surround the lobule of the ear which they elevate and displace. Symptoms. — Symptoms are produced by the larger tumors only. Most frequently the symptoms are facial paralysis and partial deaf- ness, the latter being due to narrowing of the external auditory canal. Usually these tumors cause no pain, and it is easily un- derstood why the majority of the patients seek surgical aid so late. On an average, pa- tients carry these tumors eight years before they seek surgical aid, notwithstanding the great disfigurement. Surgical aid is usually sought because of facial paralysis or rapid increase in the size of the growth. Malignant Degeneration and Metastases. — The submaxillary tumors develop in the sub- maxillary region. If they are situated in the median part of the gland they may project into the floor of the mouth. Slow growth, encapsulation, and mobility of these tumors indicate their benign character. A malignant change is indicated by rapid growth and by the invasion of the surrounding tissue, following the rupture of the growth through a part of its connective-tissue capsule. Kiittner esti- mates that about eleven per cent of the mixed tumors which occur in the submaxillary gland become malignant. Lymphogenous and hematoge- nous metastases then develop as in carcinomas and sarcomas, depending upon whether the mixed tumor undergoes carcinomatous or sarcomatous degeneration, while the primary tumor becomes so extensive that it becomes inoperable and breaks through the skin, forming deep ulcers. Diagnosis. — The diagnosis is based upon the position of the tumor, the slow growth, nodular form, uneven consistency, and encapsulation. Fig. 443. — Benign Mixed Tu- mor OF THE Soft Palate. SIMPLE MIXED TT'MORS 973 A mixed tumor which has uiKlrryoiR' mali^jiaut degeneration can be >!itt'erentiated from a carcinoma or sarcoma only by the previous history of a preexisting tumor which has been noted for some time, and the uneven consistency. If the tumor is small, tuberculous lymph nodes and lipomas must also be considered in making a differential diagnosis. Cystic mixed tumors may easily be confused with retention cysts, which are not rare, especially in the parotid gland. Treatment. — The indication for treatment is complete removal. En- capsulated tumors of the parotid gland can usually be removed without injuring the facial nerve. If the tumor is situated in the submaxillary gland, the latter should be removed with the tumor. Recurrences are rare. They may develop from portions of the tumor which were left behind during the operation or from other small tumors within the gland. If the tumor has become malignant, the dissection should be car- ried well into healthy tissues. No eft'ort should be made to spare the facial nerve when a tumor which has undergone malignant changes is situated in the parotid gland. Recurrences develop early even after the most radical procedures, and the prognosis is bad if the tumor has already become malignant. Mixed Tumors in Other Parts of the Head. — Similar tumors, but of a simpler structure, are also found adjacent to the parotid and sub- maxillary glands in the cheek (developing from accessory salivary glands), in the upper lip, in the skin of the nose, and finally within the orbit adjacent to the lacrymal gland. (Vide Plate I, Fig. 3, p. 884.) Macroscopic Appearance and Histology. — Upon section mixed tu- mors usually have a lobulated structure, and so mottled an appearance that they can scarcely be mistaken for any other variety of tumor. Soft and hard, solid, cystic, and different colored areas are intermingled. ^Microscopically ejiithelial-like cells and stroma, the relative propor- tion, form, and arrangement of which vary in different tumors, depend- ing upon whether they are simple or complicated, are foimd. The epithelial-like cells are cubical and cylindrical, and arranged in solid cords, in alveoli, in glandlike, or cystic and dilated tubules. De- pending upon the character and arrangement of the cells, different areas may resemble histologicalh' an adenoma or a carcinoma. "Wilms thinks that the glandular areas in these tumors resemble somewhat, histologically, the anlage of the parotid, submaxillary, and lacrymal glands. In some of the areas, canals, cysts, and alveoli are found which are lined with flat epithelium (including basal and prickle cells and the horny layer of the skin — Ilinsberg, Wilms). The stroma consists of a fibrillar connective tissue containing elastic fibers or a cellular embryonal tissue. jNIyxomatous, cartilaginous and bony areas are also found in the complicated tumoi-s. Different areas 974 DIFFERENT VARIETIES OF TUMORS of sucli a tumor may, therefore, resemble a fibroma, a spindle-cell sar- coma, a myxoma, chondroma or osteoma, depending upon the character of the stroma. The relation between the parenchyma and stroma of these tumors varies a great deal. These differences explain the number of different terms, such as enchondromas, enchondroma mucosum, and .myxomatodes, chondrosarcoma, chondroadenoma, which were earlier applied to these tumors. Wilms's Theory as to Origin. — Wilms believes that not only fully de- veloped tissues, but also embryonal cells and tissues in different stages of development are found in these tumors, for the glandlike tubules re- semble closely the an] age of the gland in which they occur. He believes that the flat epithelium is derived from the epithelium of the mouth cavity or orbit depending upon the position of the tumor. He thinks that the mixed tumors of the salivary glands and allied tumors occur- ring in the palate develop from embryonal rests consisting of epithelium and mesenchyme which have remained latent for a long time. It de- pends upon the rate of growth and the character of the different cellu- lar elements whether a simple or a complicated mixed tumor develops. Voncmann's Theory of Metaplasia. — The opinions of different au- thors concerning the exact nature and classification of these tumors differ. Kauffmann, Nasse, Volkmann, and others regard the mixed tumors of the salivary glands as endotheliomas. They believe that the stroma may become converted into tissues of different type as the result of metaplasia, and that the columns of cells and glandlike tubules are formed by the proliferation of the endothelium lining the tissue spaces and lymphatic vessels. This view is disputed by Hinsberg, Wilms, and Ribbert. The last classifies these tumors with fibroepithelial growths and believes that they develop from displaced glandular germinal tis- sue, the stroma of which, because of its intimate relation to the branchial arches, is capable of forming bone and cartilage. Hinsberg holds a somewhat similar view, believing that the tumors develop from dis- placed islands of the parotid anlage and embryonal periosteal tissue sepai-atcd ft'oin the mandible. Mixed Tumors of the Breast. — According to Wilms, tumors of the breast, which have sometimes been described as cystosarcomas and adeno- sarcomas with epidermoid cysts (Grohe's cystic fibrosarcoma with epi- dermoidal metaplasia), sometimes as atheromas or cholesteatomas, the latter combined with cystosarcoma phyllodes (Hackel), should be clas- sified as mixed tumors. Clinically they arc most closely related to adenomas, but they are much less conniion. They are found in women of middle and advanced age, occasionally in men. SIMPLE mixi;d Ti mors 975 Thoy appear as iKxliilar, well-clefined tumors, which may be easily moved \ij)on the surroun(liii»i: tissues, aud are covered by non-adherent skin. These tumors may jirow rapidly from the beginning or after some time to attain considei'able size. Finally they invade the skin and the latter ulcerates. ^Metastases have not been observed. The diagnosis is not easih'^ made. Depending upon the rapidity of growth these tumors are sometimes regarded as libromas and adenomas, at other times as sarcomas. Amputation of the breast is indicated to prevent recurrence. Macroseopically the cut surfaces of these tumors vary in api)ear- ance, as sometimes they are solid, while at other times they contain spaces and rotind cysts. Hard and soft areas, some of which are com- posed of mucoid tissue, are intermingled. ]\Iicroscopically these tumors differ a great deal from the adenomas, eystadenomas, and cystosarcomas which they resemble so closely clinically. Adenomatouslike tissue is found, together with epidermoid cysts with cheesy contents and cysts lined with scpiamous ei)ithelium. The stroma is composed of adult and embryonal connective tissue, containing large nuudjers of nmnd and spindle cells, loose mucoid' tissue, cartilaginous and osteoid masses. Sometimes the blood vessels liave proliferated, and the tumor sinudates an angioma. The origin of these tumors is most satisfactorily explained by Wilms. He believes that they develop from displaced ectodermal tissue, to which is also attached some mesenchyme. These fragments become enclosed within the breast tissue, and later proliferate to form glands, skin, and different types of connectivt^ tissue. Mixed Tumors of Urogenital System. — The mixed tumors found in the urogenitid system are nuich more malignant than those occurring in the salivaiy glands and breast. They are found most frequently in the kidneys. They may develop in young children, and occasionally are of congenital origin, both kid- neys being frequently involved. These tumors develop most commonly within the substance of the kidney, the renal tissue being displaced and destroyed by the new growth. The tumor, composed of large nodules and covered by the tibrous capsule of the kidney, replaces the latter organ. Frequently only a small amount of renal tissue remains at either pole. The tumor is either se})arated from the ad.jacent renal tissue by a layer of loose connective tissue, or is united to it by intil- trating masses and columns of cells. After rupture of the fibrous cap- sule, the tumor invades the surrounding tissue. Polypoid masses may also extend from the tumor into the pelvis of the kidney. These tumors grow rapidly and constantly, and become very large. Finally they may till the greater pail of the abdominal cavity. They 976 DIFFERENT VARIETIES OF TUMORS produce lymphogenous and hfematogenous metastases, the latter follow- ing invasion of the renal vein. The prognosis is bad. Even the results following extirpation of the tumor and the remains of the kidney are not good, as these tumors recur rapidly. IMetastases and the weakened condition of the patient contribute to the poor results of these operations. It may be seen upon section that a number of different kinds of tissue occur in these tumors. Dense, firm, fibrous areas alternate with vascular, soft ones which resemble in structure a sarcoma. ]\Iicroscopically one finds adult and embryonal fibrous tissue with sarcomatous characteristics, mucoid tissue, cartilage, and smooth and striated muscle fibers in different stages of development. Within the stroma lie tubular glands which remind one of the canals of the primi- tive kidney, for their vesicular extremities, which are surrounded by connective tissue and frequently are invaginated, resemble somewhat glomeruli. The glandular content of these tumors is indicated by the number of different names, such as adenosarcoma, adenomyxosar- coma, adenomyoehondrosarcoma, etc., which have been applied to them. Birch-Hirschfeld was the first to group these tumors. He called them " embryonal glandular sarcomas." In rare cases groups and masses of cornified, flat epithelium, which contained material resembling cholesterin, have been found. These mixed tumors must be the result of some developmental dis- turbance occurring during the formation of the kidney. According to Wilms, the error in development must occur very early, otherwise the number of kinds of germinal tissue displaced must correspond to the number found in the tumor. He believes that these tumors develop from germinal mesoderm separated and displaced from the vicinity of the primitive kidney. Mixed Tumors of the Vagina.— Mixed tumors of the vagina appear in small children as grapelike growths, which, like those developing upon the cervix of middle-aged people, grow rapidly, fill the vagina, protrude between the labia, and later infiltrate the pelvic connective tissues. Both forms recur rapidly, ulcerate, and become infected early, and cause death in a few years. Metastases rarely develop. The origin of these tumors, composed of different forms of sarcoma- tous tissue, together with muscle fibers, cartilage, mucoid tissue, and fat, may be most satisfactorily explained by Wilms 's theory, according to Avhich they develop from an undifferentiated, germinal, mesodermal tis- sue which is displaced during early development. A similar histological picture is presented by the rare mixed tu- mors occurring in the urinary bladder, which appear about the trigone. According to Wilms these also develop from displaced mesodermal tis- TERATOID TUMORS 977 sue. This investifrator ascribes the same origin to mixed tumors devel- oping; in the lower i)o]e of the testicle and along the vas deferens of young children, which, depending upon the character of the tissues composing them, are usually called rhabdomyomas or rhabdomyosar- comas. Ribbert has suggested tliat mixed tumors of the in-ogenital system, which are apt to occur at definite points, develop from separated ger- minal cells which migrate from the region of the kidney through the ]\Iullerian and Wolffian ducts to the uterus, vagina, and urinary blad- der, and perhaps even gain access to the vas deferens. Literature. — Birch-Hirschfeld. Sarkomatose Driisengeschwulst der Niere im Kiiulesaher (embryonales Adenosarkom). Zieglers Beitr. z. path. Anat., Bd. 24, 1898, p. 343. — Hinsberg. Beit rage zur Entwicklungsgeschichte und Natur der Mund- speicheldriisengeschwiilste. Deutsche Zeitschr. f. Chir., Bd. 51, 1899, p. 281. — Hiisler. Beitr. z. Lehre von d. Harnblasengeschwiilsten im Kindesalter. Jahrb. f. Kinderheilk., Bd. 62, 1905, Part 2. — Kaufmann. Das Parotissarkom. Arch. f. klin. Chir., Bd. 26, 1881, p. 672. — Kidtner. Die Geschwulste der Submaxillarspeicheldriise. Beitr. z. klin. Chir., Bd. 16, 1896, p. 181. — Nasse. Die Geschwulste der Speicheldriisen, etc. Arch. f. klin. Chir., Bd. 44, 1892, p. 233. — Volkmann. Ueber endotheUale Geschwulste, zugleich ein Beit rag zu den Speicheldriisen- und Gaumentumoren. Deutsche Zeitschr. f. Chir., Bd. 51, 1895, p. 1. — M. Wilms. Die Mischgeschwiilste, I-III. Berlin und Leipzig, 1899, 1900, 1902. — Weitere Literatur siehe bei Borst. Die Lehre von den Geschwiilsten. Wiesbaden, 1902, II, p. 979. CHAPTER II TERATOID TUMORS (a) COMPLICATED DERMOID CYSTS OF THE OVARIES AND TESTICLES {Wilms' s Cystic Emhryomas) The most striking characteristic of these growths, which are usually benign, is their similarity to simple dermoid cysts, which consist only of follicles of skin provided with hair and glands and have cheesy con- tents. The presence, however, of large amounts of hair, of teeth, and particles of bone indicates the complicated structure of these tumors, and for this reason they are differentiated from the simple dermoid cysts. Common Occurrence in Ovaries. — They are found most freciuently in the ovary, forming nine per cent of all ovarian tumors. These tumors are found more rarely in children than in adults, but apparently all of them are the result of anomalies in development. They develop as single or nuiltiple growths in one or both ovaries, and may be situated within 978 DIFFERENT VARIETIES OF TUMORS the latter organs as well as upon their surfaces. When situated upon the surface of the ovaries they are frequently pedunculated. When the pedicle is broken, they lie free in the lower, occasionally in the upper abdomen (e. g., in the lesser peritoneal cavity). The cysts which lie at a distance from the ovaries may have developed from accessory ovaries. These cysts usually grow slowly, but may become as large as a man's head. Then the ovary is partially or completely destroyed. Occasion- all}^ the cyst wall ruptures, and then viable germinal tissue from which other small cysts develop is transplanted upon the peritoneum. Carci- nomas, usually of the squamous-cell variety, may develop from the walls of these cysts. Symptoms — Torsion of Pedicle, etc. — The first symptoms are usually produced by pressure upon neighboring organs after the cysts attain considerable size, or by secondary disturbances which may be followed by serious consequences. Pedunculated cysts are frequently deprived of nutrition by torsion of their pedicles. When torsion occurs the cyst becomes necrotic, contracts adhesions with neighboring structures, or may rupture in the bladder or intestines. Frequently cysts after torsion of the pedicle are invaded by intes- tinal bacteria, and then suppurate or undergo putrefactive changes. A progressive fatal peritonitis may follow infection of one of these cysts. It is difficult to make a differential diagnosis between dermoid cysts and other tumors which occur in the ovary and tissues adjacent to it. Treatment. — The treatment consists of complete removal, together with the remnants of the ovary involved. Complicated Dermoids of the Testicles. — The complicated dermoid cysts of the testicle are much rarer. They are more rare in adults than in small children, in whom they are frequently congenital. Occasion- ally they develop in undescended testicles. They occur as single growths and are found only within the testicles, not occurring upon the surface, and usually develop from the substance of the organ, only small rem- nants of the latter remaining upon the surface of the tumor. Tumors situated without the testicle — for example, in the scrotum — are rare. They grow sIdwIv, the patient's attention usually first being attracted to the growth by its size, and never give rise to the severe symptoms which are sometimes associated with similar growths of the ovaries. They may be differentiated from other slowly growing tumors of the testicles by their doughy consistency. Castration is indicated in the treatment of these tumors. Macroscopic Appearance and Histology. — According to the investiga- tions of Wilms, the complieated dermoid cysts of the testicles and ovary are peculiar in that they contain a rudimentary embryonal anlage, and therefore he has called these growths cystic emhryomas. TERATOID TUMORS 979 The inner surface of the firm cyst wall, which is not of the same thickness throughout, contains a number of tumorlike projections. Some- times these projections resemble villi, sometimes noduhir thickenings, while at other times they appear as septa between caviti&s within the cyst. These projections are covered with skin, which is frequently cov- ered with masses of hair, and often contain teeth connected with pieces of bone which extend into the deeper parts of the cyst wall. Cysts of this character contain derivatives of the three germinal layers. These deriva- tives resemble the structures of the cephalic portion of an embryo, but do not have the irregular arrangement found in teratoid mixed tumors (Wilms). Subcutaneous fat, cartilage, bone, muscle fibers, and even brain tissue with corpora amylacea may be found beneath the skin lining such a cyst. In some parts of the cysts the skin becomes continu- ous with mucous membrane covered with squamous epithelium, and the latter with cylindrical or ciliated epithelium lining a canal, the char- acter and arrangement of the epithelium being similar to that found in the mouth cavity of the embryo. Some of the cysts, the walls of which contain rings of cartilage and smooth muscle fibers, resemble in structure the respiratory passages, while others, lined with goblet cells and filled with mucus, the walls of which contain smooth muscle fibers, resemble histologically the intestines. Widely different types of tissues may be found which have often been regarded as rudiments of an eye, of the thyroid gland, trachea, mammary gland, etc. The greater part of the walls of these cysts is lined with skin, the remaining part is lined with cylindrical epithelium or covered with granulation tis.sue. Naturally the different tissues do not reach the same degree of de- velopment in the different tumors. The embryonal tissues and organs which develop earliest predominate, viz., the ectoderm and the tissues and organs of the cephalic region. The development of the other tis- sues is prevented by the rapid growth of those which differentiate early (Wilms). Theories as to Origin. — Different theories have been advanced to ex- plain the development of these complicated dermoid cysts (embryomas) in the testicles and ovaries. It has been suggested that they are the result of abnormal proliferative changes in the spermatozoa or ova, which occur without fertilizatii)n, the process having been called par- tlicnogenesis. The possibility of the parthenogenetic origin of cysts of this character has been di.sputed by Bonnet. lie believes that these tumors develop from blastomeres which have not gone on to full differentiation or from fertilized polar globules. ]\Iarchand and Wilms believe that the tumors occurring in the testicle and ovary may develop from excessive, unused blastomeres. They do not accept Bonnet's view that they may develop 980 DIFFEREXT VARIETIES OF TUMORS * from polar globules, as cases have been observed in which five embry- omas have been found in an ovary, while in the normal human ovum usually only two, never more than three, polar globules are formed (\Yilms). According to TVilms these tumors develop from germinal tissue con- taining the three layers which is displaced during development. This theory explains most satisfactorily not only the development of the com- plicated dermoid cysts found in the ovaries and testicles, but also that of the teratoid mixed tumors occurring in these organs. Teratoid tumors and teratomas are supposed by some to develop from unused, displaced blastomeres, by others from fertilized polar globules. The genetic rela- tionship between these tumors and dermoids of the ovary is demon- strated by the occurrence within the abdominal cavity of tumors, which are morphologically similar to dermoids of the ovary, but have no con- nection with the latter organ. It has not been satisfactorily explained why the displaced germinal tissue produces such different macroscopic and microscopic pictures when it proliferates. (b) TERATOID MIXED TUMORS (Emhryoid Tumors, Wilms) The tumors placed in this group differ from the complicated der- moid cysts in that they are solid or polycystic; from teratomas in the absence of any highly developed rudiments. They are formed as a result of the irregular proliferation of derivatives of the three germinal layers (therefore, tridermoma, "Wilms). They have a much more varied structure than the simple mixed tumors. These tumors may develop in any part of the body in which tera- tomas occur, but are found most frequently in the testicles and ovaries. Teratoid Mixed Tumors of Testicles. — Teratoid mixed tumors of the testicles develop most commonly between the twentieth and fortieth years of life. They grow slowly to form large nodular tumors of irregular size and varying consistency. The changes produced in the surrounding tissues by these tumors are very similar to those produced by complicated dermoids. They become malignant with relative fre- quency. These tumors may assume a sarcomatous, more rarely an adenocarcinomatous structure, and may rupture through the capsule formed by the tunica albuginea, may infiltrate the surrounding tissues and form numerous metastases, which often correspond histologically to the malignant part of the tumor only. Frequently, however, the metas- tases contain the derivatives of the three germinal layers. Death soon follows the formation of metastases. TERATOID TUMORS 9S1 The varying: consistency of the slowly jifrowinf; tumors is the most important clia«i:nostic point. AVhen these tumors assume mali.ject into a dermoidlike cavity or are surrounded by amnion, 'i'hcse diflVrent kinds of tissue are held to- gether by tumorlike masses which correspond to the different germinal layers from which they develop. One gains the impression, when such a tumor is examined, that the growth of tlic cells of one of the germinal layers has been suppressed or tliat the cells have l)een i)ar1i;dly destroyed, and that the layers Fig. 444. — A Teratoma the Size of a Fist Removed from a Giri. Baby Seven Weeks Old BY Operation. The tumor lay in the foramen of Winslow, just beneath the liver and was adherent to the hepato-duotlenal ligament, from which its nutrient vessels were derived. (Lexer.) 1, The pedunculated sac of skin contains an anlage of the head, consisting of brain cavities, connective-tissue skull, well-developed scalp, and anlage of teeth which extend into the pedicle and squamous cell epithelium, which resembles that of the mouth. 2, Capsule of the tumor open. 2a, Point of attachment of tumor. The tumor also contains a cyst situated close to the anlage of the head wliich is provided with ciliated epithelium and goblet cells, mucous glands, smooth muscle fibers and hyaline cartilage (anlage of the respiratory passages). The principal part of the nodular tumor is a teratoid (polycystic) mi.xed tumor. Hi, H2, Nodules of skin attached to the head anlage. 984 DIFFERENT VARIETIES OF TUMORS which possessed sufficient growth energy have proliferated to form im- perfect organs, which, however, have no definite morphological or func- tional relations wdth each other. Diagnosis. — The correct anatomical diagnosis depends upon the posi- tion of the tumor. The nature of a superficial tumor occurring in areas in which tumors of this character are common is recognized earlier than that of a similar tumor situated in the pleural or peritoneal cavities. Of course tumors of the pleural cavities are inaccessible. If extremities or teeth can be demonstrated in tumors of the abdomen by palpation or by Rontgen-ray examination, a diagnosis can be made with some degree of certainty. In some of the cases, however, the parts are so rudimentary that it is difficult to interpret the findings. Teratomas have frequently been removed by operative procedures, but only a few of the cases have been successful. Origin of Teratomas. — A teratoma never springs from a postnatal matrix. ]\Iany of the tumors occurring about the cephalic and caudal extremities develop from germinal tissue which has been displaced dur- ing fusion of the germinal plates, and from embryonal structures which normally undergo involution, such as the neurenteric canal, the post- anal gut, the medullary tube, and the caudal vertebras. Monogerminal and Bigerminal Tumors. — Tumors developing from dis- placed rests or from structures which normally undergo involution are called monogerminal tumors, while those which resemble foetal inclu- sions are called bigerminal tumors (bigerminal teratomas or foetal in- clusions, parasitic implantations, parasites, foetiis in fcetu). It is not always easy to differentiate between these two groups. The differentiation is. usually based upon the following principle : If the tissues or organs found in the tumor resemble those normally found in the area where the tumor is situated, the latter is regarded as a mono- germinal tumor, while if the tissue found in the tumor is foreign to the area in which the former occurs it is called a bigerminal tumor. Literature. — Arnold. Behaarte Polypen der Rachen-Mundhohle. Virchows Archiv, Bd. Ill, 1888, p. 176.— Aschoff. Zysten. Ergebn. d. allg. Path., II, 1897, p. 456. — Borst. Die angeborenen Geschwiilste der Sakralregion. Zentralbl. f. allg. Path., Bd. 9, 1898, p. 459. — Engelmann. Beitrage zur Kenntnis der Sakraltumoren. Arch. f. klin. Chir., Bd. 72, 1904, p. 942.— S. Fischer. Ueber ein Embryom der Wade. Miinch. med. Wochenschr., 1905, p. 1569. — Kirniisson. Chirurgische Krankheiten angeborenen Ursprunges. Stuttgart, Enke, 1899.— Kleinwachter. Ueber operierte Kreuzbeinparasiten, etc. Zeitschr. f. Heilkunde, Bd. 9, p. 1. — Lexer. Ueber teratoide Geschwiilste in der Bauchhohle und deren Operation. Arch. f. klin. Chir., Bd. 61, 1900, p. 648;— Operation einer fotalen Inklusion in der Bauchhohle. Arch. f. klin. Chir., Bd. 62, 1900, p. 351. — Linser. Ueber Sakraltumoren und eine seltene fotale Inklusion. Beitr. z. klin. Chir., Bd. 29, 1901, p. 388.— Mar chand. Sakraltumoren. Eulenburgs Refllenzyklopiidie, Bd. 25, 1899.— /Ic/w'ZZes Miiller. Zur Kenntnis der Hodenembryome. TERATOMAS 985 Arch. f. klin. Chir., Bil. 70, 100"), p. (WH.— A'^fis.sr. BeitWige zur Oencse der sacrococcy- gcaleii Torutomo. Arch. f. kliii. ("hir., BiL 4'), 1803, p. OS"). — Otto. Uchor cinen konge- nitalen bchaarten Rachenpolypcn. \iifho\vs Archiv, BtL 115, 1880, p. 242. — Pupoi'ac. Ein Fall von Teratoma colli init Veriinderungen in den regioniiren Lymphdriisen. Arch. f. klin. Chir., Bd. 53, 1896, p. 59. — Saxer. Ein ziun griissten Teil aus Derivaten dor MetluUarplatte bcstehendes grosses Teratom im 3. Ventrikel eines 7wochentlichen Kindes. Zioglers Beitr. z. path. Anat., Bd. 20, 1806, p. S'-M.— Wetzel. Zur Kasuistik der Teratoine ties Halses. I.-D., Giessen, 1805. — Wilms. Derinoidzysten iind Tera- tome. Deutsch. Arch. f. klin. Med., Bd. 55, 1805, p. 280; — Ueber die soliden Teratonie des Ovarium. Zieglers Beitr. z. path. Anat., Bd. 10, 1805, p. 367; — Die teratoiden deschwiilste des lloilens. Ibid., Bd. 19, 1806, p. 233; — Embryome uiid einbryoide Tumoren des Hodens. Deutsche Zeitschr. f. Chir., Bd. 49, 1808, p. 1; — Multiple Em- bryome des Ovarium. Monatsschr. f. Geburtsh., Bd. 0, 1800, p. 585. — Weitere Literatur siehe bei Borfit. Die Lehre von den Geschwiilsten. Wiesbaden, 1902, II, pp. 980-982. 63 PART VII CYSTS, :n"ot ij^oludi^g cystic tumors Definition — Unilocular and Multilocular Cysts.- — A cyst is a circum- scribed cavity, the contents of which may be thin, thick, or atheromatous, separated from the surrounding tissues by a connective-tissue membrane or by tissue of complex structure. Cysts with but a single cavity are called unilocular, while cysts with many cavities are called multilocular. Cysts, as they develop, tend to become spherical, but the form is modi- fied by the resistance offered by surrounding structures, such as fascia and bone, by adhesions which the wall of the cyst contracts, and by the form of the original cavity. There are a number of varieties of cysts which have no relation whatever to true tumors, besides the cysts which develop as the result of peculiarities of growth in true tumors (embryonal cysts, cystade- nomas) and as the result of softening and liquefaction in solid tumors. Four varieties of cysts, which include the false as well as the true, may be differentiated. A true cyst has either an epithelial or endo- thelial lining, while the connective-tissue capsule of the false cyst has no lining at all. (1) VIRCHOW'S EXUDATION OR EXTRAVASATION CYSTS Cysts of this character are formed when an exudate or blood is poured out into a preexisting cavity, or one formed as the result of some pathological process. A hydrocele of the tunica vaginalis testis or of the spermatic cord is the best example of an exudation cyst. The serous exudate formed during a chronic inflammation fills the remains of the processus vaginalis peritonei. In hygromas — cysts of the bursfe and tendon sheaths — the serous or serohemorrhagic exudate formed during the chronic inflammation is likewise poured out into a preexisting cavity. An ascites, a hydrops of a .joint, or a hydrocephalus might be spoken of as a cyst, but the anatomical relations, which are not the same as in cysts, do not permit of it. On the other hand, an empty hernial sac or a menin- gocele may be shut off from the cavity with which it formerly communi- cated ; the fluid secreted by the endothelial lining can then no longer es- cape, and the hernial and meningeal sac becomes transformed in a cyst. 986 CYSTS, NOT INCLUDINCJ CYSTIC TUMORS S^2/mp^oms.— Frequently the symptoms following the development of cysts in deep viscera (liver, lung, spleen, kidney) are indefinite. The symptoms first become definite when the cyst becomes large enough to exert pressure upon neighboring structures, suppurates or ruptures. Infection followed by suppuration is accompanied by severe pain, fever, rapid loss of strength, progressive inflammation of the organ involved, Fig. 449. — Large Echinococcus Cyst in the Muscles of THE Back (Echinococcus Hydatidosus). CYSTS, NOT INCLUDING CYSTIC TUMORS 999 localized or progressive suppuration in the peritoneal or pleural cavi- ties, rupture into neighboring organs (stomach, intestines, urethra, bronchi), or through the skin. Rupture of the cyst, often produced by- trauma, is followed by toxic symptoms (with urticaria), and the diffu- sion of brood capsules and scoleces from which new cysts may develop. Rupture is an especially dangerous accident when the peritoneum is in- volved. Death follows more frequently than spontaneous healing, rup- ture or suppuration of a cyst Avhich is deeply situated. Diagnosis. — The diagnosis belongs to the province of special surgery, as the symptoms are those which follow interference with the function of the organ involved. It should be mentioned that exploratory punc- ture should be omitted when the cyst is adjacent to the pleura or peri- toneum, as the cyst may be ruptured and brood capsules and scoleces may be diffused. The external forms of ecliinocoecus — those of the subcutaneous tis- sues, muscles, intermuscular connective tissues, and superficial organs — appear as fluctuating growths which enlarge very slowly, often inter- mittently, and may exist for a number of years without causing symp- toms. The surface of the swelling is smooth or nodular, when the brood capsules can be palpated. A cyst may become as large as a child's head or larger. The swelling is round or influenced by surrounding tissues, especially when it develops in the loose connective tissues between mus- cles or along large blood vessels. Even unilocular cysts are firmly at- tached by their connective-tissue capsules to the surrounding tissues, so that the overlying skin cannot be raised when the cysts are super- ficial, or the muscles separated from them when they are deep. The cysts are usually well defined, but can only be displaced with the surrounding tissues. Tlie external forms are found mo.st frequently in the trunk and neck, the lumbar region, the abdominal wall, the axillary fossa\ and the inguinal regions. The spaces occupied by the vessels of the neck are most frequently involved. Of the different glands, the thyroid and the mammary are most freciuently affected. Cysts of the extremity are found most frequently in the internal bicipital sulcus, in the region of the adductors of the thigh, and in the i)opliteal fossa. In the head they develop most frequently in the temporal and masseter muscles and the orbit. The diagnosis of the external forms of eehinococcus is iLsually made by exclusion and by the peculiarities of the parasitic cj'sts. All fluctuating, circumscribed tumors, chronic abscesses, and cysts which occur in the area involved, such as cystic hnnphangiomas, lipomas, dermoids, hygromas, cysts of the mammary and thyroid glands, ranula, and tuberculous abscesses, must be considered and excluded. The so- 1000 CYSTS, NOT INCLUDING CYSTIC TUMORS called hydatid fremitus, which is elicited by tapping the cyst wall and is supposed to be characteristic, can be elicited only in the large uni- locular cysts. The fremitus is probably due to the movement of the daughter cysts on one another. Aspiration of the cyst and examina- tion of the fluid is naturally the most positive diagnostic method. This procedure, of course, is much less dangerous when the cyst is situ- ated in the soft tissue than when it is situated in the pleural or peri- toneal cavities. A positive diagnosis is impossible when suppuration within the cyst or a pericystic phlegmon develops. The nature of the process in these cases is generally unsuspected until degenerating cysts and shreds of the cyst wall are revealed by incision. Echinococcus of bone is not very common. Only one hundred and two cases have been reported up to the present time (Frangen- heim). The lesions, like embolic infections, are situated most frequently in the spongy ends of long bones. An old fracture or a part of a bone recently injured are most commonly attacked, the abnormal vascular relations in the callus and the lacerations of vessels produced by an injury providing favorable conditions for the deposition and growth of the parasite. The pelvic bones and vertebrae are next most frequently involved after the long bones. Isolated cases of involvement of the skull bones followed by rupture into the sphenoidal and frontal sinuses or into the cranial cavity, of the ribs, sternum, scapula, and phalanges have been observed. The multilocular form develops in bones more frequently than the unilocular. In the beginning, cysts the size of a pinhead or pea develop in the spongy tissue. As a result of the atrophy of the bony trabecule and necrosis of the surrounding spongy tissue, large irregular cavities filled wdth yellow or white fluid, w-hich contain sequestra of bone, bone sand, cysts, detritus, and cholesterin, are formed. The cysts may be unobserved for a number of years and increase in size without producing any symptoms, or the latter may consist merely of mild migrating pains and a sense of weariness. The bone is destroyed gradually, and usually, even when the cyst extends to the periosteum, there is no periosteal bone formation to strengthen the part of the bone destroyed by the enlargement of the cysts. As a result the bone involved becomes very thin, and spontaneous fracture of the long bones or rupture of a puriform mass together wdth cysts into the soft tissues may be the first indication of the disease. The symptoms of echinococcus disease of the vertebrae are those of compression mye- litis, caused by the destruction of the bodies of the vertebra involved and the development of extradural cysts. Flat bones, when involved, CYSTS, NOT IXCLUDIXG CYSTIC TUMORS 1001 become expanded, and " paielniu'iit craekliny " or fluctuation can be elicited by pal{)ati(tii. If an echinoeoecus cyst situated in an epiphysis ruptures into a joint, a large part of the latter is destroj-ed and a subluxation develops. The accumulation of material resembling that found in an abscess precedes rupture through the skin, Avhich is followed by chronic fistula. The diiKjnosis of echinoeoecus disease of bone is most difficult. The symptoms are so slight and indefinite and the disease so rare that a positive diagnosis is frequently not made until an operation is per- formed. Kiister, for exajiii^le, during an operation for pseudarthrosis Avhieli followed a second fracture of the humerus, found an echinoeoecus cyst. If a spontaneou-s fracture occurs, a myelogenous sarcoma, a tuber- culous al>scess, and gunniiata must be considered in determining the cause. If these can be excluded and there is no reactive proliferation of bone, it is pro])able that an echinoeoecus cyst is present. The findings elicited by palpation and an X-ray examination are very helpful. Ab- scesses and fistulte suggest chronic suppurative or tuberculous osteo- myelitis. Even bacteriological examination of the pus is not always positive, as the necrotic masses in a cyst frequently become infected with pyogenic bacteria. According to von Bergmann, the presence of numer- ous crystals of cholesterin in the aspirated fluid is the most important and positive finding in these cases. Treatment. — In the treatment of echinoeoecus cysts an attempt should be made to remove completely the cyst together with the capsule, and to reestablish normal conditions. The unilocular cysts situated superficial^ are most easily removed. Frequently cysts which involve the peritoneum, mesentery, and omen- tum can be completely removed. AVhen the cysts involve large viscera or large areas of the peritoneum or pleura, the haemorrhage, following attempts at enucleation, is so severe that radical removal is impossible. In these cases one must be content with incision and removal of the contents of the cyst after the cyst has been exposed and sutured to the edges of the wound. Drainage must then be continued for a number of months before healing is complete. The operation may be done in one sitting, that is, the cyst may be opened immediately after it is sutured into the wound, care being exercised to prevent the fluid from flowing back into the pleura or peritoneal cavities; or in two sittings, the incision of the cyst being postponed until firm adhesions have been established between the cyst wall and the edges of the wound. As the period re(iuired for healing after incision as above described is prolonged, the operation has been somewhat modified. Bobrow and Garre incise the capsule, after the surrounding tissues have been care- fully protected, remove the contents of the cysts, and as much as pos- 64 1002 CYSTS, NOT INCLUDING CYSTIC TUMORS sible of the membrane lining the inner surface. The parts of the cap- sule which can be easily separated are then cut away. The cyst is then closed by a double row of sutures and allowed to sink back into the abdomen. In order to protect against suppuration, and if recurrence is feared, the cyst may be sutured to the abdominal wall. If the cavity of the cyst and the transudate which forms remain sterile, the cyst gradually undergoes cicatricial contraction. The removal of a multilocular echinococcus cyst from a viscus is very similar to the operations performed for malignant growths, and should be attempted only when the cyst is small (e. g., removal from the liver by cuneiform resection). The kidney, likewise the spleen when involved, should be removed. Incomplete operations, such as incision or removal of part of the cyst, are not successful. Cysts of hone which are small may be easily exposed and satisfac- torily removed by chiseling away the bone and curetting out the cysts. If the cj'Sts are large and the bone has been extensively destroyed, re- section should be considered; if the cyst has become infected and the general condition of the patient is poor, amputation. Prophylaxis is of great importance. People who keep dogs should exercise great care. The segments of the echinococcus containing eggs are discharged in the f feces and the dog's nose may easily become in- fected. It is as dangerous to allow a dog to lick the hands and face as it is to use the plates from which a dog has eaten. It is important to keep dogs away from slaughter-houses, as they may become infected by eating material infected with echinococcus, and the disease may be spread in this way. (b) Cysticercus Cellulosse. — " The cyst provided with a tapeworm head is laiown as a ' measle ' or cysticercus cellulosa}. The scoleces, when fully developed, possess a circle of hooks, suckers, a water vascular sys- tem, and numerous calcareous bodies in their parenchyma. If they get into the human stomach the cyst is dissolved, and there develops, through formation of segments, a new chain of proglottides, a new Taenia solium." — Ziegler's " General Pathology," pp. 555-556. The eggs of the tapeworm, derived from animals or man or from the patient himself, may be carried by infected drink or food or by unclean fingers into the mouth, reaching eventually the stomach, where the capsule surrounding them is digested by the gastric juiee. The em- bryos are then carried by the lymphatic and blood vessels to different parts of the body, where they are deposited. They develop after some weeks (about nine) to form cysts (cysticercus) the size of a pea or cherry. These cysts remain viable for a number of years, and after death of the scolex cicatrize and become calcified. Occasionally cysts developing from the Taenia saginata are found in man. CYSTS, .NOT IXCLUDINCJ CYSTIC TCMOllS 1003 Wherovor the cysticercus is deposited a mild iTifhiiniiiatioii devel()[)S, which leads to a thiekeniiiu' of the eoimeetive tissues siirrouiidiug it. The cysticerci lyiiiu' in loose tissue may iiiid so that intima comes in contact with intima only. Tliis may be accomplished by the special anastomosis tu])e devised by Crile, which is a modification of the magnesium tube introduced by Payr for arterial anastomosis, or by suture accoi-ding to Carrel. The tulie devised by Crile is made of German silver ;ind is provided with two grooves upon its outer surface. The vessel is drawn through tliis tube and everted so that the intima is on the outer side. The vessel is then tied into tlie second groove, and the tube with inlinia on the outer side is then introduced into the vessel with which the anastomosis is to be made. Intima is thus ])rought in contact with intimn, and there is no foreign body in tlie blood stream. I'he blood may be transferred without clotting, the use of the radial artery of the donor and any superficial vein of the recipient yields the best results, the operation nuiy be done painlessly, tlie blood lost by the donor is restored in from four to five days, and the amount trans- ferred is under tiie immediate control of the o])erator. The rate of transference should be gauged carefully within the limits of physiologic safety. 1007 1008 APPENDIX I Transfusion Cannula. — The first model for the transfusion cannula was suggested to Crile by Dr. Mixter in December, 1906. Dr. Mixter designed and constructed a splendid model made of two parts. Payr's magnesium tube gave some good suggestions as well. The cannula now in use answers the purpose splendidly, and was developed in its present form after more than twenty various models were made. Management and Teclinic of Operation. — A suitable donor is usu- ally readil}^ obtained. We use both men and women. In cases in w^hich no immediate emergency exists the most suitable subject is singled out from among the relatives and friends. He is approached tactfully, the most opportune time being just after he has left the bedside of the patient. The gravity of the patient's condition and the only means of relief are carefully detailed, the painlessness of the procedure to both donor and recipient being assured. Almost invariably a voluntary sug- gestion to serve as donor results. Indeed, frequently an entire family and friends have offered their services. Our only difficulty, thus far, has arisen among ward patients who have a certain amount of distrust of surgeons and hospitals. Among these patients, however, I have experienced but one refusal, that being in the case of foreign parents of a child of nine, whose legs had been crushed, the argument being that the child was not worth sa^dng. In two other instances the donors were hired. In these cases the commer- cial attitude was apparent and the donors were not as tractable as those who responded to the appeal of sentiment. A careful investigation as to the health of the donor, both as to whether or not it is advisable to remove blood and whether or not there is any disease which might be transmitted, is always made. AVhen there is time ha?molysis observations are obtained from the proposed donor and the recipient. This test requires about twenty-four hours. By making the hemolysis test of the proposed donor and of the recipient various blood reactions may be obviated. Agglutination may, I think, with safety be disregarded. The operating room should be equipped with two tables, preferably of the kind Avhich permits of a change of posture from head-up to head- down. The patients ai-e given pillows in order to be made as comfort- able as possible, and are so arranged that the left arm of each may be used. The donor should be placed on the table so that, if necessary, the Trendelenburg position may be utilized. The recipient, if both postures are not available, should be arranged so that the reverse Trendelenburg may be given. This permits the better management of a possible dila- tation of the heart of the recipient and of a cerebral anaemia of the donor. I have found that it is a great aid to have a trained operative staff", so that the many details may be perfonned without delay and DIRECT TRANSFUSION OF BLOOD 1009 without speakinpr. Two small movable tables, the hei<;ht of the operat- ing tables, are most convenient for supportinj^: the arms and the instru- ments during- the dissection. One of these tables will support both arms during- the process of making the anastomosis and during the remainder of the transfusion. On either side of this table and between the two operating tables a stool is placed, which provides a comfortable and a steady position for the operator and his first assistant vis-d-vis. From the beginning until the end not an unnecessary woixl is spoken. Both the donor and the recipient, unless contra-indicated, are given a pre- liminary hypodermic of ^ grain of morphin twenty to thirty minutes prior to their entrance to the operating room. The patients are assured that they will experience no pain, save the first needle prick. In order that they may not obtain a glimpse of the operating room or of their environment, both })atients are told that, owing to the bright light, wet towels will cover their eyes, thus preventing a possible headache. They are warned of the first needle prick, and are told that cocain w'ill now be administered, that it will reipiire twenty or thirty minutes to take effect, and that in the meantime it will be necessary to massage, to prick, and to pull the tissues, but that the procedure is painless. One nur.se is detailed to relieve the monotony of waiting by substituting fresh towels, bathing the brow, administering water if desired, and giving helpful attention. Local ana\sthesia is maintained by infiltration of one tenth per cent solution of cocain with a few drops of adrenalin, first in the skin proper, and then in the neighborhood of the vessels, after which firm pressure for thorough dissemination is applied. AVheu carefully performed there is absolutely no pain in any part of the procedure until the suture of the skin at the close of the transfusion, at which time the effect of the eoeain has disappeared. In the dissection I have found it an advan- tage to use minute instruments, selecting from among the armamenta- rium of oculists and watchmakers. ^Mosquito forceps are used to catch every vessel that sheds even a drop of blood, keej^ing the field not only clean but ti-anslucent. The donor's radial artery is isolated a distance of about 3 cm. At the point of election there are a niunber of small branches which should be carefully isolated and tied, otherwise an ob- scuring hi^morrhage may occur. The small nerve branches and the vente eomites are pushed aside. The artery is then tied at its distal end, and at the proximal a screw clamp gently closes its lumen. The artery is then divided with a sharp scissors, the adventitia is drawn well over its end and sni])ped off closely. This leaves a clean open end of the vessel, but the manii)ulation and exposure to the air causes such sharp contractions that for a time its lumen is ol)l iterated. This is easily overcome by inserting into the lumen a mosquito forceps, covered 1010 APPENDIX I Avith vaseline, then gently opening the blades. This overstretching of fhe artery's lumen prevents recontraction. Any superficial vein that seems neither too large nor too small is likewise exposed, isolated, ligated at its distal end, closed by a screw clamp at its proximal part, divided near the ligature with a sharp scissors, ancl its aclventitia drawn well out over the end and snipped off closely, thus leaving a free manipulable end. The tables of the donor and of the recipient are approximated with their heads in opposite, directions, so that the vessels may be ap- proximated more readily and the stream may be transferred in nearly a straight line. The vessels are now compared with the various sizes of the trans- fusion cannula and a suitable one selected. Then with mosquito for- ceps the handle of the cannula is grasped and the cannula dipped in sterilized vaseline or oil. The vein is next pushed through the lumen. With oculist's small, self -locking forceps or mosquito hemostats the mar- gin of the vein is grasped, turning it back as a cuff over the outside of the cannula, and a fine ligature of linen tied firmly around the cuff in the second groove, the ends of the ligature being cut off. AVith one hand the cannula is steadied by means of the hemostat, and with small, locking thumb forceps or mosquito hemostats the assistant and operator grasp the end of the artery at three equidistant points and draw it over the venous cuff and cannula, tying it snugly with a small linen liga- ture in the first groove, thus completing the anastomosis. The screw clamp is then removed first from the vein, then from the artery, and the flow tested. At first, owing to the great contraction of the artery, but little blood flows across, but by liberal application of warm salt solution the vessel .soon dilates and the stream grows larger, reaching its maximum in about ten minutes. It is most important not to bruise the vessels or to break the intima. In every instance in the 51 clinical cases the technic was entirely successful. CONCLUSIONS The principal danger of transfusion, now that the technic is per- fected, is haemolysis. This apparently occurs only in disease. The dangere of htemolysis may be prevented by determining before the operation is undertaken whether the blood of the donor is hemolytic for that of the recipient. Sufficient facts have been determined by laboratory experiments and clinical observations to justify the following conclusions: Transfusion, when properly safeguarded, may be safely done. In pernicious ansemia, toxiemia, certain drug poisonings, leukaemia, acute hyperthyroidism, and uraemia, it has been of no value. In tuberculosis, carcinoma, and chronic OPSONINS AND THE INOCULATION OF DEAD IJACTERIA 1011 infections it is (»£ doubtful or at l)cst littli; value. In human sarcoma there is some evidence of value, though not yet proved. Ju patholog- ical luemorrhage it is of marked value. In suitable eases it seems to be almost a specific in the prevention and treatment of shock. In acute liaMUorrhage in animals it is specific; in human beings it has proved nu)st valuable. ArPEXDIX II OPSOXINS, PHAGOCYTOSIS, AXD THE TIIERAPET'TIC IXOCULATIOX OF DEAD BACTERIA The discovery of opsonins by AYi-ight and Douglas and the intro- duction of the inoculation of dead bacteria for therapeutic purposes mark an important epoch in the studies of immunity. It cannot be said at present M'hat the ultimate results of vaccine therapy will be, but the outlook is so promising that a brief consideration of the nature of opsonins and the value of the inoculation of dead bacteria is presented here. The discovery by Wright and Douglas that the serum from normal and innnune blood contains substances, called by them opsonins,^ which have the power to render bacteria susceptible to phagocytosis, has re- awakened interest in ^letschnikotf's theory of phagocytic innnunity. It has been shown conclusively that the phagocytosis of most bacteria by leucocytes depends upon the action of serum upon the bacteria, which in S(mie way changes them so that they are freely taken up by poly- morphonuclear leucocytes. Bacteria suspended in salt solution resist phagocytosis by washed leucocytes, while bacteria previously treated by serum and th(>n washed, i. e., freed from serum, are taken up readily 1)3' washed leucocytes. Bacteria so treated are said to be sensitized or opsonified. The character of this change is wholly unknown. There is no recognizable alteration in form, staining reaction, or function of the bacteria. ]\Iany bacteria grow freely in sera which contain opsonin. X^ormal opsonins are largely destroyed by heating the serum to 60° C. for thirty minutes, some being more resistant than others. Immune opsonins, those produced as the result of infection or experimental in- oculation of bacteria, are more resistant. This difference is attributed by most authors to their greater concentration. This view is supported in a measure by the fact that diluted immune serum frequently shows a high opsonic value: when normal serum controls show none. The » From the Latin obsono or opsoiw, '' I cater to," " I prepare food for." 1012 APPENDIX II ■whole question whether normal and immune opsonins are identical or not is still imsettled. The opsonic index represents the relative amount of an opsonin in the serum of an individual as compared with a normal standard in that case. The opsonic index with reference to a given bacterium is obtained by dividing the average number of bacteria taken up per leucocyte under the influence of the patient's serum by the average number taken up per leucocyte under the influence of the standard normal serum under conditions which are comparable. The difficulties and the numerous sources of error in the determination of the opsonic index are claimed by some to be so great as to render the results unre- liable. The uniformity of results of investigators under similar con- ditions, their agreement with what one would expect upon clinical and other grounds, would seem to indicate that in competent hands the method is of distinct value. But that it cannot be relied upon as an index of the antibacterial power of the individual under all circum- stances is certain, because opsonin, it must be remembered, constitutes only one of the antibodies produced in the reactions of immunity. It is too early to speak definitely upon the diagnostic value of the opsonic index. The conclusions of different investigators vary within wide limits, some attributing to it much, others little or no diagnostic value. From the evidence at hand it is certain that it can never be used as a routine measure for the identification of infections, because the index may be high or low in a given instance, usually depending upon whether the patient is on the improve or not. But that it may be of distinct value in certain conditions, just as the aggiutinization of ty- phoid bacilli is valuable in the diagnosis of typhoid fever, is quite likely. The evidence that inoculation of suitaMe hacteria in proper amoimts usually causes an increase in the opsonic power of the serum with re- spect to the organism inoculated is convincing. This is true in the nor- mal individual or animal as well as in chronic infections due to the corresponding micro-organism. Denys found that rabbit leucocytes in normal serum ingested virulent streptococci, but not those made viru- lent by repeated passage through animals. In the serum of the im- munized rabbits and horses the leucocytes showed decided phagocytic power over virulent streptococci. Bordet, Besredka, and v. LingeLsheim all noted the greatly increased phagocytosis of streptococci in the pres- ence of immune serum both in vivo and in vitro. Metschnikoff believed this increased phagocytosis to be due to a stimulation of the leucocytes, and designated the substances assumed to stimulate the phagocytes as '' stiraulins." In the light of the opsonic theory much of what was thought to be due to the stimulation of the leucocytes is in reality the result of opsonification. Neufeld and Rimpau have shown that leuco- OPSONINS AND THE INOCULATION OF DEAD BACTERIA 1013 cytes digested in antistreptococcic serum and tlu'U suspended in normal serum failed to take up virulent streptococci. But dijrestion of virulent streptococci in antistreptococcic serum, tlien washed in normal salt solution and mixed with leucocytes, resulted in marked phajrocytosis, thus showini; that in this instance imnnine serum may so change viru- lent streptococci that leucocytes ingest them. Rosenow has not been able to render virulent pneumococci susceptible to phagocytosis by nor- mal or innniuie seiuiii, including some of the so-called antipneumococcic sera. The demonstration that opsonins render various bacteria sus- ceptible to phagocytosis does not prove full}" that they are of any im- portance in combating infections. It must be shown that phagocytosis is the essential factor in the destruction of certain bacteria by the blood. Ilektoen has shoM'n that in all probability the relative immunity of a dog to anthrax is due to phagocytosis. Virulent anthrax bacilli grow freely in dog serum, but are destroyed in defibrinated blood as the result of phagocytosis. Denys showed that in mixtures of normal rabbit leu- cocytes and normal rabbit serum there was little or no destruction of virulent streptococci. "Whereas, when immune serum was substituted, prompt phagocytosis and destruction of streptococci took place. The serum of normal persons and patients with streptococcus infections is a good culture medium for streptococci. Ruediger has shown that nor- mal defibrinated blood, as well as the blood from patients with acute infections, have a streptococcidal effect which is roughly proportionate to the number of leucocytes present. He shows, too, that the destruc- tion of streptococci requires the presence of opsonins. Rosenow has made analogous observations with respect to the pneumococcus. In practically all experimental work in this field the phagocytic value of leucocytes is considered the same. Rosenow and Potter, on the other hand, have shown that there may be a distinct difference. The former observer foiuid a greater phagocytic activity of leucocytes ob- tained from cases of lobar pneumonia, endocarditis, and other acute infections associated with leucocytosis. The difference was so great in a number of instances that pneumococci of a grade of virulence which resisted normal leucocytes were taken up by the leucocytes engaged in the infection under identical conditions. Important as these observa- tions are, it must be remembered that they are made Avith bacteria grown upon artificial media, and hence under conditions very differ- ent from those in the tissue fluids or blood. The changes which the infecting bacteria m;iy acipiire to protect themselves against the action of animal antibodies, according to the theory of "Welch, nuist be dis- tinctly borne in mind in tliis connection. The prompt and i)ronounced phagocytosis of different bacteria in the peritoneal cavity in the pres- ence of specific immune serum would seem to indicate that opsonins 1014 APPENDIX II plaj^ the same i^art in vivo as in vitro. That phagocytosis helps the body to rid itself of some bacteria is certain, but whether opsonification and phagocytosis play the primary role or a secondary role is still doubtful. However this may be, we have in opsonins a new form of antibody that must be considered, especially in the explanation of im- munity to those infections caused by bacteria whose destruction is not accomplished by free lysins (streptococci, pneumococci, etc.). The injection of hacterial products for curative purposes originated with Koch when he introduced tuberculin as a remedy for tuberculosis. Petruschky and Richardson tried to hasten the reactions in the healing process of typhoid fever by injecting products of the typhoid bacillus. Wright and Douglas first noted the rise in the opsonic power of the serum by injection of dead bacteria in chronic staphylococcus infections. They also showed that the opsonic power for tubercle bacilli in tuber- culosis greatly increases in response to the injection of tuberculin. Upon these and other observations Wright places the method of treat- ing infections by the injection of the corresponding dead bacteria or bacterial products upon a scientific basis. The opsonic index is used as a guide -for the time that the injection is to be made and the amount to be injected. Hektoen summarizes as follows the considerations for the therapeu- tic inoculation of dead bacteria : First, the power of the injected bacterial substances to stimulate the formation of opsonins and other specific antibodies. Second, the belief that increased formation of such substances may hasten healing of the corresponding infection. Third, the apparent inability of the body under certain conditions of natural infection to produce such substances in sufficient quantities without special stimulation. The essential prerequisites for therapeutic inoculations are: First, correct etiologic diagnosis. Second, sterilized, pure cultures of the bacterium causing the infec- tion in each disease or sterile products of such bacteria; and, Third, the injection of proper doses at proper intervals so as not to unnecessarily lower the antibacterial power or cause other unfavorable disturbances. Experimental inoculation as well as auto-inoculation have a favorable effect upon the course of some chronic infections, provided, as indicated above, they do not overstiraulate the reactive powers of the organism. The essential feature of the Wright method is the use of doses of dead bacteria just sufficient to raise the opsonic index above normal and keep it there. In the tuberculin treatment of localized tuberculosis, Wright and OPSONINS AND THE INOCULATION OF DEAD BACTERIA 1015 his adlu'i'c'iits do not aim at a tuherciiliii iimmuii/atioii, but content themselves by keeping the opsonic index above normal. The dose of tubercnlin remains very small throughout. The method used by Tru- deau and others consists in giving progressively increasing doses of tuberculin, but just small enough to avoid a clinical reaction. Tuber- culous patients may be made insusceptible to ten thousand times the amount of tuberculin which would cause an initial reaction. In this method no attention is paid to the opsonic index. The coincident im- provement of the patient's condition so treated goes to show that the l>rogressively increasing doses of tuberculin without reference to opso- nin need not be harmful. The former method has been of apparent value in the treatment of chronic localized tuberculosis, excepting the pulmonary form. Its value in pulmonary tuberculosis is not so defi- nitely established. The latter method, which has been used for a much longer period, chiefly in pulmonary tuberculosis, is believed by the best authorities to have a beneficial effect in many cases. That we have in tuberculin a powerful remedy for the treatment of certain chronic cases can scarcely be questioned. But that we have still much to learn of its therapeutic indications is equally certain. The reports of its good effects are not sufficient to warrant the giving up of the well- established surgical methods, but surely the surgeon who does not use it in conjunction with other methods, or give it a trial where other methods fail, is open to criticism. It is impossible to estimate at this time how much reliance is to be placed upon the therapeutic inoculation of dead bacteria, because as yet chiefly isolated cases have been reported. But since the diseases in which such good results have been reported recover spontaneously, more extensive statistics and greater experience are needed before any satis- factory conclusions concerning the value of the therapeutic inoculation of dead bacteria can be made. INDEX 65 INDEX Alxlomen, concussion of, .518. gunshot wounds of, 608. Alxlominal cavity,- haemorrhage into, .550, 509. organs, subcutaneous injuries of, 500. tumors, diagnosis of, 768, 055. wall, varices of, 683. v^bscess, 108. incision of, 108. iXAbscess, cold, 402, 423, 437, 442. treatment of, 427. Kniiphadenitic, 230. v.^ymphangitic, 228. metastatic, 209. periprocteal, 300. retropharjnigeal, 424. , subcutaneous, 208. in general infections, 286. .syphiUtic, 458, 464. tuberculous, 412, 424. \y Abscess membrane, 200, 419. Achillotomy, 708. Acid intoxication, 505. Acne punctata, 206. pustulosa, 206. Acoin, 125. Acromegaly, 737. Actinomyces, 365. Actinomycosis, clinical forms of, 371. diagnosis of, 373. modes of infection in, 365. occurrence of, in animals, 368. in man, 368. pathology of, 368. prognosis of, 374. treatment of, 374. Actual cautery in treatment of wound, 19. Adamantinoma, diagnosis of, 923. histology of, 922. treatment of, 023. Adenomas of kitlney, 910. of liver, 910. of mammary gland, 908. of mucous membranes, 905. of salivary glands, 908. of skin, 003. of thyroid gland, 009. .Adenocarcinoma, 907. Adenocystoma, 981. Adenomata sebacea, 004. sudoripara, 904. Adenomyochondrosarcoma, 976. .\denomyoma, 889. Adenomyosarcoma, 976, 981. Adenomyxofibroma, 908. .\denosarcoma, 908, 974, 975. Adrenalin in local anaesthesia, 119. After care of patient, 77. Agglutination, 162. Agglutinins, specific, 155. Air embolism, 553. Air infection, 74. Air passages, freeing of, 110. .All>uminuria due to toxins, 162. .Alcohol, necrosis due to, 20, 495. sterilization with, 56. Alcohol compresses, 29, 157, 198. Alcohol injections, in elephantiasis, 653. in hicmangiomas, 8^31. in inoperable tumors, 775. .\Iexin, 155. .\lloplasty, 50. Alveolar sarcoma, 844. AljT^in, 12.5. .\mbocoptor, loO. Ambulatory treatment of fractures, 586. Amniotic adhesions, 642. Amputation neuroma, 895. Anaemia caused by toxins, 163. Anaesthesia, general, accidents during. 10 1019 1020 INDEX Anaesthesia, general, by sequence, 113. cardiac paralysis during, 108. discovery of, 86. interrupted, 96. mortality following, 117. pupillary and corneal reflexes in, 97. venous thrombosis following, 104. local, accidents during, 118, 125, 126. by freezing, 119. by infiltration, 119. by nerve blocking, 120. by spraying, 120. Ansesthesin, 125. Anaesthetic mixtures, 114. palsies, 104. Ansesthetics, late poisonous effects of, 115,116. Anasarca, 645. Anatomical tubercle, 403. Anchylosis, 439, 702. fibrosa, 266-270. ossea, 266-270. Aneurysm, arterial, by erosion, 664. clinical course of, 667. congenital, 664. dissecting, 665. embolic, 664. fusiform, 664. saccular, 664. spontaneous, 664. symptoms of, 666. traumatic, 665. treatment of, 673, 675, 677. varieties of, 663, 664. arteriovenous, clinical course of, 672. symptoms of, 670. varieties of, 670. vessels involved in, 671. Aneurysmal sac, character of, 665. enlargement of, 666. size of, 666. Angina syphilitica, 464. Angio-hpoma, 798. Angioma, 822. arteriale racemosum, 829. fissurales, 823. simplex hyi:)erplasticum, 822. Angiosarcoma, 966. Angiosclerosis, necrosis due U), 499. Angiotripsy, 11. Annulus haemorrhoidalis, 682. Anthrax, bacillus of, 355. carbuncle, 358. effects of symbiosis in, 355. etiology of, 355. " external forms of, 357. immunization against, 356. in animals, 355. internal forms of, 357. modes of infection in, 357. occurrence of, 357. oedema, 358. prognosis of, 359. staining of bacilli of, 355. symptoms of, 359. treatment of, 360. Antibodies, action of, in fever, 166. bactericidal, 161. Antipyretics, 167. Antisepsis, history of, 50. Antiseptics, action of, upon tissues, 20. for sterilization, 54-57. Antitoxic serum, 161. for snake venom, 329. Antitoxin, production of, 157. Aponeuroses, fibromas of, 790. Apoplexy, due to syphilis, 479. Appendices epiploicse, lipomas of, 801. Arterial thrombosis, 496. Arteries. See also Blood vessels. aneurysms of, 663. atheroma of, 661. digital compression of, 5. diseases of, 233, 661. haemorrhage from, 4. inflammation of, 233, 661. ligation of, 10, 11. in continuity, 11. necrosis following, 488. results of, 488. syphilis of, 466. transfixion of, 10. Arterioliths, 689. Arteriosclerosis, 661. results of, 663. syphilitic, 466, 499. Arteritis gangrsenosa, 302. purulenta, 233. syi^hilitica obliterans, 466. Artery forcej^s, 10. Arthritis, acute, 262-266. gummatous, 478. chronic, 712. INDEX 1021 Arthritis, deformans, 717. diagnosis of, 711). nature of, 717. patliology of, 717. symptoms of, 718. treatment of, 719. gonorrheal, 268. haemophiliac, 728. metapneumonic, 271. neuropathic, 721. tubercidous, 428. typhoid, 271. urica, 723. Arthrodesis, 70G. Arthropathy, in syringomyelia, 722. tabetic, 721. Artificial respiration, 110, 111. Artillery, injuries by, 608. Ascites, chylous, fyfyS. Asepsis, history of, 51. in private practice, 79. Asphyxia, during anaesthesia, 107. local, 512. Atheromas, 989. Atherosclerosis, 661. Atrophy of bone, causes of, 735. concentric, 734. eccentric; 734. Auricular api^endages, 643. Autotransfusion, 15. Axillary lymph nodes, tuberculosis of, 413. Bacillus aerogencs capsulatus. See Ba- cillus emphysematosus. coli communis, 186, 257. emphysematosus, 297. halosepticus, 257. of malignant oedema, 298. of pneumonia in osteomyelitis, 257. pyocyaneus, 183. typhosus, 188. Bacteria, absorption of, 154. encapsulation of virulent, 46. invasion of, 145. physiologic excretion of, 155. toxins of, 144. Bacteriffimia, 281, 317. Bacterial proteins, 145. Bactericidal agents, source of, 157-162. Bactericidal power of body, 1 55. decrease of, 156. Bactericidal serum, 161. Bactericidal substances, decrease of, 15(5. in tissue fluids, 155. increase of, 157. source of, 157. Bacterio agglutinins, 155. Bacterio hivmolysins, 155. Bacterio lysins, 155. Bacteriology of the blood, 316. Bandages, material for, 64. Barlow's disease, 746. Bee stings, 326. Behring's law, 160. Bier's passive hyi3era;mia, 310, 311, 315. Blastomycosis, animal experiments in, 388. diagnosis of, 391. geographical distribution of, 377. history of, 387. infection atria for, 390. organism of, 378. organs involved in, 378. pathology of, 383-385. prognosis of, 392. symptoms of, 381. treatment of, 392. Blepharoplasty, 130. Blood, coagulation of, 321, 322. regeneration of, after hiemorrhage, 14. transfusion of, 16. Blood corpuscles, reaction of, to stains, 158. white, emigration of, 148. Blood cysts, 521, 994. Blood examinations for bacteria, 292, 317. Blooil extravasation, absorption of, 520. cutaneous, 520. in fractures, 580. subcutaneous, 520. submucous, 522. subperiosteal, 571. Blood plates, origin of, 687. Blood vessels, formation of new, 38. injuries of, 549-551. ligation of, 488, 555. mechanical methods of uniting, 557. punctured wounds of, 557. repair of wounds in, 557. suture of, 555. Boiler for instruments, 61. Bone disease in mother-of-pearl workers, 750. 1022 INDEX Bone marrow, haemorrhages into, 572. Bone plug, Mosetig-Moorhof, 254. Bones, abnormal fragility of, 735, 736. U^ abscess of, 251. absorption of, 49. acromegaly of, 737. acute inflammation of, 236. osteomyelitis of, 236. atrophy of, 733. caries of, 420, 421. chronic inflammation of, 251, 420, 474. cysticercus cellulosse of, 1003. echinococcus of, 1000. formation of, 581. gunshot injuries of, 604. increased growth of, 255. inflammation and disease of, 236, 733. of marrow of, 238. injuries and fractures of, 571. in osteomalacia, 747. m rachitis, 738. in syringomyelia, 735. neuropathies of, 735. suture of, 593. syphilis of, 469. tabetic, changes in, 735. transplantation of, 47, 49. tuberculosis of, 416. tumors of, 812. uniting of, by nails, 593. Botryomycosis, 483. Branchial cysts, 924. Brisement force, 440. Bronchopneumonia, following anaesthesia, 98. Bubo, in glanders, 362. inguinal, 231. Buck's extension, 589. Burns, causes of death from, 627. different degrees of, 621-623. etiology of, 621. pathology of, 62, 627. symptoms of, 626. treatment of, 627. X-ray, 628. Bursae, injuries of, 538. Bursitis, acute, 273. diagnosis of, 273. etiology of, 272. pathology of, 272. treatment of, 274. gonorrheal, 263. Cadaver alkaloids, infection by, 330. Cadaver tuberculosis, 403. Callus, amount of, formed, 582. consolidation of, 582. delayed formation of, 583. Callus luxurians, 582. Capsula sequestralis in osteomyelitis, 240. Caput medusae, 683. obstipum, traumatic, 527, 704. Carbolic acid, gangrene, 29, 30, 495. Carbonization, 626. Carbuncle, 204. \y^' Carcinoma, clinical appearance of, 928. clinical course of, 960. curability of, 960. early diagnosis of, 955. etiology of, 936, 961. histogenesis of, 928. histology of, 935. implantation of, 935. medullary, 928. metastases in, 931-933. mode of growth of, 930, 931. recurrence of, 961. scirrhus, 928. Carcinoma basocellulare, 938. Carcinomas of glandular organs, factors predisposing to, 958. gross appearance of, 958. histology of, 957. Carcinomas of mucous membranes, clin- ical forms, 948. factors predisposing to, 949. Carcinomas of skin, deep, 945. distribution of, 939. factors predisposing to, 939. histology of, 937. lupusHke, 943. papillary, 946. superficial, 941. Cardiac massage, 111, 112. paralysis, 109. Caries carnosa, 421. sicca, 433. tuberculous, 419. Caro luxurians, 44. Cartilage, fibrillation of, 717. fractures of, 594. injuries of, 594. repair of fractures of, 582. Catarrh, results of, 223. treatment of, 224. INDEX 1023 Catgut, preparation of, 69. sterilization of, 69, 70, 71. Caustics, action of, 613. different kinds of, 613. Cauterization, for tumors, 773. scars following, 614. symptoms of, 613. V^ellulitis, prognosis of, 212. symptoms of, 211. treatment of, 212. V^/'Chancre, hard, appearance of, 4.3.5. diagnosis of, 456. extragenital, 455. histology of, 456. involution of, 456. treatment of, 456. Cheiloplasty, 131. Chemical injuries, treatment of, 615. Chemotaxis, negative, 148. positive, 148. Chilblains (perniones), 620. Chloroform, accidents during narcosis by, 108, 109. action of vapor of, 87. after effects of, 97. apparatus for administering, 93. chemical composition of, 86. contraindications for, 117. death from, 117. decomposition of, bj' gas flame, 98. dropping of, 93. indications for, 117. late effects of, 114. physical properties of, 86. physiological action of, 90. position of patient during, 90. preparation of patient for, 87. stage to be maintained, 90. stages of, 90. statistics of deaths from, 117. symptomatology of narcosis of, 94. tests for, 87. treatment of accidents during, 107. Chloromas, 871. Cholesteatoma, clinical course of, 919. diagnosis of, 921. Chondritis syphilitica, 476. tj"phosa, 257. Chondrodystrophy, foetal, 733. Chondroma, diagnosis of. 811. histology of, 805. indications for treatment of, 812. Chondroma, macroscopic appearance of, 805. mode of growth of, 806. regressive changes in, 806. sites for, 807. technic for removal of, 811. Chondrosarcomas, 851. Chondroosteitis dissecans, 720. luetica, 476. Chromatophoromas, 879. Chromic acid, cauterization with, 613. Chylothorax, 558. Chylous cysts, 995. Cicatricial keloid, 41. Cicatrix, formation of, 40. subsequent changes in, 38. Cirsoid aneurysm, 829. Cocain anaesthesia, contraindications for, 126. Cocain hydrochlorate, 119. indications for, 126. Cocain solutions, adrenalin in, 123. poisoning by, 125. technic of injecting, 121. Coccidioidal disease, 390. Coccus of gonorrhoea, 183. Cohnheim's theory, 755. Cold, anaesthesia by, 119. effects of, 616. Cold abscess, 425. L^ Coley's toxins, 775. Collapse, definition of, 632. etiology of, 632. symptoms of, 632. treatment of, 633. Collateral circulation, after ligation of ar- teries, 489. Colloid carcinomas, 953. Colon bacillus, 186. Coma diabeticum, after anaesthesia, 504. prophylaxis of, 504. treatment of, 505. Comedones, relation of, to atheromas, 989. Complement, 156. Compound fractures, frequency of, 595. treatment of, 596. Compresses, carbolic acid, 29. moist, 198, 207. Conchiolin, 750. Concussion, of abdomen, 518. of brain, 518. of spinal cord, 518. 1024 INDEX Concussion of thorax, 518. Condyloma acuminatum, 899. latum, 457. Continuous suture, 25. Contractures, arthrogenous, 706. congenital, 702. dermatogenous, 702. desmogenous, 702. myogenous, 703. neurogenous, 704. paralytic, 705. reflex, 704. spastic, 705. Contusions, nature of, 517. symptoms of, 517. Contusions of bones, 571. of joints, 559. Cornu cutaneum, 900. Corpora libera in joints, 563. oryzoidea, 431. Cotton, absorbent, 63. Coxa vara, 742. Craniotabes, 741. Cretinism, bone changes in, 733. Cryoscopy, 324. Cyanosis, local, 512. Cylindroma, 968. Cystadenoma, 903. papilliferum, 909. Cysticercus, 1002. racemosus, 1003. Cystocarcinoma papilliferum, 958. Cystosarcoma phyllodes, 974. Cysts, definition of, 987. exudation, 987. liquefaction, 987. mucous, 991. multilocular, 987. of breast, 993. of pancreas, 994. of salivary glands, 992. of testicle, 994. retention, 987. Dactylitis, syi^hilitic, 473. Debris paradentaires, 922. Decollement de la peau, 522. Decubitus, 491. acute, 511. Defects, covering of, 131. Deformities (contractures) of joints, 702. Degeneration, inflammatory, 149. y Delirium tremens, cardiac weakness dur- ing, 639. essential cause of, 639. prodromata of, 638. symptoms of, 638. treatment of, 639. Demarcation zone in gangrene, 498. Dermatol, 27. Dermoid cysts, contents of, 912. hning of, 912. of head, 913. of neck, 913. Desmoids, 778, 790. Diabetes, traumatic, 642. Diabetic gangrene, clinical course of, 502. complications of, 503. dangers of anaesthesia in, 504. etiology of, 501. treatment of, 503. Dilatation cysts, 988. Diphtheria, antitoxin in, 347. bacifli of, 346. causes of death in, 350. complications of, 351. diagnosis of, 351. modes of infection in, 347. of skin, 353. pathology of, 349. prognosis of, 350. susceptibility to, 347. symptoms of, 348. treatment of, 352. Diphtheritis, 349. Diphtheroid, 349. Diplococcus pneumonise, 178. Dislocations of joints, classification of, 565, 699. complicated, 569. complications of, 567. congenital, 699. diagnosis of, 566. from destruction, 269. from distention, 267. habitual, 565. mechanism of, 565. reduction of, 567-569. symptoms of, 566. traumatic, 701. Distortion of joints, 561. Diverticulum, Meckel's, 927. Drainage, capillary, 31. tubular, 32, 200. INDEX 1025 Dressings, alcohol, 20. antiseptic and aseptic, 26. definitive, 34. emergency, 34. moist, 29. sterilization of, 66. Ductus lingualis, cysts of, 926. thoracicus, injuries of, 557. thyreoglossus, persistence of, 926. thyreoideus, cysts of, 926. Dupuytren's contracture, 703. Dura mater, endothelioma of, 963. Dysplasia, chondral, 733. Dystrophy, periosteal, 733. Eburnatio ossis, in osteomyelitis, 240- sjT)hilitic, 470. Ecchondromas, 805. Ecchondroses, 805. Ecchymoses, 519. Echinococcus, multilocular, 997. of bone, 1000. of viscera, 998. treatment of, 997. unilocular, 997. Echinococcus cysts, 996. Eczema, cause of, 644. different forms of, 644. following use of antiseptics, 644. surgical significance of, 644. treatment of, 645. Eczema solare, 621. Elephantiasis, clinical appearance of, 650. course of, 649. forms of, 650. lobulated, 781. pathology of, 649. Elephantiasis cavernosa, 826. Elephantiasis nervorum, 782. Emboli, bacterial, 280. infected, 280, 690. Embolism, clinical course of, 496. diagnosis of, 691. etiologj' of, 496. prognosis of, 496. pulmonary, 690. sjTTiptoms of, 496. treatment of, 691. Embolism, air, 553. Embolism, fat, diagnosis of, 641. etiology of, 640. pathology of, 641. Embolism, fat, symptoms of, 040. treatment of, 641. Embryoma, cystic, 977. Embryonic rests, 753. Enaphysema, gangrenous or sei)tic, 301. of chest, 524. traumatic, 523. Enchondrofibroma, cystic, 807. Enchondroma, 805. of salivary glands, 971. Endangitis tuberculosa, 445. Endarteritis, chronic deforming, 661. obliterans, 661. productiva, 233. purulenta, 233. sj^jhilitic, gangrene due to, 499. tuberculosa, 445. Endocardiiun, myxoma of, 875. Endothelial cancer, 963. Endotheliomas, 963. Endothelium, nature of, 963. Endotoxins, 145. action of, 162. Endovasculitis obliterans syphilitica, 458. Enostoses, 818. Enterocystoma, 927. Ephelides, 832. Epidermal strips for grafting, 135. Epidermoids, 916. Epiphyses, separation of, 238, 245. traumatic, 574. Epithelial cysts, 912. traumatic, 917. Epithelial nests in carcinoma, 935. Epithelioma, calcified, 904. Epithelioma adamantinosum cyst! cum, 922. Epulides, 791, 854. Ergot gangrene, 513. Ergotin injections in frozen nose, 620. Erysijjelas, blood examinations in, 217. clinical course of, 217. cocci of, 213. complications of.. 217. curative effect of, 219. diagnosis of, 217. habitual, 216. of mucous membranes, 215. onset, 217. prognosis of, 218. symptoms of, 215. treatment of, 218, 219. 1026 INDEX Erysipelas, varieties of, 216. Erysipeloid, clinical course of, 220. diagnosis of, 220. organism of, 220. treatment of, 220. Erythema, due to chemicals, 613. due to freezing, 617. solare, 621. Esmarch's artificial ischsernia, 6, 7. inhaler, 101. rubber bandage, 6, 7. tourniquet, 6, 7. Ether, administration of, 100-102. contraindications for, 117. differences between, and chloroform, 99. incomplete anaesthesia by, 104. increase of mucus by, 102. of saliva by, 102. indications for, 117. lung complications following, 104. physical properties of, 99. preparation of, 99. Ethyl chloride, as a local anaesthetic, 119. Eucain, 125. Europhen, 32. Excoriations, 518. Exenteratio cranii by gunshot wounds, 607. Exercise bones, 821. Exostoses, cartilaginous, 813. fibrous, 815. Exostosis bursata, 814. , Explosions, effects of, 608. Extension dressings, modifications of, 590. technic of applying, 589. Extension, treatment of tuberculous ar- thritis by, 439. Extravasation cysts, 986. of lymph, 522. Extravasations of blood, absorption of, 520. changes in, 520. Extremities, defective growth of, uftcr fractures, 585. deformities of, after fractures, 577. dwarfism of, 733. embolism of, 496. freezing of, 617. necrosis of, embolic, 496. syphilitic, 505. rickets of, 742. Extremities, separation of, 595. terminal defects of, 733. Exudates, formation of, 148. various kinds of, 150, 151. Exudation cysts, 986. Facies tetanica, 339. Farcy. See Glanders. Fascia, injuries of, 525-528. sarcoma of, 847. Fat, transplantation of, 50. Fat emboli, 640. after fractures, 584. Fermentation, 294. Ferrum candens, 9. Fever, aseptic, 78, 167. causes of, 165. condition of respiration in, 164. of vessels during, 164, 165. definition of, 163. digestion during, 164. disturbance of nervous system in, 164. etiology of, 165. explanation of, 164. fastigium, 164. influence of, upon bacteria, 167. in subcutaneous injuries, 167. metabolism in, 164. pathological changes in, 166. prognosis of, 165. jDuLse in, 164. surgical significance of, 165. symptoms of, 164. types of, 164. Fever curves, 165. in general infections, 290. Fibrin ferment, 687. Fibroepithelial growths, 898. Fibroma molluscum, 781. Fibromas, forms of, 778. histology of, 778. mode of growth of, 778. of aponeuroses, 790. of fascia, 790. of glandular organs, 792. of mucous membranes, 789. of nerves, 792. of periosteum, 790. of peritoneum, 795. of skin, 780. of subcutaneous tissues, 789. Fibromata nervorum, 792. INDEX 102: Fibrosarcomas, rlinical course of, 84 t. (liaf^nosis of, S4'.). histology of, inolysis, 163. Ilicmophilia, control of hiBmorrhage in, 13. gelatin injections in, 13. hannatomas in, 521. Hieniorrhage, arterial, 4, 552. capillary, 4, 552. control of, 555. tlangcr.s of, 14. tleath from, 14. prevention of, 10. regeneration of blood after, 14. secondary, 553. spontaneous cessation of, 13. symptoms of, 15. treatment of, 15. venous, 4, 552. Haemorrhoids, 682. Hiemosiderin, 520. Ha-mostasis, by position, 5. by pressure, 5. by torsion, 11. permanent, 10. temporary, 5. Ha?mostatic agents, 5. Hajmothorax, 608. Halisteresis, 747. Hands, care of, 59. sterilization of, 53. Head masks, 75. Healing, beneath a scab, 41. microscopic phenomena in, 37, 38. of a wound, 36. per i>riinam intentionem, 35. per .sccuiidam intentionem, 39. Heart, direct massage of, 112. gunshot woiuids of, 608. paralysis of, during anesthesia, 109. rupture of, 599. Heat stroke, etiology of, 630. t.res'tment of, 630. Hodgkni',3 rlisease, appearance of lymph nodes in, 868. clinical characteristics of, 867. clinical course of, 868. diagnosis of, 868. treatment of, 870. HoUaender's hot-air apparatus, 9. Holocain, 125. Hordeokun, 206. Hospital gangrene, clinical course of, 308. Hospital gangrene, complications of, 309. diagnosis of, 309. etiology of, 308. forms of, 308. prognosis of, 309. treatment of, 310. Hutchinson's triad, 460. Ilydarthros. See Hydrops of joints. Hydatid, 996. Hydrocele, 986. Hydronephrosis, 988. Hydrophobia, action of virus of, 331. attenuation of virus of, 334. clinical course of, 333. diagnosis of, 333. etiology of, 331. experiments upon, 331. in dogs, 332. in man, 332. pathological anatomy of, 333. prognosis of, 335. protective inoculation against, 334. treatment of, 333. virus ofr 331. Hydrops, syphilitic, 477. tuberculous, 434. Hydrops articularis chronicus, .'S60, 712. Hydrops articularis serosus and fibrinosus, 269, 434, 435. Hydrops follicularis ovarii, 994. Hydrops processus vermiformis, 988. Hydrops tuborum, 988. Hydrops vesicae felleae, 988. Hygroma of burste, 659. Hygroma tuberculous, 442. Hyi^eraimia, active artificial, 157. inflammatory, 141. passive (Bier's), 310. Hypernephroma, 910. Hyperostoses, syphilitic, 474. Hy|}ertrophied scar, 785. Hyphomycetes, 367. Hypophysis, tumors of, 737. Hysteria, artificial necrosis of skin in, 514. Ice, in treatment of inflammation, 197. Ileus, due to volvulus, 493. Immune bohilitic, 475. S.iddle nose, sy])hilitic, 474. Salt solution, administration of, 17. indications for, 18. preparation of, 16, 17. with oxygen, 18. Salves, dressing of, 201. Salzer's chloroform canula, 96. Saprajmia, 293. Sarcoma, characteristics of, 839. classification of, 838. definition of, 838. etiology of, 841. fever with, 841. metastases in, 841. mode of growth of, 839. regressive changes in, 840. Satyriasis, 451. Scab, healing imder, 41. Sclerodermia, 408. Scopolamin-morphin anitsthesia, 114. Scrofula, 415. Scurv}', infantile, 746. Sebaceous cysts, 989. SeborrhcBa senilis, 940. Secondary haemorrhage, 4. 1038 INDEX Sepsin, 295. Septicaemia, blood changes In, 289. cryiJtogenetic, 2S9. definition of, 144. etiology of, 287. nature of, 280, 281. pathological changes in, 289. prognosis of, 290. symptoms of, 288. treatment of, 291. Sequestrotomy, 254. Sequestrum, separation of, 239, 240. tuberculous, 419. Serum, hsemolytic, 162. leucotoxic, 162. Shock, erethistic, 635. etiology of, 635. pathologic physiology of, 636. prognosis of, 637. psychical, 635. theories of, 634. torpid, 635. treatment of, 637. Shot suture, 26. Side-chain theory, 159. Silk, preparation of, 67, 68. Silkworm gut, 68. Skin, burns of, 621. congenital defects of, 643. congenital thickening of, 652. frostbites of, 617. gunshot wounds of, 603. plastic operations upon, 134. subcutaneous separation of, 522, tension planes of, 1,-2. transplantation of, 135. Skin-grafting, 47, 132, 133. early appearance of grafted area in, 47. histological changes in grafts in, 47. method of repair in, 47. technic of, 135. Skin grafts, dressing of, 136, 137. Snake bites, 326. Snake venom, action of, 327, 328. proteolytic ferments in,. 327. Soda solution for sterilization, 61. Sodium chloride infusion. See Salt solu- tion. Spinal anajsthesia, 124. Spindle-cell sarcoma, 843. Spirochaita pallida, 454. Splints, papier mach('!, 79. Spondylitis, chronic anchylosing, 716. tuberculous, 424. Sprains of joints, diagnosis and clinical course of, 562. pathology of, 561. prognosis of, 562. treatment of, 563. Spray, carbolic acid, 51. Staphylococcus pyogenes, 170, 173. Staphylotoxin, 172. Steam sterilizing apparatus, 65. Sterilization, of catgut, 68. of dressings, 66. of field of operation, 73. of hands, 53. of instruments, 60. of mucous membranes, 59. of silk, 67. Stovain, in spinal anaesthesia, 125. Streptococcus pyogenes, 173, 176. Subcutaneous rupture of muscle and ten- dons, 525, 529. treatment of, 527-530. Subcutaneous salt infusion. See Salt solution. Subcutin, 125. Suffocation during anaesthesia, 107. Suggillations, 519. Sunburn, 621. Sunstroke, etiology of, 629. treatment of, 630. Surgeon and assistants, duties of, 76. preparation of, 74. Suture, continuous, 22, 25. interrupted, 22, 24. intestinal, 25. mattress, 25. of nerves, 545. of tendons, 532. of vessels, 555. quilled, 26. twisted, 26. tying of, 22, 23. Suture materials, 67. Syncope, nature of, 633. symptoms of, 633. Synovitis, chronic serous, diagnosis of, 713. etiology of, 712. symptoms of, 713. treatment of, 714. diagnosis of, 264, 265. L\Di<:x 1039 Synovitis, forms of, 2^3. sciiueiiv of, 2()(i. treatment of, 2(io. Syi)liiiis, diagnosis of, 460. eruptive stage of, 457. galloping, 457. of bone, 469. of bursa>, 479. of joints, 477. of lymphatic nodes, 466. of lymphatic vessels, 4()7. of mucous membranes, 4(i.'i. of muscle, 465. of tendon sheaths, 478. of the skin, diagnosis of, 4(52. lesions of, 460, 461. treatment of, 463. of viscera, 479. treatment of, 479. Syphilitic dental deformities, 460. pseudo-paralysis, 476. Syphiloderm, macular, 457. papular, 457. pustular, 457. squamous, 457. Syringomyelia, arthropathies in, 721. necrosis in, 513. Tabes, arthropathies in, 721. necrosis in, 513. Tables, instrument, 62. Tsenia echinococcus, 995. saginata, 1002. solium, 1002. Tampon, of iodoform gauze, 12, 27, 200. moist, 29, 201. Technic, aseptic, 51. of blood examinations, 318. Telangiectases, 822. Temperature of body in fever, 164. Temporary dressing, 18. Tenalgia crepitans, 657. Tendon sheaths, diseases of, 657. ganglia of, 658. injuries of, 537. Tendon shortening, 711. transi>lantation, 535, 536, 711. Tendons, ganglion of, 656. open injuries of, 531. rupture of, 529. subcutaneous injuries of, 529. subluxation of, 530. Tendons, thickening of, 656. Tendo-vaginitis, acute, diagnosis of, 273. etiology of, 272. pathology of, 272. treatment of, 274. serofibrinous, 657. serous, 658. sicca, 658. Tenoplasty, indications for, 710. technic of, 710. Tenorrhaphy, 532, 533. Tenotome, 708. Tenotomy, technic of, 707. Teratoid tumors, 977. of ovaries, 978. of testicles, 978. Teratomas, 982. Tetaiuis, antitoxin of, 342. bacillus of, 335. clinical course of, 338. hydrophobicus, 340. of head, 340. pathologic anatomy of, 341. IJoison of, 336. IJrognosis of, 339. treatment of, 341. varieties of, 340. Tetanolysin, 336. TetanosiJasmin, 336. absorption of, 342. Tetragenus (micrococcus), 180. Thermo-cautery, 9. Thiersch grafts, 135. Thiosinamin, 789. Thrombi, mural, 688. obturating, 688. Thrombophlebitis, 235. treatment of, 236. Thrombosis, clinical course of, 496. etiology of, 496. l)rognosis of, 498. symptoms of, 498. treatment of, 498. Thrombus, organization of, 689. red, white, and mixed, 685. subsequent changes in, 689. Thrombus formation, factors concerned in, 687. Thyreoglossal cysts, 926. Tibia, saber sheath deformity of, in rickets, 742. in syphilis, 475. 1040 INDEX Tissue fluids, bactericidal substances in, 155. Tissues, regeneration of, 37, 38, 149. Tongue, rhythmic traction of, 112. Tonsils, tuberculosis of, 410. Tophi, gouty, 725. Torsion, control of haemorrhage by, 12. Torticollis, traumatic, 527. . Tourniquet, 7. Toxic infections, general, 281. Toxins, 145. action of, 162. necrosis due to, 496. Tracheal defects, covering of, 140. Tracheotomy, 350. Transfusion of blood, direct, 1007. indirect, 16. Transplantation, of cartilage and bone, 47. of mucous membrane, 47. of muscles and nerves, 49. Trauma, 516. Tridermoma, 980. Trifacial neuralgia, 695. Trismus, 339. Tropococain, 125. Tubercle, anatomical, 403. bacilli, 394. bovine, 394. cultures of, 395. demonstration of, 395, 396. immunization against, 397. staining of, 395. toxins of, 396. histology of, 399. regressive changes in, 401. Tuberculin-R, 397. Tuberculosis, local, general treatment of, 444. miliary, 445. of mucous membranes, 409, 410. treatment of, 410. of muscle, 408. of serous membranes, 444. of skin, clinical course of, 4(jb. clinical forms of, 403, 404. treatment of, 407. of subcutaneous tissues, 408. of viscera, 444. Tuberculosis bursitis, clinical course of, 443. diagnosis of, 443. Tuberculosis bursitis, forms of, 442. treatment of, 443. Tuberculous arthritis, clinical course of, 434. diagnosis of, 437. etiology of, 428. nodular form of, 430. pathology of, 429. prognosis of, 438. reactive changes in, 433. spontaneous healing of, 433. symptoms of, 434. villous, 430. treatment of, 439. Tuberculous lymphadenitis, diagnosis of, 413. etiology of, 411. nodes involved in, 412, 413. pathology of, 413. treatment of, 414. Tuberculous lymphangitis, 411. Tuberculous osteitis, clinical course of, 423. diagnosis of, 425. diffuse, 421. etiology of, 416, 418. pathology of, 419. symptoms of, 425. treatment of, 426. Tuberculous synovitis, suppurative, 430. Tuberculous, tendo-vaginitis, clinical course of, 443. diagnosis of, 443. forms of, 442. treatment of, 443. Tubulization, in suture of nerves, 547. in suture of vessels, 557. Tumor albus, 436. villosus, 900. Tumors, definition of, 751. classification of, 753. constitutional effects of, 762. diagnosis of, 762. etiology of, 753. metastatic growths of, 760. recurrence of, 760. regressive changes in, 760. treatment of, 772. various kinds of, 759. Turner's bone, 821. Typhoid bacillus, 188. osteomyelitis, 257. ^^9.3 i/ Q 1a. •«V ■r^'!^ <^ *^ C5/ ^^"^^i*' ^'""r/y ' '^'^sentation of the sc 1 ' I "IIIIIIIIIIIHHnH liii-LliJillllll 2002199769