HX00057509 RECAP !i| !l! i 11' .^/^ Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/americanpractic01brya AMERICAN PRACTICE OF SURGERY A COMPLETE SYSTEM OF THE SCIENCE AND ART OF SURGERY, BY REPRESENTATIVE SUR- GEONS OF THE UNITED STATES AND CANADA JOSEPH D. BRYANT, M.D. ALBERT H. BUCK, M.D. OF NEW YOKK CITY COMPLETE IIT EIGHT VOLUMES profusely miustrateb VOLUME ONE NEW YORK WILLIAM WOOD AND COMPANY MDCCCCVI • COPYEKiHT, 1906, BY WILLIAM WOOD AND COMPANY. I W ^ El PREFACE. jIHE portrayal of surgery as it is practised to-day in the United States and Canada can be best accomplished, we think, by the co-operation of a number of surgeons who have gained eminence in the particular sphere of activity which they are invited to describe. A careful study of the problem which we, as editors, were called upon to solve led us to the conclusion that such a composite work would present a picture more true to life and one more perfect in detail if the different writers were not confined within boundary lines too strictly drawn. While this course would almost necessarily involve a certain amount of repeti- tion, we believed this redundance to be counterbalanced by the fact that the sum total of information supplied could not fail to be greater than if the plan of closer restriction were to be adopted ; for experience has shown that no xwo writers are likely to treat a subject in precisely the same manner or to furnish exactly the same set of details even in important matters. The first one of the eight volumes of which this treatise is to be composed is herewith submitted to the consideration of the Profession, and we sincerely trust that this product of the com- bined labor of all concerned will command the respect and con- fidence of those who consult its pages. The Editors. CONTRIBUTORS TO VOLUME I. LEONARD WOOLSEY BACON, Jr., M.D., New Haven, Conn. Instructor in Operative Surgery, Medical De- partment, Yale University. JOSEPH COLT BLOODGOOD, M.D.. Baltimore, Md. Associate Professor of Surgery, Johns Hop- kins University; Associate in Surgery, Johns Hopkins Hospital. HARLOW BROOKS, M.D., New York, N. Y. Assistant Professor of Pathology, University and Bellevue Hospital Medical College; Pa- thologist to Montefiore Hospital and to St. Vincent's Hospital; Visiting Physician to City Hospital. JOSEPH D. BRYANT, M.D., New York, N.Y. Professor of the Principles and Practice of Surgery and of Operative and Clinical Sur- gery, University and Belle\TJe Hospital Medi- cal College ; Visiting Surgeon, Bellevue and St. Vincent's Hospitals; Consulting Surgeon, Hos- pital for Ruptured and Crippled, Woman's Hospital, and Manhattan State Hospital for the Insane. WALTER J. DODD, Boston, Mass. Director of -Y-Ray Laboratory of the Massa- chusetts General Hospital. HARVEY R. GAYLORD. M.D.. Buflfalo, N. Y. Professor of Surgical Pathology, Medical De- partment, University of Buffalo, N. Y.; Attend- ing Surgeon, Erie County Hospital; Assistant Surgeon, Buffalo General Hospital. PRESTON M. HICKEY. M.D., Detroit, Mich. Professor of Radiography, Detroit Post-Gradu- ate School of Medicine; Professor of Pathol- ogy, Detroit College of Medicine; Radiog- rapher to Children's Free Hospital. THEODORE A, McGRAW, M.D., LL.D., Detroit, Mich. Professor of Surgery, Detroit College of Medi- cine; Attending Surgeon, St. Mary's Hospital; Consulting Surgeon, Harper's Hospital. JAMES E. MOORE, M.D., Minneapolis, Minn. Professor of Surgery, Medical Department, University of Minnesota ; Surgeon-in-Chief, Northwestern Hospital. ALBERT GEORGE NICHOLLS, M.D.. CM., Montreal, Can. Assistant Professor of Pathology and Bacteri- ology, McGill University, Montreal; Assistant Physician to the Montreal General Hospital; Pathologist to the Western General Hospital, Montreal. EDWARD HALL NICHOLS, M.D., Boston, Mass. Assistant Professor of Surgical Pathology, Har- vard Aledical School; Assistant Visiting Sur- geon, the Boston City Hospital. ROBERT B. OSGOOD, M.D., Boston, Mass. Assistant Orthopedic Surgeon, ^lassachusetts General Hospital ; formerly Skiagrapher to the Children's Hospital, Boston. PAUL MONROE PILCHER, M.D., Brooklyn, N. Y. Assistant Surgeon, Methodist Episcopal Hospi- tal, Brooklyn. STEPHEN SMITH, M.D., LLD.. New York, N. Y. Formerly Professor of Anatomy and Clinical Surgery, Belle\nie Hospital JNIedical College: Consulting Surgeon, Bellevue. St. Vincent's, and Columbus Hospitals ; President. State Board of Charities. ALDRED SCOTT WARTHIN, Ph.D., M.D., Ann Arbor. Mich. Professor of Pathology and Director of the Pathological Laboratory. University of Michi- gan, Ann Arbor, Mich. CONTENTS. Preface, ........ Introduction: Evolution of American Surgery, PART I. SURGICAL PATHOLOGY. Inflammation, ........... 71 The Nature and Significance of the Various Disturbances of Nu- trition Observed in Connection with Surgical Diseases and Conditions, ........... 146 Processes of Repair, ......... 256 Tumors and Tumor Formation, ....... 291 Theories of Tumor Formation, ....... 370 Parasitical Relations of Cancer, ....... 387 PART II. COMPLICATIONS AND SEQUELS. Infections which Sometimes Occur in Various Surgical Diseases and Conditions, ........... 415 Surgical Shock, . . . . . . . . . . . 4'63 PART III. GENERAL SURGICAL DIAGNOSIS. General Principles of Surgical Diagnosis, ..... 501 The Body Fluids in General Surgical Disease, with Special Reference to Their Diagnostic Value, ........ 555 The Epiphyses and Their Radiographic Interpretation, . . 578 The Technique of Radiographic Work as Applied to Surgery, and the Interpretation of Radiographs, ...... 599 PART IV. GENERAL SURGICAL TREATMENT. General Principles of Surgical Treatment, and the Various Proced- ures, Instruments, etc., that Facilitate the Application of These Principles, ........... 691 PART V. GENERAL SURGICAL PROGNOSIS. General Prognosis in Surgical Diseases and Conditions, Index, . . . ' . 771 799 INTRODUCTION. INTRODUCTION. THE EVOLUTION OF AMERICAN SURGERY. By STEPHEN SMITH, M.D., LL.D., New York City. The American Practice of Surgery has had three distinct periods of de- velopment, each of wliich was characterized by conditions sufficiently marked to constitute an era in the history of its evolution. The first period extended from the settlement of the country to the organiza- tion of medical schools — 1765-67— and may be called the primitive era. During this period there were but few surgeons who had been qualified to practise by a systematic course of education, for to obtain such an education required an at- tendance upon foreign schools, and few students of that time had the means necessary for such an undertaking. To meet existing conditions the future practitioner was compelled to become an apprentice to a practising physician, and "read mecUcine and surgery" in his office. His surgical text-book consisted of a copy of Bromfield, Gooch, White, Pott, or any other reputable author of that day, and his diploma, at the expiration of his apprenticeship, was the cer- tificate of his master that he had served the appointed time. There were a few notable instances of surgeons, in the later years of that period, who had graduated from foreign schools, whose practice was of a high order for that time. But their practice was along the lines taught in the schools of London and Edinburgh. The second period extended from the establishment of medical schools in this country to the introduction of anffisthesia and antiseptics into surgical prac- tice — 1846-72 — and may be called the formative era. During this period the foundations of a distinctly American practice of surgery were laid by the or- ganization of medical schools, in which the future practitioners of surgery in this country were to obtain a competent education. Two discoveries were made during this period which revolutionized the practice of surgery — anaesthesia and antisepsis. The first abolished pain as a disturbing element during operative procedures, and the second prevented sup- puration during the healing process ; together they effected a painless operation 3 4 AMERICAN PRACTICE OF SURGERY. and healing of the wound by first intention — results hitherto sought m vain by the elder surgeons. These discoveries swept away the long-established metes and bounds of the field of operative surgery, and made it as limitless as are the diseases and injuries of the hmnan body and man's desire and efforts to relieve them. The third period, which is now passing, may be called the practical era. The surgeons of to-day are makmg the history of this era, and hi this work they will record its marvellous progress for a quarter of a century, and illustrate with historical accuracy the intricate procedures, the instruments of precision, and the vast variety of ingenious apparatus and appliances with which they accomplish results which in the second period would have been regarded as miraculous. It will be the scope and purpose of this introductory paper to review those conditions of the formative, or pioneer, period which gave to the American prac- tice of surgery whatever national traits and peculiarities have characterized its evolution. It will be our aim in this exposition to trace the origin and develop- ment of the scientific spirit which inspired and controlled the pioneer surgeons of that period, rather than to record the notable achievements of individuals, with names and dates in due succession, which have only a chronological inter- est. We shall not attempt, therefore, to follow the precise historical order of ' subjects, but shall endeavor to secure that continuity of thought, on the part of the student, essential to a just appreciation of the genius of American surgery. The detailed history of American medicine and surgery has been amply written by competent authorities, and can be readily consulted by those seeking specific information as to names, dates, or events. Two questions arise at the outset of this review which it is important to de- termine, in order that no injustice may be done to any one who may claim rec- ognition in our narrative, either to the distinction of being a discoverer, or to honors due to a surgeon. These questions are: First, Who is a discoverer? sec- ond, Who is a surgeon? The definition of a discoverer was long since made by the Rev. Sidney Smith, as follows: "That man is not the first discoverer of any art who first says the thing, but he who says it so long, so loud, and so clearly that he compels man- kind to hear him." The same opinion is happily expressed by Prof. Howard A. Kelly, of Johns Hopkins Hospital, viz. : " Any claim to priority in medicine and surgery always rests, by consent of the profession, not upon the date of perform- ance, but upon the date of publication." He very pertinent!}' adds : " Reflection will only confirm this dictum by showing that the printed word is, after all, the only possible arbiter which can be appealed to when disputes arise." The definition of an American surgeon, which will correctly apply to a given specified class of practitioners during the past century and a half, would seem to include the entire profession, for circumstances compelled every physician, INTRODUCTION. 5 especially during the early part of this period, to perform the duties of a surgeon. But there has always been a class of practitioners who have devoted themselves, by preference, to the practice of surgery and have been recognized as surgeons. The definition of surgeon which is best adapted to the purposes of this work was made by Dr. Valentine Mott, one of the highest authorities on this subject to whom we can refer, who says : " We regard those as surgeons, and those alone, who have, by conscientious devotion to the study of our science and the daily habitual discharge of its multifarious duties, acquired that laiowledge which renders the mind of the practitioner serene, his judgment sound, and hands skil- ful, while it holds out to the patient rational hopes of amended health and pro- longed life." The evolution of American surgery began with the first organized efforts to give the medical students of this coimtry systematic instruction for the purpose of fully qualifying them for practice — 1765-67. Whatever other influences may contribute to the formation of the special peculiarities of the practice of a profes- sion, it is the education of its individual members which determines, more largely than any other factor, its individuality. The school formulates the principles which govern the future acts of its pupils. But the quality and value of the in- struction of the school depends entirely upon the qualifications of the teachers. Before we can properly estimate the practice of the Amei'ican surgeon, therefore, we must inquire as to his educational qualifications and then as to the condi- tions under which he performed his professional duties. American surgery had its origin in the medical schools of London and Edin- burgh. Prior to the organization and establishment of medical colleges in this country, the graduated surgeons took their degrees from the British schools. And during the succeeding half century the more ambitious students of surgery who graduated from the home schools took post-graduate courses of instruction in the schools and hospitals of the mother country. A reference to the teachers of the science and art of surgery in the British schools during this period enables us to form a just estimate of the qualifications of their American graduates to create an adequate system of medical education in this country. In London we recognize Percival Pott (1713-88), John Hmiter (1728-93), Everard Home (1763-1832), John Abernethy (1764-1831), Astley Paston Cooper (1768-1841) as teachers and writers of their times who exerted the greatest power over the progress of scientific surgery. To these more prominent names should be added the names of William Blizard (1743-1835), Henry Cline (1750- 1827), Charles Bell (1778-1842), Benjamin Collins Brodie (1783-1862), Ben- jamin Travers (1783-1858). Of these teachers the one Avhose genius more com- pletely dominated all others was John Hunter, the most conspicuous figure in the annals of modern surgery. Many American students placed themselves under the immediate instruction of this great master, and their subsequent achievements attest the value of his teachings and example. As surgeon in the 6 AilERICAX PRACTICE OF SURGERY. British army in tire Spanish Peninsula, 1761-63, he had acquired valuable knowledge of military surger}-, which he imparted to his pupils and which they utilized in our colonial wars. In the Edinburgh school the Monroes — father, son, and grandson — ruled supreme from 1725 to 1846, a period of one hundred and twenty-one years. The elder ]Monroe was a pupil of Cheselden and was the first professor of anatomy in the University of Edinbm'gh ; he gave clinical lectmes on siu-ger}*, was a writer of much distinction, and took rank as an authority on manj' subjects. His son was professor of sm-gery imtil 1810, when he was succeeded by his son, who re- tained the position until 1846. Of the Monroes, the elder was the most eminent as a teacher and surgeon, and by his reputation gave more character to the university school than his son or grandson. For more than a centmy and a hah Edinburgh was regarded as a great centre of medical education, and few American medical students who went abroad to complete their education failed to attend and graduate at the universitJ^ Scarcelj' less attractive to students who visited Edinburgh dming the years 1790 to 1800 was the private school for anatomy, surgery, and obstetrics of John and Charles Bell. Jolm Bell was a bold and fearless surgeon, a brilliant operator, a vigorous writer, and a caustic critic. His school was conducted in op- position to the University JMedical College, and the two most prominent profes- sors of the latter — Alexander Mom-oe and Benjamin Bell — were the subjects of the most imsparing criticism on the part of the founder of the new school. Charles Bell was eminent as an artist, writer, and teacher, and for several j'ears the school was the favorite resort of the more advanced medical students, espe- ciall}' those American ^^sitors who were devoting themselves to surgery. But few American students, comparatively, visited the schools and hospitals of Paris, except incidentally in their travels. Before 1750 Jean Louis Petit was for a long period the most eminent surgeon of Paris, and it was his genius which gave direction to French sm'gery. Le Dran and Le Cat (1700-68), con- temporaries of Petit, were active in hospital work, and later, in the eighteenth and the beginning of the nineteenth centurj^, the more emment teachers of surgerj- in the Paris hospitals were Desault (1730-95), Sabatier (1732-1811), Deschamps (1740-1824), and manj^ others of less note. Mr. Erichsen, in his address on "Impressions of American Surgery," truth- fully remarks : " The method of doing things in surgery is transmitted directly from the master to the pupil; the American sui'geon of a past generation ac- quired in this way the traditionary art of British surgerj-, and has transmitted it dh'ectly to his descendants. Surgeons of both nations drew then- inspiration from the same source and drank at the same fomitain of knowledge." Though American surgery was originally but a transplanted root of British surgery and its subsequent evolution has been along the inlierited lines established by the parent, it is not difficult to distinguish, at many points of contrast, that the INTRODUCTION. 7 American practice of surgery has always been characterized by a freedom of thought, a promptness of action, and an affluence of resources quite unusual in British practice. Foreign surgeons, accustomed to the observance of technical rules of practice, attributed the independent spirit of American surgeons in their methods of operating to ignorance of the established rules, or to mere reck- lessness. But experience has proved that the American practice of surgery, from the earliest periods, has illustrated the genius of British surgery, suddenly emancipated from the thraldom with which the traditions of the barber sur- geons fettered the progress of scientific surgery in Europe during the eighteenth and the early years of the nineteenth century. It should be premised that, at the period of the organization of medical schools in this country, surgery had not assumed the position of a science and an art in the medical schools of the capitals of Europe. As a branch of medical instruction it was subordinated to that of medicine, and little else was taught than bandaging and the method of performing the few recognized operations. Wliatever didactic surgical teaching was given was in connection with other branches, especially anatomy, and often with midwifery. The more prominent surgeons in the centres of medical education in Europe were struggling to give an independent position to surgery in the curriculum of the schools, but the op- position of the ruling authorities was overpowering during the eighteenth and far into the nineteenth century. And this opposition to a separate chair or pro- fessorship of surgery was especially dominant in the Edinburgh school, from which so many American medical students graduated. Educated as were most of the founders of our first medical colleges in the traditions of that school, it is not surprising that, with a single exception, they began to build on similar foun- dations. That exception was the Medical Department of King's College, New York. In 1765 the Medical Department of the College of Philadelphia was formally organized, chiefly through the efforts of Dr. John Morgan and Dr. William Ship- pen, Jr. They were natives of Philadelphia and graduates of literary institu- tions. They studied medicine in due course in the offices of prominent physi- cians, the former with Dr. Redman, and the latter with his father, and completed their professional education in the British schools. Dr. Shippen began to give lectures on anatomy in 1762, and annually repeated the course until 1765, when the Medical Department of the College of Philadelphia was organized. In the scheme of instruction the promoters of the school followed the European plan of giving surgery a subordinate place in connection with other branches, and united it with anatomy. Dr. Joseph Carson, historian of the Medical Depart- ment of the University of Pennsylvania, says: "The medical school of Phila- delphia may be said to be the legitimate offspring of that of Edinburgh." Dr. Shippen, though not a surgeon, but devoted to the practice of midwifery, was appointed professor of anatomy and surgery, and held this position imtil 8 AMERICAN PRACTICE OF SURGERY. 1805, a period of forty years. It appears, from the announcement of his lectures, that the instruction m surgery was hmited to "all the necessary operations of surgery" and "a course of bandages." Considering how few operations were regarded as necessary and how important was the use of the bandage, we can estimate the character of the surgical instruction imparted at that time. Dr. Shippen was a popular teacher, and by his devotion to the duties of his- profes- sorship, amid the distractions caused by the war of the Revolution, and the dis- sensions of the profession, powerfully aided in preserving the founda,tions on which the Medical Department of the University of Pennsylvania, the successor of the College of Philadelphia, had been reared. In 1767, the Medical Department of King's College, New York, was organized, and on the 2d day of November of that year the introductory address to the first course of lectures was given. In the plan of instruc- tion in surgery adopted by the promoters of this school, we recognize the first departure from Euro- pean methods and the initial step in creating a class of distinctly American siu-geons. The faculty not only exhibited a commendable spirit of independence of the traditions of the past, but they demonstrated un- equivocally that they recognized higher ideals of sur- gery as a science and an art than were prevalent La foreign countries. Under the leadership of Dr. John Jones, surgery was divorced from all other branches of a medical education and erected into an indepen- FiG 1 —John Jones (1729- ^^^^^ professorship. Dr. Jones was appointed full pro- fessor of surgery, the first appointment of the kind in this country, and gave the first lecture on the ninth day of November, 1767. He gave an annual course of lectures until the college was closed by the war of the Revolution, 1775. John Jones (1729-91) was of Welsh origin. His grandfather, Dr. Edward Jones, was from Wales, and came to this country in the famous ship Welcoine, with William Penn and his colony. He married a daughter of Dr. Thomas Wynne, Speaker of the Assembly of Penn's colony. His son, Dr. Evan Jones, settled at Jamaica, Long Island, N. Y., where John Jones was born in 1729. He was educated at a private school in New York, and, at the age of eighteen j^ears, began the study of medicine with Dr. Thomas Cadwalader, of Philadelphia. He visited London and attended the lectures of Dr. William Hunter and the practice of Mr. Percival Pott, in St. Bartholomew's Hospital. In 1757, he again visited France and obtained the degree of Doctor in Jledicine from the University of Rheims. In Paris he attended the anatomical lectures of Petit, and received instruction from Le Dran and Le Cat, in Hotel Dieu. Dr. Jones began the practice of surgery in the city of New York in 175.3, and acquired a wide reputation for skill and success. He performed the first operation INTRODUCTION. 9 of lithotomy, and subsequently was so successful in this field of practice that he was not only extensively employed in the treatment of calculus of the urinary bladder, but, according to Mease, his success was so great that the operation of Uthotomj^, which had fallen into disrepute in other States, owing to the failures of operators, was rendered popular. Dr. Jones enlisted as surgeon in the Continental Army, but soon retired on ac- count of ill-health. In 1780 he removed to Philadelphia, became surgeon to the Pennsylvania Hospital, and was the professional attendant, on occasions, of Wash- ington and Frankhn. He died on June 23d, 1791, at the age of sixty-three. Dr. Jones was eminently qualified to be the founder of a system of surgical education. The qualities of his mind fitted him to be a teacher, and his standard of professional qualification was ideal. He was devoted to surgery as a science and an art, and cultivated it with passionate zeal. He travelled extensively and availed himself of every opportunity to acquire knowledge. Although he made specialties of anatomy and surgery, his general studies took a wide range and his inquiries extended to the collateral sciences. He made warm friends of the most prominent surgeons of that time in the hospitals abroad, and was a favorite student of Pott, of St. Bartholomew's Hospital, London, and of Petit and Le Dran, of Hotel Dieu, Paris. He attended the lectures of Dr. William Hunter, and must have been brought into more or less intimate association with his brother, John Hunter, who was nearly the age of Dr. Jones and had just com- pleted his studies, 1752. But he probably derived no other benefit from such association than perhaps a more intense devotion to his professional studies. Dr. Beck, in his "Historical Sketch," remarks of Dr. Jones: "He was well fitted by education and his various accomplishments to become the instructor of others"; and adds: "Not merely as the skilful operator, but as the scientific surgeon and the first teacher of surgery in the colonies, he justly deserves to be styled the Father of American Surgery." Dr. Mease, his student and biographer, thus speaks of Dr. Jones's qualifica- tions as a teacher of surgery : " Viewing the science in an enlarged and honorable light as comprehending the most extensive view of our nature, and as tending to the alleviation and abridgment of human misery, he taught his pupils to despise the servile conduct of those who consider the profession as worthy of cultivation only in proportion to the emoluments which it yields, and to rely upon the solid- ity of their own endowments as the best security of general esteem and for the acquisition of business." He taught the twofold nature of surgery — first, as a science; second, as an art — and urged his students to become medical as well as operative surgeons. In the following statement he formulated his opinion of the true surgeon : " Be- sides a competent acquaintance with the learned languages, which are to lay the foundation of every other acquisition, he must possess an accurate knowledge of the structure of the human body, acquired not only by attending anatomical 10 AMERICAN PRACTICE OF SURGERY. lectures, but by frequent dissections of dead bodies with his own hands. This practice cannot be too warmly recommended to the students of surgery. It is from this source, and a knowledge m hydraulics, they must derive any adequate notions of the animal economy or physiologJ^ . . . There must be a happiness, as well as art, to complete the character of the great surgeon. He ought to have firm, steady hands, and be able to use both alike; a strong, clear sight; and, above all, a mind calm and intrepid, 3'et humane and compassionate, avoiding every appearance of terror and cruelt}^ to his patients, amid the most severe operations." He made the following distinctions between the qualified and imqualified surgeon: "Whoever has acquired just and general ideas of the natm'e of a dis- ease will seldom be at a loss how to apply them on particular occasions; and, to him who wants those ideas, no. rules or directions will be of liiuch consequence." He concluded his introductory lecture as follows: "As to those gentlemen who will neither read nor reason, but practise at a venture, and sport with the lives and limbs of their fellow-creatures, I can only, with Dr. Huxliam, advise them seriously to peruse the sixth commandment, which is, 'Thou shalt not kill.'" Immediately on the close of the war the third pioneer medical school was organized. This was the Medical Department of Harvard College, Cambridge, Mass., established in 1782. The plan adopted was that of the foreign schools, anatomy and surgery being imited in the same professorship. Dr. John Warren, who was the chief promoter of the school and whose lectures on anatomy before the students of Harvard had attracted much public attention, was appointed the pro- fessor of anatomy and surgery. John Warren (1753-1815) was born in Rox- bury, Mass., on the 27th of July, 1753. He was a younger brother of Gen. Joseph Wan-en, a sirr- geon, who fell at the battle of Bunker Hill, June 17th, 1776. He was educated at Harvard Col- lege, which he entered at the age of fourteen. He then began the study of medicine with his brother, and on receiving his degree he located in Salem at the age of twenty years. Like his elder brother, Joseph, Dr. John Warren was an ardent patriot, and joined Colonel Pickering's regiment as a volunteer, and marched to the defence of the military stores at Concord. He was present at the first iDattle at Lexington. He was after- ward attached to the main army under the immediate command of General Wash- ington. He was at many important battles, as that on Long Island, at Princeton, and his services were highly appreciated by the Commander-in-Chief. After suffer- ing a severe attack of fever, he was assigned to dutv at Boston, where he remained Fig. 2.— John Warren (1753-1815). INTRODUCTION. 11 until the close of the war. In 1780 Dr. Warren gave a course of lectures with dis- sections at the MiUtary Hospital, and in the following year they were more public and the students of Harvard College were permitted to attend. These lectures led to the establishment of the Medical Department of Harvard, the first course of lectures being given in 1783. Dr. Warren occupied the chair of anatomy and surgery for \apward of thirty years. He died April 3d, 1815, of ossification of the valves of the heart and of the aorta, from the sjmiptoms of which he had long suffered. Dr. Thacher, a pupil of Dr. Warren, thus describes his personal appearance : ■" He was of about middling stature and well formed ; his deportment was agree- able ; his manners, formed in a military school and polished by intercourse with the officers of the French army, were those of an accomplished gentleman. An elevated forehead, black eyes, aquiline nose, and hair turned up from his fore- head gave him an air of dignity which became a person of his profession and character." Of Dr. Warren's qualifications to be a pioneer in establishing a system of ■surgical education, we have ample evidence. Dr. James Jackson, an excellent authority, says: "Dr. Warren's mental attributes were of a high order. . . . His reasoning faculties were acute and powerful. ... He possessed a peculiar tact for the accurate observation of disease and in rapidly arriving at conclu- sions. The rapidity of his bodily movements was equally remarkable. . . . His intellectual activity and celerity of motion were manifested in all of the habits of his life." During the latter years of the eighteenth and the early years of the nine- teenth centuries, these pioneer schools underwent many changes in their plans ■of organization. The Medical Department of the College of Philadelphia became the Medical Department of the University of Pennsylvania in 1791; the Medical Department of King's College became the Medical Department of Columbia College in 1784, and, finally, the College of Physicians and Surgeons in 1810. But a more important event in the history of these schools than their plans of organization was impending. A new era was dawning which was ■destined to unpart to the mstruction in surgery a scientific spirit hitherto tmknown. This department was no longer to occupy a subordinate position and be taught in connection with anatomy, chemistry, midwifery, or some other branch, but was to be the subject of an independent professorship, as in the original organization of the Medical Department of King's College, New York. This change in the system of surgical education was due to the genius of John Hunter, whose researches in the latter half of the eighteenth century gave to surgery the character, dignity, and responsibility of a true science. While the teachings of the British scientist made slow progress in the schools of Europe, on account of national prejudices and jealousies, they early took deep and abid- 12 AMERIC.IX PRACTICE OF SURGERY. ingroot in the virgin and fertile soil which the young and plastic medical schools of America afforded, and thj-ough which they were to mould the character of its future surgeons. It was a fortmiate circumstance that a corps of American students appeared at this critical period in the history of surgery in this country, thoroughly qualified by temperament and education ta become the propagators of the principles and practice of the new faith through these pioneer schools- The first American surgeon, familiar with Hunter's doctrines, who became. a professor of surgery in this country was Dr. Wright Post, of New York. Wright Post (1766-1S2S) was born at Hempstead. Queens County, N. Y., Feb- ruary 19th. 1766. He was educated by Daniel Bayle}^, a teacher in that locality. At the -age of fifteen he entered the office of Dr. Richard Bayley, a prominent surgeon of New York, as a student of medicine. In 17S4, at the age of mneteen, he went to London and became the house pupil of ^Mr. Sheldon. He became thorouglily famil- iar ■nith the teachings of Hunter, and was un- doubtedly there when that surgeon performed his first operation of ligating the femoral arterj- for aneurism, 1785. In 1786 he retmned to New York and gave lectures on anatomy. In 1792 he was appointed professor of surgerj- in the jMedical De- partment of Columbia, formerly King's College. From 1796 to 1807, when the CoUege of Phj'sicians Fig. 3.— Wright Post (1766-1S2S). ^^^d Surgeons was Organized, Dr. Post taught anat- omy and surgery, apparently without a rival, in Columbia College. ■ He was the first professor of anatomy and siugery in the College of Physicians and Surgeons, but in 1811 the chair was cfi\'ided, at his special solici- tation, and he retained the chair of anatomy, teaching surgerj' only clinically. In 1813 he received the honorarj' degree of Doctor in Medicine from the regents of the I'mversity of New York, and in 1821 was elected to the office of president of the College of Physicians and Surgeons, a position which he held until 1826, when he resigned. He died in 1828, at the age of sixty-two. For upward of f ortj' years he was a prominent figure in the medical schools and haspitals of New York, in the former giving didactic and in the latter clin- ical instruction. In his lectm-es he taught surgerj- as a true science, and m his practice he demonstrated it as a high art. He was also the legitimate and worthy successor of Dr. John Jones, being appointed to the chair of surgery in the reorganized iledical Department of Columbia College, formerly King's Col- lege, in 1792. Dr. Valentine Mott, one of his most devoted pupils and eminently qualified to give a judicial opmion, thus characterizes Dr. Post's qualifications as a teacher and practitioner of surgery: "He was unrivalled as an anatomist, a most beau- tiful dissector, and one of the most luminous and perspicuous teachers I have INTRODUCTION. 13 ever listened to, either at home or abroad. His manners were grave and digni- fied; he seldom smiled, and never trifled with the serious and responsible duties in which he was engaged, and which no man ever more solemnly respected. His delivery was precise, slow, and clear — qualities inestimable in a teacher — and peculiarly adapting his instructions to the advancement of the jvmior portion of the class. As an operator he was careful, slow, and elegant, and competent to any emergency contemplated by the then existing state of surgical science." In 1811, the College of Physicians and Surgeons, the successor of the Medical Department of Columbia, originally King's College, New York, restored surgery to the position of an independent professorship, which was assigned to it in 1767, and Dr. Valentine Mott was appointed to the chair. av%(;|i{N\ Fig. 4.— Valentine Mott (17S5-1S65). Valentine Mott (1785-1865) was born at Glen Cove, Long Island, August 20th, 1785. His father. Dr. Henry Mott, a native of Hempstead, Long Island, was the son of Adam Mott, an Englishman and disciple of George Fox, the founder of the sect of Friends. He was educated at a private school at Newton, where his father practised his profession, and at the age of nineteen entered the office of his relative. Dr. Valentine Seaman, a prominent surgeon of the New York Hospital. Young Mott remained with Dr. Seaman from 1804 until 1807, when he graduated from the Medical Department of Columbia College, in which Dr. Wright Post was the professor of anatomy and surgery. Soon after graduation Dr. Mott visited London, and became the pupil of Sir Astley Cooper, then the foremost surgeon of that city. He spealcs of profiting by the teachings of the two Clines, Abernethy, the two Blizards, and Sir Everard Home. He remained in London two years, diligently working in the hospitals and assisting Cooper in his operations. He then visited the Edinburgh school and attended the lectures of Gregory, Home, Duncan, Hope, Monroe, and John Thompson. On returning to New York in the following spring, 1809, Dr. Mott obtained the consent of the trustees of Columbia College to deliver a course of lectures and demonstrations on operative surgery, 1810, in the anatomical rooms of Columbia College. He had to secure his own material by stealth, but he was amply repaid by the success of his lectures, which he claimed were the first "private lec- tures on any medical subject" in this city, and he states that he was "the first to demonstrate to a class the steps of surgical operations, as then taught and practised by the highest professional authorities." To these lectures he attributed his ap- pointment to the professorship of surgery in Columbia College, 1811, which imme- diately followed. This appointment was actually made on the advice of his pre- ceptor, Dr. Wright Post, then professor of anatomy and surgery in the College of Physicians and Surgeons, as well as in Columbia College. He continued in this posi- tion until 1826, when the professors resigned in a body on account of differences with the regents. The Rutgers Medical College was then organized, and Dr. Mott 14 .1.AIERICAX PRACTICE OF SURGERY. entered the faculty as professor of surgery. Tltis school continued but five yeare. Dr. ^lott was next appointed professor of operative surgery and surgical anatomy in the College of Physicians and Stu-geons. a position -n-hich he resigned in 1834, on ac- count of faihng health. He now travelled extensively in Etu-ope, Asia, and Africa. On his retiu-n he tinited in the effort to estabhsh the Medical Department of the Uni- A'ersity of Xew York, and in 1S40 was appointed the professor of surgerj-. Though the school had a verj^ able faculty, the fame of Dr. Mott was its greatest attraction to students, and its classes soon far exceeded any hitherto gathered in this city. In 1850 he resigned this position and again -\isited Europe. On his return he was ap- pointed emeritus professor of operative surgerj' and surgical anatomy in the College of Physicians and Surgeons, and commenced his cotu-se, November 7th, 1850, with an address on "Reminiscences of !MecUcal Teaching and Teachers in New York," an interesting re\"iew of the progress of surgery in this city for half a century. In 1852 he accepted the position of emeritus professor of sm-gery in the ^ledical De- partment of the University of New York, which he held until his death, gi%'ing an- nual coitrses of lectures, cliiefly chnicaL He died after a short illness from embolism affecting the right leg, April 26th, 1865, his last words being, "Order, truth, punctu- aUty.'"' Dr. Gross says : " The personal appearance of Dr. Mott was eminently prepos- sessing. Tall and erect, with broad shoulders and a fine muscular development, he had an open, handsome countenance, a frank, manlj' exjoression, and a dignified yet cordial manner. His statui'e was fully six feet, his forehead high and promi- nent, the mouth small, the nose aquUiae, the chin round and dimpled, the eye large, of hazel hue, and shaded by a hea^^ brow, and the hau" in early life nearly black, with a slight iacliQation to brownish. His features were regular, and indic- ative of the benevolence which formed so remarkable a trait in his character. " The late Dr. Joseph ^I. Smith, who was present as a medical student when Dr. Mott made his first appearance in the lectm'e-room, says: "When Dr. Mott appeared iu the lecture-room of the College of Physicians and Surgeons, soon after his return from Europe, in company with the professor, his appearance made a marked and most favorable impression upon the class. His dress was scrupu- lously neat, his hah" powdered, and his bearing com'tly and dignified. All of us regarded liim with a feeling of deference amoimting to awe. '" The cjualifications of Dr. }.Iott as an educator were of the highest order. He was a careful and accurate student of the medical and collateral sciences, and based his practice of surgery upon the principles which the}* inculcated. He had been trained at home in the school of Hunter bj' his preceptor, Dr. Wright Post, and abroad by Home, Abemethy, and Cooper. He was the legitimate successor of Dr. John Jones and Dr. Wright Post in la}Tng broad and deep the foundations of sui'gical education, not only in the schools of Xew York, but in the colleges of the coimtry organized by graduates of these metropolitan schools. The successor of Mott in the College of Physicians and Surgeons, X'ew York, was Dr. Alexander H. Stevens, a gi-aduate of the University of Pennsylvania in ISll. Stevens was trained in the school of Phvsick, and learned the science of INTRODUCTION. 15 surgery as taught by Hunter. His graduating thesis was "On the Proximate Cause of Inflammation," which involved a discussion of first principles; but so well did he accomplish his task that his essay received complimentary notices from Dr. Rush and others. His teaching was characterized by a thorough ex- position of each subject in simple but terse language, with quaint and striking illustrations. Alexander Hodgden Stevens (17S9-1S69) was a native of New York City. He was a graduate of Yale College in 1807, and of the Medical Department of the Uni- versity of Pennsylvania in 1811. In 1814 he was appointed professor of surgery in the New York Medical Institute, and in 1818 he became one of the visiting surgeons to the New York Hospital. In 1826 he was appointed professor of surgery in the College of Physicians and Surgeons, as the successor of Mott. He retired in 1838 on account of failing health, and was made emeritus by the board of regents. He died in 1869. ,; ^^ S^^ -^ The true successor of Stevens was Dr. Willard Parker, though the chair of surgery was occupied for two sessions by Dr. Alban G. Smith, of Kentucky. Parker became the professor of surgery in 1840, having been called from the Cincinnati College, Ohio. He was a graduate of the Harvard Medical College and a private pupil of Dr. Jolin C. Warren. Thus it happened that the chair of surgery, once occupied by Jones and Post, then made illustrious by Mott, one of its own pupils, next filled by a representative of Physick, was now to be given to a student of Warren. Parker had many of the cjualifications of the best class of teachers. His very presence and M personality commanded the confidence, respect, ^ and even admiration of students. His mental attributes and his temperament rendered his teaching practical rather than theoretical and speculative. He readily grasped the essential facts of any subject matter, and at once en- deavored to estimate their practical value. This peculiarity of his teaching was attractive to students and practitioners, and always gave him large and attentive audiences. His special characteristics as a teacher of surgery were seen to the best advantage in the clinics which he organized in the lecture-room of the college, the first of the kind in this coimtry. Here, in a familiar manner, he illustrated the diagnosis and treatment of surgical diseases and applied the principles which he taught to practice. The influence of such instruction, continued for a generation, upon the practice of surgery in this country cannot be estimated. Fig. 5. — Willard Parker (1800-1SS4). 16 MIERICAN PRACTICE OF SURGERY. It is certain that scores of graduates from the school ckiring that period became reputable practitioners, and many attained to distinction as teachers. Draper, his student and biographer, states that it was " in his character as a public teacher that Parker impressed himself most powerfully upon all who came within the sphere of his attractions. He loved to teach ; he was inspiring and suggestive ; there was something about his enthusiasm that was contagious ; he never failed to be interesting and to inspire others with something of the en- ergy that swa3'ed his own soul; he was alwaj's aspiring to the highest and .best in professional knowledge, and was constantly helping to lift others, ambitious to attain it, to a higher plane." Willard Parker (1800-18S4) was born September 2d, ISOO, in Hillsboro, N. H. He graduated from Harvard College in 1826, and in 1827 was appointed house phy- sician to the Marine Hospital at Chelsea, where he spent two years. He was a pupil of Dr. John C. Warren, and served one year as house sm-geon in the Massachusetts General Hospital. He graduated in medicine from the Harvard School in 1830, and soon after accepted the professorship of anatomy in the Berksliire ^ledical CoUege at Pittsfield, Mass. In 1832 he delivered a course of lectures on surgery in the same institution. In 1836 he was appointed professor of sm-gery in the Cincinnati Medical CoUege, and in 1839 accepted the professorship of smgery in the College of Phj^sicians and Smgeons of New York, a position he held thirty' years. On retiring he was appointed emeritus professor, and continued in that relation to the college until his death in 1884. In the year 1805 the teaching of surgerj' was divorced from anatomy and ob- stetrics, and erected into an independent professorship, by the governing body of the ]\Iedical Department of the University of Pennsylvania, originally the Medical Department of the College of Philadelphia, and Dr. Philip Syng Physick was appointed to the new position. He was admnably adapted b}^ ultimate association with Hunter, in his experimental work, to inau- gurate in that pioneer school the doctrines taught by his master. It was the concm"rent testimony of contemporary wTiters that Dr. Physick's teaching of surgery placed it on a rational and enduring 1. \ \ basis as a science and an art. Fia. 6. — Philip S\-ng Phvsick -r,, ... r^ ,-„ . , ,^_„„ , „„„ (176S-1S37) " Thihp Syng Physick (1768-1837) was born m Philadelplna on the 7th day of July, 1768. He was of English descent and received his coUegiate education at the University of Penn- sylvania, from which he graduated at the age of seventeen. He studied medicine in the office of a phj-sician for three years, and in 1789, at the age of twenty-one, went to London and became the private pupil of John Hunter and a member of his family. He was appointed a member of the house staff of St. George's Hospital through the influence of his master, with whom he seems to have been a favorite, INTRODUCTION. 17 for at the close of his residence Hunter requested him to become his partner. He visited Edinburgh and remained a year attending a course of instruction, receiving his medical degree in 1792, at the age of twenty-four. Dr. Physiclc returned to Philadelpliia and began practice under the most favor- able conditions. In 1794 he was elected a surgeon of the Pennsylvania Hospital, and in ISOO he was in^dted to lecture on surgery to the students in the university school. In 1805 the professorship of surgery was created in the university, and Dr. Physick was appointed to the chair. He held the position thirteen j-ears, when he rehnquished it and accepted the chair of anatomy, which he retained until 1830 in co-operation with a colleague. He died in 1837. Dr. Physick is described as a man of mediujn height, ■with pale, regular, classic features; in manners reserved to the degree of shyness; as to health, the victim of indigestion and catarrh; and in temperament pessimistic, forbidding, and devoid of a sense of hmnor. In the daily routine of practice he was prompt and precise, requiring his patients only to answer questions, and never allowing them to indulge in explanations. The same precision marked his operations, and, having a small, delicate, and facile hand, every step in the procedure was taken with an accuracy that impressed on the student a most useful lesson. Dr. John Bell remarks: " Dr. Physick was from this time in possession of the widest field for the exercise of his talents." He was "listened to by the large class in the university, through the members of which he could disseminate the principles of surgery imbibed from his celebrated preceptor, John Hunter^ strengthened and enforced by his o'mi meditation and personal experience ob- tained m hospital and private practice." Dr. Joseph Carson, the historian of the Medical Department of the Univer- sity of Pennsylvania, thus speaks of Dr. Physick's method of instruction : " The lectm-es were carefully wi'itten out and delivered with the manuscript before him or in hand; for it was an axiom with him that, on so miportant an occasion as the instruction of youth in an art so necessary to the well-being and happi- ness of mankind, every care should be taken to render the inculcation of prin- ciples and practice clear to the comprehension of students. . . . His dignified bearing and imposing presence, his emphatic manner, and painstaking execution of his duties deeply impressed his pupils and commanded the profoundest def- erence." Intimately associated with Dr. Physick in the duties of his professorship, from the year 1807 to 1818, was his nephew. Dr. John Syng Dorsey. John Syng Dorsey (1783-1818) was born in Philadelphia, December 23d, 1783. His mother was a sister of Dr. Philip Syng Physick. He was educated at the Friends' School, Philadelphia. At the age of fifteen he entered the office of liis uncle, as a student of medicine, and in 1802, at the age of nineteen, he graduated from the Medical Department of the University of Pennsylvania. In the foUomng year, 1803, he visited London for the purpose of continuing his studies, vdih letters of introduc- tion from his uncle to Sir Everard Home, the brother-in-law of John Hunter, then 18 AMERICAN PRACTICE OF SURGERY. one of the most eminent surgeons of that citj^. He next visited Paris, where he was attracted by Boyer, whom he most frequently mentions in his correspondence. He returned in 1S04 and began practice in Philadelphia. Soon after, he became the prosector to his uncle, the professor of surgery in the university, and in 1807 he was appointed adjunct professor of surgery. In 1808 Dr. Dorsey was appointed one of the surgeons of the Pennsylvania Hospital, and in 181.3 he published a work en- titled "The Elements of Surgery," in two volumes. In 1818 he was appointed pro- fessor of anatomy on the death of his predecessor, Dr. Wistar. Dr. Dorsey, how- ever, was not destined to enjoy the advantages and the honors which this position gave him. He delivered a brilliant introductory to the course of lectures which he had plaimed, on the second day of November, 1818, but was attacked with typhus fever on the evening of that day, and died on the twenty-third day of the same month, at the age of thirty-five. The appointment of Dorsey to the position of adjunct professor was rendered necessary on account of the frequent attacks of illness of his uncle, thereby ren- dering his attendance on lectures uncertain. Dorsey was an accomplished lect- urer and a practical surgeon of great skill. Professor Chapman, his colleague, says that, with the exception of Dr. Physick, "He was indisputably the most accomplished surgeon in our country, and this high praise is conceded to him on account of the number and variety, the difficulty of his operations, and the skill, dexterity, and boldness with which they were performed. Clear in his views and of sound judgment, he had great mechanical ingenuity, delicacy of touch, and promptness of decision; and hence in conducting an operation, how- ever new or complicated, there was a tone and firmness of manner which always inspired confidence and success. As a teacher of medicine his merits were great and universally acknowledged." He was also an artist of such skill as to attract the favorable notice of persons prominent in that profession. Dr. William Gibson (1788-1868) was the successor of Physick, and main- tained the reputation of the University Medical College, Philadelphia, for thirty- six years. He was a graduate of Princeton College, where he took high rank as a classical scholar. He pursued his medical studies in Edinburgh, and was a pupil of John and Charles Bell. He graduated from the Edinburgh school with distinction, his thesis on "Necrosis," written in Latin, attracting attention on account of its classical style. On his return he was appointed professor of sur- gery in the University of Maryland, and in 1819 he succeeded Physick in the chair of surgery in the Medical Department of the University of Pennsylvania, a position which he held until 1855. He died in Savannah, Ga., in 1868. Gibson was a teacher of surgery who always interested students by his positive and earnest manner of delivery and by his accuracy and clearness of statement. In 1824 he published his "Institutes and Practice of Surgery," which passed through several editions and was for many years the accepted text-book of sur- gery. Thus as a teacher of surgery in the largest medical school in the country INTRODUCTION. 19 and as author of the text-book of its theory and practice which was widely ac- cepted by the profession, Gibson was one of the early promoters of a sound surgical education for upward of a generation. Dr. Henry H. Smith (1815-90) succeeded Gibson in 1855. He was a native of Philadelphia, and received both his collegiate and medical education at the University of Pennsylvania, where he graduated in medicine in 1837. He was the first of its graduates to be appointed to its chair of surgery. He is spoken of as " excellent and unexceptional in his style of speaking — quiet, self-possessed, systematic, and thorough." His most important contribution to the practice of surgery was a work entitled "A System of Operative Surgery." He resigned the professorship of surgery in 1871, and was ^ appointed emeritus. Dr. D. Hayes Agnew (1818-92) succeeded Smith in 1871. He was a native of Lancaster, Pa., and a graduate from the University Medical Col- lege, Philadelphia. After a brief residence in the country, he located in Philadelphia, and began private teaching of medical students. His success as a teacher was very great, and he attracted large classes of students from all sections of the country. In 1854 he was appointed one of the sur- geons of the Pennsylvania Hospital, and while in ... , .1 1 • 1 Fig. 7. — D. Hayes Agnew (ISIS- that position he created a pathological museum. jggo^ In 1863 he accepted the position of demonstrator of anatomy and lecturer on clinical surgery in the Medical Department of the university. In 1870 he was selected as professor of operative surgery; in 1871 he became professor of the principles and practice of surgery in the same institution. Agnew fittingly closes the history of surgical teaching in the Medical Depart- ment of the University of Pennsylvania during the period mider review. In- structed in the policies of this school, and already distinguished as a surgeon and skilled as a teacher by a large experience as an instructor in anatomy, pathology, operative and clinical surgery, he entered upon his duties not only qualified to maintain but to advance its reputation as the true exponent of the science and art of surgery as formulated by Physick. In 1806 Dr. John C. Warren became associated with his father. Dr. John Warren, in teaching anatomy and surgery, and succeeded to the full professor- ship on the death of the elder Warren in 1815. John Collins Warren (1778-1856) was born in Boston, August 1st, 1778. He was the eldest son of Dr. John Warren, the founder of the Harvard Medical College. He graduated from Harvard College in 1797, and after a year's delay began the study of medicine. In 1799 he went to London and entered Guy's Hospital as a dresser 20 AMERICAN PRACTICE OF SURGERY. Fig. S. — John C. Warren (177S-1S56). to Mr. William Cooper, senior surgeon to that hospital, who was soon after suc- ceeded by JMr. Astle}' Cooper, his nephew. After a year's service he left London for Edinburgh, where he attended the lectm-es of Monroe and Jolm and Charles Bell, and received his medical degree. He visited Paris, where he remained one year attending lectures, and then returned home in 1802. He was the founder of the Massachusetts General Ho.spital and one of its surgeons until his death. In 1806 he was associated with his father in the chair of anatomy and surgerv, and on the death of the latter in 1815 he became full professor, ..^^^^^s and continued in that pbsition until 1847, when ^^ a professorship of siu-gery was created, and he t became the emeritus professor. He died May /' 4th, 1856. He was educated in the traditions of the Edinburgh school and was influenced in his teaching and practice by the precedents of British surgery. The successor of ^^"arren in the Harvard school, in 1847, was Dr. George Ha3T\'ard (1791-1863). He was a natiA^e of Boston, a graduate of Harvard College in 1809, but he graduated in medicine from the University of Pennsylvania in 1812. As a teacher, it is stated, " thoroughly versed in the principles and theorj' of surgery, he was a remarkably practical and popular teacher in the professor's chair and at hospital clinics." He died in 1S63. In 1849 Dr. Henrj- J. Bigelow succeeded HajTvard as professor of surgery in the Harvard school, and continued in that position until 1882, a period of thirty- three jTars. Bigelow was qualified by birth, ^..^—^ mental endowments, and preparatory training, not only to maintain the high standard of edu- cational qualifications which the Han-ard school required of its graduates, but to advance that standard so that it kept pace with the rapid development of the medical sciences dur- ing the period of his service. It is well stated of him that as "inventor and discoverer by nattu-e, his constant aim was to enlarge the boundaries of his profession, and to this end his fertility in ideas and remarkable mechanical ingenuity came to his aid." He was pre-emi- nently a master of both the science and the art of surgery, and in his teachmg he was able so to combine principles and prac- tice that the student became proficient m both branches of the subject. Henry Jacob Bigelow (1818-1890) was a native of Boston, and son of Dr. Jacob \ Fig. 9. — Henry Jacob Bigelow (ISIS- 1S90). INTRODUCTION. 21 Bigelow. He graduated at Harvard College in 1837, and received his medical degree from the same institution in 1841. In 1845 he began teaching surgery in the Tre- mont Street iledical School, and in 1849 he was appointed professor of surgery in the Harvard Medical College, a position which he held until 1886, a period of thirty- seven years. He was elected a member of the surgical staff of the JIassachusetts General Hospital in 1S46. He died in 1890. This brings our narrative of the pioneer medical schools to the close of the Normative period in the eA^olution of American surgery. They had laid broad and deep the foimdations on which the character of its future practice was to be con- stmcted. During the quarter of a century which has since elapsed these schools have been the master builders on those fomidations, and to-day they are miiver- sally recognized as occupying a foremost position among the world's best insti- tutions for medical instruction. Along the line of succession to the fotmders of surgical education in these fii'st schools, we recognize the names of surgeons whose achievements in practice are the crowning glory of American surgery. Not less illustrious in the annals of surgery are the names of many of the graduates who went forth from these schools, imbued with the highest ideals of professional character and animated by the adventurous spirit which pervaded all ranks of our yoimg communities, to establish other schools at the centres of population. The promoters of the new colleges were more frequently enthusi- astic young surgeons, whose ambition found its most natural expression in teaching others the science and art of their profession. We have not space to follow the development of these schools, nor would it be instructiA^e to dwell upon their indi- vidual peculiarities further than is necessary to illustrate the American independ- ence of precedents and the resourcefulness of their promoters, as seen in the organization of several of the earlier schools by graduates of the pioneer colleges. In the year 1798 the Medical Department of Dartmouth College, at Hanover, N. H., was established, at the suggestion of Dr. Nathan Smith, a graduate of Harvard Medical College. The most interestuig feature in the organization of this school was the composition of the faculty, which consisted of a single person, viz., its promoter, Dr. Nathan Smith. For twelve years he gave courses of lectiues on all of the different branches of medicine then taught, except two coiuses in the department of chemistry. Nathan Smith (1762-1829) was born at Rehoboth, Mass., September 30th, 1762. His education was obtained at the pubhc school. At the age of twenty-four he wit^ nessed a surgical operation, which so impressed Mm that he determined to study medicine, and accordingly apphed to the surgeon to be admitted to his office as a student. He was directed to prepare himself for admission to Harvard College be- fore commencing the study of medicine, which he promptly did, and was then al- lowed to enter and register as a student. After three years of study he located in practice at Cornish, Vt. Soon after, he attended the lectures on medicine and collateral sciences at Harvard College, from which he received the degree of Bachelor of Medicine in 1790. He returned to his practice, wMch he pursued with marked 22 AMERICAN PRACTICE OF SURGERY. success for five or six j^ears. During this time lae became mucli impressed witli tlie low grade of educational qualifications of the practitioners with whom he was iDrought in contact. On this account his biographer states that " he was led to project a med- ical institution in connection with Dartmouth Col- lege, in order to rear up for the widespread regions of the interior of New England a race of better educated, more enlightened, and more skilfi.il phy- sicians and surgeons." His plans being approved by the president of the college. Dr. Smith s.ought to better qualify himself for the new duties by attending the schools of London and Edinburgh. He returned in September, 1797, and early in the year 1798 began a course of lectures which em- braced the entire circle of the medical sciences, as then imderstood, and which he repeated for twelve successive years. In 1813 he was invited to the chair of "physic and surgery" in the recently established Medical Department of Yale College, which he accepted. He subsequently gave one course in Dartmouth "College, one in "\"ermont University, and five in the Medical Institution of Bowdoin ■College at Brunswick, Maine. He died January 26th, 1829, in the sixty-seventh year of his age. 'Fjq. 10.— Nathan Smith (1762- 1S29). In estimating the character of Dr. Nathan Smith as a surgeon and teacher of surgery, we have the judgment of his colleague in the Yale Medical College, Prof. Jonathan Knight. He sa3's: "For the duties of a practical surgeon, Dr. Smith was eminently qualified. ... To these he brought a mind enterprising, but not rash; anxious, yet calm, in deliberation; bold, yet cautious in opera- tion. . . . There was no formidable array of instruments, no ostentatious prep- aration; ... all useless parade was avoided. . . . His whole mind was bent upon its performance." "As an instructor," says Professor Knight, "the reputation of Dr. Smith was high, from the time he began the business of instruction. . . . That for many years he gave instruction upon all the branches of medical and surgical science, that this instruction was to classes of intelligent young men, and that many who were thus instructed have become eminent in their profession, prove not only versatility of talent, but variety and extent of information, with a happy method of commimicatuig it. . . . He sought no aid from an artificial style, but merely poured forth, in the plain language of conversation, the treas- ures of his wisdom and experience. . . . His object was to instill into the minds of his pupils the leading principles of their profession, not entering fully into the details of the practice, but leaving it for them to apply these principles to in- dividual cases as they should present themselves. These principles he would illustrate by appropriate cases furnished by a long course of practice, related INTRODUCTION. 23 always in an impressive, and often in a playful manner, so as at once to gain the attention and impress the truth illustrated upon the mind. ... He endeavored to inspire them, both by precept and example, with a love of their profession, with activity in the practice of it, and a zeal for its best interests." Of the influence of Dr. Smith upon the profession of New England, Professor Knight remarks: "His influence over medical literature was equally extensive. This influence was exerted, through his large acquamtance among medical men, by his advice and example, as well as more directly through the medium of the various medical schools which were favored with his instructions. By means of his influence thus exerted, he effected, over a large extent of country, a great and salutary change in the medical profession. The assertion that he has done more for the improvement of physic and surgery in New England than any other man will by no one be deemed invidious." From Dr. Nathan Smith's school at Dartmouth many students graduated who became reputable surgeons, and one, Dr. Reuben D. Mussey, achieved a national reputation, both as a surgeon and as an educator. Like that of his master, Mus- sey's early life was a continuous struggle to obtain an education and prepare for his future work. He was evidently adapted for pioneer duties, as he early under- took experimental research. While a student, he controverted Dr. Rush's the- ory of the non-absorbent power of the skin by a series of carefully conducted experiments. His thesis on this subject attracted much attention. His contro- versy with Sir Astley Cooper, in which he maintained that a fracture of the neck of the thigh bone within the capsule could unite by bone, illustrated Mussey's careful study and observation, and the tenacity with which he held his opinions. As a teacher his work was in the West, and chiefly in Cincin- nati. He was the founder of the Miami Medi- cal College. Reuben Dimond Mussey (1780-1866) was a native of Pelham, N. H. His father was a physi- cian, but the son had to earn the means to enable him to obtain an education. He graduated from Dartmouth College, in 1803, and became a pupil of Dr. Nathan Smith, and graduated in 1806. ''"'■ ''■''"'''''Zf; Mussey (17S0- After three years of' practice he attended the lect- ures in the University of Pennsylvania, from which he graduated in 1809. He located in Salem, Mass., and soon became prominent as a successful surgeon. He began to give lectures on different medical subjects, and in 1822 he was appointed professor of anatomy and surgery in the Dartmouth Medical School. In 1833-35 he lectured on anatomy and surgery in the Bowdoin Medical College and in 1836-37 he gave the course on surgery in the medical college at Fairfield, N. Y. In 1837 he was invited to professorships in New York City, Nashville, Tenn., and Cincinnati, Ohio. 24 AMERiaO PRACTICE OF SURGERY. He accepted the latter and became the professor of surger}- in the Ohio Medical Col- lege, a position which he held fourteen years. He then organized the Miami Medical College, and remained connected vnth it until he retired from active duties, in 1858, and located in Boston. He died in 1866. Gross speaks verj' disparagingly and even contemptuously of Mussey's per- sonality and his power as a teacher. He says : " Mussey was of low stature, of an attenuated form, with high cheek bones, a prominent chin, a small gray eye, and ungraceful gait." As a lecturer he "was dull in the extreme. He was- not only slow in his delivery, but deficient in his animation and in grace of manner. His words came forth tardily, as if he were in doubt as to their precise import or as to the construction that might be put upon them by his hearers." His lect- ures were not " learned, profound, or discursive, ... for Mussey was not a man of reading." He adds: "If w-e may be able to credit those who professed to be able to judge of them and who had listened to other teachers on similar topics, his lectures must have been instructive." Probably Gross places the true esti- mate on Mussey's teachmg in his conclusion: "His lectures owed their chief value to their practical adaptation to the daily and hourly wants of the practi- tioner." The abilities of Dr. Nathan Smith as an educator and his activity in estab- lishing new medical schools Avere transmitted to his son, Dr. Nathan R. Smith. For more than half a century as a teacher in many medical schools, and as an author and inventor, the latter exerted a marked mfluence upon the progress of scientific surgery. He was an attractive lecturer, a skilful operator, and an mgenious uiventor. One of his most useful publica- tions is his "Memoirs," m which he reproduced the substance of his father's teaching. His most hnpor- tant invention was an anterior splint for fractm'es of the thigh. Nathan Ryno Smith (1797-1877) was a native of New Hampshire. He graduated from Yale College in 1 SI 7, studied medicine under his father's direction, and received his degree from the Jefferson Medical College, Philadelphia, in 1820. He located in Burlington, Vt., ^ , and in 1825 founded the Medical Department of the Uni- ^^ J^'' \ 1'^, ' versity of Vermont, and was appointed its first professor of anatomy and surgery. In 1826 he was called to the """,^^^5^" —■'!"° ^"^ ^ chair of anatomy in the Jefferson Medical College, Phila- delphia. In 1827 he became professor of surgery in the University of Maryland, Baltimore, and in 1828 accepted the chair of medi- cine in the Transylvania University, Lexington, Ky. After twelve years' service he returned to Baltimore as professor of surgery in the University of Maryland. He retained this position until 1870, when he resigned and became professor of chnical surgerv- He died in 1877. INTRODUCTION. 25 In 1817 the Medical Department of Transylvania University was established at Lexington, Ky., and the first opportunities were offered to obtain a medical education in the Southwest. The founder of this school was Dr. Benjamin W. Dudley, one of the most eminent surgeons of that period. There was no medical college west of the Alleghanies, and the need of facilities for medical instruction of a rapidly increasing profession in the great Southwest was very pronounced. Dr. Yandell, the historian of "Pioneer Surgery in Kentucky," remarks as fol- lows : " The history of the Medical Department of Transylvania University . . . would practically cover- Dr. Dudley's career, and would form a most interesting chapter on the development of medical teaching in the Southwest. . . . Dr. Dudley created the medical department of the institution and directed its policy." The testimonies in favor of Dudley's qualifications as a teacher of surgery are numerous. One of his colleagues thus speaks of him as a professor: "He was magisterial, oracular, conveying the idea always that the mind of the speaker was troubled with no doubt. He was always, in the presence of his students, not the model teacher only, but the dignified, ui'bane gentleman; conciliating regard by his gentleness, but repelling any approach to familiarity, and never, for the sake of raising a laugh or eliciting a little momentary applause, descend- ing to coarseness of expression or thought. So that to his pupils he was always and everywhere great. As an operator they thought he had distanced competi- tion. As a teacher they thought he gave them not what was in the books, but what the writers of the books had never understood. They were persuaded that there was much they must learn from his lips or learn not at all." Benjamin Winslow Dudley (17S5-1S70) was born in Virginia, April 25th, 1785. When one year of age his father removed to Lexington, Ky., where he was reared, His opportunities for obtaining an education were very meagre. He studied medicine in the office of a physi- cian and received his degree from the University of Pennsylvania two weeks before he was twenty-one, in 1806. Ambitious of success as a surgeon, he deter- mined, after two or three years of practice, to visit the hospitals abroad. Not having sufficient means at his command, he purchased a flat-boat, loaded it with produce, and took it to New Orleans, where he exchanged it for flour. This cargo he took to Europe and sold at a considerable advance, and with the proceeds pros- ecuted his surgical studies for a period of four years in the hospitals of Paris and London. He returned to Lexington in 1814, and rapidly acquired reputation as a surgeon. In 1817, largely through his influence, the Medical Department of Transylvania University was established, and Dr. Dudley was appointed the professor of anatomy and surgery. He died in 1870. Fig. 13. — Benjamin Winslow Dudley (17S5-1S70). 26 AMERICAN PRACTICE OF SURGERY, In 1826, Jefferson Medical College, of Philadelphia, was founded by Dr. George McClellan, a graduate of the Medical Department of the University of Pennsylvania. McClellan was a type of the aspiring and aggressive young sur- geons of that early period. He had been a pupil of Dorsey, the assistant of Physick, a brilliant lecturer and accredited author. Soon after his graduation McClellan began teaching anatomy and surgery, and his vivacity of manner and fluency of speech attracted large classes. It is stated that as a public teacher his style was purely extemporaneous; he became so absorbed with his subject as to be vmconscious of those around him. His lectures achieved a popularity and produced an effect seldom equalled. As a practical surgeon he took rank with the most successful practitioners of that day. The school which he foimded has been one of the largest contributors, in its graduates, to the ranks of eminent practical surgeons and teachers. George McClellan (1796-1847) was born at Woodstock, Conn., on the 23d of December, 1796. He was of Scotch descent. He prepared for college at an academy in his native town, and entered the sophomore class of Yale College at the age of sixteen. On his graduation in 1815 he began the study of medicine in the office of Dr. Thomas Hubbard, of Pomfret, afterward professor of surgery in the Medical School at New Haven. In 1817 he attended lectures in the Medical Department of the University of Pennsylvania, and entered the office of Dr. John Syng Dorsey, then professor of materia medica and anatomy in the university. In 1818 he became a member of the resident staff of the Philadelphia Alnisliouse. He located in Philadelphia and began to give private lectures on anatora3^ In 1825, in co-operation with friends, he obtained a charter for the Jefferson Medical College, in which he occupied the professorship of surgery until the year 1838, when the professorships were all vacated by the trustees and a new organization formed, from which Dr. McClellan was excluded. He applied at once to the legislature for a charter of another college, which was granted, and "The Medical Department of Pennsylvania College," at Gettysburg, was established. The lectures were commenced at Philadelphia in November, 1839. At the close of the fourth annual course of lectures the faculty resigned, owing to pecuniary com- pUcations, and Dr. McClellan retired to private practice. He died suddenly, of perforation of the colon, on the 8th day of May, 1847. One of the most illustrious surgeons and educators of our period was a private pupil of McClellan, a graduate of the Jefferson Medical College, and his successor to the chair of surgery — Dr. Samuel D. Gross. It is impossible to estimate the vast influence of Gross upon the character of surgical practice during his long career of over half a centurj^, and in the threefold capacity of an original investi- FiG. 14.— George McClellan (1796- lcS47). INTRODUCTION. 27 Fig. 15. — Samuel David Gross (1S05-18S4). gator, a popular teacher in many schools, and an accepted authority on general surgery. Samuel David Gross (1805-84) was born near Easton, Pa., July 8th, 1805. He received a classical education and for two years was a pupil of Dr. George McClellan, graduating in medicine from Jefferson Medical College in 1828. He located in Phila- delphia, and in 1830 published a work on "Diseases _^ and Injuries of the Bones and Joints." In 1833 he #=^^*-^ — _ s&^-x became demonstrator of anatomy in the Medical Col- ^ '^'•' ^ lege of Ohio, and in 1835 he was appointed professor of pathological anatomy in the Medical Department of the Cincinnati College. His lectures were the first delivered in this country on that subject, and resulted in the preparation of a work on the " Ele- ments of Pathological Anatomy," the first work of the kind in the English language. In 1839 he was appointed professor of surgery in the University of Louisville, Ky., and in 1850 he was appointed profes- sor of surgery in the Medical Department of the Uni- Tersity of the City of New York. He gave but a single course of lectures in New York, and returned to his former position in the Louisville school. In 1865 he was appointed professor of surgery in the Jefferson ^iledical College, Phila- delphia, from which he retired in 1882. He died in 1884. Dr. Isaac M. Hays has given the following graphic but truthful description of Gross as a man and as a teacher: "Dr. Gross's magnetic form and dignified presence, his broad brow and intelligent eye, his deep, mellow voice, and benig- nant smile, his genial manner and cordial greeting remain indelibly impressed upon the memory of all who knew him. He was a man of deep mind and broad views, and he was a model of industry and untiring zeal. . . . His style was vigorous and pure. It is safe to say that no pre- vious medical teacher or author on this continent exercised such a widespread and commanding in- fluence. . . . His writings have been the most learned and volmninous and his classes among the largest that have ever been collected in this country." In 1837, Rush Medical College, of Chicago, was founded by Dr. Daniel Brainard. This was the pioneer medical school in the Northwest, and has alwa}^s maintained a high grade of surgical in- „ ,„ ^ , struction. riG. 16. — Darnel Bramard (1S12-1866). Daniel Brainard (1812-66) was a native of Wlrltes- borough, N. Y. He was educated at the public schools and studied medicine in the office of the village physician. He attended two courses of lectiues at the Medical 28 a:\ieric.\x practice of surgery. College at Fairfield, N. Y., but graduated from the Jefferson Medical College, Phila- delpliia, in 1834. He began to give lectures on anatomy and surgery in the Oneida Institute, and in 1836 removed to Cliicago. He went abroad in 1839 and returned in 1841, when he was appointed professor of anatomy in the University of St. Louis, Mo. He took an active part in organizing the Rush Medical College, which was chartered in 1837, and opened in 1843, Brainard occupying the chair of surgery. He died in 1866. Brainard began teaching at an early period of his professional career, and thus ciualified himself to be an educator. He followed the trend of enterpris- ing young men of that day, and sought fame and fortune in the far West, locat- ing in Chicago. In this growing city and future metropolis Brainard found an ample field for the exercise of his talents as a surgeon and, finally, as an edu- cator. He became eminent as a practical surgeon, and in the establislmient of Rush iledical College he found his opportmiity as a teacher. In the latter capacity we have the testimony of his biographer that : " As a teacher he stood without a rival." The pioneer teacher of surgery in the extreme South was Dr. Warren Stone (1808-72), of New Orleans. He was a native of Vermont and studied medicine under Dr. Amos Twitchell, one of the most famous surgeons of that day in this country. He took his medical degree at Philadelphia in 1825, and located in Xew Orleans. He was connected with the Medical Department of the University of Louisiana from its organization in 1834. During the first and second sessions he discharged the duties of demonstrator, and was appointed surgeon to the Charity Hospital. In 1836 he was appointed lecturer on anatomj^, and in 1837 professor of that branch, at the same time giving the lectui'es on surgery. In 1839 anat- omj' was separated from sm'gerj^, and he as- smned the full duties of the chair of surgery. For upward of a third of a century Stone taught large classes of students and exercised - a great mfiuence upon the practice of sm-gery. Gross attributes his success to his large heart and the native powers of his mind, strong and •^^^- . ' ' well poised. One of the most conspicuous stirgeons of the Fig. 17.-A^arren Stone (1S07- g^^^j ^.j^^ ^^ ^^ ^^^.j -q^j ^q^j. ^^ ^^^ 187S). ' . part as a teacher in the newly organized medical schools, was Dr. Paul F. Eve. He was a native of Georgia, a graduate of the University Medical College, Philadelphia, and later an attendant upon the lectures and practice of the leading surgeons of London and Paris. He began teaching in 1832, in a small college in Georgia, and from that time until his INTRODUCTION. 29 death he was engaged hi giving courses of lectures on surgery in a large number of colleges. On his final settlement in Nashville, Tenn., he became eminent as a practical sm'geon. As an instructor he was popular and had flattering offers of professorships / of surgery in the older colleges. Paul Fitzsimmons Eve (1806-78) was a native , of Augusta, Ga., born in 1806. He graduated at Franklin College, Athens, Ga., in 1826, and received his medical degree from the University of Pennsyl- vania in 1828. After an absence in Europe of three years, he returned and was appointed professor of surgery in the Medical College of Georgia, 1832, recently organized. In 1850 he was appointed to the chair of surger}^ in the University of Louisville, as successor to Gross, but retained the position only one session, when he accepted the professorship of ^^^ is.— Paul Fitzimmons Eve surgery in the University of Nashville. In 1868 he (1S06-187S). was called to the chair of surgery in the Missouri Med- ical College, St. Louis, but after two courses of lectures he returned to Nashville and became professor of clinical and operative surgery in the Nashville Medical College, then being organized. He had invitations to accept professorships in colleges in New York, Philadelphia, New Orleans, and Memphis, but he declined them and remained in Nashville until his death in 1878. The founder of the St. Louis Medical College, Missouri, was Dr. Charles A. Pope, one of the most prominent surgeons of the West at that period. The establishment of a medical school on the Pacific Coast was effected by Dr. Cooper, a surgeon having a wide reputation for his skill as an operator and his enterprismg spirit. We cannot farther trace the progress of the schools which were to educate the future surgeons of this country in the principles of scientific surgery and to illus- trate by precept and practice its art, But must notice other educational forces which have more or less effectively impressed a national stamp upon the Ameri- can practice of- surgery. First, and most important, is the development of clinical instruction as a necessary qualification of the surgical student on his graduation. The value of clinical instruction was recognized and efforts were made to supply it by the medical officers of the Pennsylvania Hospital, as early as 1765. Cluiical lectures were subsequently given in the almshouses of Philadelphia and New York, and later in the New York Hospital and the Massachusetts General Hospital. There arose, however, two serious difficulties that obstructed the progress of this most important improvement in medical education. In the first place, there was early developed an intense prejudice on the part of lay mana- gers of hospitals against the exposure of patients to the observation of medical 30 AMERiaiN PRACTICE OF SURGERY. students and to the public discussion of theii- ailments. It was believed that the inmates would regard such exposure as an outrage upon common decency and universally rebel against the practice. Happily, experience proved, not only that patients did not resent such treatment, but that they were always gratified with being selected as the subjects of special attention and study, while those who were passed by complained of neglect. Again, the fact developed that those hospitals were most efficientlj^ and carefully supervised in the medical and surgical service where the visiting staffs gave clinical instruction. The result of these experiences has been, not only the removal of all prejudices against clini- cal teaching in hospitals, on the part of the public, but a disposition of man- agers to encourage the medical schools to use the service for the purpose of teaching. In the second place, there was a class of teachers who were opposed to hospital attendance by medical students imtil they had regularly graduated from the schools. It was alleged that midergraduates could not be benefited by at- tending lectures on subjects which they could not by any possibility imderstand, and about which they were liable to obtain false views that would prove very det- rimental m practice. Experience, however, established the fact that the most thoroughly qualified graduate in both teclmical and practical knowledge was the student who had received clinical instruction from the outset of his comse of study. Prior to 1861 clinical instruction was, however, little more than an interest- ing incident in the life of the medical student. He ^asited the hospitals to wit- ness an advertised operation in the interval of lectures, rather for the relaxation and excitement which the occasion afforded than for any positive knowledge he expected to acquire. But a most important change in medical education was impending. Clinical teaching was to become an essential part of the system of instruction, and attendance upon its lectures was no longer to be a pastime, but a compulsory duty with every aspirant for graduation. This advance in medical education was largely due to Dr. James R. Wood, of New York. On the reorganization of Bellevue Hospital, New York, the visiting staff of physicians and surgeons, imder his guidance and direction, began to give systematic courses of clmical instruction to the medical students of the several colleges. The staff included yomig men of marked ability, ambitious of success as teachers, and animated with that genuine entluLsiasm which stimulates stu- dents to high endeavor. Dr. James R. Wood, Dr. William H. Van Buren, Dr. John T. Metcalfe, Dr. John 0. Stone, Dr. Benjamin W. jMacready, Dr. Lewis A. Sayre, Dr. George T. Elliott were lecturers who always attracted large classes. So popular had these lectures become during the years 1855-60, that it was de- termined to organize a chartered medical college, in which clinical instruction should form part of the prescribed course of study. Bellevue Hospital Medical College began its career in 1861, with the avowed pin-pose of combining didactic and clinical instruction. The popularity of the clinical teaching in the hospital gave tlie new college immediate success. INTRODUCTION. 31 James Rushmore Wood (1813-82) was born in the city of New York, on the 14th clay of September, 1813. He had but hmited opportunities for education at the Friends' Seminary, in New York City. He began the studj^ of medicine in 1829 with Dr. David L. Rogers, and attended his first course of lectures at the College of Physicians and Siu^- geons, in 1831. He graduated in 1834 from the Medical College at Castleton, Vt., and was soon after appointed demonstrator of anatomy in that College. He located in New York and rapidly ad- vanced to an influential position in the practice of surgery. He became comiected with the man- agement of Bellevue Hospital, then an almshouse, and in 1847 he effected a complete change in the organization of that institution, b}' converting it from an almshouse, under a resident physician, into a hospital, with its visiting and resident staffs of physicians and surgeons, and under the direction Fic. i9.-James R.Wood (1S13-1SS2). °^ ^ '^^^^^^^^ ^oard. He began a systematic course of clinical instruction, which drew large numbers of students to its wards and led to the creation of the Bellevue Hospital Medical College in 1861. Wood was appointed professor of operative surgery and siu-gical pathology in the new school, a position which he held upward of fifteen years, and on retiring was appointed emeritus professor. He died in 1882. Dennis, the biographer of Wood, states that he "was foremost in the view that medicine is a science pre-eminently of demonstration as well as of observa- tion, and it was the union of clinical and didactic teaching that in his opinion best attained the object of medical education." Hospital instruction in the practice of surgery has become increasingly im- portant in these later years, when anesthesia and antisepsis have given to the technique of operations a scientific precision, even to the minutest details of the preparation of the patient, the operator, his assistants, the room, the appliances, the administration of the ansesthetic, the immediate aid of the surgeon, and, finally, the preparation and application of the permanent dressings. The high- grade technical operator regards each of these innumerable details as vitally essential to the success of the operation. But it is impossible to gain the requi- site expertness in the manipulation of these complex details except under the conditions which are enforced in a modern hospital. The hospitals of this coun- try, therefore, now so numerous and well equipped, have become essential fac- tors in the education of surgeons for practical duties. Hundreds of surgeons graduate annually from our hospitals, fully c^ualified bj^ education and practice to undertake the most responsible duties of their profession. But the modern hospital not only serves as a school for perfecting the young surgeon during the period of his education in the manual or art of surgery, but it supplies conditions nowhere else obtainable, which enable the surgeon to apply 32 M'lERICAN PRACTICE OF SURGERY. those arts in practice with almost absolute success. In other words, the modern well-equipped hospital is essential to the highest degree of success in the practice of surgery, whatever may be the skill and experience of the individual surgeon. Within the walls of thousands of hospitals in this country are found ready and awaitmg his order every condition, thing, or circumstance which the surgeon can possibly in any emergency require for successful practice. And these hos- pitals are increasing at a rate that positively insures to every communitj^ the opportunity of having every variety of disease or injury, amenable to surgical treatment, immediately placed under conditions most favorable for recovery. Not only are public hospitals increasing in such vast numbers, but on every hand surgeons are establishing their own private hospitals, equipped with every- thing required for the most successful work. To these should be added the in- creasing number of large priA^ate corporate hospitals, where operations are daily performed by the score, with an accuracy in all the details of the procedure comparable to that performed by instrimients of precision. Large nimibers of these hospitals are devoted to special classes of diseases, as the eye and ear, the throat and nose, the genito-urinary apparatus, and in each will be found the highest grade of surgical practice. Some of these corporate hospitals are de- voted to general siu^gical practice, where operations are performed on a vast scale and with marvellous success. Finall}-, there are corporate hospitals which combine not only all the specialties with general surgery, but they are supplied with laboratories for biological and pathological investigations, and appliances for every form of mechanical and instrumental treatment. These great institu- tions, which are rapidly increasing in various parts of the country, indicate that the time is approaching when the American practice of surgerj', in all its details, will be established on strictly scientific principles. "The Training-school for Nurses" in the modern hospital, inaugurated in 1872 in Bellevue Hospital, New York, is a factor in the successful practice of surgerj^, the value of which it is quite impossible to estimate. That these schools have revolutionized practice is the universal testimony of both phj-sicians and sur- geons. Only the operator himself can, from his individual experience, appre- ciate at its full value the assistance of the expert and reliable nurse, who pre- pares his patient, deftly meets every want and emergencj' during the operation, and during the critical hours or days or weeks of convalescence faitlifully watches every s}Tnptom, rightly interprets its meanmg, whether for good or for evil, and promptly and mtelligently applies the prescribed remedial measure. So essen- tial has the trained nurse become to success in the practice of surgery in this country that every hospital, however small, has its corps of nurses, and no sur- geon will operate without their aid when it can be obtained. It is often alleged that our system of medical education is very defective in the advantages of pathological research which are afforded by large inuseums. INTRODUCTION. 33 The few morbid specimens which individual surgeons were able to save in their practice threw but little light on obscure questions of pathology, and it has been believed that only in the great museums of Europe can such studies be ade- quately pursued. Efforts to supply this want have been made by individual surgeons, notably by Dr. James R. Wood, of New York, and Dr. Thomas D. Miit- ter, of Philadelphia. But there is much truth in the conclusion of Hamilton, who consulted all of the great museums of the world, while preparing his work on "Fractures and Dislocations," to determine positively doubtful questions: " Nothing is more unreliable than the testimony furnished by cabinet specimens whose clinical history is wholly unknown, and in reference to which in many cases it is impossible to say whether their present condition was du e to trauma- tism before or after death, or, mdeed, whether it was not due to some long-pre- existing pathological cause." In place of the museum the colleges have now their well-equipped labora- tories and their courses of instruction in the closely allied branches of a complete medical education, viz., biology and pathology. In these departments the stu- dent has immediate access to the healthy and morbid specimens, so freshly prepared as to be wellnigh living in their accuracy of illustration, with necessary demonstrations of all doubtful questions by the instructor. As a means of firmly implanting in the student's memory useful practical facts, the present method of teaching these subjects in the laboratory has many and important advantages over the mere study of museum specimens. The literature of a profession is not only a safe guide to the estimation of the scientific spirit which inspires its practice, but it is an important educational force in developing the character of the coming generations of practitioners. In this view the literature of American surgery deserves proper estimation. Its development has necessarily kept pace, both in quantity and quality, with the progress of the schools in raising the standard of medical educational qualifica- tions. From one book in a quarter of a century it has increased to a score of books in one year, and from one serial publication it has multiplied to fifty peri- odicals. It began, both in book and in serial form, during the last quarter of the eighteenth century, and was for a considerable period but little more than a transcript of British surgical literature. As such, however, it shows a wise and judicious discrimination on the part of authors to meet the wants of the practis- ing surgeon. But, in time, books and even articles were published, which on ac- coiuit of their originality were epoch-making in their influence. The author of the first surgical work was Dr. John Jones, of New York, and it was written to meet the emergency which confronted the medical profession at the opening of the war of the Revolution. Dr. Jones was well qualified for this task. He had been educated in the British and French schools, had practised surgery with great success in New York for a score of years, had given full VOL. I. — 3 34 AMERICAN PRACTICE OF SURGERY. courses of lectures on surgerj- in the ]\Iedical Department of King's College for seven j'ears. His special qualification for this task gi-ew more directly out of his experience in the war on the Canadian frontier, between the English and French, in 1755, where he won distinction as a surgeon. The remarkable case of the French general, Baron de Dieskau, who was woimded and taken prisoner and placed in charge of Jones, illustrates his skill as a military surgeon. The general was wounded in the hip, in the thigh, in both knees, and through the pelvis, the latter wound inA^olving the urinary bladder, so that urine escaped from the wound of entrance and of exit. Though the conditions under which the patient was treated were most imfavorable, he recovered so as to be able to re- turn to Eiuope. Dr. Jones's work was entitled "Plain, Concise, Practical Remai-fcs on the Treatment of Wounds and Fractures." It was printed at Xew York, in 1775, but in 1776 a second.edition was issued at Philadelphia, to which was added the popular work of Van Swieten on " The Diseases Incident to Armies and Qimshot ^Youncls." The work was what its title annoimced — smiply plain, concise, and practical remarks on all that at that time was known of militarj' surgery. The merits of the book lie in its adaptation to the wants of the surgeons of the Con- tinental Army, few of whom had any useful surgical knowledge, theoretical or practical. The only works on surgery at the time were meagre treatises, and even these were accessible to but few. The appearance of Dr. Jones's work, in small manual form, at the very beginning of the war, was an achieA'ement of national importance. Dr. David Ramsay, a contemporarj' medical historian, says this work ''will long remain a monument both of professional skill and patriotism of its author," Notwithstandmg the progress of the schools and the great impulse that had been given to the study of scientific surgery by Himter's teachings, especially among v^ierican students, nearly forty years elapsed after the issue of Dr. Jones's work < before another native surgical treatise appeared. In 1813 Dr. John Syng Dorsey, of Philadelphia, published a systematic work, entitled " Ele- ments of Surgery," in two volumes, 8vo, which reached a second edition in 1818, and a third in 1823. It was a work of great merit for that period, as it faithfuUy illustrated the practice of British surgery, but, in addition, it gave publicity to Physick's surgical teachings, which might otherwise have been lost to surgeons. The value of this work was recognized by the Edinburgh school, which adopted it as a text-book. In 1824 appeared '' The Institutes and Practice of Surgery," by Prof. William Gibson, professor of surgery in the Medical Department of the University of Pennsylvania, in two volumes. It was announced to be " outlines of a com^se of lectures," and "published at the request of students who want a text-book"; the "work must be considered as a mere outline of the lectures, to be filled up by numerous ilkistrations, chiefly models, morbid preparations, magnified draw- INTRODUCTION. 35 ings, and imitations on the dead subject. The last two modes of instruction I consider pecuUarly my own." That this work was well received we learn from the preface of the second edition, which appeared in 1827 : " The praises which have been bestowed on the work by European and American critics, though far beyond, in many instances, any merit I should be entitled to claim," etc. In the preface to the third edition, which appeared in 1833, the author says: "This work has been pronotmced by hypercritics a book on the practice of medicine." He adds: "A greater compliment could not have been paid to it, and yet it argues a very narrow view on the part of those who strive to affix limits to sciences which blend and often unite in every possible way." He defends this featm-e of his work on the groimd that practitioners in this country must prac- tise both medicine and surgery. That the work was well adapted to the wants of the profession is evidenced by the appearance of a fourth edition in 1835 and a fifth edition m 1838. In 1859 appeared "A System of Surgery," by Prof. S. D. Gross, professor of surgery in Jefferson Medical College, in two large volumes. The author says: "The object of this work is to furnish a systematic and comprehensive treatise on the science and practice of surgery, considered in the broadest sense. . . . My aim has been to embrace the whole domain of surgery and to allot to every subject its legitimate claim to notice in the great family of external diseases and accidents." He continues: "It may safely be affirmed that there is no topic, properly appertaining to surgery, that will not be found to be discussed to a greater or less extent in these volumes." This system of surgery was a work of very unequal merit, owing to the treatment of such a wide range of subjects by a single author, but it became the text-book of the schools and retained that position through many editions. Although the works of several British surgical authors appeared and were republished in this country during this period, the native works of Dorsey, Gib- son, and Gross were generally accepted as text-books and guides to American practice. In addition to these works on general surgery, several treatises on special branches of practice were published and deserve notice. As the authors of these works were surgeons educated in the home schools, the text illustrates the stage of progress in the practice of these specialties to which they had at- tained. In 1851 Gross published a work entitled "A Practical Treatise on the Dis- eases and Injuries of the Urinary Bladder, the Prostate Gland, and the Urethra." This treatise has the merit of being the first complete work in the English lan- guage on these organs. At the time of its appearance several British surgeons had written monographs on these subjects, but no one had ventured to cover the whole field as did the American author. The only other accessible complete treatise of the kind was that of the French authority, Civiale. In his preface Gross states that his sole object "has been to furnish a monograph on the dis- 36 AMERICAN PRACTICE OF SURGERY. eases and injuries of the urinar}^ organs that should be^Yorthy of the favorable consideration of his professional brethren and of the present state of medical science in this country." This work greatly improved the treatment of genito- xu'inary diseases and laid the foundation of that specialty as it is now recognized in the schools. In 1860 Dr. Frank H. Hamilton published his work, entitled, " A Practical Treatise on Fractures and Dislocations." It was the first treatise on these sub- jects written in the English language and supplied a pressing want. Hamilton was amply qualified for the task which he undertook. He had been a teacher of surgery from his graduation, in several colleges, and had a large experience as an expert witness in suits against physicians, so frequent at that time. The subject of litigation was usually malpractice m the treatment of fractures. The great diversity of opinions among surgeons at these trials and the entire absence of any reliable authority was the incentive that prompted him to undertake the investigations which form the basis of this treatise. He was indefatigable in the pursuit of facts, and endeavored, by experiments and personal visits to patholog- ical museums in this country and Europe, to verify every statement and judi- cially establish every opinion which he should record. Frank Hastings Hamilton (1813-86) was born at Wilmington, Vt., Septem- ber 10th, 1813. He received his classical education at Union College, Schenectady, ,N. Y., and graduated in medicine from the Medical f,.^Sr Department of the University of Pennsylvania in 1833. He located at Auburn, N. Y., but removed to e Rochester, and in 1848 to Buffalo, and in 1862 to New ^^^ ""^"^ York. He gave courses of lectures on surgery at the , ^ i Pittstield Medical School, Mass., and at the Geneva Medical College, N. Y. On the establishment of the Medical Department of the University of Buffalo he was appointed professor of surgery, a position which he held until his removal to New York. He gave courses of lectures in the Long Island Medical College, and was appointed professor of the specialty, "Fractures and Dislocations," in the Bellevue Medical College, New ^^^ '' c^ York, in 1862. Soon after, he enlisted as brigade sur- Fig 20 —Frank. Hastmgb Hamii- geon and served in the Army of the Potomac, acting as on ( - ). medical inspector in 1863, but ill health compelled his resignation.. In 1875 he re- signed his professorship in the Bellevue Medical College. He died in New York, August 11th, 1886. In the preface to the seventh edition of the treatise, published in 1884, the author reveals in apologetic terms the conscientious and judicial spirit in which the work is written : " From the beginning of his studies the author has found one of his most difhcult labors in attempting to eliminate from the branch of science which he has undertaken to teach the numerous 'false facts' or im- INTRODUCTION. 37 reliable statements derived from these several som-ces, and this must be accepted as his apology for his repeated expressions of scepticism in reference to testimony, some of Avhich has been accepted, as is believed without sufficient examination, by Avriters whose opinions might be regarded as of more value than his own." Its thoroughly scientific character, its accurate historical review, its large range of well-digested facts, its careful analysis of current theories and opinions, and its pure English style placed it at once among the classics of surgical litera- ture. Although out of print, it still maintains its position among surgeons as the most reliable authority in the English language on fractures and dislocations. Hamilton's work led to the establishment of a " chair of fractures and dis- locations" in the Bellevue Hospital Medical College. In 1861 Dr. Freeman J. Bumstead, of New York, published a work, entitled, "Pathology and Treatment of Venereal Diseases." The object of the author was to furnish the student a full and comprehensive treatise on the venereal dis- eases, and the practitioner a plain, practical guide in their treatment. The work of Bumstead was received with great favor, and created so much interest in venereal diseases that the medical schools began to introduce courses of in- struction on this subject as a specialty. Several editions of this work appeared, and during the lifetime of the author it maintained its position as the most com- plete and reliable work on venereal diseases in the English language. ■ During this period large numbers of monographs appeared on surgical sub- jects, some of which were of a high order of merit and greatly improved methods of practice. Several of these publications will be noticed in other sections of this paper. In his historical sketch of the medical literature and institutions of this coun- try, Dr. John S. Billings, an eminent authority, remarks : " Since the year ISOO medical journalism has become the principal means of recording and communi- cating the observations and ideas of those engaged in the practice of medicine, and has exercised a strong influence for the advancement of medical science and education." That the medical profession of this country has improved this method of advancement, is shown by his summary of medical journals published down to 1876, the number being one hundred and ninety-five, including reprints of foreign journals, making in all sixteen hundred and thirty-seven volumes. It is the universal testimony of surgeons that they have derived more benefit in the details of practice from the current information furnished by medical journals than from text-books of surgery. The growth of medical libraries in this country is another striking feature of the evolutionary process by which the practice of surgery has advanced to a more and more nearly perfect state of development. In these latter days there is a flood-tide of surgical publications. The pioneer surgeons complamed that they had no books to consult and had to rely on their own unaided judgment in the emergencies of practice; but modern surgeons have such a surplus that 38 AMERICAN PRACTICE OF SURGERY. they are compelled to adopt the co-operative plan, so popular in business circles, of forming libraries capable of accumulating all of the current surgical literature, for the use and common good of surgeons of every grade. These libraries are becoming more and more the great centres of education of the entire profession, and their influence in elevating the grade of practice becomes daily more and more evident. There are now 164 medical libraries in the United States, contain- ing a total of 912,330 volumes. With this review of the development of the educational qualifications of American surgeons, we are prepared to estimate the value of that education, as illustrated in the performance of the practical duties of their profession. We can select only the more important questions in the practice of British surgery at the beginning of our period, and consider their treatment by American sur- geons. This examination will bring prominently into view the special charac- teristics of the American practice of surgery. Mr. Erichssen, in his "Impressions of American Surgery," already referred to, remarks : " The bent of the mind of the American surgeon is, like ours, prac- tical rather than scientific." There is ample proof that the achievements of American surgeons are to be fomid in the field of practice rather than in the laboratory. This fact is not due to a lack of interest on the part of American surgeons in the truths of science nor to failure to appreciate their value when applied to practice, but rather to the social conditions under which the surgeon begins his career. The commmiity in which he locates is yoimg, compared with, those of the old world, and professional and business success is popularly esti- mated by those activities which have the greatest publicity. \Vliatever may be the qualifications of a graduate of one of our medical schools for a successful career as a scientist, if he has had the training of a practical surgeon in a modern hospital, he will almost invariably be so fascinated by the glamour of operations as to subordinate science to practice. The American practice of surgery has always been characterized by self- reliance and resourcefulness. This has been due in part to the more limited means and agencies at the command of the practitioner in this country, and in part to the adventurous spirit which has always inspired every department of American activity. Thousands of surgeons have been compelled to practise their profession far removed from access either to the aid or the advice of a com- petent surgeon or to necessary instruments and remedial agents. Many new and difficult operations have been performed under these conditions and with a re- markable degree of success. It is true that operations under such circumstances are liable to have no scientific value, unless they incidentally suggest or reveal important facts hitherto unknown ; but they do demonstrate, as no other method can, the boldness and daring of the operator and his mental equilibrium and re- sources in emergencies. A review of the practice of surgery in the early periods INTRODUCTION. 39 of our national history proves that these attributes have always been dominant features of the qualifications of American surgeons. As we have already stated, the practice of surgery in this country illustrated the progress and growth of British surgery transplanted to a virgin soil. Edu- cated in all the traditions of the foreign schools, but unhampered by them in his practice and usually left to his own resources, the pioneer American surgeon was compelled to resort to new and untried, and even unheard-of methods, to meet emergencies. On this account the practice of surgery in this country has neces- sarily been characterized by a freedom from arbitrary and often impracticable rules, which have a controlling force with surgeons of the older countries. It has been very frequenty asserted that this freedom from technical rules in the practice of surgery is liable to result in dangerous adventures on the part of the surgeon, quite incompatible with judicious conservatism. But such has not been our experience ; on the contrary, this very freedom has developed such an overpowering sense of personal responsibility that the surgeon has proceeded with a degree of caution the equivalent of true conservatism. The evolution of the practice of American surgery necessarily kept pace with the progress of the medical schools m developing the educational qualifications of the future surgeons of the country. Prior to the year 1800, the three pioneer medical colleges had graduated too few students to have exerted any marked influence upon the profession at large, especially in regard to the practice of sur- gery. But during the first quarter of the nineteenth century the number of med- ical colleges rapidly increased and the grade of teaching greatly improved. The result appears in the increased activity of surgeons in performing formidable operations and the independence which characterized their departure from rules established by the foreign schools. It is during this period that we begin to trace the line of cleavage between Aiiierican and European surgery, and from this time we more and more frequently meet the word "American" in surgical literature, in connection with new inventions and methods of operation. It was, therefore, during the early years of the nineteenth century that the evolution of what may properly be termed "the American practice of surgery" began to appear, and it is from that period we shall begin to trace its development and illustrate its dis- tinctive features. The treatment of aneurism was a subject of absorbing interest to British sur- geons at the close of the eighteenth century. Hunter had perfected Anel's method of ligatuig the artery on the proximal side of the tumor, and had established the following principles: 1. The ligature should be applied at a sufficient distance from the tumor to insure a healthy condition of the artery. 2. The artery should not be disturbed more than is necessary to secure the passage of the ligature. 3. One ligature is sufficient. 4. The wound should be healed by first intention as far as possible. 40 AMERICAN PRACTICE OF SURGERY. Hunter's operation was performed with indifferent success by British sur- geons, accordmg to Home, owing to modifications which they made of the pro- cedure of the original operator. The surgeons of the continent ignored this method of treating aneurism, cliiefiy because it liad a British origin. But there was present at Hunter's first operation a yoimg American surgeon from the city of New York, who thoroughly comprehended the opinions of the operator, and appreciated at its full value the immense importance of the operation. Dr. Wright Post was a pupil of a member of the staff of St. George's Hospital at the date of Hunter's first operation, which was performed in that hospital in Decem- ber, 1785. Post returned to New York in 1786, and soon took a high rank as a teacher of anatomy and surgery. The treatment of aneurism by the new opera- tion was evidently the theme of some of his lectures, for Mott, his most eminent student, says Post expressed the opmion that not only one carotid artery might be ligated for aneurism safely, but that both might be interrupted by ligature on the same person without harm, long before Astley Cooper operated on that artery. Post's first operation was the ligation of the femoral artery for aneurism, in 1796. The patient had a femoral aneurism caused by a wound of the artery fifteen years previously. The precise location of the aneurism is not given, nor the point at which the ligature was applied. The patient recovered in the usual time and the tumor gradually duninished until it was reduced to a size not ex- ceeding one inch in diameter. An interesting feature of the case was a continu- ance of the pulsation of the tmnor, which Post attributed to the increased size of the anastomosing vessels due to the long continuance of the aneurism. The limb became as useful as it was before the accident. This was the first operation for the cm-e of anevirism on the Hunterian prin- ciple in this coimtry, and the beginning of the operator's career as the practical exponent of the Hmiterian method of treating aneurism. The first operation of ligating the common carotid for aneurism in this coun- try was performed by Post, January 9th, 1813. The tmnor was situated below the angle of the jaw on the right side, and measured six inches in length, four inches in breadth, and two mches in height. Two ligatures were applied and the artery was divided between them. The case did well and was discharged at the end of four months. The patient returned in two months, the timior being large and fluctuating. It soon after opened and there was a hemorrhage of thirty oimces. It opened in a second place and discharged pus and blood; severe hemorrhage occurred several times, and once the patient was thought to have lost two quarts. Extensive suppuration occurred at the site of the aneurism, but the patient fuially recovered. The peculiarities of this operation were: (1) The passage of two ligatures around the artery, about three-quarters of an mch apart; (2) the passage of the ligature through the artery to prevent its slipping from the end of the cut ar- INTRODUCTION. 41 tery, as recommended by Dionis and Cline; and (3) the division of the artery between the ligatures. The danger of hemorrhage from the sHpping of the hga- ture from the cut end of an artery was at that time regarded as very great, and to prevent it the needle was placed on the ligature after it was tied, and the thread was passed through the artery close to the ligature and tied with the knot already made. One year later, January 4th, 1814, Post applied a ligature to the external iliac for inguinal aneurism. It was the second operation on the artery in this country, Dorsey, of Philadelphia, having operated in 1811 successfully. The important feature in Post's case was the necessity of opening the peritoneal cavity to reach the artery, and the recovery of the patient. It is stated in the report that the strength and thiclmess of the peritoneum were considerably greater than natural, and its adhesion to the ligament so firm that the separation, which is ordinarily so easily effected. Was found in this case alto- gether impracticable. To arrive at the artery, therefore, under these cir- cumstances, it was necessary to cut through the peritonemu, and thus " expose the patient to the additional hazard of inflammation of this membrane, to which it is generally supposed to be very liable when an opening is made into the common cavity of the abdomen." But to accomplish this object there was no alternative, nor did Post hesitate in proceedmg with the operation in this manner. On the 28th of November, 1816, Post again ligated the common carotid ar- tery for a pulsating tumor of the neck. The patient recovered from the opera- tion, but died two years later, and the autopsy disclosed a tumor with no indi- cations of a previous aneurism. It was to this case that Mott often alluded in his lectures, illustrating the difficulties of correctly diagnosing an aneurism from an abscess or solid tumor overlying an artery. At the consultation Post diagnosed the tumor as an aneurism, Stevens as an abscess, and Mott as a solid tumor; Stevens suggested to Post the propriety of exploring it by puncture, whereupon Post responded by handing Stevens a lancet. Stevens declined by passing the lancet to Mott, who refused to receive it, and Post was allowed to exercise his discretion. Post's last and most notable pioneer work was the ligation of the left sub- clavian, in its third part, for aneurism of the brachial artery. This was the eighth recorded ligation of the subclavian artery, the third which recovered, and the first in this country by the new method. The most interesting feature of the case was the rupture of the aneurism and the discharge of its contents during convalescence, with the final complete recovery of the patient. From this review it appears that Dr. Post, previous to the year 1816, had applied the ligature successfully to five different arteries, twice to the carotid. His success has not been excelled, if we consider the complications he encorm- tered, in any period anterior to antisepsis. The secret of his success, aside from 42 AMERICAN PRACTICE OF SURGERY. his great skill as an operator, is found in the extreme cleanliness, not only of his person, but of his instruments and the womid and dressings, thus securing asep- sis. In the case of opening the peritoneum, he followed the operation with "an active cathartic, composed of an infusion of senna, manna, and cream of tartar, which caused frequent and copious discharges" — a form of treatment w^hich some distinguished operators have latterly adopted as a preventive of peritonitis. Brilliant as had been the career of Post m his pioneer work of introducing the new method of treatmg aneurism into American practice, Mott, his pupil, was destined to excel him in the number, variety, and severity of operations, and in the perfection and precision of details. He had a genius for scientific operative surgery. Nothing was done haphazard. Every detail, however mi- nute and apparently unimportant, was carefully studied, and provision was made to meet every possible accident. He was by habit and training an aseptic surgeon. His personal neatness attracted public attention. His instruments were carefully cleaned before as well as after each operation, and every one as- sisting was required to be clean and to protect the wound and parts around it from every possible source of contamination. One of his pupils illustrated his habitual cleanliness as follows : Being present when another surgeon opened an abscess, Mott rolled up his coat sleeves, put his hands behind him during the operation, and, when the pus began to flow, proceeded to wash his hands as if he had been the operator. Mott's trainmg was well adapted to prepare him to take up the work which his preceptor was about to lay down. In addition to his pupilage under Post, he visited London and became an assistant of Mr. Astley Cooper. Cooper was the first to apply a ligature to the carotid artery for aneurism — 1805 — but un- ■ successfully. In 1808 he repeated the operation, successfully, and Mott was present as his assistant and always spoke enthusiastically of this opportunity to witness what was considered pioneer work in operative surgery. A few montlis later, Cooper attempted to ligate the left subclavian between the scaleni muscles, but failed. Mott took part in this operation also, and was deeply impressed with the difficulties of the procedure and Cooper's skill and candor. He says: " After working indefatigably with all his emment skill and superlative tact for an hour and a half, he abandoned the operation." Mott's pioneer work began with the ligature of the arteria innominata. This was not only his greatest achievement in operative surgery, but it was the most brilliant operation ever imdertaken by any surgeon in the history of operative surgery to that date. Nor has it ever been excelled in this department of sur- gery, if we give due weight to all of the circumstances attending the operation. It was by no means suddenly conceived and executed as an emergency opera- tion, but was the ripe fruit of years of study and preparation. He states that "since the publication of Allan Burn's invaluable work on the surgical anatomy of the he-ad and neck, I have laeen in the habit of showing, in mv surgical lect- INTRODUCTION. 43 ures, the practicability of securing, in a ligatui'e, the arteria innominata; and I have had no hesitation in remarking that it was my opinion that this artery might be taken up for some condition of aneurisms, and that a surgeon with a steady hand and a correct knowledge of the parts would be justified in doing it." The proper case presented itself March 1st, 1818, and he says : " I could not for a moment hesitate in recommending and performing the operation." Dr. Wright Post, whom he had so often aided, now became his adviser and assistant. Though the operation failed after giving the most encouraging prospect of ■success, Mott was not disheartened, but regarded its practicability and propriety as satisfactorily established by this case, and predicted that it would prove to be "the bearer of a message to surgery, containing new and important results." The arteria innominata was repeatedly ligatured subsequently, but it was re- served for an American surgeon to secure the first successful result. The oper- ator was Dr. A. W. Smyth, of New Orleans. The operation was performed in 1864. In this case the carotid was ligated at the same time, and on the fifty- fourth day the vertebral was also ligated. Scarcely less memorable than Mott's operation on the arteria innominata, and creditable as a great surgical achievement, was Dr. J. Kearney Rodgers' liga- tion of the left subclavian, within the scaleni muscles. The operation was per- formed on the 14th day of October, 1845. It is an interesting fact that Mott was one of the consultants and opposed the operation, though he admitted that it might possibly " be tied by a careful and well-informed surgeon," yet he " con- sidered that it was improper to do so." Colles, of Dublin, who was the first to ligate the right subclavian in its first part, condemned a similar operation on the left, stating that there was " such a combination of difficulties as must deter the most enterprising surgeon from undertaking this operation on the left side." Of the consultants, Drs. Mott and Stevens, though opposed to the operation, had such confidence in Dr. Rodgers's ability that they left the question of an op- eration to his discretion. In his report of the case Dr. Rodgers says: "Although a decided majority of the consultation agreed as to the propriety of the operation of securing the artery for aneurism, still, as my colleagues kindly left it with me to decide whether it should be midertaken, I felt it incumbent on me to investigate the subject with great care, and accordingly gave it my most sedulous attention. I was the more anxious because, in the only case in which the attempt had been made by Sir Astley Cooper, in 1809, that eminent surgeon failed in securing the vessel. ... I had always considered it as a perfectly justifiable operation, and one that a careful surgeon conversant with anatomy could accomplish if the tumor were of moderate size." Rodgers did not hesitate to a.ssume the responsibility which the action of his colleagues imposed upon him, and, true to his convictions of duty, proceeded to execute the trust committed to his care. The operation proved to be, in every 44 AMERICAN PRACTICE OF SURGERY. respect, as difficult as had been alleged, but he was fully prepared for every emergency. The ligature was successfully applied, and for several days every- thing promised success; but on the thirteenth day a hemorrhage occirrred, which was repeated, and the patient died on the fifteenth day. The lesson which Rodgers drew from the operation was that the vertebral artery and, if possible, the thyroid axis should be secured at the same time by ligature. In concluding his report he says that, though the operation was misuccessful in curing the aneurism, he trusts, "from the knowledge thence derived, we. shall be enabled to enlarge our sphere of usefulness, and be the means of preservmg human life." John Kearney Rodgers (1793-1851) was born in this city in 1793. He was the son of Dr. J. R. B. Rodgers, an eminent phj^sician of this city during the latter part of the last century. He was a graduate of Princeton College, New Jersey. He studied medicine under Prof. Wright Post, of the College of Physicians and Surgeons, and graduated in 1816. He then visited Europe and attended the lectm-es of Sir Astley Cooper, Brodie, Travers, and Abernethy. On his return he was appointed surgeon to the New York Hospital, on the resident staff of which he had served. He died of portal phlebitis, on the 9th of November, 1851, aged fifty-eight years. ilott was the first surgeon wdio ligated the primitive iliac for aneurism. The operation was performed on the 15th day of March, 1827, and was executed with his usual care and attention to all of the details. The size of the tumor and the adhesions of the peritoneum rendered the procedure very difficult, but the operator was rewarded with the recovery of his patient, who was living thirty years after. In the practice of other surgeons the operation has proved very fatal. During the first twenty-five years after Mott's operation, the common iliac was ligated eighteen times with fourteen deaths — a mortality of upward of seventy-seven per cent. The experience of Mott in the ligation of arteries was very great and his suc- cess far exceeded that of any contemporary surgeon. According to his own state- ment, he ligated the arteria innominata once, unsuccessfully; the common iliac once, successfully ; the subclavian artery m its third part six times, all the cases were successful; the common carotid thu'ty-two times, with but five failures; the external iliac six times, with two failures (one patient died of drunkenness) ; the femoral fifty- three times, the failures being unknown. He had but one case of mortific; ition of the extremity after ligature of an artery. This success Black- man attributed to Mott's great attention to the most minute details, both dur- ing the operation and duruig the subsequent treatment of his patients. In 1812, Gibson, of Philadelphia, placed a ligature on a bleeding vessel in a gunshot wound of the grom, and after the death of the patient it was foimd that the injured vessel was the common iliac. The operation had no scientific value, and should not be classified with operations deliberately planned and executed. The ligation of the external iliac was first performed in this cotmtry, as already INTRODUCTION. 45 noted, by John Syng Dorsey. This was a most creditable performance, and antedated Post's operation three years. Dorsey operated August 19th, 1811. The special feature of his case was the use of an aneurismal needle, consisting of a blunt bodkin of silver, properly bent, and held in a curved forceps, the handles of which were firmly tied together. The curved forceps used on this occasion to pass the aneurismal needle was the invention of Physick, and was also used by Post in his operations. It is interesting to notice that a thermometer was em- ployed to test the temperature of the limb, and it was foimd to become five de- grees colder than the other. Gratifying as was the success of American surgeons in their pioneer work in the ligature of arteries, and accurate as was the technique of the operation which they had devised, there was still a fatal defect which was to be remedied, viz., hemorrhage on the separation of the ligature. The practice of applying a silk ligature so tightly as to divide the inner coat of the artery, for the purpose of securing the union of the ruptured surfaces, was the rule with surgeons. The result was the gradual division of the artery by a process of ulceration due to the irritation of the imabsorbable ligature, and if union had not taken place, as too often happened, hemorrhage was the result. Physick, trained in the school of Hunter, suggested the remedy for this evil, viz., the use of "dissoluble" liga- tures, the pressure of the internal surfaces of the artery together without injur- ing its coats, and healing the wound by first intention. At his suggestion, and under his directions, a series of experiments were performed with animal mate- rial, and French kid, which was absorbed after several days without injury to the artery, was selected, as described by Dorsey. A very important contribution to the subject of animal ligatures was made in 1827 by Dr. Horatio Gates Jameson, of Baltimore, Md., in a prize essay, en- titled, " Observations upon Traumatic Hemorrhage, Illustrated by Experiments upon Living Animals." Horatio Gates Jameson (1778-1855) was born at York, Pa., in 1778, and gradu- ated in medicine from the University of Maryland in 1813. He located in Baltimore, Md., and attained a high rank as a surgeon. He was the founder of Washington Medical College and professor of surgery, 1827-35. He died August 24th, 1855. Jameson's conclusions were as follows : 1. If an artery is sufficiently healthy to admit of its obliteration by adhesion of its sides, it is best done by a ligature which will neither cut its coats nor strangulate, except in parts, the true vasa vasorinn, so that the continuity of the vessel shall not be destroyed, although we obliterate its calibre. 2. If an animal ligature of the proper kind be properly applied, the vessel will be obliterated, the wound may be healed by the first intention, and the liga- ture will not cause suppurative inflammation, but in due time, being dissoluble, the whole will be removed by the absorbents; there will be no breach of con- 46 a:\iericax practice of surgery, tinuity in .the artery. . . . The vessel, which durmg the state of inflammation and effusion of Ijmiph was converted into a cord, will pretty soon afterward be resolved into a flat string of white cellular structure. The experiments of Dorsej' and Jameson brought the operation of ligating arteries to scientific perfection by preventing secondary hemorrhage and secur- ing healing of the womid by first intention. An important feature of Jameson's experiments, to which he seems to have attached little importance, was the discovery that, as the animal ligatm'e under- went absorption, it became " completely enveloped in a strong membranous capsule. . . . This arrangement of the capsule seemed to have the effect of drawing the button-like knobs (ends of the ligature, in the state of yellow pulp) together, and was thus closing the vessel. . . . The capsule covering the knobs or ends of the string was fully equal in strength to the outer coat of the artery, and therefore there was no tendency to hemorrhage." In the demonstration of this encircling ring or capsule ^hich forms when animal ligature is employed for ligature, Jameson anticipated Lister, who describes it in his experiment as a^ ring of new tissue enveloping the dissolving animal ligatm'e. He regarded it as of great importance in the prevention of hemorrhage. It certainly strengthens the artery at the point of ligature, where the artery has been rendered very weak by the strangulation of nutrient vessels. It is in effect like the provisional callus which forms at the seat of fracture of a bone — a temporary means of pro- tecting a weak point in the vessel mitil repair takes place. Jameson not only demonstrated at that early period the true method of procedure to secure success in the ligature of arteries by experiments on ani- mals, but by a large series of operations in practice, as in ligating the carotid, the iliac, the femoral, the radial, and other arteries. But the real value of his teaching, though sustained by the authority of Physick, was not appreciated by contemporary surgeons. It was not until the introduction of antiseptics had awakened a new interest in measures for the prevention of suppuration of wounds that the practice of Jameson received the attention which it merited. Meantime his demonstrations had been forgotten, and the new method became popular as one of the features of antiseptic surgery. Essentially, however, the practice of to-day is along the lines laid down by Jameson. The employment of metallic ligatures, as silver wire, by Dr. Warren Stone, of New Orleans, and lead and other metals, has not proved as useful as animal material, owing to its liability to find its way out in time, with suppuration. Amputation of limbs, which had been the subject of contention dm'ing the latter half of the seventeenth and the whole of the eighteenth centuries, was at its culmination on the opening of the nineteenth century. The questions at issue were: (1) Shall the method be the circular or flap, with their many modi- fications? and (2) shall the healmg be by first intention or by granulation? In INTRODUCTION. 47 1816 there appeared in Baltimore "A Tract on Amputation," by Prof. John B. Davidge, of the University of Maryland, the object of which was to introduce the "American method" of amputation. The "tract" is a very complete trea- tise on amputation, being a careful and critical review of the methods of proced- ure since the time of Celsus. The author states that he had been investigating the opinions and works of the surgical writers of France and Britain for ten or fifteen years, anxious to bring amputation to some degree of perfection. The "American method" is as follows: Two lateral semi-elliptical flaps are made, one on either side of the limb, consisting only of the skin and cellular tissue. These are dissected from the muscles and of a size sufficient to cover, freely and easily, the whole stump when laid together; that is, each flap must be at least the semi- diameter of the limb and so full as not to be in any way upon the stretch when laid down. The flaps being thus dissected from the muscles and reflected back, a circular cut is to be made with a large knife perpendicularly down to the bone, and completely around it ; the muscles are now separated from the bone an inch or more farther up, and then, with the muscles well retracted, the saw is applied as closely as possible to the edge of the muscles, and the bone sawed off. The vessels being all well secured, the flaps are well coaptated and adjusted to the face of the stump, and maintained in position by adhesive straps, the ligatures being brought out of the lower angle of the wound. The advantages claimed for this method are: 1. Complete drainage, thus preventing suppuration from retained fluids, as occurs when the wound is trans- verse. 2. The freshly cut surfaces are accurately applied to each other, which favors union by first intention, and no foreign body, except the ligatures, will " provoke inflammation or disquiet the economy of the parts." 3. The stump is more serviceable for future use than those left after other methods. "The American method" was approved by many surgeons and was fre- quently performed with marked success, but it did not receive the attention which its merits deserved. Several years since, the writer made a careful study of the results of the different methods of amputation in our hospitals, and, com- ing to the same conclusion as Professor Davidge, drew similar figures of the line of incisions and the resulting stump, though unaware of the existence of this "Tract on Amputation." John Beale Davidge (1768-1829) was born at Annapolis, Md., 1768. He attended medical lectures at Philadelphia and Edinburgh, but received his degree at Glasgow, 1793. He located at Baltimore, 1796. In 1807 he founded the Medical Department of the University of Maryland, and was the professor of anatomy and surgery, 1807- 29. He took a prominent position as a surgeon, had a "pleasing address, very remarkable colloquial powers, and high professional character." He died in 1829. The reduction of dislocations was a subject of great interest to British sur- geons. According to Mr. Pott, the leading authority in British surgery during 48 AAIERIC-1^' PRACTICE OF SURGERY. the latter half of the eighteenth century, dislocations were reduced by force. Of the machines for that purpose, he saj^: "Many or most of them are much more calculated to pull a man's joints asunder than to set them to rights." With true scientific intuition he declares that " replacing a dislocation would require very httle trouble or force, were it not for the resistance of the muscles and tendons attached to and connected with them." Little if any useful progress was made in the direction pointed out by Pott, to determine the principles governing the reduction of dislocations, imtil the attention of American surgeons was directed to the subject. Now, the most formidable of these dislocations, those of the femur at the hip-joint, are reduced in American practice without violence or pain, by simple manipulation of the limb with the hands. The several steps in the process of investigation, by which the principles governing the natural and ra- tional method of reducing all dislocations was discovered, illustrate the scientific spirit of American practitioners as well as teachers of surgery: — Occasional reductions of dislocations at the hip-joint during manipulations of the limb, even after protracted efforts had been made at reduction with power- ful machines, have been recorded from the time of Hippocrates. But they were regarded as accidents, having no scientific value. Physick reduced a dislocation of the femur by manipulation in 1S12. after the pulleys had failed. He believed that the cause of previotis failm'e was due to the escape of the head of the bone through a rent in the capsule, and that the head had become fixed as in a button- hole, from which he dislodged it. In lS-31 Dr. Nathan R. Smith, of Baltimore, Md., pubUshed "Eemarls on Dislocations of Uie Hip-joint," and states that the principles which he endeavors to establish, relative to reduction, were derived in part from the lectures of his father, Dr. Nathan Smith, professor of surgery in Yale College. It appeal's from the record that as earh- as ISll his father explained a method of reducing the dislocations of the femur at the hii>joint by manipulations of the limb with the hands, without the aid of mechanical appliances. His method of procedure was based on a careful study of the action of the muscles attached to the upper ex- tremity of the femur. The author thus states his conclusions : " There is, no doubt, a constant mechanical principle upon which the i-eduction is effected ia such cases, and one which would perhaps succeed in nearly aU cases if we knew how to employ it tindei^tandingly and with precision, and did not avail our- selves of it by mere haphazard. If a gentle movement of a pecuhar kind succeed in one case of complete dislocation on the dorsum ilii after all other means have failed, ought not this movement, if well understood, to succeed in other cases better than the usual mode? The mechanism of these dislocations is certainly the same in all of this variety, . . . furnishing the same impediments and the same aids in every case. This frequent failure of art and the success of accident satisfy me that there is some important principle relative to the mechanism of these dislocations which is not understood. Accident ought not to accompUsh INTRODUCTION. 49 the reduction of a bone with more ease than art. When it does so, such accident should be our instructor, and teach us the mechanism by which it operated, and this we should repeat in similar cases." The author then proceeds to discuss the mode of applying force in the reduc- tion of dislocations of the hip, and, in illustration of the adaptation of manipula- tion to meet the varying action of the muscles affected by the dislocation as com- pared with the pulleys, he mentions the case of reduction by Physick and adds a case narrated by his father, "in which he promptly succeeded by the mere force of hands in effecting reduction." The description of the muscles concerned in reduction is given in detail and the method of manipulating the limb is illus- trated with engravings. "The free flexion of the thigh upon the pelvis" was re- garded "as a very important part of the compound -movement." For twenty years no further attention seems to have been given to the subject, and it is doubtful whether the views of Nathan Smith had become known to the profes- sion at large. In 1851 Dr. William W. Reid, of Rochester, N. Y., published a paper on "Dislocation of the Femur on the Dorsum Ilii. Reduction without Pulleys or Any Other Mechanical Power." He states that he had been present at several operations for the reduction of dislocations at the hip-joint by means of pulleys, and was impressed with the apparently unnecessary force employed. For ten years he studied the mechanism of these dislocations, and came to the conclu- sion that " the difficulty lay in the extension of the . . . adductors and rotators, and that all traction ... on the dislocated bone only increased this tension, and could do nothing toward bringing it into place, except at the hazard of al- most certain rupture of some of these muscles or of fracture of the neck." Guided by this conclusion and the experience gained by his experiments, Reid practised manipulations and evolutions on the skeleton imtil he had deter- mined that " dislocation of the femur on the dorsum ilii ... is reduced with the greatest ease in a few seconds or minutes, without much pain, without an assist- ant, without pulleys ... or any other mechanical means, simply by flexing the leg on the thigh, carrying the thigh over the sound one upward over the pel- vis, as high as the umbilicus, and then by abducting and rotating it." Reid gave wide publicity to his paper and discussed his method before medical societies. Surgeons in hospital practice who tested its merits found that it was a vast improvement upon the pulley and other appliances. In 1853 Dr. Moses Gunn, professor of surgery in Rush Medical College, Chi- cago, who had taught Reid's method, published an account of experiments made in 1851-52 to determine the obstacles to reduction of hip-joint dislocations. His conclusion was that the " untorn portion of the capsular ligament, by bind- ing down the head of the dislocated bone, prevents its ready return over the edge of the cavity to its place in the socket." He rejected the opinion of Reid that the opposing forces are the muscles. The untorn portion of the capsular 50 a:\iericax practice of surgery. ligament to which he refers is " the anterior and inferior half of the capsule " (which includes the ilio-femoral or Y-ligament of Bigelow), and this, he states, is " the sole agent which gives character to those dislocations, and, with the excep- tion of the fascia lata, the only obstacle to he overcome by our efforts to reduce them." In 1861 Dr. Henry J. Bigelow, professor of surgery m the Harvard Medical College, who also had taught Reid's method, was led to expose a jomt, the luxa- tion of which had been the subject of a lecture, and was surprised to observe the simple action of the ligament (the anterior and inferior half of the capsule, al- luded to by Gunn). The dislocated joint was in the following condition: 1. Great laceration of the muscles about the joint. 2. The ligamentum teres broken. 3. Laceration of the inner, outer, and lower parts of the capsule. 4. The anterior and upper parts of the capsule uninjm'ed, and presenting a strong fibrous band, fan-shaped, and slightly forked. On dividing the remaining tendinous and muscular fibres about the joint, excepting this fibrous band, it was found that the four commonly described dislocations of the hip could still be exliibited without difficulty, and that in each of them the anterior portion of the capsular ligament, which alone remained, sufficed at once to direct the limb to its appropriate position and to fix it there. On the other hand, if the entire capsule of the hip-joint be divided and the muscles left intact, these dislocations are but imperfectly represented. The conclusion of Professor Bigelow, as a result of his investigations, was that the muscles play but a subordinate and occasional part, either in hindering re- duction or in determining the character of the deformity, but that these condi- tions are chiefly due to the resistance of the ligament. The practical result of this conclusion is thus stated by Bigelow: "The theory here advanced recog- nizes the anterior portion of the capsular ligament as the exponent of the total agency of the capsule in giving position to the dislocated limb, and, what is more important, is so identified with the phenomena of luxation that reduction must be accomplished almost wholly with reference to it." This discovery led Bigelow to review the whole subject of dislocations at the hip-joint and determine the peculiarities of each and the special methods of re- duction applicable to the different forms. The course of study which he pursued in demonstrating the Y-ligament and its relations to the position of the head of the femur in the several dislocations, and the exact direction in which the forces emplo}-ed in reduction should be applied, forms one of the brightest chapters in scientific surgery. Thus, after a generation of investigation by American surgeons, the "con- stant mechanical principle upon which the reduction is effected" in hip-joint dislocations, suggested bj' Nathan R. Smith, was discovered, and the method of Reid, by which a dislocation on the dorsum ilii " is reduced with the greatest ease in a few seconds or minutes, without much pain, without an assistant, without INTRODUCTION. 51 pulleys," was made applicable to all dislocations at the hip-joint. Though Bige- low gives the paternity of the new method, which is concisely expressed in the words "flex, abduct, evert," to Nathan Smith, the world is indebted to Reid for the practice of reducing dislocations on the dorsum ilii by manipulation, and to Bigelow for an extension of that method to all other forms of dislocations at the hip-joint. The treatment of fractures was vigorously discussed by foreign surgeons at the beginning of the last century. Samuel Cooper, author of the " Surgical Dic- tionary," and historian of British surgery, referring to the comparison of French and English surgery by Roux, 1814, states that, with the exception of the teach- higs of Pott, " it cannot be said that we had made a single improvement of con- sequence in the treatment of any particular fracture." We shall illustrate our subject by noticing the improvements made by Ameri- can surgeons in regard to a single fracture, viz., that of the femur. Fractures of this bone were the theme of constant discussion by French and British surgeons at the close of the eighteenth and the beginning of the nineteenth centuries. The controversy had become somewhat of a national issue. Pott, on the part of the British surgeons, advised that the limb, flexed at the hip and knee, be laid on its side, supported only by lateral splints loosely applied, the body being in- clined to that side. His contention was that, by thus relaxing the muscles, the fragments fall into position and require no other support than side splints. De- sault, on the part of the French, placed the limb in an extended position and applied an external splint from the crest of the ilium to a point below the foot and attempted extension and counter-extension as the governing principle in the treatment of these fractures. Though both of these methods had merits, in practice they proved defective. The relaxation of the muscles effected by Pott's method was very desirable, but it was impossible to maintain the limb quiet in that position without more restraint from appliances than the two splints supplied. The extension and counter-extension by means of a long side splint in Desault's method was very im- portant, but the plan of securing it was inefficient; the extending and counter- extending bands, acting obliquely, tended to draw the upper fragment and the foot outward, while that at the foot caused painful excoriations at the ankle. The two principles on which these methods of practice were based were not, therefore, effectively applied by the means devised by their respective advocates. American surgeons took an active interest in the treatment of fractures of the femur, and at an early period began to make improvements upon the French and British methods of practice. Physick, if we accept Dorsey as authority, preferred Desault's straight position, for the reason that "the muscles very speedily accommodate themselves to the new position caused by the action of the extending and counter-extending bands at the extremities of the splint." 52 A^AIERICAN PRACTICE OF SURGERY. As the external or long splint extended onlj' from the crest of the ilium to a point bej'ond the sole of the foot, the upper band around the thigh, acting obliquely to the shaft of the femur, tended to cbaw the upper fragment outward and thus prevent coaptation of the fractured surfaces; while the lower band, acting in a similar manner, turned the foot outward and displaced the lower fragment. To remedy this defect Phj'sick extended the splint upward to the axilla and placed a crutch-like form on the end to prevent rubbing against the patient's side. The perineal extending band, fastened to the upper end of the splint, now made trac- tion nearl}' in line with the shaft of the femur, and no irritation of the hip oc- curred. This improvement was made about 1800. To remed}' the defective action of the band at the foot, he added a transverse foot-piece, over the end of which the extending band was passed, which made traction in line with the shaft of the femur. These improvements greatly in- creased the efficiency of the splint and added to the popularity of the treatment in the straight position. Dorsey says : " I have for twelve or fourteen years vnt- nessed the effect of this mode of treatment in the Pennsylvania Hospital, where more accidents are admitted than in any other uistitution in America, and I am safe in asserting that the success of the practice has been sm'passed by that of no other hospital in the world." He admits that some surgeons have become dissatisfied with this mode of treatment, owing to the excoriations caused by the bands especially on the foot. It was in this particular feature of extension and comiter-extension that American surgeons perfected the method of treatment of fractures of the femur in the straight position. In 1S61 Dr. Gurdon Buck, of Xew York, published an ^j,^ account of the method of treating fractures of the thigh in the New York Hospital, with illus- trations. This was the most important contri- bution that had to this time been made, as it remedied the great defects of the methods hith- erto employed to effect extension. " Buck's ex- tension" is too well known to the students of surgery to requii'e explanation. It is sufficient to state that its publication was the culmination of a century of persistent effort on the part of the most reputable surgeons of this country and ' ^^ -~ Europe. Fig. 21. — Gurdon Buck (1S07-1S77). Gurdon Buck (1807-77) was born in New York City, yiay 4tli, 1S07. He graduated in medicine from the College of Physicians and Surgeons, New York, in 1S30, and entered the Xew York Hospital as a member of the resident staff, serving by preference on the medical division. In 1833 he went abroad and spent two years in the hospitals of Paris, Berlin, and A'ienna. On his return he located in Xew York, and in 1837 was appointed one of the visiting sur- INTRODUCTION. 53 geons of the New York Hospital, a position which he held until his death, a period of forty years. During his connection •with this hospital it received most of the surgi- cal cases of the city, and its surgical staff was constituted of the most eminent surgeons of New York. He was appointed surgeon of St. Luke's Hospital on its organization, and subsequently occupied the same position in the Presbyterian Hos- pital. Dr. Buck was a most painstaking and successful practitioner and made im- provements in many branches of surgery, as in the operation for bony ankylosis at the knee-joint, in the treatment of oedema glottidis, and in lithotomy and lithotrity. He was also greatly interested in plastic surgery, and published, in 1876, a mono- graph entitled "Conintwiions to Reparative Surgery." But the apparatus which he devised for the application of traction in the treatment of fractures of the femm: will long be regarded as his most useful contribution to the practice of surgery. He died March 6th, 1877. Lithotomy was an operation of the first importance during the eighteenth century, and tlie various methods of procedure were subjects of endless discus- sion. American surgeons who were educated abroad returned to practise in this country, ambitious to gain reputation as successful lithotomists. Many became good operators and some attained an eminence equal to that of the most reputable lithotomists abroad. Dr. John Jones, of New York, had a wide reputation as a successful lithotomist as early as 1760. Physick, of Philadelphia, was not only a successful operator, but he improved the gorget. Jameson, of Baltimore, was a skilful operator and advocated healing the wound by first intention by placing the patient on his side, with a catheter retained in the bladder. Dr. Benjamin W. Dudley, of Kentucky, became famous for the large number of operations which he performed, amounting to two hundred and twenty-five, and for his great success, having one hundred consecutive cases without a death. But in the matter of numbers. Dr. John P. Mettauer, of Virginia, excelled him, having a record of four hundred cases. In 1824-25, according to Jameson, of Baltimore, some of the most distin- guished surgeons of America performed Civiale's operation of " lithontrity " as a substitute for lithotomy, " in all which attempts there were complete failures." The operation was, however, subsequently advocated by Randolph, Gibson, Nathan R. Smith, and others, under the title "lithotripsy," but it did not sup- plant the older operation of lithotomy. In the progress of American practice both lithotomy and lithotripsy were destined to be supplanted. Bigelow, impressed with the great distensibility of the urethra as shown by Otis's experiments, began to use much larger evacuating tubes in the operation of lithotrity, with the result of being able to remove much larger fragments of the stone than formerly, and of thus reducing both the num- ber of operations and the length of time of each trial. The new operation was gradually perfected under the title of " litholapaxy " (evacuation), and it has largely superseded all other methods of removing calculi from the urinary bladder. 54 AMERICAN PRACTICE OF SURGERY. "Hip-joint disease" was a fatal or a crippling affection of childhood which surgeons regarded as helpless and hopeless by any method of treatment known prior to the year 1800. But American surgeons have stricken hip-joint affections from the category of incurable diseases and placed it among the more simple and curable forms of sickness peculiar to childhood. The method of treatment was determined after careful study of the pathological conditions of the hip-joint by three surgeons at different periods. The history of their work admirably illus- trates the process of evolution of practice based on scientific principles. . Dr. Physick returned from Europe a student of scientific surgery as taught by his preceptor, Hunter. One of these principles was that rest is the first and essential factor in the correct treatment of inflammation. He applied that prin- ciple to the treatment of hip-joint disease, about the year 1800, in the following manner: He employed "a splint properly carved so as to be adapted to the irregular size, shape, and position of the diseased hip-joint, thigh, and leg. It must also be carved so as to fit the principal part of the same side of the trimk. The whole must be long enough to extend nearly half way round the parts to which it is applied. In those cases in which the thigh is bent upon the pelvis and the leg upon the thigh at the knee joint, the surgeon must by no means attempt to force the limb into a straight splint. . . . The splint must be made angular at those parts so as to adapt itself to the exact position of the limb, however crooked it may be. After the patient has worn a splint of this shape for some time, the inflammation and swelling become so much relieved that the limb can be placed in a much straighter position; and now it becomes necessary to have a second splint constructed, which will adapt itself to the altered condition of the parts." Randolph, Physick's son-in-law, makes the following statement of the results of the new method of treatment which imperfectl}^ secured rest to the inflamed joint: "The success which Professor Physick has met with from his mode of treating hip-joint disease has been so highly encouraging as to induce him to be- lieve that he can effect a cure in all recent cases, and many even of long standing, provided the joint be not disorganized." The next step of progress was the cure of the " disorganized" cases. In 1853 Dr. Alden March, of Albanj-, N. Y., published the results of a series of studies in the pathological museums of this country and Europe, for the purpose of deter- mining the condition of the hip joint in advanced disease. His conclusion was that the pressure of the two inflamed joint surfaces led to destructive ulceration of the cartilages, and his practical inference was that if traction of the limb were added to fixation of the jomt, sufficient to relieve the pressure of the head upon the surface of the acetabulum, not only would ulceration be prevented, but cases where ulceration already existed might be cured. To meet this indication he applied the long splint, as in fracture of the thigh, with extension and counter- extension. The result was immediate relief to the pain and final recovery of INTRODUCTION. 55 the more intractable cases. Greatly as this method improved the treatment of Physick and enlarged the number of curable cases, there was still a class of feeble patients who could not bear the long confinement and large suppuration that followed the necrosis of the head of the femur, and eventually succumbed to exhaustion. The final question in the problem of treating hip-joint disease was, therefore, How can fixation of the ■ oint and traction of the leg be effected while the patient is allowed to walk? The clew to the answer was given by Dr. Henry G. Davis, a surgeon of great inventive skill, of Worcester, Mass., in 1860. He devised a splint which imperfectly effected the object, but which suggested to those en- gaged in that special field of work the proper apparatus. Davis's splint espe- cially impressed Dr. Lewis A. Sayre, of New York, who was devoting much at- tention to this disease, and who states that he had long recognized the impor- tance of an appliance that would secure fixation, traction, and ability to walk, and endeavored to construct such an apparatus, but did not succeed. On ex- amining Davis's splint, Sayre readily discovered not only the essential features of a rightly constructed hip splint, but he detected the real cause of the failure of the inventor to meet conditions necessary to success. He immediately under- took to construct a splint which would meet the indications now so apparent to him, and the result was a splint which has since been known by his name and which is the perfection of surgical art. As a teacher and author, Sayre so clearly and persistently demonstrated and illustrated the scientific treatment of hip- joint disease that he compelled the profession to adopt the new method. The result of this half-century of stvidies relating to hip-joint disease is in the highest degree creditable to American surgeons. The class of children that at the beginning of this period died after years of intense suffering, confined to their beds, are to-day met on the streets, at school, and on the playgrounds, in the enjoyment of healthy activity. A death from hip-joint disease is unknown in mortuary statistics. Orthopedic surgery, as a specialty, had its origin in this country in the clin- ical lectures of Dr. William Detmold (1808-1900), of New York. He was a native of Hanover, Germany, a graduate of the University of Goettingen, and a pupil of the famous orthopedist, Stromeyer. He located in New York City in 1837, and devoted himself to the practice of orthopedic surgery. For the purpose of giving instruction in this specialty he established a public clinic, and gave courses of lectures which were largely attended by medical students and practitioners. He was a skilful operator and introduced Stromeyer's method of tenotomy, which he practised with the greatest freedom. Though Detmold discontinued his clinics prior to 1860 and rarely published papers, it was through the influence of his teaching that the first impulse was given to an interest in orthopedia, which resulted finally in raising it to the position of a distinct branch of surgical practice. 56 MCERICAX PRACTICE OF SURGERi'. 1 /% -yvaHam Detmold (ISOS- 1900). Detmold as a teacher of orthopedia was succeeded by Dr. Lewis A. Sayre, then an enthusiastic young surgeon who was devoting himself to the treatment of cases of deformity. As one of the founders of the Bellevue Hospital Medical _,_^ College, 1861, he urged the establishment of a "°°' ' it. professorship of orthopedia, and on its creation he was appointed to the position, the first in this covmtrj'. Saj're's annual course of lectures gave a powerful impulse to the study and practice of orthopedic surger}^ throughout the entire country. His attractive personality, his resist- less enthusiasm, his vast resources for clinical illustrations afforded by Bellevue Hospital, and his bold and often brilliant operations, inspired students and practitioners, gathered from all parts of the United States, with a genuine de- termination to practise orthopedia. The in- fluence of Sayre's teaching was greatly increased bj' the publication of his lectures in 1876, which formed a complete treatise on orthopedic practice. Though many surgeons occasionally performed operations for deformities, and frequently papers were published narrating individual cases and methods of treatment by apparatus, it was not until the Bellevue school had created a professorship of orthopedia, and Sa}Te had given to that profes- sorship the character and importance of a special branch of surgical education, that orthopedia as- sumed the position of a specialty in sm'gical practice in this coimtry. Lewis Albert SajTe (1S29-1900) was a native of New Jersey and a graduate of Transylvania University, Kentucky. He studied medicine in New York City and graduated from the College of Physicians and Surgeons in 1842. In the same year he was appointed prosector to the chair of surgery in that institution, a position which he held until 1852. In 1853 he was appointed one of the visiting surgeons of Bellevue Hospital. In 1861 he was one of the founders of Bellevue Hospital Medical College, and at his suggestion the professor- ship of orthopecha was established, which was subsequently assigned to him. He re- tained this position until 1897, when ill health compelled him to retire. He died in 1900. GyncECology as a special branch of operative surgery had its origin in the ex- perimental work of Dr. J. Marion Sims. " Silver as a suture is the great surgical achievement of the nineteenth century," was the declaration of this pioneer Fig. 23. — Lewis Albert Saj-re (1S29-1900). INTRODUCTION. 57 surgeon in his anniversary discourse before tlie New York Academy of Medicine in 1S57. In this discourse Sims describes at length and eloquently two of the most important events in the history of the American practice of surgery, viz., the introduction of silver wire as a suture, and the method of curing vesico- vaginal fistula. The two discoveries were the result of a single course of experi- mental studies, "conducted," as the author states, "on the principles of a ra- tional inductive philosophy." The original purpose and object of Sims was the cure of vesico-vaginal fistula. After repeated failures and a careful study of everything connected with the operation that might contribute to his want of success, he was finally, after four years of patient effort, led to the conclusion that the silk suture was the cause of failure. Instead of abandoning his enterprise, he turned his attention to the solution of another problem, apparently more difficult than the one on which he had expended so much time and study. The question now to be settled was, AVhat material can be used for suture that will not, like silk, act as a seton? He had read the experiments of Levert, of Mobile, Ala., made in 1829, at the suggestion of Physick, which proved that wire or lead caused no irritation, and also the statement of Mettauer, of Virginia, that he had used lead wire in operations with success. Sims had, in fact, used lead wire in his experiments, but without success, and therefore he turned to silver as offering more advantages than other metals. He operated with silver wire on the 21st of June, 1849, upward of three years after his first experimental operation, and with entire success. The value of that operation in the relief of human suffering, by the powerful impulse which it gave to operative surgery, can never be estimated. Sims first published the details of the operation in 1852. It established the specialty of "gynaecology," of which Sims is the founder, but in the comprehen- ( sive scope of his work he was a general surgeon. J. Marion Sims (1813-83) was born in South Carolina, January 25th, 1813. He graduated in medicine at Jefferson Medical College in 1835, and located in Montgomery, Ala. In 1853 he removed to New York, where he was successful in establish- ing the Woman's Hospital, in which he practised gyna'cology, clinically, rendering popular his opera- tion for the cure of vesico-vaginal fistula. He re- peatedly visited the European capitals, where he per- yig. 24, j. Marion Sims formed his special operations, and received honors (1813-1SS3). and decorations from the French, Italian, Spanish, and Belgian Governments. He invented many instruments adapted to the opera- tions which he was accustomed to perform. He was in Paris at the breaking out of the Franco-Prussian War, and was made surgeon-in-chief of what was called the 58 AMERICAN PRACTICE OF SURGERY. "Anglo- American Ambulance Corps," composed of eight Americans and eight Eng- lishmen. This organization was at the battle of Sedan and was assigned to duty in connection with a large hospital where upward of twenty-six hundred wounded were treated. Dr. Sims continued his connection with the Woman's Hospital from its or- ganization in 1855 to his death in 1883. The series of studies which have terminated in the scientific treatment of diseases of the appendix vermiformis enters largely into the American practice of surgery. The initial step in these studies was taken in 1856, on the publica- tion of a paper by Dr. George Lewis, entitled, " A Statistical Contribution to Our Knowledge of Abscess and Other Diseases Consequent upon Lodgment of For- eign Bodies in the Vermiform Appendix, with a Table of Forty Cases." Lewis was a young physician of New York who had recently had a fatal case of ap- pendicitis, and at my suggestion made the collection of cases which formed the basis of his paper. Professor Kelly, of Baltimore, in his great work on " Appen- dicitis," speaks of Lewis's paper as "by far the most complete investigation of the diseases of the appendix up to the date of its publication." In this paper Lewis brought prominently to the attention of American sur- geons the operation of Hancock, of London, who in 1848 deliberately opened an abscess formed in the region of the appendix and as a result of its diseased condi- tion, and cured his patient. Lewis's paper excited great interest among surgeons, and led Dr. Willard Parker, of New York, to repeat the operation of Hancock. In 1867 Parker published the histories of four cases on which he had operated, and in all but one he had not operated until fluctuation was distinct. In his early cases he feared to operate, as he was uncertain of the diagnosis, but in one case he ventured to operate in the early stage of the disease, and saved his patient. He did not, however, advocate an early operation, but advised a delay of five days, as a rule, in order that it might be determined whether suppuration had occurred, believing, as I often heard him remark, that an operation was required only when it was certain that pus had formed. Pro- fessor Kelly states of Parker's work: "From the date of his teaching opera- tive treatment of appendicitis began an evolution which ended in the revolution of surgery." But Parker's operation only sought the evacuation of pus, as in opening an ordinary abscess, the offending gangrenous appendix being left in the wound. The next step was the removal of the appendix, which was done in this country in May, 1886, at Roosevelt Hospital, New York, by Dr. R. J. Hall. This opera- tion was only an incident in the case . The next step in advance was to be the excision of the appendix as a necessary part of the operation. Parker's opera- tion was performed from time to time, and in 1875 Gouley tabulated twenty- five cases. There was a reduction of mortality from forty-seven per cent in 1867 to fifteen per cent in 1882. The removal of the appendix as a necessary part of the operation was not, however, undertaken until 1887, when Dr. Thomas G. INTRODUCTION. 59 Morton, of Philadelphia, deliberatelj' planned and executed its removal, thus perfecting Parker's operation. Many questions still remained unsettled, especially as to the diagnosis, the ■cases requiring operation, the exact time of operating, and the method of pro- cedure. These questions were finally A'ery definitely settled by two remarkably able scientific papers. The author of the first was Dr. R. J. Fitz, of Boston, whose article, "On Perforative Inflammation of the Vermiform Appendix," ap- peared in 1886 ; and so thoroughly were these doubtful questions discussed and determined that the paper has been pronounced an "epoch-making memoir." Professor Kelly says that Fitz "has done more than any single individual to bring about a right understanding of the morbid conditions affecting the vermi- form appendix." Again he refers to Fitz's work as follows: "The time was ripe, the man appeared, and surgeons, needing but the assurance of safety, gratefully accepted this transfer from the domain of internal medicine, and began with alacrity to develop the operative procedure." The paper of McBurney, published in 1889, was a critical review of all ques- tions relating to the operation, and its conclusions determined the details of procedure with so much precision that there have been only minor changes in the methods which he prescribed. Thus, commencing with the investigations of Lewis and the tentative operations of Parker, and terminating with the scientific inductions of Fitz and McBurney, in their classical papers, have American sur- geons established the proper treatment of inflammatory affections of the appen- dix vermiformis. It has not been our purpose to notice the achievements of individual sur- geons except as they have resulted in important reforms in practice. But there have been instances where surgeons have performed acts or adopted methods to meet conditions hitherto unknown to them, which illustrate American ingenuity and enterprise. Several of these examples deserve notice. Amputation at the shoulder joint was introduced into practice during the eighteenth century by French surgeons. The first operation in this country was performed by Dr. John Warren, of Boston, as early as 1781. Dr. Warren had had a large experience in operative surgery during the Revolutionary War. The operation was performed in the Military Hospital at Boston, where Dr. Warren was giving lectures to physicians and students. The details of the opera- tion were not published, but it was successful. In 1792 Dr. Nathan Smith trephined hone for the cure of an abscess. The patient was aged nine years; there was a collection of matter in the thigh, ex- tending from above the knee nearly to the trochanter. An incision was made from near the knee joint upward eight inches; a large discharge of pus took place, and the bone was found denuded of its periosteum two-thirds of its length. He determined to wait and see if granulations would appear on the denuded 60 AMERICAN PRACTICE OF SURGERY. bone; but as they did not, and the bone became of a dark color, he decided to remove a portion in such manner as to go through the dead part, let that be more or less. He used a trephine — ''the round saw employed in operating on the skull" — nearly in the centre of the denuded part, and removed a piece of bone down to the medullary substance. Purulent matter issued in pulsations from between the bone and the medullary substance. In a few days " the bone, which was a pearly white, a little verging to brown, where exposed to the exter- nal air, changed its appearance, assuming a carmine color, and finally recov- ered, with no other loss of substance than a thin scale." Previous to the year 1806, amputation at the hip joint had been performed but once by British surgeons, and in that case the operation resulted fatally. In that year Dr. Walter Brashear, of Kentucky, performed this amputation successfully. The operation consisted of two procedures: First, the surgeon amputated at the middle third of the thigh in the usual way and ligated the vessels; second, he made an incision on the outside of the limb from the point of previous operation to the hip joint. Then he detached the soft parts from the bone and disar- ticula,ted it. The patient made a good recovery. Walter Brashear (1776-1S09) was a native of the State of Marj-land. He received his education at the Transylvania University, Kentucky. He attended a course of lectures at the University of Pennsylvania and then travelled extensively; on his return he engaged in merchandise for twelve j^ears, when he resumed practice at Bardstown, where he perfonned the amputation. He removed soon after to Lexington, Ky., and after a few years of successful practice he retired to the State of Louisiana. He was not a graduate in medicine. Fig. 25.— Walter Brashear (1776- He died in 1809. 1809). The first applications of a ligature to the common carotid were for the arrest of hemorrhage in open wounds. In the performance of this operation American surgeons were anticipated eighteen days by British surgeons. On the 4th of November, 1803, Dr. JIason Fitch Cogswell, of Hartford, Conn., attempted to remove a tumor which developed in the parotid gland and parts adjacent; in the progress of the dissection the tumor had to be separated from the carotid artery, which it surrounded. The effort failed, and the operator placed a ligature around the artery, which he then severed. The case progressed favorably, the ligature separating on the fourteenth da}^, but on the twentieth day one of the anastomosing arteries under the forepart of the jaw began to bleed, and, no effort being made to check it for a considerable period, the loss of blood was so great that the patient sank and died. The operation of Dr. Cogswell was entirely original with him, as was the INTRODUCTION. 61 second case, by Dr. Amos Twitchell, of Keene, N. H., original with that surgeon. This case was one of sloughing of the internal carotid following a gunshot wound ; the patient made a good recovery. This operation was performed on the eigh- teenth day of October, 1807. The first case of ovariotomy, by Dr. Ephraim McDowell, of Kentucky (1771- 1830), was deliberately planned and executed by a surgeon who had never "seen so large a substance extracted, nor heard of an attempt or success attending any operation, as this required." The woman rode sixty miles on horseback to the place of operation. The operation was performed in Decem- ber, 1809, by an "incision about three inches from the musculus rectus abdominis, on the left side, continuing the same nine inches in length, parallel with the fibres of the above-named muscle, extending into the cavity of the abdomen, the parietes of which were a good deal contused, which we ascribed to the resting of the tumor on the horn of the saddle during her journey. The tumor then appeared full in view, but was so large that we could not take it away entire. We put a strong ligature around the Fallopian tube near the uterus; we then cut open the tumor, which was the ovarium and fimbrious part of the Fallopian tube, very much enlarged. We took out fifteen pounds of a dirty, gelatinous-looking substance, after which we cut through the Fallopian tube and extracted the sac, which weighed seven and a half pounds." The wound was closed with interrupted sutures and adhesive strips between them, and the ligature on the Fallopian tube was brought out of the lower angle of the wound. The report adds: "In five days I visited her, and, moch to my astonishment, fomid her engaged in making up her bed." The patient returned home in twenty-five clays in good health. It is reported that the operation created such public opposition that a mob collected around the house in which it was performed, prepared to attack the surgeon if he failed. An account of the operation was published several years after in an obscure journal, and was so imperfectly reported as to be discredited; hence it has had no other importance than an historical incident. Twelve years later, in 1821, Dr. Nathan Smith, of New Haven, Conn., per- formed the operation of ovariotomy, having no knowledge of any previous sim- ilar operation. He was led to make the operation from his observations in dis- secting the body of a patient who had died of ovarian dropsy after being tapped seven times. The sac was found to be the right ovarium, which filled the whoJo abdomen, but it adhered to no part except the proper ligament, which waf no Fig. 26. — Ephraim McDowell (1771-1830). 62 AMERICAN PRACTICE OF SURGERY. larger than the finger of a man. He had seen two other autopsies of women who suffered from ovarian disease, and noticed that the sacs were unattached, except to their own proper hgaments. He inferred that while the tumor remained movable it might be removed with a prospect of success. His operation was as precise in all its details as the most modern method. The external incision be- gan about an inch below the umbilicus, directly in the linea alba, and extended downward three inches; the sac was evacuated with trocar and cannula and then drawn out, bringing with it a considerable portion of omentum, which was sepa- rated and the bleeding vessels tied with leather ligatures. When the ovarian ligament was brought out it was cut off, two small arteries were tied with leather ligatures, and the stump was returned; some adhesions of the sac were separated and the mass was removed. The incision was closed with adhesive plaster and a bandage applied over the abdomen. No unfavorable symptoms occurred, and in three weeks the patient was able to walk about. Smith's well-devised and executed operation hadno proper publicity, and hence it had no effect in introducing a new procedure into practice, but, like McDowell's operation, simply illustrates the great abilities of the individual surgeon. Surgery of the abdominal cavitj^ began to attract attention toward the close of this period, but the few operations that were practised were incidental and accidental rather than deliberative. There had been some preparatory- work done, as in the experiments on the treatment of wounds of the intestines. As early as 1805 Dr. Thomas Smith published a thesis presented to the faculty of the Medical Department of the University of Pennsylvania, entitled, "On Worinds of the Intestines." The thesis was based on the results of twelve ex- periments on dogs, undertaken to prove the value of the different methods of treatment of womids of the intestines. He made transverse and longitudinal v>-ounds, divided the tube, exsected portions, and cut away triangular sections. Pie used the mterrupted and the continuous suture. The vivisections were very carefully made and the results accuratelj^ stated. This paper was highly cred- itable as an effort to determine, at that early day, by scientific inquiries, the proper method of treating wounds of the intestines. He used the silk suture, and found that when he cut the thread near the knot, returned the bowel, and permanently closed the external woimd, he had better results than in cases \^■here he followed the common practice of allowing the ends of the suture to depend from the wound for the purpose of removal when it separated. Con- trary to the prevailing views, he found that longitudinal wounds healed as promptly as transverse wounds. Dr. S. D. Gross, then professor of svn-gery in the University of Louisville, Ky., published (1843) his monograph, entitled, "An Experimental and Critical Inquiry Into the Nature and Treatment of Wounds of the Intestines." The object of the author was to "inquire into the process employed by nature in re- pairing wounds of the intestines," and "particularly to determine, if possible. INTRODUCTION. 63 the value of the more important methods of treatment recommended from the time of Ramdohr down to our own." But the great operations of ovariotomy by Dudley and Nathan Smith stood as permanent beacon lights for half a century, indicating the direction of the explorer for new fields of conquest, before the pioneer appeared who dared to penetrate the peritoneum and effectively treat the viscera which it invested. Dr. J. Marion Sims, guided by the same inductive method of reasoning and in- spired by the scientific spirit which characterized his introduction of silver wire into practice, not only advocated the free exposure of the peritoneal cavity for the purposes of surgical operations, but he boldly led the way in his operation for gall stones. The result of his pioneer work has been the almost limitless ex- pansion of the field of operative surgery. Though anaesthesia was introduced into the practice of surger}' in 1846, and exerted a marked influence upon its evolution during a quarter of a century of the period of which we write, it was not until antisepsis had united its marvel- lous energy to ansesthesia that the American practice of surgery underwent a complete revolution. We have, therefore, reserved a sketch of the historj^ of this greatest of all American discoveries to the close of the formative and the beginning of the practical period, when through the combined influence of these agencies the practice of surgery was placed securel}' on a scientific basis. The introduction of anaesthesia into the practice of surgery was not only the most notable achievement of American surgeons at that time, 1846, but, in its far-reaching influence upon the practice of surgery, anaesthesia has proved the most important evolutionary force hitherto discovered. The story of the strug- gle of the contestants for public recognition of priority in the discovery of ana?s- thesia forms one of the saddest and most revolting chapters in the history of the sciences. So fierce and relentless was the conflict that three of the four claim- ants became insane. Two of the latter were driven to suicide. Standing on the vantage-ground of half a century since the bitter contest closed, we are in a po- sition to determine not only the part which each claimant had in the discovery of anaesthesia, but to whom the verdict of history awards the merit of intro- ducing anaesthesia into the practice of surgery. The term ancesthesia was suggested by Dr. Oliver Wendell Holmes, as appears from the following letter to Dr. Morton, dated November 21st, 1846 : " Everybody wants to have a hand in the great discovery. All I will do is to give you a hint or two as to names, or the name to be applied to the state produced and to the agent. The state should, I think, be called anaesthesia. . . . The adjective will be ana?s- thetic. Thus we might say the state of 'anaesthesia,' or the 'anaesthetic state.'" On the 30th day of March, 1842, Dr. Crawford W. Long, of Jefferson, Jack- son County, Ga., removed a small glandular tumor from the neck of a patient, who had been rendered completely insensible by the inhalation of sulphuric 6^ • AMERICAN PRACTICE OF SURGERY. ether. The operation was completely successful, as the patient was not con- scious of the procedure and made a good recoverJ^ This was the first case of the employment of an anesthetic in the practice of surger}^ recorded in modern sur- gical literature. It was not an accidental occurrence, but the result of careful observation and experiment in a truly scientific spirit. Dr. Long had witnessed the effects of nitrous oxide — laughing gas — in rendering persons insensible to painful injuries when under its influence, and, to satisfy himself of this fact, he took the gas himself, and received injuries that he was not conscious of until he recovered from the effects of the gas. These experiences induced him to under- take his first surgical operation while the patient was mider the influence of the anaesthetic. Dr. Long continued to employ ^ antesthetics in his surgical practice for seven years, or until 1849, before he published an :;: „ ' account of his discovery. Crawford W. Long (1816-78) was born on the 3d day of November, 1816, in Danielsville, Madison ^^M County, Ga. He graduated from the University of ■^^^ -^ Georgia in 1835, and from the Medical Department P'vi of the Universit_v of Pemisylvania in 1839. He Jj^ began the practice of his profession at Jefferson, I ''C Jackson County, Ga. The operations which he per- l '" formed were of a minor character, as there were no hospitals at that time accessible to him. He ^°- ^''■("^''^sf ^' -^^^ was also deprived of the advantages of medical societies and medical journals, but his success as a surgeon gave him a local reputation of the highest character. He died on the 16th day of June, 1878. On the 11th day of December, 1844, Dr. Horace Wells, a dentist of Hart- ford, Conn., having observed that persons who took laughing gas and received injuries were unconscious of pain until they recovered from the effects of the gas, had one of his own teeth extracted while he was fully under the effects of the gas, and experienced no more pain than "the prick of a pin." On recover- ing, he exclaimed: "A new era in tooth pulling! It is the greatest discovery ever made." He introduced it into his dental practice and daily extracted teeth without pain. Impressed with the value of his discovery, in 1845 Dr. Wells vis- ited Boston for the purpose of giving it greater publicity, but failed in awaken- ing an interest in those he consulted. It is alleged that he attempted the use of sulphuric ether, but did not succeed in accomplishing any practical results with it. On the 30th day of September, 1846, Dr. W. T. G. Morton, a dentist of Bos- ton, Mass., administered sulphuric ether to a patient and extracted a tooth without pain. Morton had been a pupil, and subsequently a partner, of Wells, INTRODUCTION. 65 and through the medium of these close relations the former had become famihar with the experiments and practice of the latter in the use of nitrous-oxide gas in dental operations. In attempting to repeat Wells's methods of practice, Morton found difficulty in securing a supply of gas, and applied to Dr. C. T. Jackson, a chemist of Boston and his former instructor. On learning what use Morton was to make of the gas, Jackson suggested the use of sulphuric ether, which would have the same effect, required no apparatus, was entirely safe, and was readily obtained. It was on this advice that Morton performed the operation of Sep- tember 30th. In the belief that he had made a discovery of great pecuniary value, Morton took out patents, both in this country and [in Great Britain, imder the name "Letheon." On the 16th day of October, 1846, Dr. John C. Warren, one of the surgeons of the Massachusetts General Hospital, removed a small vascular tumor from the neck of a patient, under the full influence of the "letheon," the identity of which Morton concealed b}^ adding to the ether aromatic oils. The operation was per- formed at Morton's request, in order to test the value of the anaesthetic in sur- gical operations. Though the trial proved entirely successful, the effort of Morton to conceal the true nature of "letheon" prejudiced the surgeons against its fur- ther use until he acknowledged that the active agent in the preparation was sulphuric ether. The anassthetic was then freely tested in capital operations, Dr. Warren resecting a lower jaw and Dr. Hayward amputating above the knee joint. The success of these operations, while the patients were under the influ- ence of the anesthetic, was so complete and satisfactory as to gain the applause of not only the eminent operators and surgical staff of the hospital, but of the entire medical fraternity of Boston. The Massachusetts General Hospital at once became a luminous centre, ushering in the dawn of the new era in the prac- tice of surgerJ^ Scarcely a half year passed before its rays illuminated every hospital in the capitals of this country and Europe, and anaesthesia in the prac- tice of surgery was imiversally acknowledged as the greatest and most benefi- cent discovery in the annals of science. Morton subsequently petitioned Congress for an allowance from the public treasury as the discoverer of anaesthesia Ln surgical operations, and thus brought under public discussion the question of priority. The friends of Long, Wells, and Jackson appeared before the committee of the House, to whom the matter was referred, and contested Morton's claims. Congress failed to take action, and the contest passed unsettled into history. In the light of the preceding facts we conclude that Dr. Crawford W. Long, a surgeon, first used ether as an anaesthetic in the practice of surgery, but did not publish the fact tmtil others had independently repeated his experiment. 2. Dr. Horace Wells, a dentist, was the second person to use an anaesthetic, but limited it to nitrous-oxide gas in dental operations. 3. Dr. W. T. G. Morton, a dentist, experimented to find an anaesthetic La dental operations, and was led to 66 AMERICAN PRACTICE OF SURGERY. use sulphuric ether at the suggestion of Dr. C. T. Jackson, a chemist. Morton succeeded so well that he concluded that he had made a discovery of great pe- cuniary value, and obtained patents. In order to give it publicity and repute in the profession, he solicited Dr. John C. Warren to use it in the Massachusetts General Hospital during an operation. 4. Dr. C. T. Jackson, a chemist, merely suggested that sulphuric ether is more readily used as an anaesthetic than nitrous oxide. There is a monument standing in the Public Garden of Boston on which is inscribed the verdict of history as to the honor and glory of introducing anaes- thesia into the practice of surgery : To commemorate the discovery that the inhaling of ether causes insensi- bility to pain, first proven to the ivorld at the Massachusetts General Hospital in Boston, October, A.D. MDCCCXLVI. Antisepsis in the practice of surgery had its origin with British surgeons. The principles on which its employment is based were scientifically established by Mr. Lister during the years 1870-75, and by him reduced to a definite system of practice which has been universally accepted. But, like all innovations upon long-established customs which are revolutionary in their operations, antisepsis was received by the older and more conservative surgeons of Europe with doubt and hesitation. But the American surgeons who visited Edinburgh and wit- nessed the practical application of antiseptics under the directions of Mr. Lister, and the remarkable healing of wounds without suppuration, were profoundly impressed with the far-reaching influence of the discovery upon the future prac- tice of surgery, and hastened to introduce the new method into hospitals at home. The announcement of the results of antisepsis in the treatment of wounds was received m this country with genuine American enthusiasm, and the pre- scribed antiseptic agents were immediately placed on trial in scores of hospitals. The results justified the claims of visitors to the wards of the Edinburgh surgeon, and antisepsis took its rightful position as an indispensable factor in the Ameri- can practice of surgery. And in the application of antisepsis to practice, the surgeons of no country have excelled the American in their efforts to adapt means to an end in the construction of operating-rooms and their equipment with every conceivable device to secure perfect asepsis of the patient, the sur- geon and his assistants, the instruments, the wound, and its dressings. In hun- dreds of hospitals in this country the antiseptic treatment is carried out with such precision of details as to eliminate pus in operated cases. The results are simply marvellous. Operations that half a century ago were unthought of and even unthinkable on account of their danger, are daily performed with the most absolute success. In many operations which once had a high death rate the INTRODUCTION. 67 mortality has been reduced so as to be merely nominal, and in a few once capital operations the death rate has been eliminated from the record altogether. In the year 1826 Professor Sewall, of Colmiibia College, Washington, D. C, reviewing the progress of medicine in this country during the sixty years of its then national existence, spoke in the following eulogistic terms: "If in sixty years, with the limited means we have possessed and with all of the difficulties we have had to encounter, we have produced the best system of medical educa- tion, the most perfect system of medical police that has been exhibited to the world; if we have produced some of the best practical and elementary books, and some of the most eminent physicians and surgeons of any age or country; . . . what will be our advance in the sixty years to come?" Those sixty years have passed, and an additional score of years have been added to the number, and how insignificant and even contemptible appear the system of medical education, the medical police, and the medical literature of that period! Then there were twenty medical colleges, giving instruction an- nually to about two thousand students; now there are one hundred and fifty- seven medical schools, educating upward of twenty-eight thousand students. Then the medical police was limited to gratuitous advice to the civil authorities; now it is a controlling force in the protection and promotion of the public health. Then but three surgical works had been published and but two medical period- icals were regularly issued ; now forty-five native surgical works were published in two years and three hundred journals are regularly issued. Then there were three fully equipped hospitals; now they are found by the score in the large cities, and scarcely a village community is without its local hospital. In concluding this sketch of the evolution of the American practice of surgery we have not sought to magnify the achievements of individual surgeons, nor even to enumerate what must be regarded as notable events in the general his- tory of surgery, except so far as such achievements and events illustrate the ele- mental conditions and forces which governed its progress and development. For this reason we have dwelt more upon the special features, educational and experimental, of the early periods of our history than upon the triumphs of these modern times, which are but the fruitage of the culture of the past. What the American practice of surgery is to-day will be amply illustrated in these pages by surgeons whose daily duties are in the special fields of which they are the his- torians. The records of that practice will justify the conclusion of Mr. Erichsen in the paper referred to : "I know no country in which, so far as it is possible to judge from contemporary medical literature, there is so widely diffused a high standard of operative skill as in this country." PART I. SURGICAL PATHOLOGY. INFLAMMATION. By ALDRED SCOTT WARTHIN, Ph.D., M.D., Ann Arbor, Michigan. I. GENERAL CONSIDERATIONS. 1. Inflammation is a Pathological Complex, Essentially Adaptive, Protective, and Reparative, Constituting the Reaction of the Body Cells to Injury, either' Direct or Referred. , Experimental and comparative pathology have given us a broad biologic conception of the reaction of cells to injury. From the lowest forms of ani- mal life up through the higher to man we find that tissue injury, when not so severe or extensive as to cause the death of the individual, excites a definite response in the animal organism. No matter what the nature of the harmful agent ("irritant") may be, this reaction on the part of the damaged organism, unicellular or multicellular, is in its essence the same ; that is, it is at founda- tion an attempt to oppose or evade the irritating agent, to counteract its harmful effects, and to repair the damage caused by it. Naturally, these protective and reparative efforts are carried out somewhat differently in the case of different animals, according as their structure is simple or complex. Likewise the great variety of injurious agents and the varying conditions under which they act must influence the course of the reaction. It may be stated also, in the beginning, that these protective and reparative processes are often inadequate or imperfect; in fact, in the attempt to protect itself the organ- ism may inflict further damage upon itself, even to such an extent that the death of the individual may ensue. In spite of these imperfections the essen- tial fact remains — the process of inflammation is at bottom protective and reparative. In the case of unicellular animals the protective process can be studied in its simplest form. In such an animal both protective and reparative functions are reduced to the basis of the single cell. It may protect itself by the extrusion or destruction of the harmful agent, the latter event being brought about by means of intracellular chemical processes akin to digestion; while cell defects due to the action of the irritant are repaired through a new growth of cell substance. In multicellular animals the division of labor among different cell groups results in the assignment of protective and reparative functions especially to certain kinds of cells, and the more complex structure of the organism necessi- tates a much more elaborate method of protection. While individual cells 72 AMERICAN PRACTICE OF SURGERY. retain to a greater or less degree the individual fimctions of the unicellular organ- ism, these become lessened or may be wholly lost as the cell gains in specializa- tion. Accordingly, in the higher vertebrates and in man we find that the removal and destruction of harmful agents are effected chiefly by wandering mesoblastic cells, lymphoid tissue, and the endothelium; while repair is chiefly brought about by the proliferation of fixed connective-tissue cells and endothe- lium. The more highly developed structure of the multicellular organism, its complex nutritive mechanism, and the important part played in the body economy by the vascular system cause the involvement of the latter to assume a very important role in the processes both of protection and of repair. Further, the influence of the nervous system is also a factor of great importance in con- nection with these processes. If we should select the most constant and characteristic phenomenon of the reaction to injury in multicellular organisms it would be found to lie in the assemblage of cells of the leucocyte type at the site of injury. These cells, indeed, may be regarded as analogous to imicellular organisms, and they pre- sent the protective functions characteristic of the latter. The difference in reaction to injury between unicellular and multicellular organisms is the result simply of the specialization of function and the more complex mechanism of the latter. It becomes clearly evident, therefore, that the essential jjrinciples imderlying the response of the animal organism to injur}^ are the same for all forms of animal life from the lowest to the highest. And it is to this reaction of the animal organism to injurious agents and the lesions produced by them that we now, in accordance with the majority of modern pathologists, apply the term inflammation. 2. Differences of Conception of the Inflammatory Process. The earliest conception of inflammation {inflammatio, phlogosis) was a purely clinical one. At the beginning of the Christian era the term was applied by Celsus to local changes in the superficial portions of the body characterized by redness (rubor), swelling {tumor), heat (calor), and pain (dolor). Since these phenomena appeared constantly as the results of certain injm-ies and irritants to the external portions of the body Celsus designated them as the four cardi- nal symptoms of inflammation. Later, a fifth symptom of disturbed fimction (functio lasa) was added. While this primitive definition ctlil exercises a tradi- tionary influence, the term inflammation has gradually come to include a large number of pathological conditions of the internal organs believed to be analo- gous to the inflammatory process, as well as all those morbid processes which in etiology and course caimot be separated from, and which pass insensibly into, conditions showing the classical symptoms. The term, therefore, gradually came to be applied to conditions in which some or all of the cardinal signs were INFLAMMATION. 73 absent or could not be recognized, and the purely clinical significance at first attached to it was weakened or lost. Such a usage may be taken as an indica- tion of the awakening realization that all the processes included under the term were in essence of the same nature and significance. And that this latter is a fact has been demonstrated beyond all doubt by the study of the minute changes in the organs and tissues in and about the inflamed area and by the results obtained through experimental and comparative pathology. From Boerhave, who regarded inflammation as the result of stasis, to Rokitan- sky, who emphasized the vascular dilatation, slowing of the blood stream, and serous exudation, to Virchow, who regarded inflammation as an overstimulation of the functional, nutritive, and formative irritability of the cells, and finally to Cohnheim, who first studied the phenomena of inflammation in the living animal directly under the microscope and was thus enabled conclusively to demonstrate that the cardinal changes are vascular disturbances leading to emigration of the white cells, serous exudation, and diapedesis of red cells, there may be traced a constant widening of the field covered by the designation in- flammation, so that the term came to be applied to the great majority of patho- logical processes in the body without reference to the original symptomatic sig- nificance. But even Cohnheim was unable to see anything in the inflammatory process of service to the body; its chief significance to him lay in the primary lesion of the blood-vessels permitting the passage of the blood elements. While giving to pathology the important knowledge of the vascular alterations occur- ring in the inflammatory process, Cohnheim threw no light upon its essential nature. His views, however, were for a long time accepted as the most satis- factory interpretation of the inflammatory phenomena, and they still influence greatly some of the leading pathologists of the present day. During the last several decades efforts have been constantly made to ascer- tain the common feature of the various processes classed as inflammatory, with the view of arriving at a fundamental conception of the inflammatory process. The varied etiology and the very different clinical and histological pictures pre- sented by different inflammations afforded no basis for a fundamental definition. In the effort to make of inflammation both a clinical and a pathological entity the term itself fell somewhat into disrepute with both clinicians and patholo- gists, and it was even proposed by some (Thoma, Andral, and others) to drop it altogether. But a new conception of the process was slowly evolving — one which would be able to harmonize all facts, remove all difficulties, and give to mflammation an entity, not as a condition or state, but as a process having in all of its mani- fold manifestations one essential unity, viz., that of protective and reparative reaction to injury. This new conception may be said to have had its origin with the discovery of karyokinetic cell-division and the demonstration that in prac- tically all inflammatory lesions cell proliferation occurs to a greater or less de- 74 AMERICAN PRACTICE OF SURGERY. gree. At first, this new formation of cells was regarded as a sequela of inflamma- tion rather than as an essential part of the process. But it was soon discovered that other features of the inflammatory process could likewise be demonstrated to be protective in character. To ]Metschnikoff do we owe the knowledge that the assemblage of wandering cells at the point of injury may precede and be independent of the vascular changes, and that this phenomenon constitutes the most characteristic and constant factor of the reaction to injury. Regarding this collection of wandering cells as primarily intended for the exercise o f their function as phagocytes, Met- schnikoff formulated a new conception of mflammation as a reaction of phago- ■ cytes against the injurious agent. The essential and fmidamental element of in- flammation is, then, a means of defence for the animal organism. ^^Trile the new conception of inflanmration as adaptive, protective, and reparative owes more to Metschnikoff than to any other modern investigator, yet his efforts to estab- lish phagocytosis as the essential element of the process must be regarded as based upon a too narrow conception. That phagocytosis is only one of the pro- tective functions of the bod}'-cells exercised in inflammation was clearly recog- nized by other investigators, and the lines of work followed in opposition to Metschnikoff's views have served to give a still firmer and broader foimdation to the new conception. The demonstration of the active participation of the blood-vessels and endo- theliimi (Klebs, Heidenhain, and others), the influence of the nervous system (Sam- uel), the part played by chemotaxis (Bordet, Leber, Buchner, Gabritschewsky, and others), and the presence in the blood and serum of antibacterial bodies (alexins) (Nuttall, Buchner, and others) served fm-ther to establish the new con- ception more securely. It has been shown also that leucocytes contain or pro- duce bactericidal substances (Buchner, Hankin, Bordet, Stokes and Wegefarth, Loewit, and others). The bactericidal action of the serum in inflammatory proc- esses has been conclusively demonstrated, as has also the mechanical protection afforded by the cellular infiltration, fibrinovL? exudate, granulation-tissue, etc. The function of the fluid exudate in diluting or washing away injuiious agents may also be mentioned as one of the protective factors of minor importance. Lastly, but constituting one of the most important factors in the body's defen- sive processes, is the production by the body-cells of antitoxins whereby injm-ious chemical agents are neutralized or destroyed. Ehrlich's theory serves to illu- minate the processes of local inflammation as well as of general infections and intoxications. Summing up, then, all the factors of the inflammatory process and viewing them in the light of modern research we see that in all anunals and in response to all kinds of injury they are essentially the same, though often varying in pro- portion, and that their imity lies in a constant tendency toward protection and repair. Inflammation, therefore, as defined above, can be regarded only as a INFLAiniATION. . 75 frocess-cormpLex essentially adaptive, protective, and reparative, called into action by a primary tissue lesion. To this view nearly all the pathologists of the present clay accede. A few examples of recent definitions may be given here : Inflammation is the series of changes constituting the local manifestation of the attempt at repair of actual or referred injury to a part, or, briefly, as the local attempt at repair of actual or referred injury. — Adajii. Inflammation is a local reaction, often beneficial, of the hving tissue against the uTitating substance. This reaction is produced chiefly by phagocytic acti\'ity of the mesodermal cells. In this reaction there may, however, participate not only changes of the vascular system, but also the chemic action of the blood plasma and tissue fluids in liquefying and dissolving the irritant agent. — PoD-m.-ssozKi. Inflammation is the reaction of the tissues to local injiuries calhng forth protec- tive measures: an imperfect pathologic adaptation, often leacUng to consequences that are dangerous per se and may defeat its piurpose. — Hektoen. On the whole the processes involved in inflammation are conservative, and, ■within the limitations which may be set by the varied and changing conditions of injury, tend to maintain the welfare and sustain the fife of the indi\'idual. — Dela- FiELD and Peudden. The reaction of the organism against injurious agents. . . . Local inflammation may be regarded as an increased tissue function which is also active under normal conditions but of so slight a degree as not to be perceived. — Ribbert. Only a few pathologists, among these Ziegler, still emphasize the tissue lesion, particularly the vascular alteration, as the most essential feature of the inflammatory process. But among surgical writers we find a small number, who, following Hueter's dicta, assert that the term inflammation should be ap- plied only to the processes caused by pyogenic micro-organisms; that is, to suppiu-ative processes. This confusion of inflammation and pyogenesis is illogi- cal and unfortimate. There is no etiological entity to which the application of the term inflammation can be restricted. Physical, chemical, and thermal agents can produce precisely the same changes as those seen in local infections. On the other hand, infection may occur without inflammation. The fact that purulent inflammations are the most common and important forms of the proc- ess falling within the province of practical surgery gives no warrant for the usurpation by this branch of medicine of the term inflammation for one particu- lar manifestation of the inflammatory process. The term has been too long applied to various other processes of essentially the same nature and significance to permit of such a narrowing of its meaning. If the phenomena of the local reaction of the body to injurious agents are in essence the same, no matter what the etiological agent may be, the term inflammation must include them all. That they are the same, in all essential respects, will be shown in the following paragraphs. 76 AMERICAN PRACTICE OF SURGERY. 3. The Reaction of the Tissues to Injuey. Injury to Non- vascular Tissues.— The cornea offers itself as suitable mate- rial for the study of the effects of injury upon non-vascular tissues. According to Senftleben and others, if the centre of the rabbit's cornea be touched with a strong solution of zinc choloride without causing an actual break in its continu- ity, there is a necrosis of the corneal cells at the point of application, with the development of an encircling zone in Avhich the corneal cells are enlarged, granu- lar, and tumefied. There is apparently no increase of wandering cells and the necrosed cells are replaced through the multiplication of the neighboring hyper- trophic cells. The two essential features here are cell' necrosis and cell division; and such a process must be regarded as the simplest form of an inflammation. It is doubtful, however, if such a simple form actually occurs under such condi- tions. It is almost impossible to repeat Senftleben's results; in the great ma- jority of cases, if not in all, the slightest perceptible injury to the cornea causes an increase in the number of wandering cells in or about the damaged area. As the neighboring vessels of the conjunctiva may show no perceptible changes, it is most probable that the wandering cells come to the damaged area out of the lymph spaces of the surrounding tissue (see Fig. 28). If a simple cut be made into the cornea, either with or without previous cauterization, practically the same changes are seen. There occurs within a short time a collection of leucocytes in and ■^'^•'^^'^Zj^ ^' -aT" -=■ '"■'' about the point of incision. At first, these are apparently attracted from the surrounding tissue, as the blood-vessels of the conjunctiva may show no changes. Cell division takes place and repair is effected. The inflammatory proc- ess consists, then, essentially of cell injury, positive chemotaxis, and cell proliferation. When the degree of the trauma is greater (re- ^'""'"'7" . -- -s.-^-"^; peatcd trauma or cauterization, repeated ap- '*£_^_ia^A^" ■■^- "" ■'''Slit/ plication of toxin), the neighboring vessels of Fig. 28.— Inflamed Cornea. Hy- the Conjunctiva bccome iiivolved, as shown by pertrophy of corneal cells ; assemblage ^j^^- j, dHatation, increased number of leucocytes, of leucocytes. {After Ribbcrt.) ^ ' and leucocyte emigration, as well as by serous ex- udation. The leucocytes mass themselves in greater numbers about and in the injured area. The number may become so great that the tissue presents the ap- pearance of a purulent infiltration. Licjuef action necrosis may take place (re- peated application of chemicals or toxins), and the histological picture produced may l^e exactly similar to that following the growth of pyogenic micro-organisms. If pyogenic bacteria are injected into the centre of the cornea and multi- plication of the organisms follows, there is first seen around the growing colony i '- ""- t;- :^ *| ;;!g^_--'-'5•■ ^'.':- , _ ■^'' 'hi"' P^ .-.,>y®^ '^ ® 4EK -.w. .^ V- "Kr; V^-.-'ISl^-c.- -.^-«S>-' ^'' ^*-:^. ^- *' .WSSs: INFLAMMATION. 77 a zone of degeneration and necrosis of the corneal cells. Within a short time leucocytes collect about the damaged area, coming first from the corneal tissues and later from the blood-vessels at the periphery of the cornea. These vessels are found to be dilated and containing an increased number of leucocytes. They present also evidences of serous exudation and emigration of the leuco- cytes. That the leucocytes come chiefly from the vessels is shown at a certain stage by their greater number at the periphery of the cornea and their gradual approach toward the area of injury. Finally, large numbers of leucocytes may be collected in the lymph spaces about the tissue lesion. If the bacteria intro- duced were of a low virulence, or if the body's resistance is sufficient to inhibit the growth of the colony or to kill it, proliferation begins and repair is effected. The inflammatory process under such circumstances in no way differs from that produced by other agents. If the micro-organisms injected are virulent and continue to develop, the Fig. 28, A. — Corneal Suppuration, a, Limbus corneiE with hyperaemia of ciliary vessels and purulent infiltration; 6, remains of epithelium; c, purulent infiltration of cornea; d, necrosis; e, pus; /, Descemet's membrane; g, endothelium of anterior chamber. {After Weichselbaum.) area of necrosis and degeneration widens, more leucocytes come into the dam- aged area, the lymph spaces contain more fluid, and the peripheral vessels show a more marked reaction. Many of the leucocytes are seen to be acting as phagocytes, having taken up large numbers of the invading organisms. After a time the leucocytes massed in the central portion of the necrotic area undergo degeneration, and a liquefaction of the infiltrated necrotic centre follows, lead- ing to the formation of an ulcer (see Fig. 28, A). The virulence of the infective 78 --LMERICAX PRACTICE OF SLTIGERY. agent may now be weakened, or the latter may be restrained from further groTvth by the leucocyte barrier. Proliferation of the neighboring corneal cells may take place,, the dead tissue and leucocytes bemg either cast off or organized, and the ulcer finally becomes completely healed. In the process of repau- new blood-vessels may grow mto the cornea from the blood-vessels of the sm-rounding tissues, and the pre^-iously avascular tissue then becomes vascularized. Should the organism be unable to overcome the vu-ulenee of the infective agent, the area of necrosis and degeneration increases and the inflammatory process extends. Injury to Vascular Tissues.— The skin or mesentery of experimental ani- mals may be utilized for the demonstration of the changes set up by injury to vascular tissues. If the slightest possible injury that can be recognized be pro- duced in such tissues by means of heat, chemical action, or aseptic incision, practically identical changes, varymg only in degree, will be fomid at the point of injury. The sunple aseptic incision may be taken as an example. The solu- tion of contmuity of the incised part leads at once to a necrosis or degeneration of the cells along the line of incision. The edges of the wotmd are almost im- mediately glued together by serum or blood clot, and there is a slight serous infiltration of the tissue bordering upon the incision. The tissue cells in the immediate neighborhood of the cut enlarge and send out processes into the exudate, binding the sides of the wound together. Protoplasmic bridges maj^ thus be formed across the wound. At the same time the neighboring capillaries show slight or moderate dilatation, and there is a slight increase of wandering cells. Later, cell proliferation with a new formation of capillaries takes place and the tissue continuitj- is again restored. In the epidermis the reaction to the injur}- is shown simply by a new formation of epithelial cells. There action to slight injm}- in vascular tissues is characterized, therefore, by slight vascular changes, emigration of leucocytes, and exudation, the chief factor of the reac- tion being progressive changes (hypertrophy and proliferation) of the tissue cells. There is, then, no essential difference in the reaction to slight mjury in avascular and vascular tissues. If the degree of injur\' be more marked, so that the tissue lesion (degenera- tion and necrosis) is more extensive, there is a more pronoimced and rapid reaction on the part of the blood-vessels. These show a marked dilatation, with slowing of the blood stream, marginal disposition of the leucoc3'tes, increased formation of hmiph, and emigration of leucocytes from the vessels. Red blood cells maj- also escape. The leucocytes collect in the tissue spaces in or about the injured area (see Fig. 29). "^lien the process is on the superficial portions of the body the classical sjmiptoms maj- be present. According to the nattrre of the irritant, its virulence, and the resisting powers of the organism, the inflam- matory process may continue to extend or cell proliferation may begin, the exudate disappears, the vessels resume their normal condition, and all traces of the injury and the reaction pass away. INFLAMMATION. 79 Should the injurious agent be one capable of unlimited growth and continu- ous injury to the bodj^ tissues, as is the case with virulent pathogenic organ- isms, the pus cocci in particular, the tissue lesion is more severe and assumes a progressive character, while the inflammatory reaction is proportionately more marked. When the focus of irritation is situated in the superficial parts of the body the classical symptoms are usually clearly defined. On microscopical examination precisely the same essential changes are found as in the non- infective inflammations, the only difference being one of intensity and adapta- tion to the different character of the injurious agent. At the point of a pyo- genic infection there is produced by the growing colony of bacteria a tissue degeneration or necrosis. About this lesion there is a rapid and marked vas- cular reaction. Within a few hours usually the vessels are found to be markedly congested, packed with red blood cells, and showing a marginal disposition of Fig. 29. — Inflamed Human Mesentery (osmic-acid preparation), a, Normal trabecula: b, normal epithelium (endothelium); c, small artery; d, vein witli leucocytes arranged peripherally; e, white blood cells, which have emigrated or are emigrating; /, desquamating endothelium; fi, multinuclear cells; g, extravasated red blood cells. X ISO. {After Ziegler.) the leucocytes, which are greatly increased in number. In the tissues the number of wandering cells is greatly increased. The mononuclear forms are very numerous and often predominate. Both leucocytes and tissue cells acting as phagocytes and containing numbers of the bacteria may be found. As a rule, the leucocytes in the immediate neighborhood of the growing colony are multi- or polymorphonuclear, while in the outer zone of the infiltration the mononuclear forms prevail. As the process advances, the damaged area becomes densely infiltrated with leucocytes, the dead tissue elements undergo liquefaction, while the leucocytes in the area of softening show signs of degeneration. The process has now reached 80 AMERICAN PRACTICE OF SURGERY. the stage known as suppuratwn, and there is formed an abscess more or less sharply defined from the surrounding tissues (see Fig. 29, A) . If on a surface, the suppuration leads to a superficial loss of substance— an ulcer. The mass of leucocytes occupying the central necrotic area constitutes pus. In this pus the great majority of the leucocytes are found to be phagocytes— that is, they con- tain numbers of the infective organism. About the border of the pus area the tissues are swollen, more or less infiltrated, the blood-vessels congested, and there is more or less hemorrhage. At this stage no evidences of cell prolifera- tion can usually be found. If the infective agent has great virulence, the proc- ess may continue to extend indefinitely with a repetition of the same phenom- ena, and finally become generalized, or the organism may succumb. If the virulence is overcome and the colony of bacteria dies out or ceases to reproduce, . -; ■.•:■-- :- -_ -: "■:■:-'- ' v^ ' p^- Fig. 29, A. — Small Abscess in Heart Muscle. Colony of pyogenic cocci in centre of necrotic area, which is surrounded by a zone of leucocyte infiltration. {After Ribbert.) cell division begins about the border of the abscess, new capillaries extend into it, and the area is gradually replaced by new tissue. The same picture of suppuration may be produced by the injection, into the tissues, of certain chemical irritants, such as turpentine, mercury, petroleum, creolin, bacterial toxins, etc. Inasmuch as under such circumstances there is no continuous production of irritating substances, as in the case of bacterial infection, the purulent reaction thus produced lasts for a shorter time, cell pro- liferation begins more quickly, and healing is attained in less time. Continuous injections, however, will cause a progressive purulent process, not to be distin- guished in any way from that due to bacterial infections, in so far as the local phenomena are concerned. In the case of certain injurious agents the inflammatory reaction is charac- terized by serous exudation rather than by leucocytic. Others still are charac- terized by the production of a fibrinous exudate. The same agent may at one time produce a reaction characterized by suppuration, at another time one characterized by serous exudation, and under other conditions it may give rise to an exudate consisting chiefly of fibrin. These variations in the inflammatory reaction are especially characteristic of those inflammations which are due to infections. The factors modifying the nature of the reaction are many: the nature of the injurious agent, the location and character of the injury, the INFLAMMATION. 81 degree of intensity, the general and local conditions of the organism, etc., all of which serve to give to the inflammatory reaction a varied clinical and patho- logical picture. Nevertheless, as we have seen above, there is a unity in the reaction to in- jury which makes of the inflammatory process a distinct entity, no matter what the nature of the injurious agent or the conditions under which it acts. Whether traumatic, thermal, chemical, or infective in etiology, or formative, serous, purulent, or fibrinous in character, the process has the entity of adapta- tion, protection, and repair against injury. As Ribbert and others have pointed out, inflammation may be conceived of as a body function — the function of protection, and comparable to the other body functions. Cell proliferation, chemotaxis, emigration of leucocytes, phagocytosis, the production of anti- bodies, etc.,: are probably always taking place in the body to some extent, but unnoticed. Only when the demand made upon this function is so great as to become locally prominent does it become manifested in the form of an inflam- .mation. If it be urged against this view that the inflammatory process often in itself is a source of danger to the organism, the same might be applied to other functions — for instance, the digestive, the products of digestion often becoming factors in auto-intoxications. Viewed broadly, inflammation is to be regarded as a phylogenetic evolution, developing as have all the other functions of the organism. 4. Etiology of Inflammation. The inflammatory process has no etiological entity. The causes of inflam- mation are not specific. Any injurious agent may produce inflammation, pro- vided its action is not so severe as to kill the organism or the tissues en masse or to inhibit the function of protection and repair. Extrinsic agents — such as mechanical, thermal, chemical, electrical, radio-active, infective, etc. — are among the most common causes of inflammation. In surgical practice it is chiefly with these extrinsic causes that the surgeon has to deal. But injurious agents capable of exciting inflammation may be produced within the body as the result of disturbed metabolism, disordered function, etc. The antemic necrosis of tissue areas due to local obstruction of the blood-vessels excites also an inflammatory reaction in the neighboring living tissues. In the great majority of cases the inflammatory reaction is probably toxic in origin. The irritant poison is chiefly, as far as surgery is concerned, bacterial. In general medical work inflammatory processes due to auto-intoxications oc- cupy also a prominent position. The agents causing inflammation may act upon the body from without (edogenous inf.ammation) or through the lymph (lymphogenous) or the blood (hcematogenous) . When the avenue -of entrance of the injurious agent (bacteria) is not known, the inflammation is styled cryptogenic. 82 A]^IERICAN PRACTICE OF SURGERY. The inflammatory process may spread by direct extension (inflammatioji hy continuity), or the injurious agent may be transported through the lympli or blood stream to other parts of the body, there to excite new inflammatory foci {metastatic inflammation). Through the excretion of poisonous substances the excretory organs may become the seat of inflammatory processes {excretory inflammation). The action of the harmful agent may be very transitory or it may be pro- longed through some period of time. Particularly is this the case with infective agents. Through the continuous new formation of poisonous substances by the colony of living parasites, an inflammatory reaction may be kept up almost indefinitely imtil the organism finally conquers or succumbs. The action of the inflammatory agent may be so slight as to produce a lesion that is clinically unrecognizable, and even on microscopical examination the evidences of damage to the tissue are with difficulty made out. At other times the action is so intense that extensive lesions easily seen by the unaided eye are produced. Usually the inflammatory reaction quickly follows the injury, the interval of time varying from a few hours to a few days ; but in some instances the reaction is long delayed. The character of the exciting cause, its virulence, the conditions of nutrition about the damaged area, the influence of the nervous system, etc., are probably the chief factors causing a delayed reaction. Some agents may inhibit the protective function or even cause destruction of some of the elements therein concerned. Roentgen rays, for example, will cause a disintegration of the leucocytes in the irradiated area and also inhibit cell pro- liferation. These facts may explain in part the long- delayed inflammatory reaction seen after repeated exposure to the rays. 5. The Factors Coxcerned in the Infl.a.mm.\tory Process. In the surveyal of the course of inflammatory processes in general, the vari- ous associated phenomena are found to fall into several more or less well-defined The Factoks Concerned in the Inflammatory Process. 1. Effects of Injurious 2. REACTION. 3. Resolution. Tissue-Lesion. Protective ana Defensive. Reparative. a. Disturbance of cell Chemotaxis. Vascular disturb- Phagocytosis. a. Cell-prolifera- relation . Leucocytosis. ances. Chemical protec- tion. h. Solution of continu- Emigration of a. Congestion. tion. b. Regeneration. ity. ■white cells. b. Stasis. a. Antibacterial. c. Organization. c. Tissue degenerations. c. Leucocytosis. b. Antitoxic. d. Cicatrization. d. Necrosis. d. Marginal dis- position. e. Emigration. /. Serous exuda- tion. q. Diapedesis. h. Thrombosis. Mechanical. Dilu(»nt. Irrigant. INFLAMMATION. 83 groups, the first of these being the immediate results of the harmful agent, the second consisting of factors essentially protective and defensive, while the third group is made up of the formative and reparative factors. The general process of the reaction to injury having been sketched above, it may now be profitable to consider more in detail the most important factors of these groups. Tissue-Lesion. — Although the primary tissue-lesion is the cause and not a part of the inflammatory reaction, it is difficult practically to separate it from the phenomena which are immediately dependent upon it, and it is, therefore, usually included in a general survey of the process of inflammation. Moreover, from the clinical side the changes occurring in the tissues, either primarily as the direct result of the action of the etiological agent or as secondary to the inflammatory process itself, are of the greatest practical importance. The pri- mary tissue lesion varies with the nature of the etiological agent, the intensity of its action, the location of the injury, the condition of the tissues, the general state of the organism, etc. At times it is so slight as not to be recognizable either with the naked eye or microscopically; at other times so severe or ex- tensive as to be recognized easily macroscopically, and clinically to attract the chief attention. This is particularly the case when the injury affects a large portion of the tissues, as in the case of extensive burns, corrosions, freezing, or severe and widespread infections. In the case of bacterial infections the tissue lesion may assume a progressive character, involving large areas by direct extension. The primary tissue lesion may be simply a disturbance of cell relationship or a solution of continuity, or it may show itself in the form of any one of the varieties of tissue degenerations or necrosis. The acute parenchymatous degen- erations, cloudy swelling, hydropic degeneration, fatty degeneration, mucoid degeneration, etc., and the various forms of necrosis, simple, coagulation, lique- faction, and gangrenous, are the most common tissue lesions exciting the in- flammatory reaction. While in some inflammations the tissue lesion may be overshadowed by the phenomena of the reaction, in others it occupies the most prominent position both clinically and microscopically. In the great majority of cases the tissue lesion involves the blood-vessels in or about the site of injury, but, as we have seen, such vascular changes are not necessarily a part of the inflammatory reaction — as, for example, in the corneal change following slight injury. Inasmuch as the vascular changes may take place at a distance from the actual seat of injury, the participation of the ves- sels in the reaction must be explained, in such cases at least, upon other grounds than that of a direct injury to the vascular walls. There is good reason for believing that the walls of the blood-vessels play chiefly an active part in the inflammatory process, and not merely a passive one due to injury. Secondary injury to the tissues is often added to the primary lesion as the result of the disturbances of circulation and nutrition and the collection of 84 AMERIC.l^' PRACTICE OF SURGERY. exudates either in the tissue spaces or hi the body cavities. To this secondary damage the inflammatory process often owes its clmical unportance. Moreover, the dead and dymg tissue acts as a further source of mjury to the surrounding healthy tissue, in that it may give rise to chemical products which are uritant, and so extend the zone of damage. This is most likely to occur in the early stages of necrosis; later, the dead tissue becomes chemically indifferent and acts simply as a foreign body. The Protective Factors. Che77wtaxis.—As sho-wn above, the chief phe- nomena of the reaction in the simplest forms of inflammation are the collection of waudermg cells at the site of iujmy and the proliferation of the tissue cells. This assemblage of amceboid cells about the tissue lesion and the injurious agent precedes the vascular changes, if the process be viewed from the stand- point of its evolution. The attractive force exerted upon the amoeboid cells is known as positive cliemotaxis. It lies m diffusible substances produced in the mjm-ed area, through altered nutrition, the death of the tissue cells, or by bac- teria. Such substances attract the amoeboid cells and cause their assemblage at the site of injiu-y. Negative chemotaxis may also occur, but positive chemo- taxis, although varying in degree, is practically the rule in the inflammatory reaction. Particularly hi the case of mfective inflammations is positive chemo- taxis marked, the great majority of pathogenic micro-organisms producmg sub- stances causing the amoeboid cells of the body to move toward the bacteria. Chemotactic influences may also be exerted upon the white cells while still in the blood-vessels, and in part at least may accomit for their occurrence in greater numbers in the vessels of the damaged area as well as for their eniigra- •tion. Such influences also direct the movements of the white cells after they have passed out of the vessels. Ordinarily the leucocytes leaving the vessels wander in the direction of the Ij-mph stream. In the case of tissue injury they wander toward the site of the lesion and the injurious agent. About the latter they collect in masses and remain in its miniediate ^acinity. Chemotaxis brings the amoeboid cells to the point where their phagocytic function may be used to some avail. Not only upon the leucocj^tes and hTnpli- ocytes are such influences exerted, but also upon the endothelial cells of the vessel wall and upon the formative cells arismg through the proliferation of the fixed cormective-tissue cells. T^Tiether regarded as a purely accidental phenom- enon or as an attribute of the injurious agent and in itself ultimately injurious, the fact remains that it becomes a force aiding in the defence and protection of the body. Vascular Changes. — ^As. the vast majority of inflammatory processes occur in vascular tissues, the involvement of the blood-vessels plaj's a very prominent role, both clinicalh' and pathologically. The first noticeable feature of the vascular involvement is an active hypersemia, the arteries being dilated and the rate of the blood current increased. In a very short time, however, there is a INFLAMMATION. 85 marked slowing of the blood stream, while the hypera?mia remains or increases, the capillaries and veins becoming greatly dilated. The rate of the blood flow may be still further diminished and very irregular. In portions of the dam- aged area a condition of stasis may exist. Thrombi may be formed in the veins. In the capillaries about the irritant (usually when infective) there are some- times formed masses made up of agglutinated red blood cells {agglutination thrombi). From the very beginning of the reaction the leucocytes increase in numbers in the vessels of the area, and as the blood stream becomes slowed their number is augmented until a condition of a more or less marked local leucocytosis exists. At the same time the viscosity of the white cells appears to be increased, since they collect in numbers along the vessel wall, where they remain adherent or move along but very slowly (marginal disposition of the leucocytes). The leucocytes adherent to the vessel walls now begin to pass out in num- bers {emigration of the leucocytes). This process is accomplished by the protru- sion of a cell process (pseudopodium) through the intercellular substance be- tween the endothelial cells. The cell protoplasm follows or "flows" after, mitil finally the entire cell has passed outside. Soon numbers of leucocytes collect outside the vessel and pass thence to the site of the injury or the in- jurious agent. Through the openings in the intercellular cement substance produced by the passage of the leucocytes the red blood cells may passively escape {diapedesis) . Hemorrhage per rhexin may also occur as a part of the inflammatory process, the rupture of the vessel being due either to extreme dilatation or to its direct involvement in the tissue lesion. At the same time there is an increased formation of lymph, the fluid col- lecting in the tissue spaces as an inflammatory adema or passing out upon a free surface as an inflammatory exudate. From the normal lymph and blood plasma the inflammatory exudate differs in its albumin content, its frequently high fibrinogen content, as well as by differences in the amomit of salts con- tained. Emigration and exudation do not always go hand-in-hand. Some inflammatory processes are characterized by a fluid exudation, others by a cellular. The passage of the fluid cannot, therefore, depend wholly upon the spaces left after the emigration of the leucocytes. Further, the difference in composition of the exudate and the blood plasma must also be taken as evi- dence of a different mode of origin. The chemical composition of the exudate also varies in different parts of the body. The significance of the vascular changes just mentioned has been the object of a vast deal of research and discussion, but we are still ignorant of much con- cernmg these processes. The modern view, however, tends steadily toward the belief that they are not simply the result of a passive lesion of the vessel walls due to the harmful agent, but that the vascular participation, particularly the part played by the capillary endothelium, is essentially an active process. The 86 AMERICAN PRACTICE OF SURGERY. increased permeability of the vessel wall may be clue to an active contraction of the endothelial cells mstead of a passive stretching and thinning. During inflammation the endothelial cells of the inflamed area become larger and more prominent; they also have the power of throwing out protoplasmic processes and of phagocytosis. Foreign bodies and bacteria may be taken up by them. They appear to be increased also in viscosity during inflammation, and the slow- ing of the blood stream and the marginal disposition of the white cells may be aided by this. Further, the character of the inflammatory exudate is strong proof that it is not simply a filtrate but a secretion produced by the selective activity of the endothelial cells. The influence of the vasomotor nerve^ upon the course of the inflammation may be taken as further proof of this view. Al- though the injurious agent may cause passive changes in the vessel wall, there are abundant reasons for believing that the vascular endothelium actively par- ticipates in and favors the occurrence of the inflammatory process. The Cells of the Inflamed .4rea.— The cellular infiltration in and about the ;seat of injury is of a less simple nature than was formerly believed. More de- tailed studies of the cells composing it show that the problems concerning the origin, nature, and function of the round cells of the infiltration are not so easy of solution as was formerly believed. Consequently much discussion has been waged over these questions. While they cannot as yet all be answered posi- tively, we have made at least some progress in our knowledge concerning the character of the cellular infiltration or exudate. In general, it may be said that the predominating forms of cells assembling at the damaged area vary accord- ing to the nature and location of the injury. As a rule, five types of round cells are characteristic of the inflammatory reaction— the finely granular oxyphile (neutrophile) polymorphonuclear or polynuclear, the coarsely granular oxyphile (eosinophile), the small lymphocyte, the large lymphocyte (hyaline cell), and the plasma cell. These different types may not always be present at the same time and in the same proportions. Although at the height of the reaction the inflamed area is usually rich in cells, the variety and proportion in a given case may vary greatly (see Fig. 30). In experimental work it has been found that the first cells to move toward the tissue lesion are the eosinophile wandering cells. The neutrophile poly- morphonuclear then respond, and at the same time the neutrophile polymorpho- nuclears in the blood-vessels begin to emigrate. As a rule, the cells of the in- filtration during the earlier stages of inflammation are chiefly the neutrophile polymorphonuclears or polynuclears with an occasional eosinophile. Under certain conditions the number of eosinophiles may be very great or this form may even predominate. As the inflammatory process increases numerous cells of the lymphocyte type appear, at first collecting about the periphery of the inflamed area, while the polymorphonuclear cells mass themselves in the centre about the inflam- INFLAMMATION. 87 matory agent. Sometimes the lymphocyte type prevails from the beginning of the process, but in the majority of cases the number of lymphocytes increases as the course of the inflammation becomes more protracted. The source of the cells of the lymphocyte type has been a subject for much speculation. Their emigration from the blood-vessels has been denied by most writers, but accord- ing to recent studies such a process undoubtedly occm's. Nevertheless, it is most probable that the chief portion of the cells of the lymphocyte type foimd in the inflammatory infiltration does not come from the vessels, but arises in the tissues through cell division of pre-existing lymphoid cells found there. The writer agrees strongly with Ribbert as to the source of the lymphocj^tes. As a rule, the lymphocytes usually appear in such numbers as to be easily recognizable only after several days from the beginning of the inflammation. They may be scattered among the polymorphonuclear leucocytes, or, as is more common, grouped in little collections. Ribbert regards these lymphocyte Fig. 30. — Isolated Cells from a Granulating Wound (picrocarmine). a, Uninuclear leucocytes; a,, multinuclear leucocyte; b, different shapes of uninuclear formative cells; c, double-nucleated formative cells; c,, multinucleated formative cells; d, formative cells in the process of tissue-formation; e, com- pleted connective tissue, x 500. {After Ziegler.) groups as representing rudimentary lymph nodes, which under the influence of the inflammatory reaction become hyperplastic either from increased cell pro- liferation or as the result of an increased number of lymphocytes coming to them from the blood-vessels. That such rudimentary lymph nodes exist every- where throughout the body there can be no doubt. Recent studies have shown their existence in practically all organs and tissues. In chronic inflammation the increasing hyperplasia of these lymphoid areas, with the development of germ centres in the inflamed area in tissues where lymph nodes with germ cen- tres are not found, is commonly enough seen and is strong evidence in support of Ribbert's views. Hyperplasia of the regional lymph nodes as a part of a local inflammatory process is a well-known occurrence. The WTiter accepts 88 AMEPJCAX PRACTICE OF SURGERY. Ribbert's interpretation of these lymphoid collections as rudmientar}' lymph nodes, and goes a step further. As he has repeatedly foimd lymph nodes with germ centres m newly formed inflammatory tissues on the pleiu-a, peritoneum, and in peritoneal adhesions, etc., where a simple hj^jerplasia is out of the ques- tion, he believes also in a new formation of l}-mph nodes as a part of the inflammatory process, the new nodes arising from the proliferation of wander- ing lymphocytes. Inasmuch as the part plaj^ed by the lymphocytes of the. inflammatoiy infiltration is not phagocytic, it is but reasonable to believe that they must possess some other function. Further mention of this will be made later. The cells of the large lymphocyte type may be in part derived from the small Ij-mphocytes or, as is more probable, are for the chief part young formative cells derived from the connective-tissue cells and endothelium. It is impossible to decide morphologically. There are no staining methods by which young formative cells may be distinguished from Ij-mphocytes. Transition forms ap- pear to exist on both sides, and it is easily understood how some writers regard these cells as of connective-tissue origin, while others regard them as belonging to the white cells and coming from the blood-vessels. The same difficulty of interpretation attends the plasma cells. These are round or oval cells staining deeply with methylene-blue and possessing excen- trically placed nuclei, which have a chromatin network and five to eight chrom- atin granules. As the protoplasm is more compact toward the periphery, the nucleus appears to be surromided by a lighter zone. ]\Iany -m-iters regard these cells as a variety of lymphocyte and claim to have seen them emigrating from the blood-vessels. Others consider them to be of coimective-tissue origin. As these cells show elongated forms graduallj' passing into cells taking part in the formation of scar tissue, and as the protoplasm of the plasma cell often shows an oxj'phile hyaline change, the writer is inclined to accept the view of their connective-tissue origin, not upon the groimd of a demonstrated histogenesis, but upon that of an apparent participation in connective-tissue formation. The plasma cells are particularly abundant in chronic infective inflammations, espe- cially in those characterized by much scar-tissue formation. In blastomycetic dermatitis nearlj- everj^ cell of the infiltration may be of the type of the plasma cell. Occasionally the plasma cells may act as phagocytes, the ■RTiter having seen them containing blastomj'cetes. Multinuclear as well as mononuclear giant cells (Fig. 30) are also found at times in the cellular infiltration, particularly in chronic infective processes and about foreign bodies. In part they may be deri^'ed from leucocytes, but the majority are of connective-tissue or endothelial origin. Their fmiction appears to be essentially protective. Summing up, we may say that the cells of the inflammatory infiltration come in part from the blood, in part from the wandering cells of the tissues. INFLAMMATION. 89 in part from hyperplastic or newly formed lymph nodes, and in part from the proliferation of connective-tissue and endothelial cells. Phagocytosis. — The polymorphonuclear leucocytes and the derivativss of the fixed connective-tissue cells and endothelium have the power of taking up foreign bodies, particularly bacteria. To a less degree the cells of the large lymphocyte type show also the same property. To this process the term phago- cytosis is applied; the cells exhibiting it are designated phagocytes. While such a property is, in the case of monocellular animals, chiefly a nutritive function rather than protective, it has evolved in the multicellular animals to a function of certain forms of cells serving chiefly as protective agents. Through chemo- taxis the cells capable of phagocytosis are brought to the place where their function may be exerted to the greatest advantage. Particularly in the case of bacterial inflammations does this function serve the body as a protective factor. Great numbers of the bacteria are often taken up by the phagocytes and rendered inert or are destroyed within their protoplasm by means of intracellular chem- ical processes. Like the other protective factors of the inflammatory process, phagocytosis is not a perfect means of protection. The phagocytes themselves may be destroyed by the bacteria they have taken up, or they may fail to ren- der inert those they contain within their protoplasm and may thus disseminate them throughout the body by means of the lymph or blood stream. In spite of these facts the unprejudiced observer must realize the great protective value to the body of phagocytosis as it ordinarily occurs in local pyogenic inflamma- tions. The view that it is only an accidental utilization of a function primarily intended for nutrition is not in any way an argument against an appreciation of its utiUty. Extracellular Protective Factors. — Not all the cells of the inflammatory in- filtration have the power of phagocytosis, and the inference naturally arises that they must possess some other function as far as the inflammatory process is concerned. The fact that the blood serum and the serous exudate contain bactericidal substances (alexins) has been demonstrated by many investigators. The source of the alexins has been ascribed by many to the leucocytes, the anti- bodies arising either as a cell secretion or as a product of cell disintegration. That the leucocytes contain bactericidal substances has been shown by Buch- ner, Hankin, and Loewit. Organs and exudates rich in leucocytes yield bacteri- cidal substances. Blood deprived of leucocytes shows a lessening of its bac- tericidal property. Further, Loewit has succeeded in extracting from washed leucocytes a bactericidal substance of great power. According to Kanthack and Hardy, the eosinophile cells, which also respond to chemotactic influences but are not phagocytic, act protectively by discharg- ing the eosinophile granules, which appear to affect the bacteria so that they are then taken up by the phagocytes. Stokes and Wegefarth hold that in the blood serum there are constantly present granules resembling those of the 90 Ali'IERICAN PRACTICE OF SURGERY. eosinophile and neutrophile cells, and most probably derived from them. When these granules are filtered out of the blood it loses its power of destroying bac- teria, but this property may be restored by adding leucocytes and granules. The researches of the last decade have made it evident that the cells of the leucocyte type afford the body protection not only by means of phagocytosis, but by producing and giving to the blood serum or inflammatory exudate bac- tericidal substances. Antitoxic substances may be produced in the same way. Further, the leucocytes of the inflammatory mfiltration may prevent the spread of a harmful agent by means of a denselj^ packed cell barrier formed about the primary centre of injury. Dming the process of repair the white cells may also serve as a source of food to the formative cells, the latter often containing them in various stages of disintegration. The Fluid Exudate. — That there is a direct relationship between the forma- tion of the fluid exudate and the cause of the tissue lesion is shown by the fact that the foniier increases in amount and varies in character with the nature and severity of the irritation produced. The location of the injury and the general condition of the bod}' and nervous system are also factors influencing the amount and character of the fluid exudate. As stated above, there are very good reasons for believing that the fluid exudate is not a filtrate pure and simple, but is a secretion of the vascular walls. Only by means of such a view is it possible to explain the character of the fluid, its difference in composition from the blood serum, and its varying character in different parts of the body. Such differences can be interpreted only as an indication of a selective activity on the part of the endothelium. In the fluid exudate there are present both antibacterial and antitoxic sub- stances, but, as mentioned above, these are most probably formed by the cells and set free into the fluid exudate. On a body surface the fluid exudate may wash away or dilute the mjm-ious agent. In the tissue spaces the inflammatory ojdema may also serve a similar purpose. The formation of fibrm in the exu- date may also be a factor of advantage in limiting the spread of the bacteria. Since its production is associated with the disintegration of leucocytes and others of the wandering cells, it may be associated with the production of anti- bodies or ferments having the power of destruction or digestion of the irritant. Further, the fluid exudate may also serve in increasing the nutrition of the inflamed area and in this way promote cell growth. Part Played by the Nervous System.— Wh\[e acute inflammatory processes may occur independently of the central nervous system, the vessels of the in- flamed area either responding directly to the irritant or through the peripheral nerves, it has been shown experimentally that removal of the vaso-constrictor influence accelerates an inflammatory reaction, while removal of the vaso- dilator influence retards it. Further, influences from the central nervous system alone, without the occurrence of a local injury, may set into action all INFLAMMATION. 91 the phenomena of local inflammation. Such inflammatory reactions of nervous origin may be seen in cases of hysteria and in hypnosis. It is also probable that some of the so-called "sympathetic inflammations" are in reality referred processes having a central nervous origin. Inflammatory reactions may thus be produced along other branches of a nerve supplying a region in which there is a primary inflammation. Likewise, areas whose nervous supply comes from the same part of the brain or cord as that supplying an inflamed part may similarly be involved. Such questions, however, need more thorough investiga- tions before we can unhesitatingly accept such a referred origin. Of the existence of purely trophic nerves there is as yet not a shadow of absolute proof. The inflammatory changes so often seen in parts devoid of nervous supply, as the result of the section or complete destruction of the spinal cord or nerves supplying the part, may be explained as the result of the tend- ency of such tissues to receive trauma in connection with their lowered tone, due to the lack of exercise, disturbed circulation, etc. Part Played by the Lymphatic System. — The important role played in the local inflammatory process by the rudimentary lymph nodes scattered through- out all tissues has been mentioned above. The larger regional lymph nodes and lymphatics have also an important part in inflammation, both clinicaUy and pathologically. The lymph channels leading from the inflamed area become dilated as the result of the increased amount of lymph coming from the inflamed region. Since this lymph may contain the infective agent or chemical products formed by it, the endothelium of the lymphatics in question often becomes hypertrophic and may also exercise a phagocytic function. It is also an open question if such hypertrophic endothelial cells do not produce antibodies. There is also an increased number of leucocytes in the lymph coming from the inflamed part, and some of these may contain the injiu'ious agent. Further, large num- bers of red blood cells may be found in such lymph . The lymph nodes receiving such lymph become enlarged and often painful. On section they are softer and moister than normal nodes, and usually are more or less congested. On microscopical examination they present a condition of congestion, oedema, and more or less hyperplasia of the lymphoid and endo- thelial elements. The lymph sinuses may at times be packed full of large hya- line cells of endothelial type. These especially are found to be acting as jDhago- cytes, and contain red blood cells, blood pigment, leucocytes, or bacteria. Numerous mitoses are found throughout the lymphoid tissue. Leucocytes containing bacteria may also be foimd in the lymphoid areas as well as in the sinuses. That these bacteria are dead or are reduced in virulence is evident from the fact that in the great majority of cases they do not multiply or produce local cell necrosis. Wlien the infective agent is of high virulence small areas of cell degeneration or necrosis are often found in the sinuses or lymphoid tissue, but the fact that the bacteria often soon die out in these areas without causing 92 AMERICAN PRACTICE OF SURGERY. further changes may also be taken as strong evidence of the protective functions exercised. Occasionally these are inadequate and the lymph nodes may be- come the seat of secondary inflammations, equalling or exceeding the primary in severity. The blocking of the lymph sinuses through the proliferation and hyperplasia of the endothelial cells lining them serves as a barrier to the further spread of the infective agent, and gives opportimity for the exercise of the function of phagocytosis and the formation of antibodies. The large mononuclear cells (hyaline cells) lying in the meshes of the reticulum of the lymph sinuses often contain great numbers of disintegrating red blood cells and particles of blood, pigment. They also take up disintegrating leucocytes. The number of eosin- ophile cells is usually increased in the regional lymph nodes during local in- flammatory processes. They are most numerous at the borders of the lymphoid areas along the sinuses. The active proliferation of lymphocytes may also be interpreted as protective. In the case of very virulent organisms or when the resistance of the body is lowered, the injurious agent may extend along the lymph vessels, exciting an inflammatory reaction along their course {ascending lymphangitis), and may also involve the nodes. The latter may present secondary foci without any signs of the intermediate involvement of the lymphatics. Primary cryptogenic infective inflammations are also not uncommon in lymph nodes. Such events simply go to show that the body's protective powers are not always adequate, and that at times the infective agent may conquer them and the process of tissue injury and reaction go on until the organism either finally overcomes or succumbs. Reparative Factors. — As we have already seen, the slightest possible tissue lesion excites chiefly a formative reaction — the cells at or about the seat of injury divide and replace those killed by the injurious agent. In more exten- sive and severe tissue lesions, particularly those due to infective agents, the formative reaction may be longer delayed, owing to the progressive injury to the tissues about the growing colony of micro-organisms. Nevertheless, imder all conditions cell proliferation is so constant a factor of the inflammatory reac- tion that it can be regarded not as a sequela alone, but as an essential part of the process. The tissue destroyed may be replaced by tissue of the same kind (regeneration) or by fibrous connective tissue (repair, cicatrization). Regeneration (Restitutio ad integrum). — "The process of regeneration is dependent upon the kind of tissue involved, the extent and severity of the lesion, and the mode of action of the injurious agent. If the cells of an inflamed area are but slightly damaged and retain their nuclei intact, they are quickly restored as soon as the injurious agent ceases to act. When single cells are lost without disturbance of the tissue organization as a whole, there occurs in the majority of tissues and organs a rapid replacement through the division INFLAMMATION. 93 of the neighboring cells. The connective tissues, the epithelium of the skin and mucous membranes, liver and kidney, have the greatest regenerative capacity; while ganglion cells, bone cells, cartilage cells, and heart muscle have little or none. Cell proliferation may begin as early as eight hours after the lesion, but is usually recognizable at from twenty-four to forty-eight hours. Under certain conditions, particularly in the case of chronic inflammations, the process of regeneration goes beyond the degree necessary for the restoration of the part to its original state, and there result inflammatory overgrowths and hj^per- plasias, which may be of no service to the body or even of a disadvantage. Such hyperplasias are often found about the margins of slowly healing ulcers. Repair. — When the tissue injury is so marked as to cause a break in the continuity of the mesodermal tissues, there is an incomplete regeneration in that there is formed at the seat of injury a new tissue, which differs more or less from the original tissue and shows also a more or less marked loss of func- tion. This new tissue arises through the proliferation of the fixed connective- tissue cells and endothelium about the seat of injury. It consists essentially of proliferated connective-tissue cells (fibroblasts) and new capillary loops, and is infiltrated with mono- and polynuclear leucocytes. Formative cells arising from such tissues as the periosteum, bone-marrow, or muscle are known as osteoblasts, chondroblasts, and sarcoblasts, accordinglj^ as they form bone, carti- lage, or muscle. In the case of injury to epithelial tissue, newly formed epi- thelial cells may also be present in the formative tissue. The formative cells themselves have the power of amoeboid movement and may appear as wander- ing cells. They are sometimes multinuclear or may appear as mononuclear giant cells. They vary greatly in form, are usually branched, and have large bright oval nuclei which do not stain deeply, thereby resembling the nuclei of epithelial cells. For that reason formative cells are often called epithelioid cells. The formative tissue is known as granulation tissue. It is extremelj' vascu- lar; hence to the naked eye it is red in color. The vessels (newly formed capil- lary loops) are characterized by a wide lumen and a wall consisting of a single layer of endothelial cells, which usually appear hypertrophic. The new capil- laries arise as offshoots from the vessels in or near the inflamed area. The new capillaries extend out into the necrotic tissue or exudate at the seat of in- flammation. Between them lie the fibroblasts, embedded in a fluid or semifluid intercellular substance infiltrated with leucocytes. As the fibroblasts increase in number and come to lie more closely together and to supersede the leuco- cytes, fine fibrillse begin to appear in the intercellular substance. As this differentiation of the intercellular substance takes place, the formative cells become smaller, the blood-vessels contract, the granulation tissue gradually becomes changed into scar tissue, and the process of repair comes to an end. In the scar tissue small groups of lymphoid cells may remain for a long time 94 AMERICAN PRACTICE OF SURGERY. after all other signs of inflammation have disappeared. They may be inter- preted as persistent hyperplastic rudimentary lymph nodes. The phenomena of cell proliferation are essentially reparative, but they are also to some extent protective. The zone of granulation tissue about an ab- scess or at the bottom of an ulcer may act as a barrier against the further spread of the infective agent into the surrounding healthy tissues. The great num- ber of thin-walled vessels with their active endothelial cells favors the produc- tion of a serous fluid containing antibodies. Afanassieff has shown that the action of the cells and serum of a healthy granulation tissue is bactericidal. Nevertheless, in some cases the formative tissue may become necrotic as the re- sult of increased virulence of the infective agent, secondary or mixed infection, or weakened resistance due to circulatory disturbances, general ansemia, etc. Moreover, granulation tissue cannot restore the lost function of the part de- stroyed. Again, in some cases the formation of granulation tissue is so excessive as to be of disadvantage or even an injury to the organism, while in other cases still the resulting contraction of the scar tissue may cause additional functional disturbances. The reparative processes, like the protective, are also imperfect and inadeciuate. 6. Symptomatology. The classical symptoms of the inflammatory process (calor, rubor, dolor, tumor, and fundio Icesa) may be manifested when the inflammation is located upon the sm-face of the body. Calor (Heat).— The increased warmth of an inflamed area located upon the body surface is due to the active hypeisemia, the dilated blood-vessels favoring the greater amount of heat dispersion. The inflamed part becomes warmer than it was before only as the result of the increased blood flow. Although many writers have believed in a local increase of heat production, the most careful measurements have failed to demonstrate such a local rise in temperature, the temperature of the affected area never being higher than that of the blood in the left ventricle. The temperature of the body as a whole may be raised (fever). 'While measurements may fail to show any such increased local heat production, it is not at all improbable that such does occur as the result of molecular changes due to the action of the inflammatory agent. Such local increased heat production may easily be compensated by the local increase of heat dispersion, so that the local temperature may be maintained at no greater height than that of the internal organs. The increased temperature may serve a protective function in inhibiting or killing off the infective agent. Rubor (Redness). — This is the direct result of the hypersemia. At fii'st, the inflamed area is uniformly bright red; later, as the blood current slows and a condition of stasis supervenes, the color becomes darker or even bluish, although around the periphery there may persist a bright-red zone. The central portion INFLAMMATION. 95 of the damaged area may be antemic and present a grayish or yellowish color, while around the periphery there is a surrounding zone bright red in color. As the new capillaries extend out into the necrosed area the latter gradually becomes red. During the course of the inflammatory process the diffuse red color often shows a mottling of darker spots, which do not become pale when pressed upon. They are the result of scattered hemorrhages. Dolor (Pam). — The local pain and tenderness may be explained as the result of the increased pressure exerted upon the nerves, their direct irritation by chemical products, or their direct participation in the inflammatory process. In the case of inflammatory conditions of the internal organs, less often of the body surface, the pain is often referred to other parts. Usually this is to parts supplied by branches of the same nerve as that supplying the inflamed area. Tumor (Swelling). — The swelling of the inflamed area is easily explained by the increased amount of blood in the part, the assemblage of cells, the increased formation of lymph, and the swelling of the tissue elements. The lymph stasis (inflammatory oedema) of the inflamed area plays a very prominent role in the enlargement of the inflamed tissues. It is due in part to the changes occurring in the regional lymphatics and lymph nodes, and in part to the diminished elasticity of the inflamed tissues. Altered Function (Functio La?sa). — The alteration or loss of function of the inflamed part is the result chiefly of the tissue lesion, the injury or destruction of the parenchymatous cells, the result of pressure, etc. Constitutional Ssonptoms. — Even in the simple, non-infective forms of in- flammation there may be more or less constitutional disturbances, such as gen- eral malaise, headache, fever, etc., but these symptoms are exliibited to the most marked degree in the case of pyogenic inflammations. High fever, pain in the bones and joints, headache, gastro-intestinal disturbances, nervous disturbances, delirium, etc., may characterize the clinical course of these processes. These sjmiptoms are due to the absorption of toxic substances {piomdins or toxins) from the inflammatory focus. To this general intoxication the terms toxinamxa or septicwmia are usually applied. The poisons absorbed in these conditions may cause a degeneration or necrosis of the epithelium of the liver or kidneys, and the symptoms of acute urtemia may be added to the others. In fatal pyo- genic infections (septiccemia or pymnia) the kidney lesion is usually the imme- diate cause of death {acute degenerative nephritis). The effects of such intoxi- cations upon other organs — as the heart (cardiac insufficiency, "heart failure"), for example — may also be added to the general clinical picture. In the case of chronic inflammations a chronic intoxication may lead to secondary chronic inflammatory processes in the liver, kidney, or other internal organs. Chronic suppurative processes may give rise to a general amyloid degeneration, with its resulting clinical picture. 96 AMERICAN PRACTICE OF SURGERY. 7. Involvement of the Organism in the Inflammatory Process. The inflammatory process is essentially a local reaction to local injury. While the significance of the term might be extended to include the general processes of protection and defence (immunity) of the body against infections or mtoxications, it is inadvisable to do so and better to reserve the term for the local reaction to injury. Further, in the case of general infection or in- toxication of the body, the protective reaction is deprived of the greater part of the phenomena (hypersemia, chemotaxis, emigration, serous exudation, etc.) that characterize the local reaction to injury. In the general reaction the chief phenomenon is the production of antibodies. As a result of the local process, however, the general protective influences are often called into action, and, indeed, must be considered an essential part of the former. This is particularly the case when the inflammation is due to infective micro-organisms producing toxic substances, that when taken up into the blood and lymph cause injury to the cells of the body. Such poisons may arise from the growth of saprophytic micro-organisms in the necrotic tissue or in the exudates at the site of the primary lesion (saprcemia), or from toxins produced there by pathogenic organisms (toxincemia, septicccmia) . The exciting cause (bacteria) may be spread through the body by means of the lymph or blood stream Qmcteriamia) , and give rise to secondary foci of tissue injury and reaction {lymphogenous and hcvmatogenous metastasis). In the case of pyogenic organisms the formation of secondary abscesses is known as pycania. The entrance into the blood of pathogenic micro-organisms and their growth there with the production of a general intoxication, but without the formation of secondary local inflammations, are usually called septiccemia, although this term is also ajjplied to the condition of toxingemia alone without the presence of bacteria in the blood. A combination of pysemia and septi- cemia may also occur {septicopya:mia and pyosepthannia) . The general organism ma}- also be affected in other ways by the local inflam- matory process. In certain organs of the body auto-intoxications may be pro- duced as the result of disturbed function due to inflammation. In the case of glands having an internal secretion, inflammatory processes may lead to severe or fatal disturbances of general metabolism. The interdependence of the fmic- tion of one organ with that of another may also be disturbed as the result of local inflammation. 8. Classification of Inflammations. According to their etiology inflammations may be classed in general as traumatic, thermal, toxic, infective, etc. The non-infective inflammations are often spoken of as simple or aseptic. The terms idiopathic, sthenic, and asthenic inflammations are no longer used. INFLAMMATION. 97 Inflammations are classed as acute, subacute, and chronic, according to their course. AVhen the process rapidly arises and quickly passes it is termed acute; when slowly progressive over a long period of time it is classed as chronic. Processes occupying an intermediate station may be known as subacute. In general, acute inflammations are characterized by abundant exudation, chronic inflammations by abundant production of connective tissue. Such a distinction does not, however, always hold good, but applies to the great majority of cases. According to their location inflammations may be classed as superficial, parenchymatous, or interstitial. Superficial inflammations are those situated upon a body surface. Upon mucous membranes the inflammation is more often designated a catarrh. A parenchymatous inflammation is one character- ized by degeneration or necrosis of the parenchymatous cells of an organ, while an interstitial inflammation is one in which the connective tissue or supporting stroma of the organ is chiefly involved. Such a distinction is somewhat arti- ficial, since all inflammatory processes necessarily are interstitial, the interstitial reaction following and being dependent upon a damage to the parenchymatous cells. As a rule, the term parenchymatous inflammation is applied to conditions of tissue lesion (degeneration or necrosis) in which the inflammatory reaction may not yet have appeared, so that interstitial changes are not yet apparent. Since the term interstitial has largely come to be used as a synonym for productive inflammation, — that is, those inflammations which are characterized particularly by proliferation of the connective-tissue cells, — it serves to designate a certain class of inflammatory processes more or less chronic in nature and due chiefly to chronic intoxications. The character of the tissue lesion also serves as a basis for a classification of inflammation. When tissue degenerations — such as cloudy swelling, hy- dropic, fatty, or mucoid degeneration — are more prominent as the tissue lesion than is the inflammatory reaction, the inflammation is usually styled degener- ative. Since those forms which are characterized by mucoid degeneration usu- ally occur upon mucous membranes, they are embraced in the more general des- ignation of catarrh. Tissue lesions of the nature of a marked necrosis give to the inflammatory process a necrotic character. The necrosis may be of the type of simple, coagu- lation, liquefaction, caseation, or gangrenous. A coagulation necrosis occurring upon a surface, particularly upon a mucous membrane, is usually styled diph- theritic, or the entire process may be known as diphtheritis. A fibrinous exu- dation is usually associated with the latter process. Secondary infection of the tissue lesion Avith saprophytic bacteria gives to the process the type of a gan- grenous inflammation. A prunary gangrenous inflammation may also occur. Infection with the gas-forming bacteria gives rise to an emphysematous gangrene. Caseous necrosis is found particularly in the case of certain chronic infective inflammations, tuberculosis, syphilis, etc. 98 AMERICAN PRACTICE OF SURGERY. The classification according to the character of the exudation serves a very practical purpose both clinically and pathologically. There may be distm- guished, first, a serous inflammation, characterized by the production of a more or less abundant fluid exudate containing relatively but few cells. When the percentage of fibrin is so high as to make it a very prominent featme of the exu- date, it is classed as fibrinmi-s. When the cellular infiltration of the inflamed area is but slight, it is spoken of as a small-celkd infiltration; but when the cells are so nmnerous as to pack densely the area, or when occurring in such mmibers in the fluid exudate as to give it a thick, cloudy appearance, the inflammation is styled ipundent. The liquefaction of the piu-ulent area is knowoi as suvpura- tion, and the resulting mixtiue of leucocytes, tissue fragments, etc., is called pus. An exudate containing large numbers of red blood cells may be styled hemorrhagic. Various combinations of these forms may occur, such as sero- purulent, serofibrinous, fibrinopurulent, etc. Inflammations are also often classed according to their mode of resolution or the sequela? of the inflammatory process. Some inflammations cause marked atrophy of the part affected {atrophic infiammations) ; others are characterized by marked proliferation of the comiective-tissue stroma {interstitial, productive, hyperplastic, indurative, cirrhotic, etc.). Serous sm-faces may become greatly thickened or opposing sm-faces may become vmited tlu^ough the organization of the exudates gluing them together {adhesive or plastic infiammation). In the case of certain chronic uifections, large tmnor-like growths of granulation tissue may be produced {gramdoma). Marked sequete of such a nature as to charac- terize the inflammation occur more often as the result of protracted chronic inflammatory processes than as the result of the healing of acute processes. Varieties of Inflamm.a.tion. Etiology. Chronicity. Location. Tissue-Lesion. Exudation. Sequelae. Traumatic Acute. Superficial (ca- Degenerative. Serous (catar- Atrophic. (simple). Subacute. tarrh). Necrotic. rhal). Hyperplastic Thermal. Chronic. Parenchyma- 1. Simple. Fibrinous. (productive). Toxic. tous. 2. Diphtheritic! Purulent (sup- Indurative. Infective. Interstitial. 3. L iquefactiouj purative). (sup pur a- Hemorrhagic. Adhesive. Granuloma. tion). 4. Caseous. 5. Gangrenous. 9. Resolution of the Infl.\mmatory Reaction. That the inflammatory reaction be brought to a standstill and the process terminate in healing, it is necessary that the exciting cause should cease to act, the necrotic tissue and exudate be disposed of, the nutritive and circulatory conditions be restored to the normal, and the tissue defect, if any, be repaired. Cessation of Cause. — The action of the injurious agent may be of very INFLAMMATION. 99 short duration, as in the case of certain forms of trauma. In the case of poisons the pouring out of a fluid exudate may dilute the irritant or wash it away. In infective inflammations the bacteria may be washed away by the fluid exudate, cast off with tissue sloughs, or rendered non-virulent, or are killed by the phago- cytes and the extracellular bactericidal substances formed during the inflamma- tory reaction. The irritant substances formed by bacteria may be neutralized by antitoxins. Disposal of Necrotic Tissue. — Dead cells or tissue elements may be cast off as a slough, liquefied, in part absorbed and utilized as nutriment, or replaced by granulation tissue (organization). The sequestration and absorption of necrotic tissue require a certain amount of time. The greater the amount of dead tissue, the slower the removal and the more protracted the healing process. As a rule, the inflammation persists as long as necrotic tissue is present. Disposal of the Exudate. — Serous exudates may be quickly taken up by the l3miph stream. Fibrinous exudates, when soon liquefying, may also be quickly absorbed. Firm fibrinous exudates and large collections of pus are re- moved with difficulty and prolong the course of the inflammation. Exudates upon a surface may be cast off. Firm exudates often become liquefied and are then more easily absorbed. When liquefaction does not take place, the exu- date acts as a foreign body and prolongs the inflammation, eventually becoming replaced by granulation tissue (organization). Scar tissue is ultimately formed. Restoration of the Normal Circulation. — With the cessation of the action of the injurious agent and the removal of dead tissue and exudates and the establishment of reparative processes, the hyperajmia of the vessels of the in- flamed area subsides, the leucocytosis and emigration diminish, and the number of wandering cells in the tissue spaces becomes lessened. Ultimately the normal vascular conditions are restored, and the nutrition of the part again becomes normal. Wlien the irritant is of slight intensity and diu-ation, as in the case of a slight tramna, bmn, corrosive poison, etc., the restoration of the vessels may take place in a very short time. In the case of more extensive tissue lesions, the normal vascular conditions are more slowly restored. When granulation tissue has replaced a tissue defect, the newly formed blood-vessels become smaller as the transformation into scar tissue takes place. Collections of Ijonphoid cells may persist long after all other signs of the in- flammatory reaction have disappeared, and are best explained on the groimd of hyperplastic iTidimentary lymph nodes. In general, the restoration of the normal vascular conditions depends upon the duration of the exciting cause, the amoimt of dead tissue and exudate to be disposed of, and the size of the defect to be filled in. Repair of the Tissue Defect. — This is accomplished by cell proliferation leading to regeneration or repair, according to the nature and severity of the inflammatory agent and the character of the tissue involved. When only single 100 AMERICAN PRACTICE OF SURGERY. cells are lost or the organization of the tissue is but slightly disturbed, there oc- curs in the majority of tissues a rapid regeneration. In the case of more exten- sive lesions, solution of continuity, womids, fractiires, necrotic inflammations, suppurations, etc., there is first formed a granulation tissue, which later becomes changed to scar tissue. Evidences of the beginning of cell proliferation may be seen microscopically as early as eight hours after the injury, but the process is usually not well established until after twenty-four hours or later. The estab- lishment of cell proliferation is dependent upon the cessation of the exciting cause and the supply in abundance of the materials necessary for the nutrition of the cells. In some cases the phenomena of cell proliferation are so early established and form so marked a characteristic of the inflammation as a whole that it may be styled a productive or a proliferating inflanmiation. All factors delaying the progress of healing, such as large areas of necrosis, large masses of purulent or fibrinous exudate, etc., give to the inflammation the character of a chronic process. 10. The Healing of Inflammations. The termination of the mflammatory reaction is knoTsm as healing. The factors constituting the resolution of the inflammatory process and upon which the healing process depends have been considered in the previous section. It is, of com-se, evident, according to the standpoint taken in this article, that the entire course of an inflammation is directed toward a common end — that of healing; and it is, therefore, not possible to separate wholly the reparative factors from those pm'ely protective. Wliile the enthe inflammatory reaction is, broadly viewed, a healing process, the term is used here in a narrower sense as applying to the final phases of the reaction. Healing by First Intention (per primam intentioiiem) . — In the case of an incised Mountl of the skin whose edges are glued together by serum or blood or are held together by sutures, the inflammatory reaction, in the absence of bac- terial infection, is slight. Along the edges of the wovmd there is at first an abundant exudation of serum containing more or less blood; this, coagulating, holds the opposing woimd sm-faces together. At the same time there occurs along the edges of the wound a cellular infiltration, which is usually not very marked and reaches its maxhnum in a few days. "When sutures have been used the infiltration is usually more marked about these than along the edges of the womid. By the end of twenty-four hom-s cell proliferation is usually well established along the edges of the womid. By the third or fourth day there is formed a granulation tissue, which replaces the exudate or blood clot between the woimd surfaces and miites them together. The formative tissue extends also on both sides of the wound for some little distance along the blood- and lymph-vessels into the neighboring sound tissue, thus blending the wound into the neighboring tissue in such a way that the edges of the original line of INFLAMMATION. 101 incision become indistinct. (See Fig. 31.) At tlie same time a regeneration of the surface epithelium is taking place, the epithelial cells at the edge of the wound pushing over the wound surface and dividing to form many layers. The forma- tive tissue along the line of the incision gradually becomes less rich in cells, its blood-vessels contract, and there is a differentiation of fibrillar in its intercellular substance. Nevertheless, for a long time afterward the scar thus formed may show evidences of proliferation and cellular infiltration. Finally, the place of the incision can no longer be made out, as the line of scar tissue comes to re- ■^v.'"^^^^ ^3-_@#»5^'-f-Cr^ 3 :M(m^j§^'T--'3^% Fig. 31. — Healing of Incised Wound of Skin united by Suture (Flemming's solution, safranin). Prep- aration made on the sixth day. a, Epidermis ; b, corium ; c, fibrinous exudate, in part hemorrhagic ; d, newly formed epidermis, containing numerous division figures, and witli plugs of epithelium extend- ing into the underlying exudate; e, division figures in epithelium at a distance from the cut; /, pro- liferating embryonic tissue, developing from tlie connective-tissue spaces, and containing cells with nuclear division figures, and in part also vessels with proliferating walls; g, proliferating embryonic tissue with leucocytes; h, focus of leucocy1:es in deepest angle of wound; i, fibroblasts lying within the exudate, one showing a nuclear division figure ; k, sebaceous gland ; I, sweat gland. X 70. (After Ziegler.) semble the neighboring coimective tissue. The time necessary for the complete healing of such a wound depends upon its size, the thickness of the layer of exudate or blood clot lying between the opposing woimd surfaces, and the pro- liferative capacity of the tissue. The formation of granulation tissue along the line of incision is not always imiform; it may be absent in places or vary greatly in amount at different levels. The surface epithelium may extend across the wound before the formative tissue has developed below. Occasionally it may become hyperplastic. Wlien much scar tissue is formed, its later contraction 102 AMERICAN PRACTICE OF SURGERY. causes a flattening or even depression of the cutaneous surface. The papiUary bodies may not be regenerated and a smooth scar may result. (See Fig. 32.) Healing by Second Intention {mr seomdam intentionem) . — In the case of an open wound of the skin whose edges cannot be brought together, there oc- curs, in case the wound does not become infected, a serous or bloody exudation followed by cell proliferation at the base of the wound. Within twenty-four hours the base of the wound is deep red in color and more or less swollen. It is covered with a reddish-yellow exudate. After twenty-four hours there begin to develop over the base of the wound small red papules of formative ..j^^<-^L/j( Fig. 32. — Cutaneous Portion of a Laparotomy Cicatrix, Sixteen Days after the Operation (Mueller's fluid, litematoxylin, Van Gieson's). a, Epithelium; b, corium; c, subcutaneous fat tissue; d, scar in corium; e, new epitlielial covering ;/, scar in fat tissue. X 38. {After Zieglcr.) tissue. These increase in number and become confluent, so that by the fourth or fifth day the entire floor of the wound may be covered by a granular red surface, over which lies a more or less thick, grayish, gelatinous layer of exu- date. This exudate is very rich in albumin and fibrinogen, and contains many round cells, chiefly of the polymorphonuclear variety {"pus cells"). Many of these show degenerating nuclei. The formative tissue {granulation tissue) at the base of the woimd con- sists of fibroblasts, newly formed capillary loops, and leucocytes embedded in a fluid or semifluid intercellular substance. In the latter there is soon developed a fibrillar ground substance. Over the surface of the granulation tissue there is a layer of exudate rich in fibrin and containing many pus cells. INFLAMMATION. 103 (See Fig. 33.) At the edges of the wound there is a rapid proliferation of the epithelium, and a layer of newly formed epithelial cells pushes in from the periphery over the wound granulations, often extending deep down under- neath the superficial layer of exudate. As the wound becomes covered with epithelium and as the granulation tissue is gradually differentiated into fibrous connective tissue, the proliferative processes gradually come to a standstill. The scar thus formed is at first very vascular and of a red color. It is often elevated and covered with hyperplastic epithelium. As the scar tissue con- tracts the vessels become smaller and many of them are obliterated. The new tissue also loses in volume. Ultimately the scar becomes pale, smooth, and often depressed. The papillary bodies are either not regenerated or they are reproduced only to a slight degree. For a long time the tissue of the scar is rich in cells, but these gradually become reduced in numbers and the tissue be- comes dense and hyaline, showing rela- tively few cells. New elastic fibres may be formed. The regeneration of the cutaneous glands depends upon the severity of the original injury. If portions of the glands are preserved, new glands may be formed from these. The process of healing by second intention is the same in the case of wounds of the internal organs in which the defect is large enough to be filled in with granulation tissue visible to the naked eye. In the case of surfaces not covered with epithe- lium, the new scar tissue is covered with endothelium (mesothelium) or be- comes adherent to neighboring struct- ures. In the case of infected wounds and in ulcers due to pathogenic micro-organisms, the process of healing is essen- tially the same, although more prolonged. In the case of large defects healed by second intention, the resulting contraction of the scar tissue may lead to marked deformities of the organ involved. Healing of Abscesses. — In the case of small abscesses the pus may be quick- ly liquefied and absorbed, and the defect is closed up by granulation tissue which is transformed into scar tissue. In the case of larger abscesses there is formed about the periphery of the cavity a zone of granulation tissue known Fig 3o — Wound Gran il t n^ irom an Open Wound \Mth Fibrmopurulent Co\ermg (Muellers fluid, ha?matoxylin). a, Granulation tissue; b, fihrinopurulent layer; c, blood-vessels. X 135. {After Zicgler.) 104 AMERICAN PRACTICE OF SURGERY. as the abscess membrane {pyogenetic membrane). As the contents of the cavity are gradually liquefied and absorbed, the zone of granulation tissue extends toward the centre and gradually fills up the defect. Scar tissue is then formed and the process of healing is complete. If the process of liquefaction and ab- sorption is incomplete, the pus may become inspissated or calcified. Healing of Ulcers.— Ulcers heal by second intention, as described above. Healing of Empyemata.— Large amounts of pus may be absorbed from the body cavities. Wlien the process of absorption is slow or if the pus is inspis- sated, the tissues enclosing the pus produce formative tissue and the healing process is precisely the same as that in the case of an abscess. Large amounts of granulation tissue may be formed in the case of chronic empyemata. If the process is incomplete the remains of the pus may become calcified. Healing of Fibrinous Inflammations.— Upon a mucous surface fibrinous exu- dates are cast ofi^ or liquefied. Only rarely (healing diphtheritic processes) do they become organized. In the case of the pulmonary air spaces, masses of #'r.' -f* Fig. 34. — Scheme of the Organization of a Fibrinous Exudate on Serous Membrane. 1, Cellular infiltration beneath the fibrin; 2, first extension of fibroblastic tissue into the fibrin; 3, replacement of fibrin by fibroblastic tissue; 4, fibrin nearly wholly replaced by vascular formative tissue; 5, complete replacement of fibrin and beginning contraction ; 6, contraction and transformation into scar tissue. {After Ribbert.) coagulated exudate when not liquefied and absorbed may be replaced by gran- ulation tissue, which fills up the alveolar spaces, leading to an induration of the lung {fibroid -pneumonia). The fibroblastic proliferation proceeds either from the connective tissue of the septa or from that of the alveolar walls. Upon serous surfaces a deposit of fibrin usually leads quickly to proliferative processes, so that as early as the fourth day fibroblasts may be seen extending up into the fibrinous layer. This is soon followed by a growth of capillary loops, and the fibrin layer is gradually replaced by a vascular granulation tissue, which later becomes changed to a dense hyaline scar tissue. (See Fig. 34.) Re- mains of the fibrin may persist in the new tissue for a long time. If the exudate was limited in area the new tissue becomes covered with endothelium (mesothe- lium), but when it is of large extent the opposing serous surfaces usually become united by the process of organization (adhesions). Such inflammations are usu- ally spoken of as adhesive. (See Fig. 35.) It is evident that the character of the healing process is dependent upon the amount of the fibrinous exudate and the INFLAMMATION. 105 situation and relations of the affected serous surface. In the case of small de- posits the organization of the fibrin leads to, thickenings of the serous mem- brane. The gluing together of two serous surfaces by a fibrinous exudate leads also to the formation of adhe- sions. When the amount of fibrin is small and the two sur- faces move upon each other, stringy adhesions may be formed. Large amounts of fibrin may fail of absorption and be- come inspissated or "calcified. Healing of Thrombi. — Coag- ulated masses in the blood-ves- sels are replaced by connective tissue in the same maimer as are fibrinous exudates upon serous surfaces. There is a fibroblastic proliferation of the cells in the vessel wall. Fibro- blasts and newly formed Capil- Fig. 35.— Formation of Adhesions between the Layers of . 1 . -I j_ • , l_^ the Pericardium in Fibrinous Pericarditis, a, Epicardium: lary loops extend out mtO the ^^ ^^^.^^^^ i^^^^. ^_ ^,^^^^3 ti^^^,, containing remains thrombus, which is gradually of fibrin; d, connecting bridges of formative tissue. (^After , , , , , Weichselbaum.) replaced by vascular granula- tion tissue, which later is transformed into a denser fibrous connective tissue. The vessel lumen may be obliterated or the vessel wall may present local thickenings. Failure of organization may be followed by calcification of the thrombus. Healing of Necrotic Areas.^Masses of necrotic tissue that cannot be dis- posed of by sloughing and sequestration are replaced by formative tissue and scar tissue, in the same manner as takes place in the case of fibrinous exudates and thrombi. The organization begins at the periphery and extends toward the Fig. 36. — Foreign-body Giant Cells attached to Silk Thread. {After Ribbert.) centre of the dead area. Large masses may become encapsulated, the central necrotic material becoming inspissated, calcified, or liquefied. Healing of Foreign Bodies. — In the case of bland foreign bodies that are easily absorbed, the process of healing takes place in the same manner as in the case of fibrinous exudates or necrosed tissue. The foreign substance is 106 AMERICAN PRACTICE OF SURGERY. liquefied and the defect replaced by scar tissue. Small bodies that cannot be liquefied are taken up by phagocytes and in the course of time are gradually removed from the body (dust, carbon, tattoo, etc.). In the case of bodies too large to be taken up entire by phagocytes, there occurs in the granulation tissue developing about them a formation of large multinuclear giant cells, which at- tach themselves to the surface of the foreign body and cling to it (foreign-body giant celU.) (See Fig. 36.) These cells resemble the physiological osteoclasts. If the foreign body is slowly soluble (catgut, etc.) these cells gradually bring about its disintegration. When the foreign body contains crevices, the protoplasmic processes of the giant cells extend into these and gradually widen them. If the foreign substance is insoluble (hairs, silk, silver wire, etc.), the giant cells cover- ing it gradually give place to a capsule of scar tissue (encapsidation). In the case of smooth bodies (glass, etc.) the amount of granulation tissue formed A B C Fig. 37. — Anterior Chamber of Rabbit's Eye after Injection of Agar. A, Three days later. Iris be- low ; above, the homogeneous agar containing leucocytes and some fibrin. B, eight days later; large for- mative cells about the agar mass. C, three weeks later; spindle cells replacing agar. {After Ribbert.) may be very small. Not all foreign bodies excite the production of giant cells; hard bodies coming from without the body favor most their production, but ex- trinsic soft bodies may also cause their formation in large numbers. (See Figs. 37 and 38.) They are, however, frequently seen about necrotic tissue (dead muscle fibres). The giant cells arise from the connective-tissue cells and the endothelium. Mitotic division of the nuclei takes place without division of the protoplasm. While many of the giant cells appear to undergo dis- integration, some split up into fibroblasts and take part in the production of scar tissue. The leucocytes also play an important role in the reaction against foreign bodies. They usually quickly assemble at their site, take them up when pos- sible, penetrate into their crevices, and aid in the process of disintegration. Fibroblastic proliferation follows or is associated with the assemblage of leuco- cytes, many of the fibroblasts actuig also as phagocytes. INFLAMMATION. 107 11. Sequel.e of Inflammations. The sequels of inflammations depend upon" the nature of the exciting cause, the location of the tissue involved, its character and condition, the severity of the process, the length of the course, and the nature of the healing process. In a general way the most important sequelae of inflammation are those dependent upon cicatrization. The formation of scar tissue with subsequent contraction may lead to extensive atrophy of the parenchyma of the affected organ. The obliteration of serous cavities or the formation of adhesions on serous mem- branes may lead to serious impairment of function. The constriction of the r, 0. '• Fig. 38. — Subcutaneous Injection of Agar. Ten weeks after. A, Agar mass in centre of large, multinucleated giant cell showing numerous processes. {After Ribbert,) intestine by such bands of inflammatory adhesions may lead to fatal results. The contraction of scar tissue leads also to surface disfigurations and defor- mities. The involvement of old nerve trunks or of newly formed nerve fibres in the scar tissue may give rise to an "irritable scar." Through the organization of fibrinous exudate upon their serous surfaces the capsule of such organs as the liver, spleen, etc., may be greatly thickened. This thickening of the capsule may lead to a further secondary atrophy of the parenchyma. The obliteration of blood-vessels through the organization of thrombi or connective-tissue prolif- eration of their walls leads likewise to secondary parenchymatous atrophy. Through the organization of exudates lying within small body cavities, as the pulmonary air spaces, induration of the affected organ follows and the spaces are wholly or partly obliterated. The contraction of the scar tissue folloT\ang the healing of ulcers of body passages, such as the oesophagus, stomach, intes- 108 AiMERICAN PRACTICE OF SURGERY. tine, etc., may result in partial or complete stenosis. Inflammatory atresias may occur (vagina). On the other hand, many inflammatory processes lead to an overproduction of tissue. Extensive new formation of bone may follow chronic inflanmiations of the periosteum or bone marrow. Connective-tissue hyperplasias of great ex- tent may be associated with the presence of filaria in the lymphatics of the scrotum and extremities (elephantiasis). Chronic inflammations of the skin and mucous membranes may be foflowed by polypoid or wart-like hyperplasias of the connective tissue and epithelium (condylomata). Similar hyperplasias may be seen about the edge of chronic ulcers and in association with chronic infec- tive processes. Many chronic infective inflammations are characterized by tu- mor-like formations of granulation tissue (syphilis, tuberculosis, leprosy, etc.). These are usually classed under the head of infective granulomata. The process of regeneration often leads to an overproduction of epithelial structures, as hap- pens in the new formation of bile ducts occurring in hepatic cirrhosis. 12. Significance of the Infl.uimatory Process. Summing up the features of the inflammatory reaction, we find that the process as a whole is of decided advantage to the organism. Chemotaxis, phagocytosis, increased formation of lymph, hypertemia, emigration of white cells, formation of extracellular and intracellular bactericidal substances, pro- duction of antitoxins, formation of cell barriers, the increased temperature, cell proliferation, etc. — all of these factors in the process can be interpreted as serv- ing for the protection or repair of the organism. Inflammation may then be considered a body fimction. As a matter of fact, practically all the factors of the inflammatory reaction are constantly active in the body. Phagocytosis, chemotaxis, Ij^mph formation, cellular emigration, cell prohferation, etc., are constantly occurring in the body, but become manifested as inflammation only when occurring in a greater degree than under ordinary conditions. Like all other body functions, that of inflammation is subject to disturbances and is often very imperfectly carried out. Wlien the great variety of factors and con- ditions influencing it is considered, there need be no wonder at the fact that in the struggle for protection and defence the inflammatory function as a whole may appear as a harmful process rather than as a preservative one. The in- flammatory factors work more or less blindly, without discrimination. The inflammatory reaction cannot adapt itself to the anatomical and fimctional peculiarities of different organs and tissues. Thus an inflammatory reaction that may be successful from the standpoint of protection in other parts of the body may lead to fatal results in the larynx or brain, as the result of occlusion or pressui'e. Welch speaks of the " excesses, disorders, and failures incident to inflammation." As the adaptation of the animal body to the extrinsic factors INFLAMMATION. 109 influencing it is an imperfect one, so is the local reaction limited and imperfect. Against some injurious agents the organism ■ is able to produce but a slight reaction. The serous exudate may have little or no bactericidal action. The formation of antitoxin may be limited or not occur. Positive chemotaxis may not occur. The phagocytes, instead of destroying, may be destroyed or may transport the injurious agent (bacteria) to other parts of the body. The pour- ing out of an exudate into the pericardial cavity may seriously impair the effi- ciency of the heart. Collections of exudate in the pleural cavity cause inter- ference with both respiratory and cardiac functions. Meningeal exudates cause cerebral compression; the filling up of the pulmonary air spaces with exudates causes respiratory and circulatory embarrassment ; inflammatory processes upon the heart valves are followed often by stenosis or insufficiency, etc. The con- traction of scar tissue may lead to severe secondary anatomical changes and functional disturbances. In its somewhat blind method of carrying out its protective function, the inflammatory reaction creates conditions that are in themselves harmful or dangerous. In the attempt to overcome the primary injury, the creation of such dangerous conditions is at times unavoidable. \¥hile such injurious effects of the inflammatory reaction give to it, when viewed from the standpoint of the clinician, the character of a harmful process demanding surgical intervention, they should not blind him to the essential biologic facts. Inflammation is an exaggeration of normal body functions — a struggle for protection and self-preservation — becoming manifest as the reaction to local injury. 13. General Indications for Treatment of Inflammation. While taking the ground that the inflammatory reaction is but an exaggera- tion of normal body fimctions aimed at protection and repair, the necessity for medical and surgical intervention is not denied. On the contrary, such active intervention becomes more clearly indicated as the limitations and imperfections of the protective and reparative processes are recognized and the better under- stood. Having gained the knowledge that inflammatory processes possess a unity, we are put in a position to apply logical and scientific methods of treat- ment. And it is to this knowledge that the surgery of the last twenty years owes its wonderful advance and its brilliant victories. The discovery of the nature of the most common and important etiological factors of inflammation, and the knowledge of the body's means of defence and protection against these agents, have raised the treatment of inflammation to a wonderful plane of ad- vance. Surgery, in so far as the treatment of inflammation is concerned, has, also, become protective and defensive. Realizing the limitations and imperfec- tions of the body function, it attempts to aid its protective and defensive powers, to limit them when necessary, and to avoid the " excesses, disorders, and failures " no MIERICAN PRACTICE OF SURGERY, of the inflammatory reaction. Tlie surgeon supplies tlie additional higher func- tion of judgment and discrimination in the struggle for self-preservation. He seeks to avoid the most dangerous etiological agents, to prevent simple iniunes from becoming progressive (infection), to limit infection when it has occurred, to aid in the destruction of the infective agent, to control the body's defensive powers in such a manner that damage may not result from the collection of exudates, to shorten the course of the reaction by the removal of necrotic tissue, exudates, etc., and to further the com-se of repau- by the coaptation of wound sin-faces, removal of dead tissue, etc. In addition, the smgeon endeavors to support the organism as a whole, to keep up its tone, to increase its resistance, to counteract the effect of general intoxications, and to prevent their occur-rence. By means of bactericidal sub- stances and antitoxins the body may be rendered immune to certain agents that otherwise would excite tissue lesions and inflammatory reaction. The surgeon may supply at the very beginning, before serious damag* is done, those ele- ments which the body itself can produce only later in the course of an infection after more or less severe local injury has occm-red. To this especial branch of treatment we look for greater results. The aid which the surgeon brings to the body's protective forces is, however, still imperfect. The course of many infections he carniot check, his operative procedures may often do more harm than good, the bactericidal substances which he uses may injure the tissues, he may lower the local resistance instead of raising it by the removal of exudates, and he may be the means of dissemina- tion of the infective agent. Such imperfections of surgical technique we look for the future to remove. As our knowledge of the biologic facts underlying the inflammatory reaction increases, so will the methods of treatment become perfected. II. ACUTE INFLAMMATION. 1. Acute Simple Inflammation. The term simple inflammation is usually employed to indicate a reaction to trauma, or to thermal or chemical agents, rather than one resulting from infection (infective inflammation). The term "aseptic injiammation" is sometimes used as a synonym, but the impropriety of this is evident. Since the non-infective inflammations are usuall}^ non-exudative in character, these terms have also been used interchangeably. Further, since the non-infective inflammations usu- ally terminate in repair or regeneration, they are often spoken of as formative inflammations. But inflammatorj^ reactions of exactly the same clinical charac- ter may be produced by bacteria of low virulence, the colony quickly dying out, so that the process is non-exudative and non-progressive. Bacterial prod- ucts (toxins) produce similar inflammatorj^ reactions. For that reason it is not INFLAMMATION. Ill best to limit the term to non-infective processes, even though in the great major- ity of cases simple non-exudative inflammations are not the result of infection. The term simple inflammation is, therefore, used here to indicate the simple re- action to injury when it is characterized not by exudative processes but by formative. Simple inflammations may be caused by mechanical injury (friction, blows, cuts, wounds of any nature, surgical operations, etc.), burns, freezing, corrosive poisons, poisons having local irritant action, electricity, radioactivity, anaemia, distin^bed nutrition, etc. As mentioned above, an infection with germs of low virulence that quickly die out may produce a similar clinical and histological pictm-e. The symptoms of simple inflammatory reactions are the five cardinal ones, more or less modified by the etiological factor and the location of the injury. As a rule, the hyperemia of simple inflammation is less marked than in the exudative forms. Since the various forms of simple traumatic injury are the most common causes of simple inflammation, the symptoms usually observed are, first, a certain degree of redness, warmth, and swelling about the injury, with more or less pain or soreness. The intensity and character of the pain are dependent largely upon the location of the lesion. Even with the slightest wound there may be some constitutional symptoms, notably some elevation of temperature. The general symptoms are usually not marked unless the wound is severe or covers a large surface. Symptoms of shock may be associated with those directly due to the injury. As simple inflammations are not progressive and do not spread, the symptoms usually reach their height during the first two or three days and then gradually disappear as the process undergoes resolution. The microscopical picture is that of a simple inflammatory reaction charac- terized chiefly by the assemblage of wandering cells and the proliferation of the connective-tissue cells and endothelium. The healing of wounds may take place either by first or by second intention, according to the character of the wound. Treatment. — The treatment of simple inflammations is directed chiefly toward the prevention of infection with pyogenic organisms, to minimize the tissue damage as much as possible, and to hasten resolution. At the same time attention is directed toward the relief of the symptoms. General Measures. — Of the more general measures to be carried out in the treatment of simple inflammations, rest is of the greatest importance. If there are constitutional symptoms (fever) the patient should be kept in bed; other- wise, rest of the affected part will suffice. Elevation of the inflamed part often gives marked relief. The diet is of great importance, particularly after surgical operations. Nutritious and easily digestible food should be supplied. Milk diet, either as fresh or sterilized milk, or mixed with lime water or potassium bicarbonate, is indicated after most operations, except those in which move- 112 AMERICAN PRACTICE OF SURGERY. ments of the bowels are not desired for several days (operations upon rectiim and perineiun). Light nutritious diet may be substituted for the milk diet or may follow it, as indicated. Boiled or distilled water should be given frequently in small quantities. Nutrient enemata may be given when food caimot be borne by the stomach. Thirst is often markedly relieved by enemata of physio- logical salt solution. Several days after the operation a more varied solid diet may be given. Alcohol should be used with caution. It may be of service as a temporary stimulant when the pulse shows signs of cardiac weakness. During convalescence the lighter alcoholic drinks may be used as tonics. On the whole, the general treatment is directed toward the support and building up of the organism. Of actual drug treatment little or none is usually indicated. Antipyretics probably do actual harm and are contraindicated in surgical cases. Pvugatives are to be used with judgment and discrimination for the pm-pose of preventing intestinal auto-intoxications. They are also occasionally indicated to relieve the tension arising from collateral congestions and to excite peristalsis. Dia- phoretics and diuretics are now rarely employed. Pure water given frequently in small quantities serves best for these indications. Wlien the pain is severe morphine may be used with discrimination, but it should never be given as a matter of routine. The first night after an operation may often be passed to greater advantage if a hypodermic injection of morphine is given. Under other conditions one-eighth to one-sixth of a grain by the mouth usually suffices. If indicated it may be given in a rectal suppository. On the whole, it is better to look upon the use of morphine as a last resort and to avoid its use in private practice whenever possible. The pain and restlessness may often be successfully combated by other means. Warm baths, hot or cold pack, potassium bromide, sulfonal, trional, and other hypnotics may be used. Phenacetin is often of service in relieving neuralgic pains. Chloral should be used with the same pre- cautions as morphine. The period of convalescence from injury or operation demands careful hygienic measures. Massage, directed active and passive exercise, proper diet, rest, etc., should be systematically carried out according to the needs of the case. Tonics may be given when the patient is anaemic or shows little inclination for food. The symptoms of shock are often added to those of the inflammatory reac- tion. This is most likely to be the case after injuries to the abdominal cavity, scrotum, spinal column, etc. Extensive burns of the skin, lightning or elec- trical shocks, corrosions, etc., are frequently followed by shock. Conditions of nervous excitement predispose to shock, while narcosis or alcoholic intoxication serves to inhibit it. The treatment will be considered mider the proper heading. Local Treatment. — The chief consideration in the local treatment of in- juries is the prevention of infection. The general principles of aseptic surgery will be treated in another chapter. In this place only the treatment of the INFLAMMATION. 113 simple inflammatory reaction following the proper treatment of the woimd or injury will be considered. It will be assimied that the wound or part has been carefully cleaned and made aseptic, hemorrhage checked, coaptation secured, and proper dressings applied. Under such conditions in the great majority of cases no especial local treatment will be found necessary. Attention to the general prmciples given above are usually sufficient, inasmuch as the inflamma- tory process quickly reaches its height and passes to a rapid resolution. Never- theless, there are certain general principles of local treatment which may often be applied with the greatest benefit. These principles all aim toward the relief of tmpleasant symptoms and to assist the resolution of the process. Rest of the affected part is one of the most important factors in relieving the pain, reducing the amount of tissue damage, and preventing unnecessary exu- dation and swelling. The position of the part is also of great importance in assisting the reaction. As a rule, elevation of tlie injured part is found to be of advantage. Strapping, bandaging, or encasing the part m plaster-of-Paris dressings may be necessary to secure immovability. In the case of fractures splints are used. Functional rest of the injured part is often desirable or neces- sary, in order to bring about resolution. This may be secured in various ways, according to the organ affected. Cold is often of great service in reducing the discomforts of the inflammation. Applied by means of the ice bag or ice coil, through which a constant stream of ice water is kept flowing, it often greatly reduces the pain and lessens the exu- dation and swelling. Its use is contraindicated when the vitality of the part is lowered and when the venous stasis is marked. When the temperature of the inflamed area is not much increased, its color cyanotic, and the swelling marked, the application of cold may cause actual damage. Gangrene ma^' follow the over-zealous use of the ice bag. The simple application of cold cloths or the immersion of the affected part in cold water often has a marked soothing effect. Cold water allowed to drip constantly upon the bandage or dressings may be employed for the same purpose. The individual conditions of the case are, of coiu-se, to be considered in the employment of cold according to any one of these methods. Heat is also an important factor in the treatment of simple inflammatory reactions. It may be applied by the use of hot poultices and dressings, hot dry cloths, hot air, hot sand, irons, bricks, etc., hot-water bags, bottles, etc., hot- water coil, hot-water bath, etc. Many surgeons make a marked distinction be- tween the use of dry heat and the employment of moist heat. The degree of warmth is also of importance, as the action of heat varies according to its degree. A moderate degree of heat, as in the case of a warm poultice, causes a dilatation of the superficial vessels, increases the hyperemia, and thereby is of direct aid to the inflammatory reaction in increasing its protective factors, in flushing the tissue, and in increasing the exudate. A greater degree of heat may contract the 114 AMERICAN PRACTICE OF SURGERY. superficial arterioles and lessen the hyperaemia. It is, therefore, usually applied at the beginning of an inflammation. Its utility is doubtful and the inflam- matory reaction may be delayed as the result of its application. As a rule, the use of moderate moist heat (poultices, fomentations, etc.) is often of service in the later stages of inflammation, in many cases undoubtedly hastening the proc- ess by promoting exudation and causing an earlier resolution. Such effects are seen especially in local processes that "come to a head" or "point" (suppura- tive inflammation). As a matter of fact, the choice between dry or moist cold and dry or moist heat probably lies wholly in the line of convenience, ex- pediency, and comfort. Cases are, therefore, to be treated individually, so far as the employment of these agents is concerned. Ligature of arteries supplying inflamed parts has been recommended as a means of checking inflammatory processes in certain parts of the body. Such a procedure is based upon an incorrect conception of the inflammatory reaction and must be regarded as a harmful and dangerous method of treatment. It belongs to the old antiphlogistic conception of the process ("starving of the inflammation"). Bleeding. — Venesection is now rarely employed. In certain cases, where there is a general venous stasis, its employment may be of value. Local bleed- ing is often resorted to when the local stasis is extreme, the part cyanotic, and the temperature lowered. This is particularly the case in severe injuries to the extremities after fractures of bones and rupture of large vessels. The stasis may be so extreme that fresh arterial blood cannot gain access to the part, and there may be serious danger of gangrene. Free incisions may relieve the venous stasis, allow the arterial blood to flow mto the part, and so permit of the col- lateral circulation being established. The incisions should be long and deep enough to relieve the tension. Superficial scarification rarely succeeds in ac- complishing this. The incisions should, therefore, be deep enough to reach through the subcutaneous tissues into the muscle. Alternating short incisions or deep punctures may be employed. The contents of hsematomata should be removed. All of these procedures should, of course, be carried out according to the i^rinciples of aseptic surgery. In regions where it is not desirable to make incisions leeches might often be employed to advantage, but they are rarely made use of at the present time. The modern tendency is to interfere less and less with the inflammatory reaction and to devote the chief attention to the maintenance of asepsis. For that reason local incisions, like venesection, are now rarely performed. The use of counter-irritants, at least in the case of acute inflammations, has also nearly become obsolete. Wlien resolution is delayed and there is danger of the process becoming chronic, counter-irritation may often be used to great advantage. Mustard plasters, tincture of iodine, fly blisters, cutaneous irritants of various kinds, and the actual cautery may be employed. Counter-irritation INFLAMMATION. 115 acts by the production of an active hypera;mia and the estabUshment of a fresher inflammatory reaction, which may aid. in advancing the older sluggish process toward resolution. Exudates may in this way be more quickly ab- sorbed, the part is flushed out by the increased circulation through it, and the processes of repair stimulated. Compression may often be used to advantage to diminish the swelling and exudation, and thus to hasten resolution and shorten the period of convales- cence. It is of particular value in the case of inflamed joints. It may be applied by means of splints, casts, elastic stockings, bandages, etc., and may be made use of both in the early and in the late stages of the inflammation. It should not be employed when the vitality of the tissues is low or when the circulation is greatly disturbed. The pressure should be applied equally and should not cause pain. The rest given to the part is probably the chief factor in the favor- able results often obtained, although there can be no doubt that the absorption of exudates may be hastened by pressure. Old chronic swellings, in particular, are favorably affected by continuous pressure and often are made to disappear quickly by this means. The local use of drugs supposed to have specific action on the inflammatory process has been practically discontinued. With the exception of bactericidal substances or of substances supposed to exert such action, local applications are now rarely made. The best surgical methods discard such treatment en- tirely. Aseptic methods are better than antiseptic; the agents used for bac- tericidal purposes may in themselves cause damage to the tissues. In the case of wounds and in operations upon parts already infected, the use of such anti- bacterial agents may be necessary, and in such cases those substances should be employed that cause least tissue injury or irritation. Aseptic cleansing should first be employed to the fullest extent possible, and, when thoroughly carried out, it should suffice. In the case of wounds containing foreign substances, dirt, etc., pure carbolic acid, in connection with alcohol, mercuric-chlorid solutions, etc., may be used as indicated. In the case of burns, local applications may be employed for the purpose of relieving the pain (antiseptic dusting powders, etc.). The astringent solutions so popular as local applications to inflamed parts have little or no value. The resolution of acute simple inflammations is brought about by means of simple cell reproduction, healing by first intention, or by second intention, as described in detail in previous paragraphs. 2. Acute Serous Inflammations. When the inflammatory exudate consists chiefly of fluid containing but few cellular elements, it is termed serous and the inflammation is spoken of as a serous inflammation. The collection of the fluid exudate in the tissue spaces 116 AMERICAN PRACTICE OF SURGERY. gives rise to an inflammatory wdema. Upon free surfaces the serous inflamma- tions manifest themselves as serous catarrhs. Since there is usually a marked mucoid degeneration of the epithelium of such an inflamed membrane, the exu- date comes to contain a large amount of mucus {mucous catarrh.) (See Fig. 39.) At times there is also a marked desquamation of the surface epithelium (des- quamative catarrh). The presence of leucocytes in the exudate may give it the character of a seropurulent catarrh; when fibrin is present, the exudate may be classed as serofibrinous. Collections of serous exudate in the body cavities as the result of inflammations of the serous membranes are spoken of as serous effu- sions. Small, circumscribed collections of serous exudate beneath the horny layer of the epidermis, with the liquefaction of the lower layers of the epithe- ^ M> ! J Fig. 39. — Mucoub Catarrh of a Bronchus (Mueller'a fluid, amlmc-bron n; a, Cihated epithelium : a, , deeper cell la\ers, b, goblet cells, c, cells sho^nng marked mucous degeneration, c, mucoid cells with mucoid nuclei; d, desquamated mucoid cells; «, desquamated ciliated cells; /, layers of drops of mucus; /i, layer consisting of thready mucus and pus corpuscles; g, duct of mucous gland filled with mucus and cells; h, desquamated epithelium of the excretory duct; i, intact epithelium of the duct; k, swollen hyaline basement membrane; I, connective tissue of the mucosa, infiltrated with cells in part; m, dilated blood-vessels ; n, mucous gland filled with mucus ; 7ii, lobule of mucous gland mthout mucus ; o, wander- ing cells in epithehum; p, cellular infiltration of the connective tissue of the mucous glands. X 110. {After Ziegler.) Hum, give rise to vesicles and blisters. (See Fig. 40.) Larger ones are termed bidke and blebs. Serous inflammations occur most frequently upon the mucous and serous membranes. They may be caused by thermal, chemical, and infective agents. The pyogenic cocci, the diplococcus of pneumonia, the colon bacillus, influenza bacillus, typhoid bacillus, bacillus of tuberculosis, etc., may produce serous, seropurulent, or serofibrinous inflammations. Inflammatorj^ oedema may be caused by the anthrax bacillus, the colon bacillus, the gas-forming bacillus, etc. The clinical picture of a malignant cedema may result. Localized inflammatory INFLAMMATION. 117 ccdemas are also produced by certain drugs, irritant poisons, bites of insects, stings, etc. Vesicles, blebs, bullae, and blisters. may be produced by burns, cor- rosive poisons, chemical irritants, friction, and many forms of infection. The majority of the serous inflammations fall into the province of general medicine rather than into that of surgery. The serous catarrhs are rarely treated by the surgeon. On the other hand, the treatment of blisters, blebs, serous effusions, and inflammatory oedemas is chiefly surgical. The symptoms of serous inflammations are those of inflammation in general. Since they are usually of bacterial origin, the general symptoms are more severe than in the case of a simple inflammation. The general picture of an infective process is presented, the condition running a more or less definite course. Fever and the general constitutional intoxication are more or less pronounced. The Fig. 40. — Section through the Border of a Blister Caused by a Burn (alcohol, carmine), a, Horny layer; b, retc Malpighii: c, normal papillae; d, swollen cells, some of whose nuclei are still visible, though pale, wliile others have been destroyed; e, interpapillar}' epithelial cells, the deeper ones intact, those of the upper layers are drawn oiit longitudinally and in part are swollen and have lost their nuclei; /, total liquefaction of the cells; g, interpapillary cells, without nuclei, swollen and raised from the cutis; ft, total degeneration of interpapillary cells which have been raised from the cutis ; k, coagulated exudate (fibrin) lying beneath the uplifted epithelium; i, flattened papillse infiltrated with cells. X 150. (After Ziegler.) general principles of treatment of inflammation apply here, while treatment is also directed against the etiological agent and the extension of the process. Such general treatment usually lies outside the surgeon's field, and he is called upon to treat the purely surgical features of the case, such as the serous effusion or the blister, bleb, or bulla. Treatment of Blisters. — Blisters or blebs when tense should be evacuated under aseptic precautions, but the epidermis should not be removed. The part may then be dressed with an antiseptic dusting powder or ointment, or dry antiseptic dressings may be applied. Treatment of Effusions. — Serous effusions may coUect in the pleural, peri- cardial and peritoneal cavities, the meningeal spaces, and in joints, tendon 118 AMERICAN PRACTICE OF SURGERY. sheaths, bursEe, etc. The amount of fluid may be so great as to cause serious pressure symptoms. The cardiac and respiratory functions may be seriously embarrassed by serous effusions in the pleural or pericardial sacs. Fatal results may be brought about by the increased pressure upon the brain or cord from the accumulation of serous exudate in the intermeningeal spaces. The move- ments of the joints may be seriously interfered with as the result of serous in- flammations of the synovial membranes. The relief of pressure symptoms, therefore, becomes the most important indication so far as the surgical treat- ment of these conditions is concerned. It is a waste of time to attempt this by means of counter-irritation, attempts at specific treatment, methods of absorp- tion, etc. Thoracentesis, lumbar puncture, aspiration of the joint cavity, etc., carried out according to the principles of aseptic surgery, yield the most certain, safe, and satisfactory results. Acute inflammations are thus kept from becom- ing chi-onic, and the secondary changes in organs from pressure are avoided. When carefully carried out, aspiration is practically without danger. In the case of large effusions, it is usually best to remove part of the fluid at one sitting and the remainder at another. The after-treatment is wholly medical, unless secondary infection should occur. 3. Acute Fibrinous Inflammations. When the fluid exudate contains a large amount of fibrin, the inflammation is spoken of as fibrinous, and the exudate is classed as fihrinoiis or serofibrinous, as the case may be. Frequently the exudate may consist almost wholly of a thick mass of fibrin, which is deposited over the surface of the affected part (croupous or membranous infiammation) . Such inflammations occur chiefly upon the mucous membranes, serous surfaces, and in the limgs, but fibrinous exudates may also be formed in tissue spaces of certain organs (lymph nodes). Fibrinous exudates occurring upon mucous membranes are often associated with a necrosis of the superficial epithelium {diphtheritic inflammations). The causes of fibrinous inflammations are chiefly infective agents — the pyogenic cocci, par- ticularly the streptococcus; also the Diplococcus pneumonite, the Bacillus diph- thericp, etc. The streptococcus and the diplococcus give rise chiefly to croupous inflammations of the lungs and pleura, while the bacillus of diphtheria causes diphtheritic processes in the upper respiratory tract. The streptococcus also causes diphtheritic inflammations in the respiratory tract, genito-urinary tract, and elsewhere. The irritant gases, inhalations of hot air or flame, and the cor- rosive poisons are also capable of producing fibrinous inflammations, chiefly of the diphtheritic type. Upon the mucous membranes the fibrinous exudate may appear as a whitish layer or patch, or it may foi-m a dense grayish membrane. The exudation may begin beneath the epithelium, pushing up the latter, which may degenerate or INFLAMMATION. 119 become necrotic. The surface is then covered with a grayish membrane infil- trated with leucocytes and containing the remains of the necrotic epithelium. In other cases the exudate follows the desquamation of the fibrin. Surfaces still covered with epithelium ma}^ become covered with a fibrinous exudate from exudation occurring through neighboring denuded parts. Successive exudations may give rise to layers of fibrin pushed up from below. Crystal-like forms of fibrin may be found, usually having a leucocyte or a red blood cell as a centre. The fibrin itself is usually reticular or arranged in coarse strands lying parallel with the surface, more rarely perpendicular to it. A distinct stratification is often seen. The connective tissue below is hyperamic, infiltrated with wander- ing cells, and shows an inflammatory oedema of more or less marked degree. In the tissue spaces small threads of fibrin may be found, while the dilated lymph spaces ma)' show a thick network of fibrin threads. In the diphtheritic process the fibrin threads may be found lying between the necrotic epithelial cells. (See Fig. 41.) Upon the serous surfaces the fibrinous exudate may appear to the naked eye as a delicate film or in the form of small granules giving the surface a rough or granular appearance, or there maj' be formed thick j-ellowish or yellowish-red deposits, which often give to the surface a felted or villous appearance {cor vil- lositm). Microscopically, the fibrinous deposit may be granular or thready, or even appear in dense hyaline masses or stratified bands. The endothelium is usually desquamated in whole or in part or is necrotic. The connective tissue is more or less infiltrated with leucocytes, the blood-vessels are congested, and the tissue spaces filled with fluid containing fibrin threads. Numerous leucocytes may be present, giving the exudate a fibrinopurulent character. The villous character so often seen upon the pericardium and pleura is due to the gluing together of the opposing surfaces by the sticky fibrin and the motion of the two layers drawing the fibrin out into strings, adhesions, or into villous projections. In the lungs fibrinous inflammations are characterized b)' the filling up of the alveolar spaces by a reticular network of fibrin, enclosing in its spaces leu- cocytes, red blood cells, and desquamated alveolar epithelium. Fibrinous exu- dations are also found in the kidney tubules, the bladder mucosa, endometrium, etc. In the lymph nodes and spleen fibrinous exudates may appear in the lymph sinuses of the former and the follicles of the latter. As a rule, the fibrinous inflammations are much more severe than the serous ones, the general symptoms are more marked, and the symptoms of intoxication become of paramount importance. In the respiratory tract the disturbance of respiration becomes a feature of great importance. Diphtheritic inflammations of the upper air passages may result fatally from the stenosis caused by the formation of the membrane upon the mucous surface of the larynx, trachea, etc. Croupous inflammations of the lungs usually involve an entire lobe. There is, in consequence, embarrassment of respiration and insufficiency of the right 120 AMERICAN PRACTICE OF SURGERY. heart. In the case of fibrinous inflammation of the serous surfaces the symp- toms are similar to those caused by serous effusions (pressure symptoms). The presence of the fibrin delays absorption, and resolution and healing are there- fore retarded. The fibrin itself acts as a foreign substance or as dead material, and excites quickly the process of organization. Thickenings and adhesions consequently usually follow fibrinous inflammations. Indm-ation of the lung €5* Fig. 41. — Sect on from an Inflamed L\ulaCo\ered with a Stratified Fibr nou Membrane, from a case of diphtheritic croup of the phalangeal organs ("Mueller bflmd hsematoxjlm eosm) a Surface layer of eoagulum, consisting of epithelial plates and fibrm and containing numerous colomes of cocci; 6, second layer of eoagulum, consisting of fine-meshed fibrin network enclosing leucocytes; c, third la3'er of eoagu- lum. King upon the connective tissue, and consisting of a \\ade-meshed reticulum of fibrin enclosing leucocytes; d, connective tissue infiltrated witli cells; e, infiltrated boundary' layer of the connective tissue of the mucous membrane; /, heaps of red blood cells; g, widely dilated blood-vessels; /i, dilated lympii-vessels tilled with fluid, fibrin, and leucocytes ; r, duct of a mucous gland distended with secretion; k, transverse section of a gland; I, fibrin reticulum in the superficial layer of connective tissue. X 45. (After Ziegler.) may follow croupous pneumonia. Diphtheritic inflammations of the bladder, uterus, intestines, etc., are of importance to the surgeon, because they often follow surgical operations upon these organs. The prognosis in such cases is always grave. The streptococcus is the most common infecting agent. The majority of fibrinous inflammations fall within the province of general INFLAMMATION. 121 medicine ratlier than in that of surgery. Although often associated with or arising chrectly from surgical conditions, the treatment in the majority of cases is usually purely medical. Obstruction of the respiratory passages by croupous or diphtheritic membranes may necessitate surgical operations, such as trache- otomy or lar3Tigotomy. Fibrinous inflammations of the serous membranes in the great majority of cases demand aspiration and removal of the accompanying fluid. The peritoneal cavity may be opened in the case of fibrinous peritonitis and the exudate washed out by sterile physiological salt solution. The forma- tion of peritoneal adhesions and bands maj^ necessitate surgical intervention because of secondary complications. In fibrinous arthritis the synovial cavity may be aspirated and the exudate withdrawn or washed out. In all cases of acute fibrinous inflammation the condition of the patient's kidneys should be carefully ascertained. Acute degenerative nephritis often brings the case to a speedy end. 4. Acute Purulent Inflajimations. When the inflammatory reaction is characterized chiefly by a leucocytic exu- date, the inflammation is styled purulent. If the leucocyte mfiltration is not so marked as to be evident macroscopically and is unaccompanied by liquefaction of the affected area, it is usually spoken of as a small-celled infiltration. When the leucocytes are so numerous as to give to the tissues a white, grayish, or creamy color, the infiltration is styled purulent. Such an exudate poured forth upon a free surface gives rise to a white or creamy, cloudy fluid called pus, and the inflammation is designated a purulent catarrh. (See Fig. 42.) A persistent and marked catarrh of this nature is often called a blennorrhcea. Collections of purulent exudate within the body cavities are known as purulent effusions or empyeinata. A purulent vesicle — that is, a collection of pus beneath the horny layer of the epidermis — is known as a pustule. Larger collections are called purulent blebs and bullce. The collection of large numbers of leucocytes within the tissue spaces is usu- ally followed by a liquefaction and dissolution of the affected area. This process is termed suppuration, and the resulting cavity filled with leucocytes and tissue debris is an abscess. The contents of the cavity are also designated as pus. When the suppurative process occurs upon the surface of the skin or mucous membranes, there is a superficial loss of substance giving rise to an ulcer. The process of suppiiration, when extending through the tissues, often gives rise to duct-like tracts known as fistulas or sinuses. The inflammatory exudate often assumes the character of a seropurulent in- flammation when the fluid portion is abundant. The infiltration of the tissues by such an exudate gives rise to a pitrulerit aclenia. (See Fig. 43.) Purulent and seropurulent inflammations, when rapidly involving large areas, particularly of the subcutaneous or subserous tissues, are designated as phlegmons or phlegmo- 122 AMERIC.l^' PRACTICE OF SURGERY. nous in^ammations. Large pus cavities may thus be formed. The presence of fibrin in pm-ulent or seropurulent exudates gives rise to a fibrinopiirulent in- flammation. Such inflammatory exudates are of very common occurrence in the serous cavities, lungs, and upon mucous membranes. The exudate of an in- flammatory oedema or phlegmonous inflammation often bears this character. Suppuration. — The steps of a suppuration may be traced as follows: There is, first, a primary tissue lesion, either degenerative or necrotic. This is fol- lowed by hypersemia, marginal disposition of the leucocytes, collection in the tissues of mononuclear cells, diapedesis of leucocytes with pol}Tnorphous nuclei, phagocytosis, and increasing emigration of the leucocytes until the tissue be- FiG. 42. — Purulent Bronchitis. Peribronchitis, and Peribronchial Bronchopneumonia in a Child one year and three montlis old (Mueller's fluid, h::ematoxylin-eosin). a, Purulent ; b, mucoid broncliial con- tents; c, Ci, broncliial epithelium infiltrated with round cells and partly desquamated; d, infiltrated bronchial wall "n-ith greatly dilated blood-vessels; e, infiltrated peribronchial and periarterial connective tissue ; /, alveolar septa, in part infiltrated with cells ; g, fibrinous exudate in the alveoli ; h, alveoli filled with exudate rich in cells; i, alveoli filled with exudate containing few cells; k, cross-section of a pul- monary artery; I, bronchial, peribronchial, and interacinous vessels showing marked congestion. X 43. (After Ziegler.) comes denselj' packed. The injured or necrotic tissue elements now undergo a liquefaction, while the leucocytes contained in the fluid thus formed begin to degenerate. Both primary and secondary tissue damage, therefore, usually occurs in an area of suppuration. The tissue may be killed at once by the in- jurious agent or it may be damaged, to die later during the process. The leu- cocyte collection, the fluid exudate, the abnormal conditions of pressure and nutrition, the disturbance of relationship, possibly also chemical substances pro- duced by the body cells, etc., play a part in the secondary liquefaction which INFLAMMATION. 123 always distinguishes a suppurative process. It is very probable that the leuco- cytes play a chief part in this dissolution of the dead or damaged tissue. In all acute suppurative processes and in all exudates rich in leucocytes, peptones and albumoses are found, and their formation may be the result of an extracellular action of the leucocytes. Such a "digestion" of the dead area may also be interpreted as protective or reparative. Upon a surface the dead tissue is usu- ally cast off before complete liquefaction has taken place. In demarcating inflammations the process of liquefaction takes place only at the periphery of the dead area where the leucocytes have assembled. The involvement of the leucocytes in the liquefaction process may be explained by the abnormal condi- tions under which the cells are placed, the failure of reproduction, bacterial sub- stances producing leucolysis, etc. When the area of necrosis is very large the process of suppuration is usually incomplete and takes place only at the periph- Tic 4S— II at ^ono St ■cut m ibcl I indk b pur lent l\lo OPUS M\o<5ts (al 1 ol 1 J to\ eob ) scrap r 1 ent partl_ oagulated exudate X 45 a Trans 5rsely ( ifter Z egler.) ery of the necrotic tissues. In the case of deep-seated areas of this kind, there is left behind a fatty debris which ultimately undergoes caseation or liquefac- tion, or may become inspissated and impregnated with lime salts. Histolysis — that is, tissue liquefaction — is the essential feature of suppuration, and this is brought about by proteolytic ferments produced by the body cells and the bacteria. Pus. — The purulent exudate upon a free surface and the product of suppura- tion are both called pus. It appears, ordinarily, as a creamy fluid, more or less mucoid, having usually an alkaline reaction, although not infrequently acid, and having a peculiar sweetish odor. When poured into a glass cylinder, pus com- monly separates into two layers — the upper one consisting of a transparent, yel- 124 AMERICAN PRACTICE OF SURGERY. lowish fluid {"liquor puris"), while the lower layer is thick, opaque, whitish or yellowish in color, and consists of the more solid constituents. The upper layer resembles the lymph and blood serum in its composition. The albumin content is generally somewhat lower, but it may be higher. Fibrinogen, as a rule, is not present, so that pus ordinarily does not coagulate. Globulin, albumose, leucin, tyrosin, and other extractives, more or less mucin or pseudomucin, fats, choles- terin, etc., are found in pus. The chief salts present are sodium chloride and magnesium and calcium phosphate. Proteolytic ferments, antibacterial and antitoxic substances, arising from the bacteria and from the body cells, are also contained in the serum of pus. The specific gravity varies from 1.030 to 1.033. As might be expected from the varied etiology and the varying conditions under which pus is formed, both its macroscopical appearances and its chemical composition vary greatly. It may be thin {"ichor"), having a low specific gravity and containing flakes and shreds of fibrin. Lactic, butyric, valerianic, and other organic acids may be contained in it and give it their characteristic odor. Hydrogen sulphide (HoS) may be present in it, and pus containing so many gas bubles as to give it a foamy appearance may be seen in case of infec- tions with the gas-forming organisms. A very foul odor may be occasioned by the growth of putrefactive organisms. The presence of blood may give it a bright red or brown or chocolate color {sanies). A blue or green color may be given to pus by the Bacillus pyocyaneus. An orange-colored pus may be produced by a deposit of crystals of hsematoidin. Red pus occurs rarely as the result of the presence of a large chromogenic bacillus. It may be distinguished from bloody pus by the fact that the red color does not change upon the dressings when dry, while blood soon takes on a brown color. A fecal color and odor may be present in pus in the peritoneal cavity, or such pus may be bile-stained. The chief cellular constituent of pus is the polynuclear leucocyte. A pus cell is nothing more than a leucocyte. In fresh pus the nuclei of the pus cells may stain as well as those of the cells of the inflammatory inflltration. Usually after suppuration is established numerous degenerating cells are found in the pus, their protoplasm showing fatty and granular degeneration. In old pus nearly all of the pus cells may show karyorrhexis or karyolysis. Besides the polymorphonuclear leucocytes there may also be foimd in pus eosinophile cells, large hyaline mononuclear cells, as well as cells of the small lymphocyte type. Occasionally the mononuclear cells may predominate. The older the process the greater the proportion of mononuclear cells, as a rule. The nuclei of the pus cells are usually very irregular in shape, probably as the result of amoeboid motion at the time of fixation, or the varied nuclear shapes may be due to be- ginning karyorrhexis. Round, oval, or spindle cells, arising from the prolifera- tion of the fixed connective-tissue cells or endothelium, may also be present m the pus. There is as yet no method of distinguishing between the round cells of the Ijmiphocyte type and those arising from the tissue cells. Cellular detritus INFLAMMATION. 125 resulting from the primary tissue lesion and the suppurative process are also contained in pas. Shreds of tissue, blood, blood pigment, fibrin, parasites, foreign bodies, caseous and calcareous masses, cyst contents, hyaline bodies, etc., may at times be found in pus. The cells of the pus produced by pyogenic or- ganisms are of the same character as those occurring in pus produced by means of chemical irritants. In so far as the body reaction is concerned, there is ab- solutely no difference in the morphology of the two kinds of pus formation. Since purulent reactions are in the great majority of cases due to pyogenic infections, there may be found in the pus, as a rule, the organisms producing it. Their presence may be demonstrated by cultural methods or by stained prepa- rations of the pus. In the case of some organisms — actinomyces, for example — grayish or yellowish granules are formed by the organism, and these may be seen macroscopically. In many cases, however, the pus is sterile, the infecting or- ganisms having been wholly destroyed. The death of the bacteria causing the purulent reaction is ascribed to the action of bactericidal substances produced by the bacteria themselves or by the body cells. The latter source is the more important. Sterile pus possesses bactericidal properties to a greater extent than does normal blood serum or lymph. We must believe that pus, in its essential elements, leucocytes and serum, is protective. Phagocytosis and the formation of antibodies constitute its chief functions. In this sense, then, all pus is laudable. Inasmuch as the purulent reaction varies in degree according to the virulence of the infective agent, pus has come to be itself regarded as the harmful agent. The etiological agent should not be confounded with the reaction to the injury produced by it. Pus may be dangerous, in that it may contain the pyogenic organisms or because of certain conditions favoring secondary tissue damage; but the essential biological fact should not be lost sight of — the 'production of pus is a protective reaction to injury. The limitation of the term pus to that pus alone which contains pyogenic bacteria is a purely arbitrary usage and not practical. Hueter's dictum, that pus can be produced only by pyogenic organ- isms, has been many times disproved. Further, in a great many cases of infec- tion with pathogenic bacteria, the latter, by the time suppuration has occurred and pus has formed, have been entirely destroyed, and the resulting pus is sterile. Further, the so-called pyogenic organisms may give rise to simple, serous, or fibrinous reactions, instead of purulent. Inasmuch, however, as clinically puru- lent inflammations are almost without exception due to micro-organisms, it is easily understood why many clinicians come to regard the process and the in- fective agent as having the same significance. The purulent reaction is due, in the great majority of cases, to infection with the Staphylococcus aureus, albus, and citreus and the Streptococcus pyogenes. Next to these, rank as the most common pyogenic organisms the Diplococcus pneumonia', Bacillus mucosus capsulatus. Bacillus coli communis. Bacillus p])o- cyaneus, Bacillus typhi abdominalis, Bacillus influenzce, and Actinomyces. Other 126 AilERIC.^N PRACTICE OF SURGERY. organisms more rarely exciting purulent reactions are Micrococcus tetragenus, bacilhis of chicken cholera, 'bacillus of swine plague, Micrococcus intracellularis, Bacillus prodigiosus, Proteus Zenkeri, Micrococcus pyogenes fcetidus, Bacillus mallei, a variety of Blastomycetes not yet classified, Oidium albicans, Tricophyton toiisurans, Sporothrix ScJienckii, Bacilhis aerogenes capmlatus, Bacillus anthracis. Bacillus tuberculosis, etc. Of the animal parasites, the ameeba of dysentery is associated in such a way with abscess of the liver as to make it very probable that it is the etiological factor. Among the chemical substances that produce a pmulent reaction when intro- duced into the tissues are mercury, oil of turpentiue, creolin, croton oil, silver nitrate, petroleum, zinc chloride, digitoxin, bacterial proteins, also animal and vegetable proteins. Practically, such chemical suppurations are almost wholly experimental and are rarely met with clinically except as the result of hypo- dermic injections. The suppurations produced by chemical agents are histo- logically and biologically exactly the same as those produced by pyogenic organisms. They differ from the latter only in that thej' do not contain infec- tive agents capable of indefinite grovsih, that they heal more easily, do not spread, and do not give rise to metastasis. The common pyogenic organisms are constantly present upon the skin, in the respiratory and genital tracts. A lowering of the local resistance, as through a wound, is usually necessarj' for infection. The occurrence of suppuration is, however, favored by acute and chronic infectious diseases, chronic valvular dis- eases, diabetes mellitus, etc. Variola, scarlatina, diphtheria, typhoid fever, gonorrhoea, measles, dysentery, and influenza predispose greatly to secondary infections with the Streptococcus pyogenes and other pyogenetie bacteria. Mixed pj'Ogenetic infections are not uncommon, the staphylococcus and the strepto- coccus being most frequentlj' associated. The general sjonptoms of purulent inflammation are more marked than those of simple reactions. The affected area is greatly swollen, tense, and bra-nmy, and of a bright red color. The local pain is severe and of a throbbing or boring character. In the case of suppurative processes there is usually a chill or there are repeated chilly sensations, with a sudden rise of temperature. The fever usually persists until the pus is discharged. In the case of an abscess on the surface of the body, the advent of suppuration is shown by the softening of the centre of the inflamed area and by fluctuation. At the centre of the soft area a light-colored spot appears, which ultmiately ruptures by "pointing." After the free discharge of pus the general and local sjTiiptoms gradually dimin- ish. The hyperemia disappears, and the swelling lessens so that the skin be- comes wrinkled, and the pain ceases. Should the fever and other constitu- tional symptoms persist, an extension of the process locally may be taking place or metastasis of the infective agent has occurred. Purulent inflammations show a tendency to spread in the direction of least INFLAMMATION. 127 resistance. They may be subfascial or subperiosteal and spread along beneath the fascia or the periosteum. In the muscles the inflammation extends along the intermuscular connective tissue. It also follows along the blood-vessels and nerve trunks. The symptoms of deep suppuration develop more gradually than when the process is superficial. Pain and fever are the first signs; there may be no swelling or surface redness. The surface of the inflamed region may then become oedematous, and later red and tender. As the process approaches the surface the symptoms become more marked and characteristic. The condition of pyaemia or septictemia may develop in the case of any local purulent inflammation. The constitutional symptoms become correspondingly more severe, the fever more marked, chills more frequent, and a typhoid state may supervene. The clinical picture may be further marked by the effects of the toxins upon the heart muscle, kidneys, etc. The case may finally terminate in cardiac insuflSciency or uraemia. The purulent process may spread diffusely throughout the tissues (phlegmon). When it occurs on a body surface, there is seen an advancing line of redness and swelling. The constitutional symptoms are usually marked. The involvement of the regional lymphatics is, as a rule, a dan- gerous matter and demands prompt and energetic treatment. The primary infec- tion is often insignificant or the entrance of the infective agent is not noticed. The superficial l3miphatics running from the point of entrance become swollen and palpable, and appear as red lines or cords. The lymph nodes are swollen and tender. Treatment of Pueulent Infl,\mmations. — The chief indication is the re- moval or destruction of the pyogenic agent, and the prevention of its spread by extension or metastasis. Prompt intervention by the surgeon is demanded. The developing colony of bacteria must be reached where possible, and vigorous antiseptic measures carried out against it. Free incisions, scraping, curetting, excision, antiseptic douches, etc., are among the methods that may be carried out to this end. Antiseptic poultices and baths are also of value. In the case of extensive involvement it is often better to make multiple incisions in such a way as to secure satisfactory drainage. The incisions should be made where the resulting scar will not cause disfiguration or interfere with the function of the part. The strength of the patient must be kept up by nutritious and easily digest- ible food. Alcohol may be given. Strychnine and digitalis should be given according to the state of the heart's action. The patient should be kept in bed. The local symptoms may be met according to the methods mentioned above for the treatment of simple inflammations. Purulent Catarrhs. — The majority of these conditions are treated by the physician rather than by the surgeon. The chief form of purulent catarrh usu- ally coming within the field of surgical practice is that of gonorrhcEal infection. Purulent catarrhs of the bladder and upper urinary tract are also often treated 128 AMERICAN PRACTICE OF SURGERY. by the surgeon. In general, the local treatment of these conditions consists of antiseptic or aseptic irrigation, injections, etc., while the general indications are met according to general principles. Abscesses. — The term abscess is applied to the results of suppuration within the body tissues; that is, to a cavity filled with the products of the liquefaction of an inflamed area (pus) (see Fig. 44). It is one of the most common forms of purulent inflammation. There are numerous clinical varieties, and many desig- nations are applied to them according to their location, character, duration, etc. The term abscess is also applied by many writers to the collection of pus in the body cavities. Others prefer to class these as 'purulent effusions or empyemata, or simply to use the terms indicating the region involved (purulent pericarditis, J :'-9 ---ll tr^_., . , . ,_ Fig. 44. — Embolic Abscess of thelntestinalWallwithEmbolicPurulent Arteritis, and Embolic Aneu- rism in Cross-section (alcohol, fuchsin). a, 6, c, rf, e, Layers of intestinal wall ; /, remains of arterial wall, cross-section; g, embolus, surrounded by pus corpuscles lying within the dilated and partly suppurating artery; h, parietal thrombus; i, periarterial purulent infiltration of the submucosa; h, vein showing marked congestion. X 28. (After Ziegler.) peritonitis, etc.). Pelvic abscess is used to indicate a collection of pus in the pelvis shut off by adhesions. Subdiaphragmatic abscess is applied usually to a localized purulent peritonitis with a collection of purulent fluid between the diaphragm and neighboring organs, usually the liver. Special names, such as hoil, furuncle, carbuncle, whitloio, felon, etc., are applied to certain forms of abscess. Abscesses may vary in size from those which are microscopic or "pin-point" to those containing one or two litres of pus. Abscesses containing from four to six litres have been reported. The large abscesses are usually found in the sub- cutaneous or subserous tissues or in the intermuscular fascia. The wall of an AMERICAN PRACTICE OF SURGERY PLATE I ACUTE PURULENT INFLAMMATION; ABSCESS. {After Ziegler.) Fig. 1.— Multiple Abscesses of the Skin, due to Staphylococci. (Alcohol, carmine, Gram's method.) Child of three weeks, a. Epithelium ; 5, corium ; c, hair-follicle : d, «, purulent foci with cocci, x 40. Fia. 2. — Miliary Purulent Nephritis, Caused by Staphylococci, primary focus in skin (furuncu- losis). (Alcohol, methyl-violet, carmine.) a, Normal kidney tissue; 6, collections of cocci ; c, purulent focus. X 43. INFLAMMATION. 129 acute abscess is made up of more or less degenerated tissue elements infiltrated with pus cells. The abscess may be sharply circumscribed or the suppurative process may extend ("burrow") along the paths of least resistance. As a rule, all abscesses tend toward a surface, where they "point" or "come to a head." In the case of abscesses of the internal organs, the rupture may occur into any one of the hollow organs or body cavities or passages. Adhesive inflammatory reaction about the burrowing pus may prevent such rupture. Abscesses that do not rupture spontaneously or are not incised may, after the death of the pyogenic organism, become organized, calcified, or converted into a cyst. Large ab.jcesses become encapsulated. Healing of an abscess takes place through the proliferation of the cells of the abscess walls and the formation of a granulation tissue which gradually fills up the cavity. The processes of repair are aided by the evacuation of the pus and dead material and the apposition of the abscess walls. Metastatic or embolic abscesses arise from the transportation through the blood or lymph of the infective agent. (See Fig. 44.) Since they are often small, they are frequently called "pin-point" or "pin-head" or "miliary abscesses." (See Plate I., Fig. 2.) The occurrence of secondary foci of infection and suppuration constitutes the condition of pycemia. It occurs most frequently in the case of infections with the staphylococcus, streptococcus, Micrococcus lanceolatus. Bacillus mucosus capsulatus, and Actinomyces. The treatment of abscesses is to be discussed farther on, in a separate article devoted to this subject. Among the most common forms of abscesses are those which occur in the skin and subcutaneous tissues, known as pustules, boils, carbuncles, felons, etc. (See Plate I., Fig. L) Pustules occur most commonly as the acne pustule, and are the result of infection of the hair follicle or sweat gland, with resulting obstruc- tion of the duct. The boil or furuncle differs from the pustule only in the virulence of the infection and the depth to which the inflammation extends. The bacteria gain entrance through the hair follicles or the sweat glands. Through the growth of the infecting organisms and their formation of toxins there results an area of coagulation necrosis, which forms the "core of the boil." The part usually thus destroyed is the hair follicle and its sebaceous gland. The first symptom of the boil is the formation of a small pustule in a hair follicle, accompanied by an itching sensation. There quickly results more or less infiltration of the neighboring skin and subcutaneous tissues, and the boil becomes very sore and tender on pressure. A crust then forms at the site of the pustule. This, when removed, usually shows a well-defined circular opening from which pus exudes. Into the opening a probe may be passed for some distance. The suppuration increases, and after a few days the core is expelled and the cavity heals by the formation of granulation tissue. The staphylococcus is the most common etiological factor, although streptococcus xoh, I.— 9 130 A.AIERIC.\N PRACTICE OF SURGERY. boils are not rare. Boils not infrequently appear in succession (furunculosis). The patient usually infects himself through scratching, but in these cases there is generally some lowered resistance of the body tissues. A carbuncle is an infective, suppurative, and gangrenous inflammation of the skin and subcutaneous tissues, beginning as a boil and spreading gradually downward and laterally in the subcutaneous tissue. It differs from a boil only by the extent of the tissues involved and by the multiple points of suppuration. Staphylococci are the most common bacteria foimd in carbuncles. They occur usually in adults and old persons. As a rule, they are situated upon the back of the neck, although occasionally found elsewhere. A fully developed car- buncle has a broad, flat base. Over it the skin is elevated, reddened, and ex- *^ ./y Y^ '& ■5." I- * fn~^ '*''t« I. h \ fj;^/%»^v^_* Fig. 45. — Section of the Skin in Erysipelas Bullosum (alcoliol, alum-carmine), a, Epidermis; 6» corium : c, vesicle ; d, covering of vesicle ; e, epithelial cells containing vacuoles ; /, swollen cells with swollen nuclei; g, g\, ca^dty caused by the liquefaction of epithelial cells, and containing fragments of epithelium and pus corpuscles: 7i, h-mph-vessel, partly filled with streptococci; i, lymph-vessel filled with streptococci; A-, colony of streptococci in the tissue, i, Z, necrotic tissue; m, cellular, mj , fibrino- cellular infiltration ; n, fibrinocellular exudate in the vesicle. X 60. {After Ziegler.) tremely tense. Through the skin there may develop a number of openings from which pus oozes. These may become confluent into one or more larger openings through which large subcutaneous sloughs may be seen. Carbuncles are often several inches in diameter. They reach their full development about the end of the second week, but the process of healing may be delayed over a number of weeks. The larger carbuncles give rise often to very grave constitu- tional disturbances and not rarely result fatally. When occurring in association with diabetes the prognosis is especially grave. Panaritium or felon is a variety of subfascial abscess occurring in the fingers or hands. According to its location it may be classed as cutaneous, ten- dinous, subperiosteal, or palmar. The infection occurs through some slight skin injury, such as an abrasion, blister, callus, punctured wound, cut, etc. INFLAMMATION. 131 Cooks, dish-washers, dissectors, etc., are especially liable to these forms of in- fection. The felon occurs most frequently at the ends of the finger. The symptoms are intense, throbbing pain, with' a gradually increasing swelling, more or less fever, and symptoms of general intoxication. The complications, sequelse, and the prognosis of felons depend upon the relations of the felon to the structures of the part involved. Tendinous felons may destroy a phalanx or seriously injure a joint. More serious results of the same nature are caused by the subperiosteal felon. Lymphangitis and secondary involvement of the regional lymph nodes are especially likely to occur in association with felons. Phlegmonous inflammations are those characterized by rapid and diffuse spread- ing through the tissues (see Figs. 45 and 46). They are usually the result of a streptococcus infection. The signs of an acute inflammation are present over a large area. Sloughing takes place early and suppuration is soon established. Felons not infrequently give rise to such processes. The whole arm may be quickly involved, the skin becoming hard and brawny, covered with blebs, and the tissues of the limb as a whole very oedematous. Occasionally the process resembles that of a malignant oedema, the subcutaneous tissue becoming emphy- sematous. This condition is probably the result of an infection with the Bacil- lus aerogenes capsulatus. The occurrence of a true malignant oedema in man is still imsettled. The constitutional symptoms of phlegmonous inflammations are usually marked. The condition of septiccemia is ordinarilj' present at the same time. The treatment is the same as that for abscess. Ulcer. — The term ulcer has been rather loosely applied by different writers to a number of conditions which resemble each other in that there is a loss of continuity of a surface, either that of the skin or that of a mucous membrane . The results of suppuration, superficial necrosis, granulating wounds, etc., have all been included under this head. The pathological picture ultimately presented by these conditions is the same. In a broad sense, then, ulcers might be defined simply as a loss of continuity or a superficial loss of substance of the skin or mucous membrane, due to some form of tissue lesion. Clinically, however, the term has come to convey the impression that the loss of substance is the result, either wholly or in part, of the inflammatory reaction — that is, the result of suppuration or a demarcating inflammation. The term ulceration is used by some writers as a synonym for ulcer, by others to indicate an extensive process or the occurrence of multiple ulcers, while in the pathological usage of the term it indicates the process rather by which the ulcer is formed. The clinical variety of ulcers is very great. They are classed according to the etiology, their location, and their characteristics of spreading, healing, etc. According to etiology they are usually classed as non-specific ulcers, specific, and malignant. The non-specific ulcers include all those cases which are not due to some specific infection or to malignant disease. They are the result of trauma, infection with pyogenic or saprophytic bacteria, anaemia, pressure. 132 AMERICAN PRACTICE OF SURGERY. -r local or constitutional disease, etc. Tlie specific ulcers are those occurring in syphilis, tuberculosis, dysentery, typhoid fever, diphtheria, glanders, malaria, actinomycosis, blastomj'cosis, leprosj', etc. The malignant ulcers arise through the degeneration or infection of a superficial malignant tmnor. Carcinoma of the mouth cavity, oesophagus, stomach, intestine, and uterus, epithe- lioma, and rodent ulcer are the most frequent malignant timaors giATng rise to ulcer. Sarcoma of superficial parts less frequently ulcerates. A malignant growth may also arise in a chronic ulcer, the so-called "malignant degeneration" of an ulcer. According to theu* course ulcers are classed as acute, subacute, and chronic. According to their condition they are described as liealing, spread- ing, inflamed, phagedenic, sloughing, serpiginous, indolent, fungating, scirrhous, hemorrhagic, etc. Ulcers occur more often in adult life and in old age. They are much more frequent in men than in women, and are generally seen in indi- viduals of the lower classes. These facts are easily explained by the importance of trauma, sj'jDhilis, and the occurrence of infection as the etiological factors. j\Iany constitutional dis- eases, such as diabetes, scur^'^^, s3-philis, tuber- culosis, anjemia, etc., predispose to the oc- cm'rence of ulcers. The acute infections, rt^ifi!^~if-^ f'? particularly typhoid fever, variola, and scarla- tina, favor the development of ulcers from ex- citing causes that otherwise usually are without effect. Chronic diseases, such as chronic val- vular lesions of the heart, fatty heart, arterio- sclerosis, obesity, etc., similarly predispose to the formation of ulcers. Local predisposing causes may be found in any thing interfering with the arterial circulation, the venous or the IjTnphatic circulation. Vasomotor distm'bances often plaj^ an important part in the development of ulcers. Certain forms of skin diseases (herpes, ecthyma, pemphigus, eczema, etc.) are frequentlj' associated with ulceration. Ulcers maj' also be produced by the elimination of certain drugs (ulcerative stomatitis and ulcerative colitis caused by mercurial poisoning, etc.). The bacteriology of ulcers is extremely varied. Nearly all the pathogenic micro-organisms may be foimd as etiological agents in the production of ulcera- ^ c Fig. 46. — Phlegmon of the Sub- cutaneous Tissue, with Formation of a Vesicle through CEdema (Mueller's fluid, hfematoxylin, eosin). a, Co- rium ; 6, epidermis ; c, infiltrated fat tissue; d, focus of pus; e, cellular foci in coriinn ; /, subepithelial ves- icle due to oedema. X 30. (After Ziegler.) INFLAMMATION. 13? tion. The typhoid bacillus, Shiga bacillus, diphtheria bacillus, the amoeba coli, the malarial plasmodium, etc., are among the specific agents which may under certain conditions give rise to ulcers. Not infrequently the only micro-organ- isms found in ulcers are saprophytic bacteria. Microscopically, an acute ulcer shows a superficial loss of substance with an infiltrated base and edges. Over the base there is a layer of exudate and tissue debris. Sooner or later proliferation of the connective-tissue cells at the periph- ery gives rise to the formation of granulation tissue, and the ulcer heals by sec- ond intention. The prolongation of the healing process gives rise to the forma- tion of scar tissue about the ulcer and a hyperplastic condition of the bordering epithelium. The most common forms of ulcer seen by the surgeon are the syphilitic, varicose, traumatic, and pressure ulcers (decubitus). The treatment of ulcers is both general and local. The constitutional treatment consists in the support and building up of the body by means of proper diet and hygiene, tonics, etc. The local treatment is aimed at the cleansing and sterilization of the ulcer, the stimulation of repair, and the control of the reparative process. In the case of a recently formed ulcer the local treatment is that carried out in any suppura- tive process, being directed against the infective agent and also aimed at the relief of the inflammatory symptoms. For further details the reader is referred to the article on Ulcers and Ulceration. Fistula, Fistulous Tract, and Sinus. — An abnormal opening into a normal body cavity or organ is known as a fistula. The term is also applied to congeni- tal openings or defects as well as to openings produced by suppurative processes. "When, as the result of a " burroAving " suppuration, there is formed a long, narrow channel, the latter is designated a fistulous tract or sinus. These conditions are usually characterized by a failure of the healing process. They are often due to the presence of a foreign body, infected ligature, etc., or the position of the fistula is such that the body movements keep it from healing. Piiysiological secretion (urine, saliva, fteces, bile, etc.) may serve to keep the fistula from closing. Further, many fistulas are the result of tubercu- lous infection. Wlien the fistulous tract or sinus is superficial, it should be opened by a free incision and its surfaces curetted. Foreign bodies, ligatures, etc., should be carefully f lught and removed. Small tuberculous fistulas may be removed entire. In other cases a careful dissection of the wall may be carried out. Treatment with antiseptic washes, irrigation, injection, etc., may be instituted according to indications. As the fistula and sinus show little disposition to heal and so tend to run a protracted course, careful search should be made to ascer- tain the cause and source of the condition, and all diseased tissue should be thoroughly removed. Constitutional treatment is often of the greatest impor- tance, particularly when tuberculous infection is suspected. 134 AMERICAN PRACTICE OF SURGERY. 5. Acute Degenerative and Necrotic iNFLAiiMATiONS. ■\;^^len an organ or tissue presents extensive parenchj-matous degeneration, such as clotidy sweUmg, fatty degeneration, etc., without evidences of an inflam- matory reaction, the condition is usually spoken of, both clinically and patho- logically, as that of "acute degenerative parenchymatous infla^nmation." In re- ality it represents the tissue lesion alone, without any inflammatory reaction as yet having been initiated. Such processes are seen particularly in the liver and kidneys, and are usually the result of intoxications, either from bacterial infections or from chemical poisons. The use of the term inflammation is, of course, not justified from the pathological standpoint, and it would be more proper to class them as degenerations. The fact that no inflammatory reaction is found is, however, due to the death of the patient before it has had time to develop; in fact, all stages may be found in different cases, from the pure de- generation or necrosis to a fully developed condition of inflammation. There is, therefore, a certain practical reason for classing all these conditions imder the head of degenerative mflammation. To the surgeon these conditions are of great importance, since they most frequently arise from the absorption of bac- terial toxins from some local focus of infection. To an acute degenerative nephritis or myocarditis the fatal termination in septicaemia, septicopysemia, and saprsemia is usually due. The treatment is chiefly preventive. The con- trol of the local infection, its restriction from spreading, the promotion of excre- tion of poisons absorbed, etc., are the chief indications of treatment. Some of the injurious agents acting upon the body produce a tissue lesion of the nature of extensive necrosis. The necrotic tissue remains unchanged for a long time, and is only rather late removed by means of sequestration, sloughing, absorption, etc. In such cases the tissue necrosis, therefore, becomes the most striking feature of the process, and such inflammations are kno'mi as necrotic inflammations. The necrosis may be apparent before the inflammatory reac- tion, as in the case of burns, corrosive poisons, freezing, anaemia, etc. In other cases, particularly in infections, the inflammatory reaction may first be seen, the inflamed and infiltrated tissues later becoming necrotic. Tuberculosis may be taken as an example of a necrotic inflammation of the latter type ; as a rule, the caseation necrosis occurs after tissue proliferation has existed for some time. Necrotic inflammations are caused chiefly by high or low temperatures, anaemia, caustics, and infection. In the cas& of the action of high or low temperatme and anaemia, the tissue necrosis occurs in the part involved. Corrosive poisons also act locally, but manj'' poisons produce necrosis not only at the point of contact, but in other portions of the body as well, after their diffusion through the blood or Ijonph. Mercury, cantharidin, the salts of chromic acid, etc., cause necrosis in the intestines, urinary passages, and kidneys, as well as at the points with which they first come in contact. Bacteria cause necrosis both at the place INFLAMMATION. 135 where they multiply and in those portions of the body where they are excreted after being absorbed. Necrotic inflammations are most frequently seen on the mucous membranes, and are usually called diphtheritic inflammations or diphtheritis (see Fig. 47). As a rule, the latter designation is applied only to those processes in which the infil- trated subepithelial connective tissue is also involved in the necrosis, but necrosis of the epithelium alone is often spoken of as epithelial or superficial diphtheritis. The necrotic epithelium may be recognized by the occurrence of white opaque patches. In a true diphtheritis the entire epithelial surface is necrotic .-.•;'^^?~^ -^\^- "^-v •.'•-,.. as well as the upper layers of con- f ' .'-"., v'f~"5?S) nective tissue, the dead parts be- !:..___:::;:' v^.,v '■- . : . ;::i'. '^J coming changed into a lumpy or j' .. ;■ ••'■7 granular mass without nuclei, or in- 1; , ., , . v'^ ';, to a hyaline mass containing fibrin. ,, r-^^-'v'y^.^''''^'.-- vAV ".'-■■ ■ Usually no evidences of structure . '''V/'jV.«7s'''' V°:/A*'' .'•■V'*!' ' .. - can be made out in the dead mass. This constitutes the so-called diph- theritic membrane. Such processes occur most frequently in the intes- tines (dysentery, diphtheritic colitis, etc.), in the vagina and uterus (diph- theritic vaginitis and endometritis), in the descending urinary tract and bladder (diphtheritic ureteritis and cystitis), and in the upper respira- tory tract (diphtheria of tonsils, fauces, larynx, etc.). In the respi- rator}' tract the process is usually caused by the Bacillus diphtheria;, in the intestinal and genito-urinary tract by the Streptococcus. The other pyogenic organisms are capable under certain circumstances of producing a similar necrosis. An infection of a wound by virulent bacteria {Staphylococcus or Streptococcus, etc.) may produce a similar necrosis of the wound granulations (ivound diphtheritis). Necrotic inflammations may also occur within the internal organs as the result of infection. The lymph nodes, spleen, and bone marrow are most frequently involved. The diphtheritic inflammations of most interest to the surgeon are those oc- curring after operations upon the intestinal and genito-urinary tracts and upon wounds. The streptococcus is the most common etiological agent. The process is very severe, the infection virulent, and the cases run usually an unfavora,ble Fig. 47. — Bacillary Diphtheritis of tlie Large Intestine in Dysentery (alcohol, gentian -violet). a, Necrotic portion of the glandular layer of the mucosa, infiltrated with bacilli ; b, intact inflamed mucosa; c, muscularis mucosae; d, submucosa; e, colonies of bacilli; /, glands with living epithe- iium; g, glands with necrotic epithelium and ba- cilli; h, connective tissue infiltrated with cells; i, blood-vessels. X 80. {After Ziegler.) 136 AMERICAN PRACTICE OF SURGERY. course. Diphtheritic cohtis and cystitis are very frequently the immediate cause of death. The latter usually occurs after operations for stone, stricture, and enlarged prostate. The treatment is chiefly preventive. After infection of this nature has occurred and the process has become established, the treatment is in general the same as that for suppurative inflammations. If an area of inflammation becomes infected with bacteria capable of pro- ducing putrefaction, the inflammatory process assumes the character of a putrid gangrene and the inflammation is designated as a gangrenous inflammation. The term gangrene alone is usually applied to the condition. While the pathol- ogist uses this term to denote a necrosis accompanied by putrefactive pro- cesses, the surgeon often uses it to designate simply the death of tissues e?i masse — that is, to signify an extensive necrosis of an exposed portion of the body. As a matter of fact, such a superficial death of tissue is practically always accompanied by decomposition, so that no essential contradiction exists in the different applications of the term. The presence of saprophytic or putrefactive bacteria may, therefore, be regarded as the most distinctive feature of gangrene. Gangrenous inflammations may be either primary or secondary. The primary form is due to infection with some specific micro-organism, and is to be regarded as a specific form of gangrene. Among the bacteria capable of producing a primary gangrene may be mentioned the Bacillus aerogenes capsulatus, B. ocdematis maligni, B. diphtheria!, B. anthracis, B. coli communis, and probably a number of other bacteria as yet not well known. Secondary gangrene may be caused by burns, freezing, deprivation of the blood supply, mechanical injury, pressure, corrosive poisons, various intoxications, and infections. In all these cases there is first a tissue lesion and inflammatory reaction, associated with or followed by secondary infection with putrefactive organisms. Two chief forms of gangrene are recognized — dry and moist gangrene. The former occurs in parts exposed to the air and therefore after necrosis quickly losing their water through evaporation. When evaporation does not occur, the parts remain moist and present a better soil for the growth of saprophytic organisms. In the dry form there is usually but little bacterial growth and consequently less de- composition; in the moist form, on the other hand, the putrefactive processes constitute the chief feature. Between the two forms there is no hard-and-fast line. A moist gangrene may become converted into a dry form by evaporation of the fluid contained in the necrotic area, while a dry gangrene, through the absorption of fluids from the surrounding tissues, may become changed into the moist. According to its origin, gangrene is also classed as traumatic, thermal, toxic, senile, idiopathic, diabetic, neuropathic, etc. According to the character of the process, there may be distinguished such forms as circumscribed, diffuse, phage- denic, etc. When the putrefaction is very marked, the gangrene is designated INFLAMMATION. 137 septic or putrid gangrene. The formation of gas in the gangrenous area gives rise to emphysematous gangrene. When the tissues contain much blood before death, they are usually black or greenish in color (black gangrene); when anse- mic, they are lighter in color, although always discolored to some extent (white gangrene). Clinically these forms are also known as warm and cold gangrene, respectively. Dry gangrene is usually circumscribed. It occurs in the parts of the body most exposed to evaporation, as the tips of the ears, nose, fingers, and toes. In the great majority of cases it is due to arterial or venous obstruction by throm- bosis or embolism, whenever the collateral circulation is insufficient to keep up the nutrition of the part whose vessels are affected. It also occurs after freez- ing, burns, corrosions, in ergotism, diabetes, senilitj^, Raynaud's disease, etc. The affected part is discolored, yellow, brownish, or black, or the tissues may at first appear bloodless and very pale. The consistence gradually becomes hard and tough, and finally the part comes to resemble leather or the skin of a mummy. A formation of vesicles or blebs may precede the mummification. Should these rupture and the corium become denuded, the process of evaporation is aided. In the early stages the odor of putrefaction is present, but is never very marked. Around the dead area there is usually present a more or less sharply marked line of demarcation. Moist gangrene occurs very frequently after severe traumatism of the ex- tremities, obstruction of the arterial or venOus flow, in certain skin diseases, diabetes, senility, acute in- _____„,^ fections, etc. Decubitus, noma, < w^S^^^ ■■ ^*^*' ,i,^ malum perforans, hysterical gan- - •> grene are varieties of the moist form of gangrene. Of the m- 8 ternal organs the lungs are most '■'' i '^^ frequently the seat of moist gangrene. It follows infarction, { inspiration pneumonia, non-re- ' ^.-^.^ ^^^^ ^ solution of croupous and puru- lent pneumonia, pulmonary abscess, atelectasis, bronchiec- tasis, neoplasms, etc. Moist Fig. 4S.— Gangrene of Portion of Foot. N, Necrosed gangrene of the mesentery P.°^*'°°' ^' "°""= °* demarcating proliferations; H, living ° "^ ■' tissue outside zone of demarcation. (After Ribberi.) follows mesenteric infarction due to embolism or thrombosis of the mesenteric arteries. Strangulated hernia, intestinal obstruction, intussusception, obstruction or strangulation of the appendix, traumatic injury of the pancreas, pancreatic inflammation, torsion of the pedicle of new growths, floating spleen, kidney, etc., usually lead to moist gangrene. Extreme passive congestion, marked oedema, infiltration of 138 AMERICAN PRACTICE OF SURGERY. the perineal tissues with urine, retention of the urine, etc., are also conditions favoring the occurrence of moist gangrene. Moist gangrene is recognizable clinically by its foul odor, discoloration, and progressive softening of the affected area. In the early stages the color is usu- ally reddish purple, but later becomes greenish, brown, or black. Blebs filled with a dirty brown fluid are formed in the skin of the gangrenous area. Ulti- mately the entire part becomes soft and partially liquefied, and the phenomena of putrefaction are presented, as in the case of a dead body. Hydrogen sulphide, ammonia, indol, skatol, fatty acids, amins, carbonic acid, and other gases are formed during the putrefactive process. When the gas formation is marked, a local or widespread emphysema may be produced. Around the gangrenous part there is usually a zone of inflammatory demarcation (see Fig. 48). . Finally, the dead tissues are either cast off or are absorbed, calcified, organized, or en- cysted. Besides the end products of decomposition mentioned above, there are formed in the gangrenous tissue diffusible poisons, which when absorbed pro- duce systemic symptoms. The intensity of the latter depends upon the amount and character of the poisons produced, the amount and rate of the absorption, and the resistance of the patient. The intoxication may be so intense as to cause death. In other cases the gangrenous process advances until death is brought about by the involvement of vital parts. Healing may occur after sequestration, organization, or calcification. The varieties of gangrene met with in surgical work are numerous. Senile, diabetic, infective, traumatic, toxic, multiple, neuropathic, hospital, emphysem- atous, X-ray, carbolic-acid, decubitus, etc., are . among the most important clinical varieties. These will be discussed more fully under the proper heading. The treatment of gangrenous inflammations is, in general, the same for all varieties. In the infective cases the treatment should be directed along anti- septic lines. In the case of obstruction to the blood supply, exercise, massage, and hot baths may be used to encourage a collateral circulation and to prevent the occurrence of gangrene. The general symptoms should be treated according to indications. As the subject of gangrene from the clinical standpoint will be treated fully ui a later article, it will not be necessary for me to enter into further details in this place. III. CHRONIC INFLAMMATIONS. Etiology. — Tlie causes of chronic inflammation are to be sought in factors that excite a progressive tissue lesion and in those that prevent prompt healing. Persistent infection, chronic intoxications, repeated injury by extrinsic agents (dust, repeated rubbing, foreign bodies, etc.), unfavorable nutritive conditions, diminished resistance, extensive tissue defects, presence of large masses of ne- INFLAMMATION. 139 erotic tissue, collections of exudate that are with difRculty removed, etc., are the chief causes of the persistence of an inflammatory reaction. Chronic infections very frequently give rise to progressive inflammations, which spread through the body by direct extension and give rise to metastases through the blood or lymph. Such chronic inflammations are caused by bac- teria and certain moulds and yeasts, which contmue to multiply in the body and constantly to give rise to new tissue-irritation and injury. To this class be- long chiefly the so-called specific infections, tuberculosis, syphilis, leprosy, actinomycosis, blastomycosis, etc. ; but persistent infections due to the ordinary pyogenic bacteria, colon bacillus, typhoid bacillus, gonococcus, pneumococcus, etc., are not infrequent. Such inflammations present a more or less distinct clinical course and s5miptomatoIogy. Chronic intoxications play a very important role in the production of chronic inflammations of the internal organs, particularly of the liver and kidneys. The chief source of the poisons is to be sought in the gastro-intestinal tract, but substances harmful to the organism may be taken in through the respiratory tract, skin, etc. In many of these chronic inflammations of the internal organs the exciting factor is probably an auto-intoxication, the poisonous substances being produced within the body itself as the result of disturbed metabolism, perverted gland function, or failure of specific internal secretions (auto-intoxi- cations). Repeated mechanical injury, though of slight degree, may give rise to a per- sistent inflammatory reaction. The repeated inhalation of irritating dusts ex- cites a chronic pneimionia; repeated friction causes inflammations of the skin or mucous membranes; pathological changes in the contents of the gastro- intestinal tract may give rise to chronic inflammations of the mucosa of this tract. The presence of concretions, foreign bodies, etc., likewise causes chronic irritation and a persistent reaction. Portions of necrotic tissues too large to be easily replaced or removed, or that are absorbable with difficulty, act as foreign bodies and excite chronic irritation and reaction. Likewise masses of purulent or fibrinous exudates act in the same manner, and the reaction persists until the exudate is completely organized, encapsulated, or calcified. Large pieces of necrotic bone may persist as seques- tra for a number of years and keep up a constant inflammation. Further, large tissue defects, such as extensive burns and ulcers, require often many months before the wound surface is covered over with epithelium and the healing process completed. Unfavorable nutritive conditions, such as general or local anaemia, chronic passive congestion, delay the coiu-se of healing and also predispose to inflam- matory conditions, m that they permit slight extrinsic agents, which ordinarily produce no tissue lesions or at least only slight ones, to set up ulcerative inflam- mations that show little tendency to heal. 140 AMERICAN PRACTICE OF SURGERY. -t .Rr' c-w In general, chronic inflammations are characterized by hyperplasia of the , „, .^ connective tissues of the affected part. Chronic inflammations of the -crous membranes, caused by chronic infection or by the presence of exu- dates not easily removed or ab- sorbed, are characterized by exten- sive thickenings of the membrane, due to the organization of the exu- "' : ;'j date or to a hyperplasia of the con- ' . 'i nective tissue of the subserosa. (See j-:t,.^«-^-''^^" Fig- 49.) The new formation of con- -~" "c"-.— -'j nective tissue, therefore, takes place A^": , - .-■ ; either upon the serous membrane or within it. Dense hyaline adhesions and thickenings mav thus result, and the capsule of such organs as the spleen and liver may be enor- mously thickened ("Zuckerguss- leber," etc.). Chronic infective in- flammations of the lung, prolonged irritation due to the inhalation of dusts, etc., cause a diffuse fibroid induration of the pulmonary tissue (chronic fibroid pneumonia, stone- cutter's lung, etc.). A persistent flow of irritating secretions, as in the case of a chronic gonorrhoea, pro- duces a marked hyperplasia of the mucous membrane and skin in the neighborhood of the genital orifices, affecting chiefly the papilla and over- lying epithelium, so that verrucose growths are produced {condylomata acuminata). Diffuse hyperplasias of the connective tissue of the skin, known as elephantiasis, may be caused by a persistent or frequently repeated trauma, the presence of parasites, etc. Chronic inflamma- tions of the periosteum and bone marrow give rise to new formations of bone. In the case of the internal 'St-^t .1" ■^M J 3 Fig. 49. — Changes in the Pleura and Lung after a Purulent Pleuritis Lasting Six Months (alcohol, orcein), a, Thickened lung tissue with gland-like alveoli, and elastic fibres in the newly formed con- nective tissue ; 6, thickened pleura ; c, newly formed connective tissue without elastic fibres; d. gran- ulation tissue covered with pus; e, elastic limiting membrane of the pleura; /, elastic fibres. X 46. {After Ziegler.) I^FLA:\iMATIOX. 141 organs, chronic inflammatory processes are characterized by a local or clifl^use hyperplasia of the connective-tissue stroma (hepatic cirrhosis, etc.). Chronic inflammations may be classed according to their causes or to the character of the changes produced in the affected part. The chief forms are chronic catarrhs, chronic abscesses, chronic ulcers, the infective gramdomata, hyperplastic chronic inflammations, and atrophic chronic inflammations. Chronic catarrhs of the mucous membranes may be caused b}' prolonged circulatory disturbances (chronic passive congestion), chemical irritation result- ing from pathological changes in the gastric or intestinal contents, chronic uifections (gonorrhoea, tuberculosis, etc.), the presence of animal parasites, con- cretions, etc. Chronic catarrhs of the genito-urinary tract are the forms most frequently falling into the province of surgery. Chronic abscesses may result from acute abscesses and are due to the same causes. In other cases they are the result of a specific infection (tuberculosis, actinomycosis, etc.), and develop more gradually witliout passing through any well-defined acute stage. Chronic abscesses have a connective-tissue wall lined with granulation tissue. They may contain pus or a material resembling pus, formed by the partial liciuef action of caseous material {"cold abscess"). The specific forms of chronic abscesses are as a rule easily distin- guished from other forms by the peculiar character of the granulation tissue of the abscess wall and also by the presence of the infective agent. Chronic abscesses increase in size as the result of a progressive destruction of the abscess wall and the neighboring tissue as well as by the continued forma- tion of pus. As they increase in size extension is usually governed by gravity and the path of least resistance. "\^Tien enlarging progressively toward the deeper tissues, they are spoken of as "congestive" or "burrouring" abscesses. The in- crease in size usually indicates the persistence of the infective agent. "Cold abscesses" are seen most frequently in cases of tuberculous arthritis and osteo- myelitis. Tlie contents of the cavity are, as a rule, slowly formed. "Cold abscesses" of the vertebrse extend downward along the spine and psoas muscles, presenting themselves as fluctuating tumors either above or below Poupart's ligament. In the great majority of cases the chronic abscess is tuberculous. Chronic abscesses also occur as sequelse of typhoid fever, influenza, variola, and others of the acute infectious diseases. Chronic idcers (see Fig. 50) may be caused by non-specific injurious agents, the ulcer for a number of reasons not healing and consequentl}' rimning a ■chronic course. Such ulcers are usuall}' found on the inner side of the lower third of the leg, and are generally associated with a chronic congestion or a varicose condition of the veins of the part. In the stomach the healing of an ulcer may be prevented or delayed by peculiar qualities of the stomach contents. In the majority of cases chronic ulcers are the result of some specific infection {tuberculosis, syphilis, glanders, etc.). Chronic ulcers vary 142 MIERICAN PRACTICE OF SURGERY. greatly in size, shape, appearance of base, edges, surrounding tissues, and general characteristics of the process. A very great variety of terms is, in consequence, applied to them. Wlien extending around a limb they are called annular ulcers. If healing begins at one edge of the ulcer while the ulceration advances at other parts, the resulting variety is known as serpig- inous. A small, slowly progressive ulcer is called an indolent ulcer. When, pale, soft, and flabby, the ulcer is designated weak or (edematous. A round or irregular funnel-shaped ulcer is styled perforating ulcer. Wlien covered with a grayish or yellowish-white necrotic layer composed of fibrin and necrotic cells, the ulcer may be classed as a croupous or diphtheritic ulcer. Raiv ulcers are those in which the base of the ulcer is composed of the body tissues, muscle or connective tissue. A dense, callous thickening of the edge and base of the ulcer I «"" %''1J.-\ ^^:^i *%! \ ^'^ ; X-^ >i -../, ^j«_.c--^r^\;5V, Fig. 50. — Floor of Chronic Ulcer, a, Superficial layer of purulent exudate; 6, zone of chronic granu- lation tissue; c, tissue at base of ulcer. (After Weichselbaum.) gives origin to the form known as cnlloiis ulcer. Excessive formation of granu- lation tissue produces an idcus elevatum hypertrophicum. The base of an ulcer may be either lower or higher than the surrounding tissue; it may be pigmented. The edges may be sharply outlined or irregular, thin or thick, adherent, over- hanging, romided, elevated, undermined, " worm-eaten," etc. They are usually of a uniform height. The tissue about a chronic ulcer may be red, swollen, cedem- atous, pigmented, eczematous, etc. Smaller ulcers may be grouped about the main one. There is usually only a small amount of discharge from a chronic ulcer. The symptoms are much less intense than in the case of an acute ulcera- tion, except when nerves are directly involved. INFLAMMATION. 143 Among the clinical varieties cf chronic ulcer seen in surgical practice are the varicose ulcers, erethistic, perforating, etc. The varicose ulcer is found on the lower or middle third of the leg, in association with varicose veins. It is usually irregular, but after a time becomes more round. The edges of the varicose ulcer are undermined, bluish, pigmented, and show slight granulation; when older, the edges are usually callous. The discharge from a chronic ulcer is, as a rule, small in amount, serous in character, and containing tissue debris and blood. About large varicose ulcers the skin is usually more oedematous, and is not rarely deeply pigmented. Eczema is a frequent complication. The develop- ment of granulation tissue is slow and limited in extent. Varicose ulcers may be of small size or may involve the greater portion of the limb. They are often multiple. The erethistic ulcer is a chronic ulcer found over the inner malleolus, particu- larly in women who have varicose veins or suffer from disorders of menstrua- tion. It is also known as the congested, irritable, or painful ulcer. Beginning as a small area of hyperemia over the inner malleolus, it gradually increases in size, becomes more painful, and finally, as the result of some slight injury, develops into an ulcer having sharply cut edges and tightly adherent base. The skin about the ulcer is thickened, pigmented, and adherent. An eczematous condi- tion is also often present. These ulcers are characterized by intense pain, due to the involvement of terminal nerves in the indurated tissue of the base and edges. They are very slow of healing and often return. The perforating ulcer is most often foiuid on the sole of the foot over the head of the metatarsal bones, but may also be found on the fingers or toes. It occurs chiefly in males past the age of forty, and is associated with constitu- tional conditions, such as syphilis, diabetes, tabes dorsalis, arteriosclerosis, etc. Sclerotic changes or thrombosis of the plantar vessels are probably the direct etiological factors in the majority of cases. The perforating ulcer usually be- gins as a small callus over the head of one or more of the metatarsal bones. Beneath the callus the abscess develops. As there is usually an accompanying impairment of sensation, the condition is neglected until the bone has become involved. There is finally formed a painless, funnel-shaped ulcer, extending to the bone. In old ulcers of this kind the epithelium may extend over the edges and partly or entirely cover the sides of the funnel-shaped depression. The discharge persists as a scanty, foul, purulent fluid, containing fragments of dead tissue and necrotic bone. Chronic ulcers may also occur in gout as the result of infection of tophi (gouty ulcer). Ulcers of the skin are of frequent occurrence in diabetics and show a tendency to spread rather than to heal. In syphilis secondary and ter- tiary ulcerative lesions are very common on the skin and mucous membranes. They may be superficial or deep, and arise from the breaking down of superficial or deep gummata. They are often serpiginous. The superficial syphilitic ulcers 144 AMERICAN PRACTICE OF SURGERY. are usually circular, with sharply cut edges and an indurated base covered with a yellowish, tenacious, purulent exudate. The deeper ones are irregular, with ragged, undermined edges and indurated, sloughing base. Tuberculous ulcers occur in the skin and mucous membranes, being of more frequent occurrence in the latter situation. They are usually secondary to chronic tuberculous proc- esses in other parts of the body, and are caused by the caseation of local tuber- cles with secondary infection. The edges of the tuberculous ulcers are usually elevated, indurated, and not undermined, and the base is made up of pale, caseous, tuberculous granulation tissue. The tuberculous ulcers of the skin ap- pear in a variety of forms clinically, and have been designated according to their most prominent characteristics (vernicose, indurated, scrofidoderm, etc.). Acti- nomycosis, blastomycosis, leprosy, and other of the specific infections often give rise to chronic ulcerative processes. More or less atj^pical formations of granulation tissue characterize various specific infections (tuberculosis, syphilis, leprosy, rhinoscleroma, actinomycosis, blastomycosis, glanders, etc.). They form nodular or diffuse chronic prolifera- FiG. 51. — Chron... A.iw|M,,. >..,,,,.. ■. .1,.^,...^ in^.^wot^, ^, ^^^^^^^^^^^ ^^^^o^x; c, submucoaa; d, muscularis; e, total atrophy of mucosa. (After Ziegler.) tions of granulation tissue, which are classed under the general heading of in- fective granulomata. As a rule, they possess more or less well-defined character- istics of structure and course, that permit of a clinical and pathological diagnosis. The presence of the etiological factor also aids in the differential diagnosis. The etiology of some of the granulomata is, however, still imknown. Various clin- ical designations are applied to different forms of granulomatous conditions (fun- gous granulations, caro luxurians, etc.). Chronic inflammations characterized by marked atrophy of the parenchyma- tous tissues, with or without hyperplasia of the connective tissue, are usually called atrophic. (See Fig. 51.) They occur particularly upon the mucous membranes of the gastro-intestinal tract and the bladder, and in the liver and kidneys. In the gastro-intestinal tract the epithelium becomes atrophic as the result of persistent desquamation or necrosis, the connective tissue either being unaffected or undergoing necrosis at the same time. It rarely shows marked hyperplasia in this location. In the case of chronic inflammations of the liver and kidneys, the atrophy and necrosis are accompanied or followed by a INFLAMMATION. 145 more or less marked hyperplasia of the connective-tissue stroma (hepatic cir- rhosis, contracted kidney). In the case of the liver, imperfect attempts at re- generation of liver tissue lead to a hyperplasia of the small bile ducts. (See Fig. 52.) Such chronic inflammations are known as productive, indurative, hyperplastic, etc. The treatment of chronic inflammations is both constitutional and local. cf a Fig. 52. — Connective-tissue Hvperplaaia and Prol ferat on of Bile Ducts in Chrome Hepatitis (al- cohol, hsematoxylin). a. aj, Liver lobules; 6, hyperplastic periportal connective tissue; c, old bile ducts; d, newly formed bile ducts; e, foci of small-celled infiltration. X 55. (After Ziegler.) The general condition should be built up and improved by proper food, hygiene, tonics, etc. The cause of the chronic reaction must be removed or inhibited when possible. Dead tissue, exudates, foreign bodies, etc., should be sought for and removed. The general indications for the treatment of inflammatory condi- tions — rest, absolute cleanliness, asepsis, etc. — should be met. The formation of granulation tissue should be stimulated in the various ways mentioned above, plastic operations and skin grafting carried out when necessary, and the promo- tion of cicatrization and new epithelial growth encouraged. VOL. I. — 10 THE NATURE AND SIGNIFICANCE OF THE VARIOUS DISTURBANCES OF NUTRITION OBSERVED IN CONNECTION WITH SURGICAL DISEASES AND CONDITIONS. By ALBERT GEORGE NICHOLLS. M.D., CM.. Montreal, Canada. ■ INTRODUCTORY. Before we can attain anj^thing like a proper compreliension of the processes with which we are to deal in the following pages, we must have some knowledge of the general principles underlying the question of the growth and development of organized structures. All those physical and chemical phenomena included under the term "nutrition," which are so peculiarly the attributes of living sul">- stance, can be understood only by a reference to the fundamental properties of protoplasm. Every living organism, whether animal or vegetable, must be regarded as being composed of one or more cells. All but the lowest forms of life are essen- tially aggregations of cells or communities of primordial units. The highest and most complicated individuals, whether plant or animal, are composed of organs, these of tissues, and these again of cells. Ultimately, then, the life history of any individual is the sum total of the life histories of its primitive constituents. The laws which govern the cell are those which govern the individiial as a whole. Every organized being begins as a single cell — the fertilized ovum. This cell is peculiar, in that it represents in a large measure the characteristic tendencies and properties of the parents. What it will become depends not only on the specific characters implanted in it, peculiarities which we speak of as inherited, but also on the influence of external forces, or environment. The first step in the development of the complete individual is the division of the ovum. The resulting cells increase in size, owing to the influence of the pabulum supplied, and finally become specialized according to the function which they have eventually to perform. We can thus recognize three funda- mental attributes of primitive cells: (1) Their capacity for multiplication; (2) their power to increase in size, and (3) their tendency toward histological differ- entiation. The term "growth" implies an increase in size of the organLsm. This in- crease is, however, not true growth, unless it be the result of forces inherent in the cells. Enlargement of an organ or tissue may be due to the deposit within DISTURBANCES OF NUTRITION. 147 it of some product of degeneration, such as fat, or to a variety of other extrinsic causes. This is not growth. The growth of the individual is the expression of the growth of his component cells. Growth, then, is ultimately dependent on an increase in the size of single cells and on a multiplication of their numbers. Growth, however, implies somewhat more than this, in a vague way, namely, the power of the cellular elements to advance in the scale of organization, or at least not to retrograde. The three factors just referred to — multiplication, increase in size, and his- tological differentiation — so far as the organs and tissues are concerned, operate in harmony and to some extent coincidently, but with regard to the individual cells are more or less mutually exclusive. Cells which are rapidly dividing are always small, since they have no resting period in which to increase their bulk. The finer details of histological differentiation form the last stage in the devel- opment of any structure. Conversely, cells which are highly specialized lose to a large degree the power of multiplication, or, if they do multiply, must first re- vert to a more primitive condition. Development is in a sense a thing apart from growth, for a cell or tissue may attain practically its full size, in proportion to the individual concerned, with- out attaining its highest degree of specialization. Generally, however, we employ the term "development" in a broad way, to include not only growth in size, but also differentiation. The capacity for growth and development possessed by all cells and tissues is not everywhere manifested in the same degree. Certain structures may take years to attain their anatomical and functional completeness, while others quickly mature and as quickly retrograde. Let us examine a little more carefully the question of multiplication of cells and the increase in size of tissues. Believing, as we do, in the doctrine that every cell is derived from a previously existing cell, we are apt to go somewhat further and assume that one kind of cell invariably gives rise to one of the same type; for example, that epithelium gives rise to epithelium, muscle to muscle, nerve cell to nerve cell, and so on. This is not necessarily so, as a little reflection will show us. The mere fact that a sin- gle, undifferentiated cell, the fertilized ovum, is the precursor of all the cells of the body and gives rise to the most highly specialized structures, such as the retina, might have prepared us for something different. As a matter of fact, when we study growing tissues we see that certain cells alone are actively divid- ing or are actively proliferative, while others do not divide, but assume other special functions. If we take the case of a growing plant, we find that at the tip of each stem or rootlet there is a mass of cells of embryonic type, which are un- dergoing rapid division. Development takes place in a very peculiar way. At the extreme end of the stem is a cell or group of cells, that always divide by transverse fission into a distal and a proximal daughter cell or cells. The distal 148 AIVIERICAX PRACTICE OF SraGERY. daughter cell at the tip alwaj-s retains its embryonic characters and keeps on dividing in the same manner. Thus, the original proximal daughter cell becomes separated from the tip of the stem by successive divisions of the apical cell or cluster of cells. The distal cells never do anything but divide. The proximal ones, however, have another destiny. They eventually cease multiplying, be- come larger and vacuolated, and eventuallj' assume the characters of the cells of the tissues to which they belong. In other words, they become differentiated. Thus we see that certain cells are specialized for multiplication, others for growth and for histological differentiation. The same thing holds in connection ■n-ith animal life. The more highly differentiated cells of a tissue do not give rise directh' and by diAosion to other cells of the same tj-pe, but in each tissue there are undifferentiated cells — mother cells, or embryonic cells — which have the special power of proliferating; and it is the daughter cells, derived from these, that reach the highest anatomical and functional perfection. Proofs of this might be multiplied. As a consequence, we may lay down the following general principles: 1. That fully differentiated cells of a tissue never give rise directty to cells of the same highly specialized tj'pe. 2. That in all tissues there are certain "embryonic" or undifferentiated cells, whose special function is to di^dde, and that the daughter cells derived from these are the ones which subsequentlj' attain the higher planes of development. 3. The more highly specialized the cell, the more difficult it is for it to reproduce its kind ; con- versely, the more primitive the type of the cell, the more easily will it prolifer- ate. These general laws, which hold good in regard to the natm-al growth and development of the organism, are equalh' true in connection with pathological processes. Injured or lost parts are restored to the normal in accordance ■nith the same laws which governed their formation in the fu'st instance. As the higher forms of cell are derived from the lower, so must they revert to a more embryonic condition before they can midergo proliferation. Finally, as we have tliree fimdamental properties of protoplasm, so we have three methods by which its A-ital energies are manifested — assimilation, nutri- tion, and reproduction. Any interference with these \\i\\ cause disease. HYPERTROPHY. In a general way, h5^ertrophy may be defined as an increase in the sub- stance of a tissue or organ, due to an increase in the nmiiber or in the size of its component cells, or to a combination of both these conditions, without any other alteration of structure. Like many other definitions, this one needs to be defined. As we have seen, growth consists in the increase of tissue by the addition of new material of the same natiue as that already existing. The essential char- acter of the part is not altered, but its bulk is increased, and it is therefore en- DISTURBANCES OF NUTRITION. 149 abled to perform more work than it had previously been doing. Up to a certain point development and growth go hand-in-hand. Wlren the time comes that all the necessary parts of a structure are complete, development ceases, although growth may for a time continue until the perfect stature and proportion of the body are attained. It is not, however, possible to fix the point at which either de- velopment or growth ceases, for in this particular different organs and structures have their own peculiarities, and much depends on personal idiosyncrasy and the condition of the bodily health. Some organs, like the thymus, reach their full perfection during childhood, and early atrophy and disappear; others, like the heart and arteries, have been shown to go on receiving increments of sub- stance and power until advanced years. Much, however, depends upon circum- stances. If the bodily health be robust and the organ in question be regularly and fully exercised, then growth will continue, or, at all events, the organ will not waste. Any addition to the amoimt of work demanded of any organ will re- sult in an increase in its size. To a certain extent this is desirable and can hardly be regarded as an evidence of disease. In fact, it is often difficult to draw the line between what may be termed physiological hypertrophies and the patho- logical overgrowths, for both are essentially conservative processes, tending to maintain the nutrition and function of the part in the highest possible efficiency. It would appear, too, as if all organs possessed, though in varying measure, a certain reserve power of growth and development, which they are able to put into action in case of necessity. In this way the extra demand is compensated. The orderly and natural progression of the metabolic processes, which is the indication of health, is dependent upon the correlation of several factors, the vascular supply of the part, its innervation, and the mutual relationship with other structures. There is, so to speak, a constant effort toward an equilibrium. In the case of overgrowth the same general laws are at work. The possibility of the occurrence of hypertrophy, and its efficiency when it has arisen, depend essentially upon the state of nutrition of the affected part. This implies an adequate vascular and nervous supply. The blood-vessels must therefore enlarge and the trophic centres be correspondingly active. The blood also must be of good quality. Once the reserve power of the part is exhausted, not only does the process of hypertrophy cease, but degeneration and atrophy take its place, resulting in functional inadequacy of the structures concerned. Consequently, as we would expect, we get the most extreme examples of hyper- trophy in the young and robust, while, on the other hand, in the aged and de- bilitated the ordinary causes will fail more or less completely to produce it. Not only, however, does the term "hypertrophy" connote an increase in size, but there may be, in addition, a formation of new tissue. Thus, in the hy- pertrophied heart the muscle fibres are more numerous, stronger, and more highly colored. In the liver of atrophic cirrhosis, while many of the parenchym- atous cells are wasted, fatty, and degenerated, new ones are formed, which are 150 AMERICAN PRACTICE OF SURGERY. almost gigantic, having large, deeply-staining nuclei. In the pregnant uterus new and relatively large and powerful fibres are produced. It is usual, therefore, to recognize two forms of hypertrophy. Where there is a simple increase in the size of the cells composing the part, we speak of quantitative or true hypertrophij; if there be an increase in the number of the cells, we speak of numerical hyper- trophy or hyperplasia. As a rule, both conditions are combined. According to the nature of the cause at work, hypertrophy may be tempo- rary or permanent. Many of the temporary hypertrophies are physiological in their nature, as, for instance, the enlargement of the uterus during gestation, the enlargement of the muscles from increased exercise, the production of new and active acini in the breast during pregnancy as a preparation for lactation. Should the cause persist or from its nature be irremovable, temporary hyper- trophy becomes permanent and may lead to important consequences. As a rule, it is possible to discover some reason for the production of hyper- trophy in a given case. There are, however, instances which are more or less obscure. Such are the hypertrophies which are occasionally seen in the thyroid and thymus glands, the spleen, tonsils, and prostate, and in warts and polypi. Some, possibly, may have an inflammatory basis, while in the case of the duct- less glands there may be some disturbance in a correlated organ. But more than this we can hardly say, in view of the present state of our knowledge, or, rather, want of knowledge. We must for the time being be content to recognize cer- tain hypertrophies, which have affinities, on the one hand, with inflammation, and, on the other, with neoplastic growth. The anatomical changes peculiar to hypertrophy are usually, though by no means invariably, manifested by an increase in the size and weight of the af- fected structure. Mere increase in weight does not, however, constitute hyper- trophy. For example, the heart may be enormously enlarged in point of its ex- ternal configuration, owing to dilatation of its cavities or from a deposit of fat upon its surface; the liver m.ay be enlarged from hypertemia or inflammatory infiltration. Conversely, the heart may present no external evidences of hj'per- trophy, in that its bulk is not increased, and yet it may be truly hyper trophied. This occurs in the so-called "concentric" hypertrophy, in which the enlarged muscle has encroached upon the cavities. Before, then, either increased size or weight of an organ can be taken as an evidence of hypertrophy, we must make sure that this increase is not due to any cause but the increase in size or number of the pre-existing cells of the part. This, as a rule, can be determined only by a careful microscopical examination. Histologically, true hypertrophy is indicated by an increase in the bulk of the individual cells. The nucleus is enlarged, often altered in shape, and stains more intensely than usual. Thus, in the case of the heart muscle, the nucleus of the fibre is enlarged and more obtuse at the poles than normal. Nuclear division is not infrequent. The cell body is also enlarged, and the cytoplasm shows an DISTURBANCES OF NUTRITION. 151 increased affinity for stains, such as eosin, being of greater intensity and bril- liancy than that of similar cells under normal conditions. In the case of pig- mented cells, such as those of the muscle, the pigment appears to be increased. These minute changes can be properly appreciated only by a comparison with the normal condition of things and by accurate measurements of the cells, al- though an expert microscopist will usually be able to reach fairly correct con- clusions without such assistance. Rarely or never do all the cells of an organ or tissue manifest the same degree of hypertrophy throughout. For, paradoxical as it may seem, hypertrophy and atrophy often go together. The cells may be increased in size but dimin- ished in number, or, conversely, hyperplasia may be accompanied by a decrease in bulk of the individual elements. Granting, then, a natural tendency of cells toward growth, which, under cer- tain circumstances, may be in excess of the normal, we find that the causes at work in the production of hypertrophy are either intrinsic or extrinsic. In the former case the abnormal tendencies to cell growth and multiplication ap- pear to be inherent in the cells, the result of some peculiarity in the germinal cells or of germ variation. Here the anomaly is present at birth or makes its appearance comparatively soon after. Extrinsic hypertrophy is usually the re- sult of increased nutrition and excessive demand upon the function of an organ, or of a disturbance of the equilibrium that ought to subsist between anabolism and katabolism. Intrinsic Hsrpertrophy. — This is congenital or else appears shortly after birth. As a rule, the internal viscera are not involved, unless we accept certain obscure enlargements of the brain, thymus, spleen, and Ijonph nodes as of congenital origin. The condition may be universal or partial. A number of organs and tissues may be affected. Hypertrophy of the epidermis gives rise to the condi- tion known as congenital ichthyosis. Increase in the amount of hair, or its ap- pearance on parts of the body that are normally destitute of it, is called hyper- trichosis. Enlargement of the nails is hyperonychia. The amount of fat may be excessive — lipomatosis or obesity. Elephantiasis is a term used somewhat loosely to designate a number of conditions which have this in common, that the af- fected part is enlarged (see Fig. 53). The tropical form of elephantiasis is not a true hypertrophy, but is more akin to inflammation. The enlargement is due to the obstruction of the lymphatics, with secondary hyperplasia of the connec- tive tissue. There are a number of congenital conditions, however — as, for in- stance, certain nsevi and enlargements of the face, lips (macrocheilia) , and tongue macroglossia) — which appear to depend on some obstruction of the lymphatics and blood-vessels, with, in some cases, apparently actual new-formation of ves- sels, which possibly may be included under hypertrophy. Perhaps the best example of congenital hypertrophy is gigantism. This may affect the body as a whole — bones, muscles, skin, nerves, vessels, and internal 152 ^LAIERIC.IN PRACTICE OF SLTIGERY. organs {general gigantism) — or some particular organ or member (partial gi- gantism). In true or essential gigantism the indi-\-iduaI affected differs in no respect from the normal, save in the one particular of size and \reight. In addition to ex- cessive size and weight, there are great strength and perfect proportion, together Fig. 53. — Elepliantiasis of the Leg ; Enormous Enlargement of the Limb, vrith Ichthyosis. {Patho- logical yiuseuni, McGill University.) with ordinarj'^ intelligence. Such giants are examples of the so-called "athletic" liabit of bod}-, and represent the hmnan body carried to its highest power in point of structme. Cases of this kind have no doubt existed, but are excessively rare. As a rule, however, giants present the unmistakable stigmata of defect. The increase in height is due mainly to excess in the long bones; the head DISTURBANCES OF NUTRITION. 153 is proportionately small; there are evidences of infantilism, knock-knee, and genital inadequacy; and, finally, physical and mental weakness. Besides this form of general gigantism, or, as it might perhaps be more cor- rectly styled, macrogenesy, there are certain less extreme manifestations of the tendency in the form of local hypertrophies, which are midoubtedly of develop- mental origin. Such are the forms which involve the head or extremities. In leontiasis ossea there is an excessive and remarkable deformity of the bones of the face and skull, which appears to be essentially a diffuse hyperostosis. Local gigantism in children is especially common in the upper limbs, and may be uni- lateral or bilateral. Hemihypertrophy of the body has also been described. One or more digits may be affected (macrodactylia) , or a whole limb. Apart from these instances of local gigantism, which are characterized mainly by an increase in the bulk of the part, there are certain other forms of numerical increase, Fig. 54. — Cross Section of the Heart, to Show Hypertrophy of the Walls. The cause ; increased peripheral tension. (Pathological Museum, McGill University.) which some authorities would include under the heading "gigantism." Such are polydactylism, accessory ribs, and supernumerary organs. Tliese peculiarities are occasionally associated with general gigantism. Extrinsic Hypertrophy. — Hypertrophies which are not dependent on some constitutional and inherent peculiarity, but are the result of some external cause, are called extrinsic hypertrophies. They are, in other words, acquired. It is undoubtedly somewhat difficult, if not impossible, in many cases to draw the line between the congenital and the acquired forms; for some cases, which closely resemble the congenital varieties, may on occasion result from external causes. Such are certain forms of ichthyosis and elephantiasis. It is not impos- sible that these external causes may have, in some cases, been operative diuing 154 AMERICAN PRACTICE OF SURGERY. intra-uterine existence. It is probable, moreover, that in many instances, even where the condition is evidently due to external influences, there is some inher- ited tendency to overgrowth of tissue as well. As in the case of cancer, there must be some predisposition of the cells before the exciting cause can wake up the latent activity. Hypertrophies not dependent on a constitutional idiosyncrasy are always the result of an increased demand upon the functional activity of the part or of some disturbance of the balance which ought to exist between waste and repair. In the majority of instances it is the former. We may recognize the following vari- eties, to be more precise, namely : (1) Hypertrophy from increased functional activity. (2) H3'pertrophy from lessened wear. (3) Hypertrophy from removal of pressure. (4) Hypertrophy from failure of involution. (5) Hypertrophy from increased nutrition. (6) Hypertrophy from chronic irritation. (7) H3'pertrophy from errors of metabolism. (8) Hypertrophy of neuropathic origin. Hypertrophy from increased work usually affects the muscles and glands, less often other tissues. In some unexplained way the unwonted physi- cal and chemical condition of the muscle or gland cell leads to excessive cell growth. Perhaps the best example of this form, which has been called labor or fiinc- tional hypertrophy, is to be found in the heart. Increased peripheral vascular tension, certain renal and pulmonary diseases interfering with the circulation, and obstructive valvular affections of the heart itself, lead to overgrowth of that portion which feels the strain most, and eventually to involvement of the whole organ. (See Fig. 54.) Again, as Thoma has shown, increased arterial tension produces hypertrophy of the middle coats of the arteries. It is a matter of common observation that increased muscular exercise results in increased bulk of the muscles. This is particularly well seen in the case of laborers, in whom certain muscle bundles or groups are often picked out. It is believed that the individual fibres increase not only in length and thickness, but also in number. Many interesting examples are also to be found in the case of the involuntary muscles. Thus, the uterus may be considerably enlarged when the seat of fibroid tumors or of hsematometra. Any obstruction in the alimentary tract — oesophagus, stomach, or intestines, — whether due to foreign bodies, tumors, adhesions, or strictures, will inevitably lead to overgrowth of the tissues above the obstructed point. The same thing occurs in the urinary bladder in cases of enlarged prostate, stricture, or calculi. In these hollow organs the walls often be- come enormously ballooned out, but with this there is always an increase in sub- stance. This affects chiefly the muscular layers, but the mucous membrane must DISTURBANCES OF NUTRITION. 155 also enlarge to accommodate itself to the changed order of things. In all such cases there is an attempt on the part of nature to overcome by muscular force the hinderance to the proper performance of function. It should, however, be pointed out that mere frequency in the performance of a muscular act is not, so far as we are aware, competent in itself to produce hypertrophy. The heart may, for ex- ample, beat more rapidly than normal for years without increasing in bulk and power. The action must at the same time be forcible. This is well illustrated in the case of mechanics. The hand muscles in those who use speed are usually not so large as in those who exert great muscular force. The same thing can be seen in the case of sprinters, athletes, greyhounds, and racehorses, who not infre- quently suffer from hypertrophied heart. In all, not only is the heart's action increased in rapidity, but it is excessively forcible. The blood pressure is tem- porarily raised during the great effort, but the rapidly-acting muscles demand an increased supply of nourishment. The first effect of this is dilatation of the heart, which subsides after the extra call has ceased, but, when such demands are repeated, finally gives place to hypertrophy. Another form of overwork is seen in some of the secretory organs. Of all glands, the kidney and the liver appear to have the greatest powers of cell growth and proliferation. In diabetics and those who drink to excess the kidneys may be considerably enlarged. Hypertrophy of the liver as a whole is rare, but the liver possesses considerable powers of regeneration, as may be seen in cases where portions of the liver have been removed. The original weight, though not the shape, is quickly restored. Hypertrophy of single cells or small groups of cells is, however, by no means uncommon. This is met with even in such acute conditions as acute yellow atrophy, and is a constant accompaniment of chronic passive congestion and all forms of cirrhosis. The "hobnails" of the gin-drinker's liver are not due, as is so often taught, to the contraction of the fibrous bands, but to an actual hypertrophy and hyperplasia of the parenchym- atous cells. Inasmuch as all such cases of cell proliferation are attempts on the part of the organism to make good or compensate some abnormal condition, these hy- pertrophies are frequently termed "compensatory." Many of them, as we have seen, are the result of disease in some part of the body more or less remote from the organ or tissue affected. An important class of cases is that which might be termed "complemental." Such are the hypertrophies which occur in one or other of a pair of organs or in structures that are accustomed to work together. Should, for instance, one kidney fail to be properly developed from agenesia or hypoplasia, or should it be at any time removed, or, again, be the subject of some disease that materially interferes with its function, the remaining kidney will attempt to overtake the increased work, and, as a consequence, will hyper- trophy. In such cases not only may there be a hypertrophy of the pre-existing structures, but, in young individuals at least, there may be an actual new for- 156 A]\IERIC.4X PRACTICE OF SI'EGERY. mation of glomeruli and tubules. The enlargement of the good kidney is usually much greater in the case of congenital deficiencj^ of the organ than in cases of acquired disease — a circumstance which goes to support the principle already indicated, that the power of regeneration is greater in young than in old cells. Smiilarly, destruction of one suprarenal may be followed by h3rpertrophy of the other, and agenesia or hypoplasia of one lung may be followed by hypertrophy of the remaining organ. In older persons, however, where one lung is the sub- ject of disease, the compensation takes the form of emphysema rather than that of true hypertrophy, inasmuch as the air sacs dilate — a condition which results in atrophy of the alveolar walls. Here, again, increase in bulk does not indicate hypertroph}'. The power of compensation, which is so strikmgly exemplified in the process of hypertrophy, is beautifully illustrated in certain affections of the lower ex- tremit}^ When, for instance, the tibia is weakened from rarefaction or necrosis or from a badly repaired fracture, the fibula becomes unduly thick and strong in order to meet the increased strain. A second and perhaps the more interesting class of cases has to do with or- gans which are fmictionally complemental. The most notable instance of this is found in connection with the thyroid gland and pituitary body, which are now generally believed to be closely related and of great unportance in the bodily metabolism. Loss of function of the thjToid, as from disease or the removal of a portion of the gland, is followed not only by hj^Dcrtrophy of the remaining part, but by overgrowth of the pituitary. Again, as Warthin has recently sho^Ti, in cases of pernicious anaemia and leukaemia, where the function of the bone-marrow appears to be impaired, the haemol}Tnph glands become enlarged and their structure alters mitil it comes to resemble that of the spleen or bone- marrow. Tissues which are normally the subjects of constant wear often attam an ab- normal size imder conditions where the loss of substance ceases. This generally occitrs in connection with the teeth, nails, and skm. The teeth are normally kept at a constant length, owing to the attrition which takes place in conse- quence of the function of mastication. If the teeth do not properly approxi- mate, as in cases where certain teeth are movable or have fallen out, or, again, in fracttires of the jaw, the unopposed teeth gradually elongate aiid may even form tusks. This is seen normalh^ in certain animals, like the wild boar, and is found occasionalh' in rodents under the circumstances mentioned. (See Fig. 55.) The tendency for such teeth to grow in a circle is explained bj' the fact that the enamel of the posterior aspect is more yielding than that of the anterior. In bedridden patients, in whom the ordinarj' wear is prevented, the nails often be- come thickened, elongated, and deformed. (See Fig. 56.) Failure to cut the nails is followed b}' a similar elongation, as ma}^ be seen in the nails of the Chinese exquisite or of the Hindu fakir. An analogous overgrowth is occasion- DISTURBANCES OF NUTRITION. 157 ally met with in the beak of birds and in the formation of horny pads on the feet of animals. Hypertrophy also results from the removal of pressure, or, to put it some- what differently, from a disturbance of the mutual tension which exists between tissues. If from any cause the brain lags behind in its development, the skull remains small in order to accommodate itself to the abnormal condition of things (microcephaly). This, however, occurs only during the developmental period of life. At a later time — that is, after adult age has been attained — any loss of substance of the brain, as from atrophy or disease, is compensated in another way. Theoretically, the wasting of the brain would leave a space between the dura and the calvarium. But, as "nature abhors a vacuum," the space is filled up either with watery fluid (hydrops ex vacuo) or by an overgrowth of the cranial vault. The diploe and the inner table are reconstructed and enlarged, so that the skull- cap may become greatly thickened, although its external appearance may remain un- altered. Such hypertrophy is usually most marked in the neighborhood of the primitive centres of ossification of the cranial bones — a fact which illustrates in an interesting way the uniformity of the law which governs growth and development, whether in normal or in diseased conditions. An analogous condition is the overgrowth of the fat which takes place about a contracted or atrophied kidney, the loss of substance being thus, though in an inadequate fashion so far as fimction is concerned, made good. Failure of involution to take place results sometimes in a permanent enlarge- ment of the affected organ. The thymus, which attains its full growth and per- fection about the second year of life, from that time on begins to atrophy, until at puberty but little of it is left, and about the thirtieth year it is represented merely by fat and connective tissue and some scanty remains. Occasionally the thymus, in its perfect structure, may persist even after puberty. Why this pe- culiarity occurs and what may be its significance are still matters for inquiry. Another and a common form is the subinvolution of the uterus, which some- times occurs after delivery. It has been laid down as a general principle that before growth or over- growth of a tissue can occur there mvist be an adequate supply of healthy blood. Fig. So. — Head of a Woodehuek, showing Hypertrophy of the Incisor Teeth from Lessened Wear. (Pathological Museum, McGill University.) 158 AMERICAN PRACTICE OF SURGERY. For only by means of an active blood supply can the nutrition of a part be kept up. If we examine a hypertrophied tissue we generally find that the blood-ves- sels supplying it are also enlarged. This is probably in most cases a secondary phenomenon. Here, as in other spheres, the demand creates the supply. But the converse is equally true, that an excessive blood supply frequently leads to hypertrophy. The enlargement of the vol- untary muscles from exercise already referred to, is not. al- together due to increased func- tion, but in a large measure to the increased degree of nutrition which this implies. For, from the very nature of the mechani- cal action, the heart is stimu- lated, an increased amount of blood is determined to the part, ,•11 id, while the wear and tear are greater than normal, the poison- ous products of metabolism are more rapidly eliminated. Apart, however, from mechanical action, many interesting examples may be cited to show the influence of a mere increase in the amount of blood reaching a certain part. The " clubbed fingers" so often seen in chronic pulmonary and cardiac affections seem to be in the main the result of venous hyperemia. A more marked enlargement affect- ing both bones and soft tissues is met with in the so-called hypertrophic pul- monary osteoarthropathy of Marie. The cause here is probably the same, aided possibly by the local action of toxins absorbed from the pulmonary lesion. The application of mustard, blistering fluids, or any substance which induces hypersemia of the skin may at times lead to an increased growth of hair. Similar overgrowths of hair are occasionally met with in the neighborhood of chronic ulcers, about the ends of stumps which have been for a long time inflamed, and about old diseased joints. Sir James Paget records having met with a curious instance of this kind in a child about five years of age. The femur had been fractured near the middle ; the case had done badly, and union had taken place with much distortion. The affected thigh was covered with dark hair like that of a strong, coarse-skinned man, while on the rest of the body the hair was as delicate and soft as it usually is in childhood. Cases such as these cannot properly be regarded as the result of inflammation, for the growth of hair is usually at such a distance from the inflamed area as to preclude the Fig. 56. — Hypertrophied Toe Nails, Removed by Operation. {Pathological Museum, McGill University.) DISTURBANCES OF NUTRITION. 159 possibility of any morbid influence, save that of hypersemia alone. This would appear also to be indicated by Hunter's classical experiment of transplanting the spur of a cock upon its comb. The comb is highly vascular, and the trans- planted spur reached striking dimensions, being about six inches long and spirally curved. It may possibly be that the congenital hypertrophies known as partial or local gigantism are a consequence of increased vascularity, although this has never been proved. Closely akin to this last form are the hypertrophies due to chronic irritation. Here an important factor is pressure. Constant pressure usually produces atrophy or necrosis. Intermittent pressure, on the other hand, often leads to hypertrophy. Common instances of this are corns, the cal- luses on the hands of workingmen, and on the feet. The necessary con- ditions appear to be a period of stimulation and a period of rest, to allow the processes of nutrition to go on. The effect of this is a hyperplasia and hyperkeratinization of the epidermis, which leads to pressure upon the papil- lary layer and consequent irritation. Subsequently adaptation may be so far carried out that a secret- ing bursa may be formed beneath the corn for the protection of the joint. More interesting still are the cases of elonga- tion and enlargement of bones resulting from in- flammation. In inflam- mation we have not only the influence of an increased flow of blood and increased nutrition, but often also the stimulating effect of toxins, bacterial or metabolic. Normally the growth of bone depends on the activity of certain specialized cells — the osteoblasts — which are chiefly situated in the deeper layers of the periosteum, at the extremities of the long bones, and at the interosseous sutures. Growth in thickness takes place by subperiosteal osteoplasia ; growth in length Fig. 57. — New Growth of Osteophytes about the Hip Joint, the Result of Chronic Arthritis. {Pathological Museum, McGill Uni- versity.) 160 AilERICAN PRACTICE OF SURGERY. is due to the action of the osteoblasts situated at the spongy ends of bones and in the epiphyseal cartilages. Increase in length of a bone depends not only on the inherent vegetative power of the cells, but also on the condition of the epi- physeal discs. Growth in length can occur only so long as the epiphyses are un- united to the shaft. After this takes place, growth in thickness and Ln density is alone possible. In young individuals, then, irritation in the neighborhood of the ends of a bone may result in increase in its length. Experimentallj', in rab- bits, the length of the bones can be increased by driving ivorj' pegs into the epiphyseal discs. The effect of chemical substances is well illustrated also in the experiments of Wegner, who was able, by feeding rabbits for a pro- longed period with minute doses of phosphorus, to pro- duce stimulation at the epi- physeal sutures, with conse- quent increase in the length of the long bones. Arsenic has a similar effect. Chronic inflammation af- fecting a bone or some of the tissues in its neighborhood in a similar way leads to increase of growth. (See Fig. 57.) Thus cases are occasionally met with where, o-n-ing to necrosis of some part of the femur, that bone has elongated tmtil the limb was an inch or two longer than its fellow. In such a case the femur does not materially alter its shape or direction. It is different, how- ever, with the tibia. The tibia is bound to the fibula at each end by liga- ments, and when it elongates it must necessarily assume a curved position unless the fibula enlarges simultaneously. The stimulating influence of the irritation may, indeed, be traced to a considerable distance from the site of the lesion. Instances are on record where necrosis of the tibia and shortening of the leg have been followed by a compensatory elongation of the femur, so that the limb as a whole was eventually no shorter than the other. Chronic ulcers of the skin and subcutaneous tissues are sometimes followed by elongation Fig. 58. — Femur; Ununited Fracture through the Great Trochanter ; Excessive Growth of New Bone. {Pathological Museum, McGill University.) DISTUEBANCES OF NUTRITION. 161 and enlargement of the underlj-ing bone. Similarly, hj^pertrophy may occur to repair a structural defect. In a badly imited fracture the permanent callus is often rery large. (See Fig. 58.) It has been shown also, in dogs, that removal of a portion of the radius is followed by an increase in size of that portion of the ulna which is directly opposite to the loss of substance. Another aspect of the subject should also be referred to. Where the epiphys- eal cartilages are united to the shaft of the bone, as in adults, or have been de- FiG. 59. — Spondylitis Deformans; Car\-ature : ' ! ~ Osteogenesis. (Pathological Museum, McGill VnivenrUij.) with Ank^'loais, due to Subperiosteal stroyed by disease, increase in length of the affected bone is no longer possible, but increase in its thickness may take place. And, in fact, even in young per- sons more or less periosteal osteogenesis usually accompanies any increase in length. Increase in the thickness of the bone is a not infrequent event in such affections as chronic, osteitis periostitis, and osteomyelitis. (See Fig. 59.) The overgrowth of the bone is, moreover, not entirely the result of external accretion, due to stimulation of the subperiosteal osteogenetic layer, but to an alteration 162 .\]*IERIC-\X PRACTICE OF SURGERY. of its internal structure. There is, in addition, a deposit of new bone on the tra- beculse, so that the cancellar spaces are obhterated and the textui'e of the bone becomes more dense and approximates to ivory (osteosclerosis). (See Fig. 60.) As we have hinted above, growth and development are in large measure a question of metabolism. In this connection the internal secretions are of the utmost moment. No doubt all the ductless glands pla}^ an important role, but Fig. 60. — Sclerosis of the Calvarium, of S3T5liilitic Origin. Note the thickness of the segment of bone (at lower part of the picture), which is also dense and ivory-like. (Pathological Museum, McGill University.) three of them stand out pre-eminently. These are the thyroid, the pituitary, and the testes. The relationships that exist between these organs are numerous and cannot be entered into fully here. There can be no question, however, that a certain mutual balance of fimctional activity on the part of these structures is essential for the maintenance of normal growth and de-s-elopment. Should this balance be upset, metabolism is disordered and disease is the result. The body as a whole may be involved or some part of it. The changes are manifested DISTURBANCES OF NUTRITION. 163 mainly in the direction of aplasia, hypoplasia, atrophy, or hypertrophy. A fa- miliar instance of imperfect growth and development of this type is cretinism, which is now generally admitted to be the result of athyroidea. Of the opposite condition, namely, excess of growth, we may cite the elongation of the bones which occurs after castration. The posterior pair of limbs is usually increased in length in eunuchs, oxen, and capons. The overgrowth of hair that sometimes occurs on the faces of women who have passed the menopause, or who are the subjects of ovarian disease, is possibly also of this nature. The most striking example, however, is acromegaly. In this curious disease, as Marie put it, there is a massive hypertrophy of bones of the extremities and of the extremities of the bones. The hands are spadelike and the fingers rounded. The lips, tongue, nose, cheeks, and ears become thickened, and a characteristic prognathic facies is in time produced. In severe cases all the bones of the body are affected. The thorax enlarges and the trunk becomes scoliotic. With this there are minor peculiarities, general physical and mental asthenia, trophic dis- turbances of the skin, and sexual apathy. In the vast majority of cases ^some lesion of the pituitary body has been found, such as hypertrophy, cystic or ade- nomatous tumors. Whether, however, the disease is the result of an increased, a diminished, or a perverted pituitary secretion is a question which at present must be tmanswered. Lastly, we have to discuss certain hypertrophies, which, for want of a better explanation, may be called neurotrophic. Such are, possibly, the cases known as "idiopathic hypertrophy of the heart." Here, the heart is hypertrophied in the absence of all of the ordinary conditions which produce this, such as arterio- sclerosis, nephritis, emphysema of the lungs, and valvular lesions of the heart. Cases have been attributed to mental overwork, worry, and the abuse of tea and coffee. It is conceivable that in such cases there may be some functional dis- turbance of the nerve terminals or ganglia in the heart muscle. Of a similar nature appear to be those cases of hypertrophied bladder which are occasionally seen in children who suffer from frequent and painful micturition, with most of the symptoms of calculus. No calculus is present, however, and at autopsy no disease of the urinary organs is found other than hypertrophy. The condition appears to be due to a too frequent and powerful action of the vesical muscle. Possibly it is to be attributed to a spasmodic contraction of the muscles about the urethra, causing a temporary obstruction. This incoordinate action of the muscle is very likely the result of disturbed innervation. ATROPHY. The term "atrophy," from its derivation, implies wasting, lack of nourish- ment. In pathological language it means a condition or process in which the cardinal feature is diminution in size of a tissue or organ, either from a decrease in 164 AMERICAN PRACTICE OF SURGERY. the size of its constituent cells or from a diminution in the number of these cells, or both. We may, therefore, distinguish between a quantitative and a numerical atrophy. The distinction is, however, entirely theoretical, for it is practically impossible to separate the two conditions. Provided that the cause remain constantly acting, a cell which at first only becomes diminutive will in time disappear altogether. Atrophy is in most respects the antithesis of hypertrophy. In hypertrophy the size and number of the tissue elements increase, resulting in augmentation of function. The affected part becomes larger. In atrophy the part wastes from diminution of its substance, and its function is correspond- ingly impaired. As we have seen in the preceding section, we have two kinds of hypertrophy — hypertrophy with growth and hypertrophy with development. Similarly we may recognize two forms of atrophy — atrophy with simple wasting and atrophy with degeneration. It is not always possible to make this distinction in any given case, for, as a matter of fact, a wasting tissue not infrequently degenerates, and, conversely, a degenerated tissue is usually smaller. Still, however, it con- duces to precision of thought to preserve this distinction in our minds and to use the term "atrophy" in a more restricted sense, namely, to indicate a simple loss of substance, without connoting any other retrogressive change. It is well, also, before going further, to get a clear idea of certain terms which are not infrequently confused with "atrophy." These are agenesia, aplasia, and hypoplasia. Agenesia and aplasia mean complete failure of a part to develop. It is rare, however, for this to be absolute. Hypoplasia is underdevelopment. The causes which induce these peculiarities operate at different periods of life. Aplasia and agenesia arise during early foetal existence; hypoplasia occurs some- what later, but before complete development has been attained. All blighting or imperfect development of parts is to be regarded as aplasia or hypoplasia. Atrophy may occur at any time during the life of the individual and implies a retrograde decrease in size after the affected part has been developed, either completely or as far as it will go. The same causes which may induce atrophy in a perfected organ may, on occasion, produce it in one imperfectly developed, so that we must broaden our definition of atrophy to include all cases of dimin- ution in size of the cells of a part, whether these cells be perfect or imperfect. Degenerative atrophy differs from simple atrophy in that the retrogressive changes which are present begin in the cytoplasm and nuclei, and later give rise to the decrease in size. We can understand the philosophy of atrophy only if we constantly bear in mind the principles already enunciated. As we have seen, all cells possess an inherent vital energy, which is manifested in the functions of assimilation, nutri- tion, and reproduction. Continuance in life, to say nothing of growth and development, depends solely upon the maintenance of a certain balance between the nutritive or building-up forces and the destructive or wasting processes. DISTURBANCES OF NUTRITION. 165 During early life, when anabolism is in excess, growth and development and the manifestations of a vigorous energy are dominant features. Later, there comes a period of equilibrium, during which the bodily powers are at their highest consummation. Later still, when the natural decay sets in, the faculties begin to fail and the machinery to give out, until the various functions can no longer be performed and the individual dies. Nutrition and waste are the two oppos- ing powers. Atrophy of tissue may, on the one hand, result from imperfect nutrition and diminished repair, and, on the other, from excessive consumption and waste. In the first instance nutrition of tissue is largely dependent, apart from the inherent vegetative force before referred to, on a sufficient supply of healthy blood and lymph, and on the existence of proper nervous stimuli. Airy disease process which interferes with the amount of blood reaching a part, or deteriorates its quality, or, again, cuts off the cells from their neurotrophic centres, results in atrophy. On the other hand, anything which increases tissue waste, as, for instance, overactivity, will give rise to atrophy. It should be remarked here that there is a general law in pathology which governs the extent and the localization of retrogressive processes, atrophies included. The more delicate and highly specialized a cell or tissue is, the more susceptible it is to external impressions; and, when injured, the less its power of repair. Therefore, the parenchyma of an organ, the secreting structure of a gland, suffers more from deteriorating influences than does the stroma. The epi- thelium of the kidney and the parenchymatous cells of the liver may waste with- out material diminution in the connective-tissue framework. As a consequence, such an organ, when the subject of atrophy, often becomes harder and more fibrous than normal, or the destroyed cells are replaced by newly formed connec- tive tissue. This change is commonly called induration. In such a case the or- gan affected becomes not only smaller, but its surface is often irregular, nodular, or warty. A change in external size and configuration is, however, not necessary in all cases. For example, in bone, atrophy may affect the trabeculae of the spongy portion and the parts bordering on the medullary cavity. The bone in this way becomes lighter and more porous, but may not be smaller (osteoporosis). Microscopically, the cells of the affected organ are smaller and usually fewer than normal. In the early stages of the process they usually stain well and the finer structure is well preserved. In more advanced cases the cells may be con- siderably shrunken and deformed, and there may be either an absolute or a rela- tive increase in the pigment (atrophia pigmentosa). Pigmentary changes are often well seen in the case of the heart muscle and the secreting cells of the liver. Atrophied ganglion cells are generally highly pigmented. In the most advanced stages the cytoplasm has all but disappeared and little remains but a shrunken, distorted nucleus, which in its turn fragments and disappears. In certain cases, as in muscle, the loss of substance is made good, so far at least as bulk is con- cerned, by an overgrowth of the connective tissue in which fat is eventually 166 AMERICAN PRACTICE OF SURGERY. deposited {atrophia lipomatosa). This appears to be an attempt at compen- sation. It may be inferred from what has already been said that we have to recog- nize two broad classes of atrophies— those which are physiological and inevi- table, and those which are pathological and accidental. Physiological or histogenetic atrophy results from the diminution of the in- herent vital powers of the cells. It implies diminished repair rather than exces- sive waste. The potential energy of each cell and tissue is directly proportional to the amount of work it has to do. As the functional importance of an organ diminishes, so does that organ begin to atrophy. When any organ becomes useless in the economy it quickly disappears. Each organ and tissue has its own life period, and at the termination of its career inevitably dies, even should it have at no time been attacked by disease. The phenomena of atrophy are to be observed in the individual from the earliest embryonic life period. Numerous examples of this truth can be cited. In the formation of the placenta certain parts of the membranes disappear at an early stage of development, and with the formation of the chorion there is coincidently a progressive atrophy of the villi. The full-term placenta has fulfilled its purpose and is therefore cast off. In the case of the foetus itself, the Wolffian and Muellerian ducts, the Wolffian bodies, the umbilical vesicle, and the omphalomesenteric duct disappear quite early. Before birth certain blood-vessels begin to be obliterated, and a few days after birth the closure of the Ductus Botalli and the umbilical vessels has already taken place. The spontaneous separation of the umbilical cord is also a manifestation of atrophy. Later the milk teeth are cast off. After puberty the thymus gland, which at first is one of the most prominent struc- tures in the body, rapidly wastes away. With the approach of middle life, lymphoid structures begin to waste and portions of the petrous and sphenoid bones disappear. Hyaline cartilage in some persons is in time converted into bone. With the onset of old age the uterus and ovaries begin to shrink, and with the induction of the menopause their function ceases. This atrophy of the ovaries is due to sclerotic changes in the ovarian arteries, in which involution changes seem to begin sooner than in the vessels elsewhere in the body. In ad- vanced life the lymphadenoid structures, the muscles, bones, and in many cases the subcutaneous fat, begin to retrograde. The lungs, kidneys, and liver are often considerably involved in the process, the brain and nervous system to a compar- atively slight extent, as a rule. The posture, gait, the blanched hair, and gen- eral appearance of the aged are due to these atrophic changes. The cardio- vascular system, on the contrary, may suffer slightly, if at all. The heart often increases in size and strength into advanced life, the blood corpuscles are formed as before, and defects of vessels, connective tissue, and epithelium are usually quickly made good. The arteries themselves, however, may tmdergo sclerotic changes. This is an important factor in the causation of the senile atrophy, in- DISTURBANCES OF NUTRITION. 167 asmuch as the nutrition of the tissues is interfered with and in this way the nor- mal retrograde processes are accelerated. In the category of physiological atro- phy must also be included the normal involution of the uterus which ordinarily occurs after parturition. Some of these physiological atrophies are of considerable practical importance. The brittleness of the bones in old age is an important pre- disposing cause of fractures. Fractm'e of the neck of the femur is not uncommon and may result from but slight violence. Not only the osseous fragility is here to be taken into account, but also the alteration of the angle which the neck of the femur makes with the shaft, as it weakens the resisting power of the part. Pathological atrophj^ may result (1) from inactivity or disuse, (2) from over- • activity, (3) from impaired nutrition, (4) from pressure, (5) from neurotrophic disturbance. Atrophy from Inactivity or Disuse.— The proper tone of a muscle and its functional perfection depend, on the one hand, on the amount and the kind of nutrition which it receives, and, on the other, on the regular and sufficient exer- cise to which it is subjected. A fully exercised muscle always has a good blood supply. A functionless muscle receives less nourishment than a normally acting one. The same principle may be applied to glands and other structures. The loss of necessity for a function, or the inability to perform a function, whether from some incapacity of the organ itself or from any extraneous condi- tion which interferes with the performance of its duty, may result in atrophy. The importance of the lack of proper function is seen in the case of certain deep- sea fishes, which possess only rudimentary eyes, in some cases covered with skin. The rudimentary, or, more correctly speaking, the remnant of the hind legs found in certain whales and reptiles is also a case in point. Again, in cases of marasmus or malassimilation the heart may be found to be quite small, below the average weight. This, in part at least, no doubt may be traced to the less- ened demand upon its services. There is less blood, and therefore less force is needed to propel it. There is less demand also for oxygenation. In such cases the atrophy is to be attributed as well to lack of noiu^ishment of the heart muscle itself. The atrophy of the acetabulum which occurs in cases of unreduced dis- location of the femur, the removal of the callus when a fractured bone has re- united, and the atrophy of the nerves after the amputation of a limb also come under this category. An organ or structure may be miable to perform its usual function, owing to some disturbance of its innervation or from some mechanical hinderance. Thus in paralytic cases the muscles and bones will in time waste. A similar result follows the immobilization of a limb, a deformity, fixation of a joint, or the presence of a tumor which interferes with the function of the part. Atrophy from Overactivity. — It has been shown above that an increased demand upon the functional activity of a part results in hypertrophy. This process, however, has its limits. The moment the reserve power of the structure is encroached upon, we see the beginning of the end. The part gradually fails 168 MIERICAN PRACTICE OF SURGERY. to respond, and hypertrophy gives place to atrophy. Overase of an organ acts by increasing waste and by giving the structure no time to recuperate. There- fore, ehmination is diminished and the toxic products of metabohsm accmnulate in the tissues. Fatigue is the keynote of the process. The failure of compensa- tion in a heart which previously may have been hypertrophied is a case in point. The brain is the chief organ which may be thus affected. Of glandular organs, probably the testicles most often suffer. Atrophy from Impaired Nutrition. — This is the atrophy which is foimd typically in cases of starvation and in all forms of chronic wasting disease. It is sometimes called marantic atrophy. The condition depends in the main on the fact that the cells are receiving an insufficient amount of nutrition for their needs. The extent and the rapidity of the atrophy depend upon the degree of metabolic change which, the affected part is able to tmdergo. Adipose tissue, for example, quickly disappears if there be any lack in the fat or fat-forming substances which are supplied to it. The bones become soft and wasted if the lime salts are witlilield. It is likely also that the deficient amount of haemo- globin in the red corpuscles is due to the deficient absorption of iron. Marantic atrophy may be general or local. General atrophy of the body is found in cases of starvation, whether from insufficient suppl}^ of food or from any condition of the digestive apparatus which prevents its proper absorption and assimilation. In such cases the fat, muscles, blood, and abdominal organs are chiefly affected. The fat disappears first, so that the angles of the body are exaggerated, the eyes sink in, and the whole body assumes a gaunt appearance. The muscles may be reduced to half their original size. The liver, spleen, and intestines, of the ab- dominal viscera, suffer most. The central nervous system, the bones, and the heart, on the other hand, show but little change. Curiously enough, lipomata do not decrease in size, even in cases where the ordinary fat of the body has dis- appeared. Local atrophies are usually due to local causes. Thus disease or injury of blood-vessels may cause atroph}^ of the part supplied by cutting off the nom'ish- ment. Sclerosis or other conditions leading to obstruction or obliteration of vessels will produce atrophy of the part involved, usually with other degenera- tive changes. We find this, for example, in the heart, from obstruction of the coronaries; in the kidney, from obliteration of a branch of the renal artery; and in the brain, from a similar condition. Circulating toxins, by their deteriorating action on the blood and possibly by a direct local effect, may bring about atrophy. The long-continued use of iodine is sometimes followed by wasting of the thy- roid and mammae. In certain cases of fracture of the femur or of other bones, the circulation through the great nutrient artery may be cut off, and atrophy of the portion of the bone thus deprived of its food supply follows. Necrosis does not occur, because there are sufficient anastomoses remaining to preserve vi- tality. DISTURB.\XCES OF NUTRITION. 169 Atrophy from Pressure.— It was pointed out above that pressure, if inter- mittent, especially if combined with friction, leads to hypertrophy. Contmu- ous pressure, on the other hand, will produce atrophy. This is in part the result of direct mjury to the cells at the site of the lesion, but it is also due to the circula- tory disturbances mduced. This form of atrophy, therefore, is passive in its nature. It is usually the result of slight pressure exerted over a prolonged period of time. Numerous examples might be cited. Among the best known are the "lacing" or "corset" liver and spleen, the foot of the Chinese lady, the flat head and flat Fig. 61. — Atrophy of the Bodies of the Vertebrae from the Pressure of an Aneurism. 3fuseum, McGill University.') {Pathological nose of certain tribes of Indians. The pressure of tumors, aneurisms, cysts, vari- cose veins, may lead to atrophy of the adjacent structures (see Fig. 61). Malposi- tion of bones, as in scoliosis, genu valgum, pes valgus, by altering the direction of the pressLU-e, will lead to atrophy of the parts unduly pressed upon. The cal- varium may be thinned from the pressure of a hydrocephalic brain, from tu- mors, and from enlarged Pacchionian bodies, or, extemalh', from wens. Disap- pearance of the alveolar processes of the jaws sometimes results from the loss of teeth, the bone being in this case subjected to unusual pressiu-e. In con- genital dislocation of the hip-joint, reposition of the head of the femiu, with 170 AMERICAN PRACTICE OF SURGERY. maintenance in the new position, will lead to the excavation of a new ace- tabular cavity. Perhaps less conspicuous, but equally complete in their way, are the local atrophies which result from the pressm-e of inflammatory exudates, scars, and constricting fibrous bands. In the so-called "nutmeg" liver the columns of par- enchymatous cells about the centrilobular vein present extensive atrophy, usu- ally combined with fatty degeneration, the result of pressure from the overdis- tended capillaries. Nutritional defects also, no doubt, play a part. Neurotrophic Atrophy. — It is generally held that there are certain nerve cells or ganglia which, to some extent at least, preside over the nutrition of the tissues and structures innervated from them. These trophic centres are for the most part situated in the anterior horns of the spinal cord. Any lesion which destroys these cells or interferes with the conductivity of the fibres in the lower motor neurones is followed by wasting of the parts with which they are con- nected. Anterior poliomyelitis, progressive muscular atrophy, bulbar paralysis, are examples of this. In syringomyelia and tabes dorsalis atrophy of the bones and joints may occur. The so-called Charcot's joints are essentially atrophic in their nature. Disorders of the peripheral nerves may be followed by such mani- festations as glossiness and atrophy of the skin, exfoliation, loss of hair, and dis- appearance of the cutaneous glands. The diminution in size of one-half of the body which results from luiilateral disease of the brain in fcetal life and early childhood, while usually designated hemiatrophy, is probably more correctly to be regarded as a unilateral hypoplasia. Many of these forms of atrophy result- ing from organic nervous disease are of practical importance to the surgeon, in- asmuch as serious deformities of the members may result. This comes about from the overaction of certain muscles which are unopposed by the wasted mus- cles. Troublesome contractures not infrequently occur. Bedsores, especially those which develop rapidly in cases of organic nervous disease, are in large part trophic in character. It should be remarked that, in the class of cases just referred to, neurotrophic disturbance is not the only factor to be taken into account. The loss of nervous impulses leads to paralysis of the muscles, and this brings on the atrophy of disuse. Again, certain vasomotor changes are induced, which interfere with the nutrition of the part. As a result of these alterations inflammatory processes are readily set up, induced by causes which would otherwise be ineffectual. Probably the neurotrophic atrophies are examples of degenerative rather than of simple atrophy. Atrophy as It Affects Certain Tissues and Organs. — Muscle. — Voluntary muscles when atrophic may be much reduced in size, owing to thinning and dis- appearance of the individual elements. The muscles are also paler and softer than normal, dry and ana3mic. They are frequently tough, owing to a relative or, in some cases, an absolute increase in the interstitial connective tissue. In DISTURBANCES OF NUTRITION. 171 such cases the muscle as a whole is somewhat grayish in color. The amount of wasting may be so extreme as to give the impression of there being nothing between the skin and the bone (living skeleton). In other cases, owing to an increased deposit of fat between the fibres, the muscle appears to be of normal size (atrophia musculonim li-pomatosa) , or it may be even larger than normal (pseudo-hypertrophic muscular paralysis). The natural pigment of the muscle fibre may be relatively or absolutely increased, causing the muscle to assume a brownish appearance. This is often well seen in the heart (hrown atrophy). Microscopically, the individual fibres appear to be shrunken, and are often tor- tuous. The striae are usually well preserved. The nuclei of the endomysium proliferate more or less. When the atrophy is complete the sarcolemma sheaths are found to contain pigment, nuclei, and multinucleated cells. There are one or two important forms of muscular atrophy which deserve more than a passing mention. Atrophy from disuse may be brought about by fracture of a muscle, tendon, or bone, ankylosis of joints, fixation by splints, or even by voluntary inactivity. In the neuropathic atrophies the process is largely confined to certain mus- cles or groups of muscles. These atrophies may be spinal, bulbar, or cerebral in origin, and often attack the muscles that are most used or those which derive their innervation from some diseased portion of the central nervous system. In manual laborers the muscles of the thenar and hypothenar eminences, the inter- ossei, and the lumbricales are apt to be first involved (Aran-Duchenne type). In other cases the disease begins in the muscles of the shoulder and arm. In cases of involvement of the medulla there is difficulty in articulation and deglutition, with drooling of the saliva and feebleness of the voice (progressive bulbar paralysis). Somewhat closely resembling the spinal atrophies is the so-called primary myopathy or progressive muscular dystrophy. There are three types — the infan- tile, the juvenile, and the adult. The first usually begins in the muscles of the face, giving rise to a peculiar, expressionless appearance, the so-called myopathic facies. The juvenile form involves the muscles of the calves, thighs, back, shoulder girdle, and arms. The adult type begins either in the lower extrem- ities or in the upper extremities and face. The anatomical cause is still a matter of dispute. The pseudo-hypertrophic form of primary myopathy occurs in chil- dren, and affects the muscles of the calves or shoulders, giving the child the appearance of a young prize-fighter. The myopathies are distinctly of a family type. They have a practical bearing for the surgeon, in that, when affecting the lower extremities, they may produce club-foot. Secondary atrophies of muscles may occur when nerves are cut in the course of operations. The heart, when atrophied, is reduced in size, the color is darker than normal, and the coronary vessels are tortuous. The epicardial fat is likewise wasted and 172 AMERICAN PRACTICE OF SURGERY. in a serous condition. Atrophj- of certain portions of the heart may result from coronarj^ disease or fatty infiltration. Atrophy of certara fibres is often com- bined with hj'pertrophj' of others. Lungs. — In the so-called hji^ertrophic emphysema there are atrophy and sec- ondary rupture of the alveolar walls, so that the spaces become enlarged. Such Fig. 62. — Caries of the Upper End of the Femur : Abscess Museum, McGUl University.') the Great Trochanter. (Pathological limgs are more bulk}' than normal, pale, and anfemic. In another form, atrophic emphysema, the same condition is combiaed with a diminution in bulk of the whole lung. Bo7WS. — Atrophy of bone may restilt from any of the causes hitherto set forth. Old age, pressure, interference with function, impoverished nutrition, mflamma- tion, and nervous disturbances maj- all play a role. The structure of the bony framework of the body is in health undergoing constant change. In the child vegetative forces are in the ascendant, with the result that anj^ loss of substance of the bone is made good and more than made good, so that the bones mcrease in size and strength. In the adult, breaking DISTURBANCES OF NUTRITION. 173 down or resorption is still going on, but is compensated by a continuous deposit of new bone through the process of apposition. In the aged, resorption is in ex- cess, and therefore the bones become lighter, smaller, and more fragile. Lacunar resorption is the process by which atrophy takes place. Certain large, multinu- cleated cells — osteoclasts — are present in great numbers in the periosteimr and bone marrow. These take up their position on the bone tra- beculse and gradually erode the bone, forming the so-called How- ship's lacima;. In the rapid re- sorption of bone characteristic of certain diseases the osteoclasts are greatly increased in numbers and lie closely packed together. The result is that the surface of the bone becomes eroded and irregular (concentric atrophy) (see Fig. 62). Should the proc- ess go on mainly about the medullary cavity, the external configuration of the bone is not altered, but the marrow space is enlarged and the bone becomes thinner (excentric atrophy). In still other cases the compact portion of the bone becomes porous, owing to the widening of the Haversian canals (osteo- porosis) (see Fig. 63). Atrophied bones are light, fragile, easily broken or sawn. The medullary substance is of- ten lymphoid in character, fatty, or the fat may be replaced by a gelatinous-looking material (ser- ous atrophy). Senile and marantic atrophy may affect the skeleton as a whole, but the senile form is apt to attack more extensively the flat bones, the calvarium, maxillee, scapula?, and pelvis. The process begins and is most marked at the points devoid of muscular attachment. Owing to the diminution in size of the vertebrae and the intervertebral discs, the height of the body is diminished and the back becomes curved. The character- FiG. 63. — ^Femur Cut Longitudinally, to show Rare- faction, Osteosclerosis, and New Growth of Bone from the Periosteum. Case of Osteomyelitis. (Pathological Mu- seum, McGUl University.) 174 AMERICAN PRACTICE OF SURGERY. istic senile facies is due to the absorption of the alveolar processes. Atrophy from disuse is more usually found in the limbs. The atrophy that affects the bones after amputation is from without and leads to the end of the bone becoming thinner and more pointed. Striking instances of atrophy from pressure are met with in cases of carci- noma and sarcoma developing within a bone. Not only is the bone rarefied but the structure is expanded. This is the cause of the so-called "egg-shell crackle," which is one of the clinical features looked for (see Fig. 64). From the point of view of structure the bones may be re- garded as consisting of a living matrix, in which is deposited an inert, dead material, the lime salts, which to a large extent give compactness, density, and strength to the tissue. The rela- tive proportions between these two elements may be considerably altered, a state of things which may possibly with some reason be considered as a form of atrophy. The proportion of calcareous salts is increased in old age, an expres- sion of what one might appropri- ately call the " calcareous diathe- sis," which is so characteristic of old age, being found not only in the bones, but in the cartilages and blood-vessels. This does not result in an increase of strength of the bones, but, on the contrary, they become more fragile than normal, owing to excessive re- sorption. An opposite condition to this is halisteresis or mollities ossium, in which the organic constituents of the bone remain unaltered, but there is a notable diminution in the amount of lime salts, so that the bone becomes soft and yielding. The most extreme form of this is known as osteomalacia. The pathological changes at work here consist, in the main, of decalcification of the old bone, with Fig. 64. — Humerus : Carcinoma of Upper Portion, showing Rarefaction of the Bone. (Pathological Museum, McGill University.') DISTURBANCES OF NUTRITION. 175 at the same time a tendency to the formation of new bone, which, however, re- mains imperfectly calcified. The process of decalcification begins at the periph- ery of the bone trabeculse and gradually extends to the deeper parts. The line of demarcation between the normal and the diseased bone is sometimes even and continuous, but may be irregular and with excavations like Howship's lacunae. Often there is formed an intermediate zone, in which the lime salts are not com- pletely removed, but remain in the form of a crumbling detritus. Eventually the bone canals become enlarged, and, with the absorption of the calcareous salts, new canals are formed in the ground substance. The matrix itself may be homogeneous or may present a finer or coarser fibrillation. Some of the bone corpuscles may be preserved, but many have atrophied or disappeared, leaving small cavities. In some cases there is a new formation of osteoid tissue, but it remains for a long time, or even permanently, uncalcified. This new tissue may be quite dense, containing only a few spaces, or it may present a laminated or fibrillated structure with large corpuscles. Osteoclasts and Howship's lacunte are not more numerous than in normal bone. The condition of the marrow varies. It may be reddish in color, with giant cells, yellowish and fatty, gelati- nous, or even fibroid. Hemorrhages and pigment are commonly to be found. Osteomalacia is a disease of obscure etiology. It appears to be rare on the North American continent. Dock finding records of only ten cases. Since some cases in women have been cured by removal of the ovaries, Fehling has promul- gated the view that it is a trophoneurosis due to reflex irritation from the ovaries. A condition of some practical interest to the surgeon is osteopsathyrosis, or abnormal brittleness of the bones. This term is used in a general way as synony- mous with fragilitas ossium. The bones become fragile, and are therefore easily broken. A slight movement, a jar, or even muscular action may be sufficient to bring about this result. The condition is a retrograde metamorphosis, and is met with especially in senile and cachectic conditions. Rarely, the condition is congenital and may be inherited. In this case it appears to be a de- velopmental anomaly, for it has been found combined with dwarfism or associ- ated with dwarfism in related individuals. Osteopsathyrosis occurs as a result of old age, cachexia, prolonged activity, pressure atrophy, and neurotrophic atrophy. It is met with in locomotor ataxia, syringomyelia, general paresis of the insane, and osteomalacia. It is also found in certain inflammatory conditions, such as rickets, syphilis, and leprosy. In inveterate syphilis with cachexia there is often a marked fragility of the long bones especially, and also of the cranium. A somewhat similar condition of os- teoporosis is the result of actinomycosis and Madura foot disease. The Nervous System. — The subject of atrophy of the nervous system is one that is beset with great difficulties and uncertainties. Here, as in so many cases, we cannot draw any distinction between atrophy and degeneration. We may 176 A^IERICAN PRACTICE OF SURGERY. be certain, however, that they are always combmed. The nervous tissue, above all structures, is particularly liable to undergo retrograde changes. It is the most delicate and highly specialized mechanism in the body. It is, therefore, especiallj^ susceptible to the deterioratmg action of a variety of agencies, while its regenerative powers are but slight. Disintegration and degeneration are con- sequently the most frequent and unportant pathological changes to which nerve tissue is liable. It is, again, not always possible in any given case to determine the etiological factor chiefly or entirely to blame. Thus, the distinction between inflaromatory and simple degeneration is often obscme. In order to get a clear appreciation of the degenerations affecting the nervous system, it is important to bear in mind certain facts. According to the " neurone concept " of the histological structure of the ner- vous system, most generally accepted at the present day, the brain and cord, with their continuations, the peripheral nerves, are to be regarded in general as a peculiar association of highly specialized cells, consisting of a large cell body with protoplasmic processes (the ganglion cell), from which proceeds a single, long, and attenuated thread (axis cylinder or neuraxone). These together consti- tute the nemone. Each nem'one is, so to speak, self-contained, and has no asso- ciation with adjacent neurones save b}' contiguity. The protoplasmic processes (dendrites) are richly branched and interlace freely about the cell body. They are believed to be nutritive in their function, and they convey impulses toward the cell body. The axis cylinders give off collaterals at different levels and ter- minate in a complicated arborization, usually about another cell, at a consider- able distance from their point of origin. The impulses passing through them are centrifugal. In general terms it may be stated that when a neiu'axone is for any cause cut off from its nutrient centre, the ganglion, it will degenerate. The process begins at the distal extremity and gradually progresses backward to the site of the lesion. When the degeneration is confined to one ph3^siological tract of the brain or cord, we speak of a "system" degeneration. When one or more such tracts are involved, we have a "combined sj'stem degeneration." Similar re- sults will follow any cause which interferes with the conductivity of the nerve fibre. In what are often called "primary" degenerations, in which the nerve bundle is acted upon directly and locally, certain tracts appear to be specially picked out, namely, the sensory nem'ones of the cord ; the central motor neu- rones, beginning in the pjTamidal layer of the cerebral motor cortex, extending through the internal capsule into the pjTamidal tracts ; and the peripheral motor neurones, which begin in the ganglia of the ventral cornua, passing through the anterior roots to the muscles. In "secondary" degeneration, due to causes act- ing from a distance, we have ascending and descending forms, according to the direction which the degeneration takes in the cord. Ascending degeneration affects usually the posterior columns, the direct cerebellar tract, and the antero- DISTURBANCES OF NUTRITION. 177 lateral tract of Gowers. Descending degeneration affects mainly the pyramidal tracts. There are many causes of nerve degeneration. Chief among them may be mentioned old age, mechanical tramna, pressure, circulatory disturbances, and various intoxications. In many instances more than one factor is at work. Simple atrophy of the brain is particularly well exemplified in old age. The organ as a whole is diminished in size, the weight being below the normal. The wasting is most marked in the frontal and vertical regions. To gross appearance the convolutions are small and the sulci wide. On section the cortical gray mat- ter is seen to be somewhat thinned. In the more advanced cases, in addition to these changes, the perivascular lymph spaces are enlarged, so that the vessels lie in wide channels. Small foci of degeneration are often to be seen {itat crible). In such cases it is not uncommon to find enlargement of the subarachnoid space and ventricles, which may be filled with fluid (hydrops ex vacuo). The cere- bellum, as a rule, escapes. Histologically, the lesion is atrophy of the specific nerve elements, ganglia and medullated fibres. Senile atrophy is to be attributed to several causes, among which may be mentioned the normal tendency to retrogression evinced by all tissues as ad- vanced life is approached, impoverished nutrition of the body, and the local effects of a scanty blood supply, due to the sclerosis of the vessels which is so constant an accompaniment of old age. In accordance with the rule that the more highly developed structures are the most liable to disease, it is that portion of the brain which has to do with the intellectual functions which suffers most. There are other atrophies, such as those local ones due to vascular changes, which might be mentioned, but they are more properly discussed elsewhere. Among the commonest forms of degeneration of the spinal cord is that due to pressure, the so-called "compression myelitis," a condition of much practical interest to surgeons. As a rule, the lesion is a transverse one, affecting all the tracts of the cord in a comparatively restricted area. The usual causes are fracture of the vertebrae, tuberculous caries of the spine, tuberculosis of the spinal meninges, tumors of the vertebral canal or of the cord itself. Central degeneration may be caused by an accumulation of blood or fluid in the central canal. As a result, we get marked interference with and, finally, destruction of the nervous structures at the site of the lesion, with widespread ascending and descending degeneration in the as- sociated tracts. The local effects are to be referred in part to the direci. influ- ence of the pressure, but probably more to the disturbance of the blood and lymph circulation. In some cases inflammation is also an associated cause. The degeneration is first manifested in the white substance, the fibres of which swell up and disintegrate. The neuraxones swell and become varicosed, and the myelin sheaths break down into fat. The ganglia are somewhat more VOL. I.— 12 178 .A3IEPJCAX PRACTICE OF SURGERY. resistant. Granular cells appear early and in considerable numbers. In the course of a few daj^s the degeneration reaches to the terminations of the neu- rones. Later, both the fibres and their sheaths ahnost entirely disappear, al- though degenerated and varicosed fibres maj' be found here and there, the num- ber of fibres remaining being dependent on the extent and severity of the original cause. The place of the destroyed fibres is taken bj' newly foiTned glia, which in time leads to contraction and sclerosis of the cord. The cord as a whole shrinks, becomes finner, and assumes a grayLsh color. In some cases, where the pressure can be reheved hj operation, the destroj^ed fibres wUl to some extent be replaced and fimction may, in part at all events, be restored. The attempt must, how- ever, be made early. Among other affections which maj' possiblj^ be put in this category of atro- phy may be mentioned disseminated sclerosis, anterior poliom5-eHtis, progi'es- sive bulbar parah'sis, progressive spinal muscular atrophj', lateral sclerosis, pos- tero-lateral sclerosis, am}-otrophic lateral sclerosis, tabes dorsalis, pellagra, and chi-onic ergotism. In how far these are due to simple atrophj- and how far to in- flammation, it is impossible to saj-. Defective nutrition, dependent on an im- poverished blood supply, is a probable cause in some cases, as, for example, in the changes in the posterior and lateral columns of the cord in pernicious anse- mia. The influence of toxins maj' be traced in other cases, as in ergotism, pel- lagra. ilany of these degenerations are important in their results, as they lead to muscular atrophy, contractures, and even malformation. Atrophy of the peripheral ner^^es, as of the cord, is not to be dissociated from the idea of degeneration. It may result from anj^ cause which interrupts the continuity of the fibres with their nutrient centres, or which destroys the trophic influence of the centres themselves. Destruction of the ganglia either in the brain or in the cord is followed b}' degeneration of the fibres proceeding from them. Severance of a neiwe tnmk, as in an accident or in the course of an ope- ration, presstue exerted continuoush^ upon a ner\-e tnmk, and inflammation are common causes. Degenerative atrophy of a nerve fibre usually begins at the point most re- mote from the trophic centre, and proceeds centripetally. Tlie degeneration which results from severance of a nerve tnmk, known as Wallerian degeneration, may be taken as a tj-pe of all the rest. Wlien separation takes place by means of a clean cut, all the fibres degener- ate practically simultaneoush- and, moreover, speedily. Within twenty-four hours after the injury the material composing the mediillary sheaths becomes cloudy and less refractive. After about tliree daj-s indentations and other indi- cations of segmentation are to be seen in the medullary sheaths and sheaths of Schwann, which later break up into droplets of myelin and fat. Next, the axis cylinders show eA-idences of atrophy and gradually disappear. They swell up. DISTURBANCES OF NUTRITION. 179 become varieosed, and vacuolated. The interstitial substance is little if at all affected. The complete removal of the products of the degeneration may be long delayed. Eventually the whole of the nerve distal to the point of injury may be de- stroyed. Degeneration in a centripetal direction occiu-s, but is comparatively imimportant, usually stopping at or close to the nearest node of Ranvier. Where the injury has been severe, isolated fibres may degenerate somewhat farther, and slight retrogressive changes may occasionally be made out in the ganglia. Somewhat similar, if indeed not identical, changes may be brought about by the action of circulating toxins and bacteria, impoverished nutrition, and cer- tain circulatory disturbances. Systemic ansemia and marasmus are important in this connection. Endarteritis and obstructive conditions of the blood-vessels bring about atrophy, largely by cutting off nutrition. Degeneration affecting one or more nerve trunks occasionally arises in the course of diphtheria, influenza, typhoid fever, typhus, smallpox, tuberculosis, the puerperiima, and in chronic poisoning with mineral substances, such as lead. Here, in some cases at least, we have the combined effect of imperfect nutrition and the deleterious action of the toxin. Occasionally, owing to some unknown infection or intoxication, the trophic ganglia in the anterior cornua of the spinal cord are destroyed — a condition quickly followed by degenerative changes in the fibres proceeding from them. Secondary atrophy of a nerve trimk may result from inactivity of the mus- cles it supplies, whether from paralysis or from fixation of the part. The nerves of special sense do not escape this process. Thus the optic nerve and tract will atrophy in cases of blindness. The Skin and Associated Structures. — Simple atrophy of the skin is mani- fested by a wasting of almost all the elements entering into its structure. It may be generaUzed or localized. It may, again, be primary or the result of some external pathological condition. As a type, we may consider the physiological atrophy which takes place in old age. In this case the cutis is thiimed, the papillae are flattened and tend to disappear, while the epidermis becomes dry and brittle. Owing to the absorp- tion of the subcutaneous fat, the skin is thro'WTi into folds. The elastic tissue involutes and the superficial vessels are degenerated. Brownish pigment may be foimd in the cells of the rete and about the vessels of the cutis. The deeper portions of the epidermis are wasted, so that the stratum comeum is less widely separated from the papillary layer. The hair follicles participate in the process, the hairs lose their pigment, become do^vmy, and finally fall out. Not infre- quently the openings of the hair follicles become obstructed, owing to the ac- cumulation of epidermal scales, so that the follicles may become dilated into cysts. In the same way the sebaceous glands may be involved, and hair follicle and gland may be expanded into a cavity containing hairs, fat, and epithelial 180 AoMERICAN PRACTICE OF SURGERY. debris, the so-called atheroma or wen. Eventually the sebaceous glands may disappear. Not micommonly the superficial epidermis is in places heaped up into scales (pityriasis simplex). Local atrophy is a common condition brought about by distention of the skin from any cause. It is found usually on the abdomen, breasts, and thighs. The commonest cause is pregnancy, but tumors, lactation, ascites, and anasarca will produce it. During pregnancy the abdomen is covered with reddish, livid streaks, which after delivery are transformed into silvery lines or scars (linese albicantes). In such areas the papillse are flattened or absent, the connective- tissue fibres of the corium are dissociated, and the elastic fibres and blood-vessels are atrophic. Pressure, as from corsets or other clothing, may produce a similar effect. Local atrophy of this type has been described as occurring in certain acute febrile processes, notably typhoid fever, and in chronic wasting disease where the subcutaneous fat has been absorbed. An idiopathic, diffuse, symmetrical atrophy has been reported by several observers. Lastly, atrophy of the skin may be neurotrophic in origin, and is met with in such conditions as lepra ansesthetica, neuralgia, and neuritis. The skin over certain areas supplied by the affected nerves becomes thin, smooth, and shiny, and there may be wasting of the glands and hair follicles. Lymphatic Nodes. — Simple atrophy of the lymphatic nodes occurs as an in- volution process in old age. The same applies to diffuse lymphadenoid tissue wherever found. The lymphadenoid structures appear to be more active in chil- dren and young adults, and physiological retrogression occurs comparatively early. The lymphoid cells are the structures chiefly affected, while the stroma is, on the contrary, relatively or even absolutely increased. The nodes are small, in- creased in consistency, and contain but little juice. Occasionally the lymphoid cells of the medullary portion disappear and the fibrous supporting framework imdergoes fatty transformation. The process gradually spreads to the cortex, and the fundamental structure of the node may in time be entirely destroyed. This change is met with chiefly in cases of chronic alcoholism. The condition of the lymphatic nodes is of considerable importance in regard to the question of infection and inflammation, inasmuch as these structures have much to do in combating disease processes of this kind. As is well known, infective processes, especially inflammation and suppuration, tend to become localized at the points where the nodes are most in evidence. Should they be damaged, either from atrophy or from disease, they are no longer competent to perform their func- tions, and the dissemination of the infective process is rendered more easy. The normal involution process which lymphadenoid tissues undergo is, in a certain sense, conservative, since structures so affected do not take up bacteria to the same extent, and hence are not so liable to suffer. The involution of DISTURBANCES OF NUTRITION. 181 the lymphoid tissue in the appendix is given as one of the reasons why appen- dicitis is less likely to occur after middle life than in the young and vigorous. Spleen. — Atrophy of the spleen occurs in old age and in chronic wasting dis- ease. It is practically of no importance. The organ is diminished in size, the capsule is wrinkled and opaque, and is thrown into folds. On section the sub- stance is pale and the trabecule; are prominent. The stroma may be absolutely or relatively increased, while the pulp is diminished. Liver. — Simple atrophy is found in advanced age, in marasmus, and in the vari- ous cachexias. A common cause is pressure, as from corsets. This leads to the formation of deep furrows and eventually accessory lobes ("lacing lobes"). Carcinoma of the oesophagus and stomach is particularly apt to cause atrophy of the liver, probably from lack of nourishment. The process affects chiefly the anterior edge of the liver. The parenchyma- tous cells waste, and eventually disappear vmtil nothing is left but the support- ing stroma. The edge of the liver thus becomes sharp and harder. In many cases the amount of pigment in the secreting cells appears to be increased (brown atrophy). Frerichs has described a special form of atrophy — melangemic atro- phy — said to be due to the blocking of the capillaries with black pigment. Acute yellow atrophy of the liver is presumably of an infective nature. It may be mis- taken for the cholaemia of obstructive jaundice. Stomach. — The part affected is the mucous membrane, which becomes thinned and the glands granular and diminished in size. Atrophy of the stomach occurs in old age, cachexia, and marasmus, and also as a result of chronic gastritis. Testes. — Atrophy of the testes occurs in old age and as a result of wasting disease. It may also be caused by pressure, as in cases of hydrocele, ha^mato- cele, varicocele, hernia, and tumors. It is said to occur also as a result of injuries to the cerebellum, or of concussion of the brain, and in paraplegia. The secreting cells of the tubules become fatty, waste, and disappear, while the connective-tissue stroma is relatively increased. A striking feature is the thickening of the walls of the tubules, which appear to be swollen, transparent, and hyaline. Prostate. — Simple atrophy is met with in from twenty to thirty per cent of old men. Occasionally it is met with in the young, as a result of marasmus, ca^ chexia, castration, the pressure of retained urine, pent-up secretion, or concre- tions, and in the impotence of tuberculosis. In the form due to constitutional causes the glandular structure is the part chiefly affected, while in that due to concretions the stroma suffers most. Ovaries. — Atrophy of the ovaries occurs as a senile change and as the result of chronic oophoritis. The senile ovary is smaller than normal, firm, nodular, and of a grayish or pearly white appearance. The albuginea is hard and may be several millimetres thick. The follicles are largely converted into small fibrous 182 .\,MERIC-\X PRACTICE OF SURGERY. masses (corpora fibrosa), with marked thickening of the theca. The arteries are iisuall}- thickened and hj-aline. Mamma. — Simple atrophy of the glandular elements of the mammse occm-s as an involution process after the menopause, and occasionallj", but b}- no means invariably, after removal of the ovaries. The wasting is often masked by an overgro-n-th of fat. Atrophy is also said to result from the prolonged adminis- tration of iodine or its compounds. DEGEXERATIOX. Closeh' associated with atrophy, and in some instances not to be dissociated from it, are certain cellular changes which we call degeneration. The term "de- generation" is often used in a loose way to designate all kmds of retrograde metamorphoses, but it is also employed in a specific and more restricted sense to indicate a particular class of retrogressive phenomena, which are characterized bj' the formation of new substances out of the cell protoplasm. Such new ma- terial may be retained within the cells or discharged from them. An abnormal increase in the production of substances normally elaborated in the cell may also possibly be included in this category. As we liaA'e seen in discussing the subject of growth and development, the vital force of cells is manifested in tliree ways, namely, in nutrition, in reproduc- tion, and in function. These, again, are dependent upon metabolic processes in the cell, whereby the potential energy of the food is transformed into actual work. Disturbances of metabolism lead, on the one hand, to abnormal gro-nth and de- velopment, and, on the other, to various forms of wasting and disintegration. As has been remarked above, we have carefully to distinguish, at least in our mental conceptions, between atrophy and degeneration, both of which belong to the great familj- of the retrograde metamorphoses. The former connotes a mere alteration in size, the latter a chemical sjmthesis of new substances. It may not perhaps be stricth' correct to state that in atrophy there are no abnor- mal chemical processes going on, but at least they are in the backgromid. In degeneration, chemical changes dominate the pictiu-e, and alteration in the size of a cell maj^ or may not take place. Frequenth^, atrophy and degeneration are combined. As in the case of atrophy and hj-pertrophy, we have to distmguish between physiological and pathological degenerations. To a certain extent degeneration is natural and not a manifestation of disease. The anunal body, and, in fact, all liATng organisms, after a preliminary period of gi-owth and development, reach a fastigium, and eventually pass into a state of decrepitude, which we call senility, or old age, characterized, so far as the cells are concerned, by inability to repair the normal waste, imperfect powers of proliferation, and diminished function. Each cell, each tissue, each complete organism has its own life period, and stead- DISTURBANCES OF NUTRITION. 1S3 ily progresses toward inevitable death. This deierioration of substance and im- pairment of function are the concomitants of atrophy and degeneration, which may in many instances be regarded as way-stations en the road to the great terminus. The rate of this progress is, however, not uniform. Some tissues and structures become old and die sooner than others. The involution of certain or- gans may, as we have seen, occur during foetal life, in childliood, or in early adult life. The process of involution is in part one of atrophy, and frequently one of degeneration as well. Physiological degeneration is the product of normal retro- gressive changes. Senile involution may, however, take place prematurely. It is then pathological. Many of the degenerative manifestations are not expres- sions of a natural, though premature, tendency to involution inherent in the cells, but are the result of some deleterious influence acting from without. Death of cells may be sudden or gradual. Rapid death of cells or tissues, without any previous abnormal changes in the cellular substance, is termed 7ie- crosis. Gradual death, preceded by diminution in size (atrophy), by abnormal" intracellular chemical processes (degeneration), or by the abnormal deposition of foreign material derived from a distance (infiltration), is called necrobiosis. This distinction between sudden and gradual death is largely theoretical, and is only valuable in that it conduces to accuracy of thought and convenience of de- scription, but it should be borne in mind that it is not always possible in practice to draw this distinction. While necrobiosis is invariably a sequel of atrophy or degeneration, the converse is not necessarily true, that pathological atrophy and degeneration inevita^bly lead to death of the cell or tissue. Provided that the cause is removed or is not constantly acting, the condition may be recovered from. It is usual to classify the degenerations — this term being used in its narrower sense — according to the nature of the abnormal substances produced. Strictly speaking, true degeneration implies the manufacture of new chemical substances out of the protoplasm of the cells themselves. It is convenient, how- ever, to discuss at the same time a somewhat similar process, that of deposit or infiltration, in which the abnormal substances are brought to the cells from some distant part of the body, or, it may be, are introduced from without, and are stored up as so much foreign material within the cell bodies. Such deposit may exist per se or be the result of degeneration in some other part of the body. As a matter of fact, the distinction between degeneration and infiltration is not always very clear, for the same or similar substances may be elaborated within the cell out of its own protoplasm or may be brought to it from afar. And, again, in the imperfect state of our knowledge, we are not alwaj^s able to trace the exact course of events in any given case. It is generally held that some substances, such as fat, melanin, and glycogen, may be of the nature at one time of a degeneration, at another, of a deposit. Warthin classifies the degenerations and infiltrations as follows: True Degeneration.— 1. Cloudy swelling. 2. Fatty degeneration. 3. Hy- 184 AMERICAN PRACTICE OF SURGERY. dropic degeneration. 4. Colloid degeneration. 5. Colloid-like bodies. 6. Mucin. 7. Pseudo-mucin. 8. Cholesterin. 9. Epithelial hyalin. 10. Cornification. 11. Pigments formed by cell activity. 12. Glycogen. Deposits. — 1. Fat. 2. Amyloid. 3. Hyalin. 4. Calcification. 5. Uric acid, urates. 6. Cholesterin, cystin, xanthin, etc. 7. Glycogen. 8. Pigment. 9. Ex- trinsic substances. Cloudy Swelling. — Cloudy swelling (granular, albuminous, or parenchyma- tous degeneration) is the commonest of the true degenerations. Here the cyto- plasm is broken up into fluid and granules of an albuminous material. The con- dition is found chiefly in the secreting cells of glands and in muscle, but,Js said to affect also, though to a less degree, the connective-tissue stroma and wan- dering cells. Organs so affected are somewhat swollen, pale, doughy, and less glistening than normal. In severe cases they have a parboiled appearance, which has been compared to raw fish. Microscopically, the parenchymatous cells are, as the name would imply, swollen, cloudy, or opaque, and the nucleus may be indistinct or even invisible. The cloudiness is due to the presence of innumerable fine particles in the cyto- plasm. These particles are so thickly placed that the normal structure and granulation of the cell body is obliterated. The particles are not fat, since they do not stain with osmic acid or Sudan III. They dissolve on the addition of weak acetic acid or caustic potash, inasmuch as they are converted into acid or alkali albumin, which is soluble. The condition is best seen in fresh specimens cut on the freezing microtome. In severe cases the chromatin of the nuclei breaks down and is diffused, and the cell may even disintegrate into a fine gran- ular debris (see Fig. 65). Cloudy swelling occurs in all infectious fevers, in various intoxications, and in cachexias. Thus it is often found in typhoid fever, variola, diphtheria, scarlatina, and septicaemia, in acute nephritis, and in poisoning from chemical substances, such as bichloride of mercury, carbolic acid, arsenic, and cantharides. The con- dition is, moreover, not to be regarded as the result of high temperature only, for it is met with in many afebrile conditions, such as carcinosis. Much more likely, it is to be attributed to the influence of some circulating toxin. The ex- tent of the process is probably directly proportional to the amount of the circu- lating toxins. The exact nature of cloudy swelling is not absolutely clear. Virchow, who first described it, found it in cases of parenchymatous inflammation, but it is undoubtedly often to be found in organs that are not inflamed. Nevertheless, it is true that in many instances it is the earliest manifestation of inflammation. There is also a close relationship between cloudy swelling and fatty degenera- tion, for the two are often combined, and, if the cause acts for a prolonged period, the former passes imperceptibly into the latter. If the condition be not extreme, recovery is possible, with complete restitutio ad integrum. DISTURBANCES OF NUTRITION. 185 Fatty Degeneration. — It is generally taught that in this form of degeneration the fat is formed out of the albuminous material of the cell body. As we shall see, there are some grounds for doubting this. The structiu-es usually affected are the parenchymatous organs, such as the liver and kidneys, but the muscles and connective tissue are by no means infrequently involved. All cells, moreover, Fig. 65. — Cloudy Swelling of the Kidney. The secreting cells are swollen and cloudy; the nuclei stain badly; the lumina of the tubules are irregular. {Leitz obj. No. 7.) {From the author's private collection.) which are out of their environment or are cut off from their source of nourish- ment, may undergo fatty degeneration, as, for example, leucocytes (pus cells) and carcinoma cells. The affected organs are usually diminished in size, soft, friable, or doughy, and of a pale yellowish or yellowish-white color. On section the surface is often greasy. The condition may be uniformly distributed through the organ or may occur in specks, patches, or streaks. A well-known example of this is the so- called "thrush-breast" heart, found often in pernicious anaemia and in some fe- brile conditions. The affected organ is usually flabby and lacking in consistency. Microscopically, the cell protoplasm contains nunlerous small, highly refrac- tile, colorless droplets. These are very irregular in size and shape, in some cases being extremely minute, in others, where the smaller droplets have become con- fluent, forming larger drops, which may almost completely fill the cell. The droplets are insoluble in acetic acid, but are soluble in alcohol and ether. With osmic acid they take a brownish or blackish color (see Fig. 66). When treated with Sudan III the finer particles stain a golden yellow; the larger are more of a carmine color. 186 A.MERICAN PRACTICE OF SURGERY. In general, fatty degeneration occurs tinder the same conditions as cloud}' swelling. Given a sufficient intensity in the cause or a sufficient length of time, and cloudy swelling will pass into fatty degeneration. We find, then, fatty de- generation in acute infectious diseases, such as typhoid, pneumonia, diphtheria, scarlatina, septicaemia, erysipelas, etc., in poisoning with phosphorus, camphor, arsenic, alcohol, and chloroform. In regard to the last-mentioned agent, it may be remarked that several cases of acute fatty degeneration of the liver, followed by death, have been recently reported in connection with chloroform ansesthe- sia. This result is fovmd in delicate or debilitated persons, especially those who have been suffering from chronic bone disease. Besides the causes mentioned, anaemia of all kinds, chronic congestion, diminished blood supply, may on occa- FiG. 66. — Fatty Degeneration of the Heart. Specimen stained with osmic acid. Fat is black. {Leitz obj. No. 7.) (From the author's private collection.) sion produce it. Acute and chronic ana:>mia from hemorrhage, pernicious anae- mia, leuka?mia, and the local anaemia caused by sclerosis of vessels, embolism, or thrombosis, are important in this connection. The conditions at the back of fatty degeneration appear to be impaired vital- ity of the cells, together with changes in the nutrition. The chief factor is be- lieved to be deficient oxygenation of the cells. This results in the cell protoplasm being broken down partly into fat and partly into nitrogenous substances which are excreted by the urine. Diminished oxygenation may be produced by a deficiency in the cjuantity of blood supplied to a part or by defective quality. By some, the albuminous and fatty changes so often found in febrile affections are regarded as due to the func- tional increase necessary to the production of the increased heat, especially in DISTURBANCES OF NUTRITION. 187 regard to the organs which are most directly concerned in the maintenance of the bodily heat, viz., the heart and the liver. Probably, however, the direct influence of bacterial toxins and the toxic products of disturbed motabolism are of more im- portance. Possibly, too, increased functional activity, amounting to overstrain, may, as in the case of atrophy, lead to retrogressive changes of this character. This is rendered likely by the fact that fatty degeneration is often chiefly local- ized to organs which are apt to be overworked : the heart, from pumping an in- creased amount of blood — blood, moreover, which may be deteriorated in cjual- ity; and the liver and kidneys, which have to excrete the deleterious substances. When we come to discuss the essential nature of the process resulting in fatty degeneration, we are led into somewhat uncertain paths. It has been almost imiversally taught by physiologists that fat is formed from proteid material. The pathologists have accepted this, and have assumed that in fatty degenera- tion the transformation is at the expense of the cellular substance. Taylor, Pflueger, Athanasiu, and others strenuously combat this view, holding that it has never been demonstrated to be possible from a chemical point of view. The ■question must in the mean time, perhaps, be left open. Bauer's experiments would, on the one hand, indicate the possibility of the older view. He found that he could produce extensive fatty degeneration in dogs by feeding them with phosphorus, in cases where they had previously lost their fats through a course of starvation. Lindemann and others also think that the marked cytoplasmic and nuclear changes in fatty degeneration are sufficient evidence of the origin of the fat from the cell protoplasm. On the other hand, even if it be true that fat is formed within degenerated cells, it is open to belief that it may possibly be formed out of carboh3^drate substances present in the cells. It can hardly be ■denied, however, that cloudy swelling is due to a chemical transformation of the cellular proteid; and, inasmuch as cloudy swelling and fatty degeneration arise •under identical conditions and are so frequently combined, the one condition often passing imperceptibly into the other, the proteid origin of the fat does not appear by any means imlikely. In view, howeA'er, of the unsettled state of the controversy, it would perhaps be more strictly correct to speak of " fatty degen- ■eration" as ''a cell degeneration associated with the formation of fat." Fatty Infiltration. — Fatt}' infiltration may be defined as a deposit of fat in the cells of an organ or tissue, without any essential change in their structure. Under ordinary circumstances fat is stored up in the cells in various parts of the body. It acts as a protection against external cold and injury, as a lubri- cant, and as a potential source of energy. The amount of fat present in any given case depends upon the quantity produced in the processes of assimilation and nutrition and the amount consumed in the oxidation incident to metabo- lism. Fat may be brought to the body in food, being emulsified and carried from the intestines by the lacteals and lymphatics and being stored up in the various cells of the body, notably those of the liver. Or, again, it may be pro- 188 AMERICAN PRACTICE OF SURGERY. duced by cellular activity from the carbohydrate and proteid constituents of the food. Therefore, an excessive amount of fat may accunmlate in the system, if there be an abnormal amount ingested or produced, or if there be a deficient consumption of the fat. Or both factors may be at work. Up to a certain point the process of fat deposit is physiological, and we must be prepared to admit wide variations in its extent as being within normal limits. When it becomes excessive we speak of obesity, adiposity, lipomatosis, or polysarcia. The process, however, is in general the same, whether under physiological or under pathologi- cal conditions. Wliat may be termed digestive fatty infiltration is well seen in the liver after a meal. On the other hand, when an animal is deprived of food for some time the liver becomes destitute of fat. An abnormal amount of fat may be laid down if there be an excess of fat in the food ingested. According to the older view, this fat was carried mechanically to the liver and deposited there. There are reasons, however, for thinking that the process is not so simple as this. The proportions of the various constituents of fat vary in the case of different animals. Now if you feed, for example, a dog on palmitin, this will be trans- formed and deposited in the various cells in the form of fat normally character- istic for the dog. This can be explained only by assuming the active interfer- ence of the cells themselves. Therefore, fatty infiltration is not a mere deposit of fat in passive receptacles, but a true metabolic process, in which the cells play a most important part. What happens is probably this : The fat ingested is immediately oxidized and employed for the requirements of the body; the fat that is deposited is the result of the metabolism of the carbohydrates and proteids brought to the cells. Whichever view is accepted, it is evident that fatty infiltration differs essentially from fatty degeneration. In the former the fat is not produced at the expense of the cell protoplasm, but from material im- ported to the cells from without. Fat, again, may accumulate owing to deficient fat consumption. Here all conditions which lead to imperfect oxidation are important. Probably of this nature is the obesity which comes on with middle age. Diminished work on the part of the cells, sluggish respiration, chronic antemia, alcoholism — all may play a part. In some cases the normal balance which should exist between fat production and fat consumption is upset without obvious cause. The food is of suitable quantity and quality, and the waste appears to be going on normally, and yet, in spite of this, fat accumulates in excess. Here there are abnormal metabolic processes going on, the exact nature of which we do not understand. Undoubt- edly in some instances there is some inherited peculiarity. In others the tend- ency is acquired. It is interesting to note in this connection the relationship which exists between the sexual system and fat production. For example, in young girls fat tends normally to be deposited in certain situations with the on- set of puberty. Women not uncommonly become stout after the menopause or DISTURBANCES OF NUTRITION. 189 on removal of the ovaries. Eunuchs are also often obese. Conversely, young women who become inordinately fat are frequently sterile. Fatty infiltration may be local or general. Local lipomatosis is to a certain extent to be regarded as complementary in certain cases. Thus, the fat is often increased about atrophic or wasted organs. For example, the fat is increased about a contracted kidney, in the interstitial substance of the atrophied heart, and between the bundles of atrophic muscle. Multiple, circumscribed, and often symmetrically disposed, fatty tumors — lipomata — are probably to be ascribed to abnormal cellular activity. Adiposis dolorosa (Dercum) also comes under this category. General obesity is not uncommon. Here the excessive deposit of fat takes place first at the points where fat is normally stored, namely, in the subcutane- ous and subserous connective tissue, in the liver, in the bone-marrow, and, later, in unusual situations, such as in the wall of the heart, in the interstitial sub- stance of the voluntary muscles, and in the submucous connective tissue. The gross appearance of a fattily infiltrated organ is characteristic. In the case of the heart, the organ is enlarged, mainly from a great deposit of fat in the epicardium. On cutting through the wall, this fat can be traced in the form of pads and streaks between the muscle bundles. In places, especially near the apex, there may be but little muscle left. In fatty infiltration of the liver, the organ is enlarged, unlike what occurs in fatty degeneration. The edges are rounde'd, and the tissue is doughy, pitting on pressure. In color it is yellow or yellowish- white. On section it is soft, fri- able, and greasy. Globules of fat can be scraped off with the knife. In ad- vanced fatty infiltration the liver may actually float when placed in water. These examples illustrate, moreover, the two types of fatty infiltration. In the former the fat is deposited in the interstitial connective tissue; in the latter, within the parenchymatous cells. Microscopically, the heart will show large masses of adipose tissue lying be- tween the muscle bundles (see Fig. 67). In the liver the parenchymatous cells show no structural changes other than those due to the mere presence of the fat. In the early stages the cells contain small droplets of fat, which later coalesce to form larger globules, almost or quite filling up the cell. In this way we get a large oil globule, surrounded by a thin shell of protoplasm, the nucleus of the cell being crowded to one side, which gives the cell a characteristic signet-ring appearance. Where fat globules are present within the specific cells of an organ, it is not always easy to decide whether we have to do with fatty degeneration or with fatty infiltration. In the former we can, on careful study, usually make out degenerative changes in the cytoplasm and in the nu- cleus. The cells are also usually atrophic, while in fatty infiltration the cells are larger than normal. Fatty infiltration, like fatty degeneration, may result in serious interference 190 AMERICAN PRACTICE OF SURGERY. with function. General obesity leads to inhibition of movement, sluggish res- piration, weak heart action, and to some extent it slows metabolism generally. Fatty infiltration of the heart in time produces muscular insufficiency and oc- casionally rupture of the wall. The liver, on the other hand, is able to perform its functions comparatively well, even in the presence of advanced fatty deposit- These results are brought about in part by the mechanical effect of the deposited Fig. 67. — Fatty Infiltration of the Heart Muscle. A mass of fat can be seen embedded in the walL {^Lertz obj. No. '6.) {From the author's private cotlectwn.) fat, and in part by the secondary atrophy of the specific cells due to pressure and imperfect nutrition. Hydropic Degeneration. — This form of degeneration is characterized by the partial liquefaction of the cellular substance, resulting in the formation of clear vacuoles withm the cell. The degeneration may take place both in the cyto- plasm and m the nucleus. The nucleus may be so ballooned out as to resemble a little sac filled with colorless fiuid. Hydropic degeneration is the first stage of colliquative necrosis, and is also found in vesication of the skin, inflammation, and in the cells of tumors. The cell and its nucleus stain badly, thus indicating that It is a retrograde process. Colloid Degeneration. — Colloid is a senn-solid, translucent, homogeneous, and structureless substance, of a yellowish or brownish color. In general appearance it resembles stiff glue. Colloid is found normally within the follicles and lym- phatics of the thyroid gland and in the pituitary body. It bears a general rela- tionship, so far as external appearance goes, to mucin, hyalin, and amyloid. Chemically, it differs from these in some particulars. Its exact composition is unknown, but it is believed to be an albuminous body containing thyroidLa. DISTURBANCES OF NUTRITION. 191 The material does not swell up in water, is not precipitated by alcoliol or acetic acid, and is stained orange-red by Van Gieson's method. Pathologically (see Fig. 68), colloid is found in increased amount in certam cases of enlarged thyroid (colloid goitre), and in some tumors of the thyroid. Material resembling thyroidal colloid is at times found within the kidney (col- loid casts), in cysts of the kidney or ovary, in the prostate and parotid, and in some carcinomata. Whether it is identical with true colloid is perhaps doubt- ful. Colloid and colloidal material must in all probability be regarded as prob- ucts of epithelial cell activity. Mucinous Degeneration. — Mucus is a homogeneous, transparent, slightly ropy material, the chemical constitution of which is not exactly known. Probably a number of substances, in general resembling one another, but differing slightly in composition, are included imder the term mucus. The principal ones known at present are mucin and pseudo-mucin. Mucin contains nitrogen and sulphur, swells in water, is dissolved in alkaline fluids, is precipitated by alcohol and acetic acid. It is non-diffusible. Pseudo-mucin dissolves in water and is not precipitated by acetic acid. From both mucin and pseudo-mucin a carbohydrate Fig. 68. — Excessive Production of Colloid m the Thyroid Gland — Colloid Struma. {Leitz obj. No. 3.) {From the author's private coiiection.) may be obtained, indicating that they are to be regarded as glyco-proteid in nature. Mucus is found normally as a secretion of mucous membranes and mucous glands, in joints, tendon sheaths, and bursse, and forms the Wharton's jelly of the umbilical cord. In the case of the mucous membranes, mucus seems to be the special secretion of certain cells, called from their appearance "goblet cells." 192 AMERICAN PRACTICE OF SURGERY. These cells, when in an active condition, contain a clear, colorless, transparent, oval globule, which eventually is extruded upon the surface of the membrane or into the lumina of the glands. Pathologically, mucus is formed in considerable quantities in various condi- tions. Thus, in inflammation of mucous membranes, there is an excessive pro- duction of mucus from the superficial epithelium and the glands. The number of goblet cells appears also to be increased. Not only so, but, unlike what oc- curs in normal secretion, the cytoplasm and even the nucleus of these cells un- dergo mucinous degeneration leading to complete destruction of the affected cells. The globules of mucin coalesce and we get a continuous sheet of stringy mucus covering over the inflamed surface (catarrhal inflammation). Pus cells, if present in the exudate, may in their turn undergo the same transformation. In such cases the presence of mucus in excess is to be regarded as protective in its nature, for, although non-bactericidal, mucus, by its mere presence, inter- feres with the action of pathogenic bacteria, and in the course of its excretion tends to flush out the diseased area. Mucoid degeneration is also not infre- quently met with in the epithelial cells of tumors, especially carcinomata, in- volving the mucous membranes. In such cases large masses of carcinomatous tissue may be converted into mucin. Such tumors have, on section, a sticky, gelatinous appearance. The epithelial cells in large part disappear, and their place is taken by a fibrillar, loosely arranged material, which strikes a bluish tinge with hsematoxylin. Pseudo-mucin is found in a large number of ovarian cystadenomata. Mucinous degeneration is also to be observed in connection with mesoblastic structures. Here the intercellular substance loses its fibrillar character and is converted into mucin. This transformation occurs in connective tissue, carti- lage, bone, bone-marrow, and fat. The connective-tissue framework of some sarcomata and carcinomata may show the change. Microscopically, in such cases we find bipolar or stellate cells, with long processes, floating in a loose, struc- tureless, colorless matrix. The majority of nasal polyps are mucinous in character. In myxoedema, a curious disease due to inadequacy of the thyroid secretion, there appears to be a mucoid metamorphosis of the subcutaneous tis- sues. Cholesterin. — Plates of cholesterin, apparently the product of degeneration, are found in atheromata, cysts, the walls of sclerotic vessels, old extravasations, and purulent exudates. In such cases it appears to be a by-product in the proc- ess of fatty degeneration. Cholesterin is found in the form of thin, rhombic plates, frequently having a small rhomb taken out of one corner. Epithelial Hyalin. — A number of substances, bearing a general resemblance to colloid or hyaline material, have been grouped under this head. Probably they are not all of identical chemical composition. Warthin would restrict the term "epithelial hyalin" to the degeneration products of epithelial cells, which DISTURBANCES OF NUTRITION. 193 resemble the hyalin of connective tissue in tliat they stain with fuehsin. In this category would come, therefore, the hyaline granules and globules found in car- cinoma cells. These have been thought to be parasites, but are really due to degeneration of the epithelial cells. Corniflcation. — Cornification occurs normally in the skin. Excessive corni- fication (hyperkeratosis) takes place exceptionally. The condition may be con- genital, as in ichthyosis congenita, or acquired. Irritation of the skin of all kinds, mechanical or inflammatory, may result in hyperkeratosis. Familiar instances are warts, callosities, and corns. Cornification may also occur pathologically in parts of the body where it normally should not take place at all or only to a trifling extent. Thus, the ducts of the cutaneous glands may be affected and even blocked. Mucous membranes also, such as those of the mouth, vagina, urinary passages, middle ear, and mastoid cells, may on occasion be transformed into skin-like structures. Keratohyalin is also produced in certain tumors of the skin, brain, and meninges. In such cases the process is a true cell degeneration, the horny material being formed by the cells at the expense of their nuclei. The nuclei shrink and ultimately disappear. Pigmentation from Cellular Activity. — The pigments found in the body are derived from various sources. They may be the result of cellular activity — autochthonous or metabolic -pigments; they may arise from changes in the blood, with liberation and modification of the hajmoglobin — hematogenous -pigments; they may be derived from the bile which has been absorbed into the tissues — jaundice or icterus; or they may be foreign material imported from without — extraneous pigments. At the present moment we are concerned exclusively with the metabolic pig- ments. Pigment normally is found in many parts of the body in the form of yellowish, brown, or black granules within the cells or in the intercellular sub- stance. Thus it is present in the deeper layers of the rete Malpighii of the skin, in the choroid and retina, in the hair, and in the ganglion cells of the central nervous system. It is found also in the connective tissue of the pia mater, the heart and other muscles, the kidneys and suprarenals. According to their chem- ical peculiarities, pigments are called melanin, haemofuscin, and lipochrome. The normal amount of pigment may be increased under certain physiological and pathological conditions. The pigmentation of the skin becomes more in- tense in certain regions during pregnancy. Sunburn results in increased colora- tion of the affected part. Freckles are a form of increased pigmentation. In Addison's disease there is an excessive formation of pigment in the skin and mucous membranes. The most extreme examples of pathological pigmentation are found in certain moles of the skin and in the melanotic sarcomata and car- cinomata. In these growths the pigment lies both within the cells and in the intercellular substance in the form of fine brownish or blackish granules. Some of these tumors are coal black. In such cases the urine may contain substances VOL. I. — IS 194 AMERICAX TRACTICE OF SURGERY. which turn black on exposure to the air (melanuria). In the examples cited it is believed that the pigment results from cellular activity of a special nature. Koelliker holds that in the skin the pigment is carried by wandering connective- tissue cells (chromatophores), which send processes between and into the epi- thelial cells, and there deposit their pigment. The source of these chroma- tophores is quite unknown. In what way the pigment is produced is also unknown. It would seem probable, however, that it is elaborated by the cells from albuminous substances. Besides the melanin found in the cases just referred to, we have hfemofuscin, supposed to be identical chemically with liEematoidin. It is found occasionally in the heart and in the unstriped muscle of the intestine. Lipochrome is a pigment, or rather a class of pigments, of obscure nature, found in the corpus luteum of the ovary as a yellow-colored fat (lutein), and in the rare tvunor known as the chloroma, which is of a pale greenish color. The so-called xanthoma of the skin contains a coloring matter belonging to the lipo- chromes. Ochronosis is a browmish or brownish-black pigmentation of the carti- lages found in rare cases. The nature of the condition is unknown. Glycogenous Degeneration. — Glycogen is a carbohydrate, an intermediate product in the conversion of starches into sugar. It is found normally in the liver, in the mucous membrane of the uterus, in the voluntary muscles and the heart muscle, in leucocytes, blood serum, and cartilage, and in most of the organs during embryonic existence. Glycogen is found in the tissues either in solution or as flakes or granules of hyaline appearance, lying within the cells or in the intercellular substance. It is soluble in water. ^^Qien treated with iodine it stains a brownish-red. Unlike amyloid, it does not give the reaction with iodine and sulphuric acid. Amyloid, again, is not soluble in water. In examining tis- sues for the presence of glycogen, it is important to fix and examine the material immediately after death, as the gl}fcogen is quickly transformed into sugar. Pathologicallj', gl}TOgen is formed in increased amounts in pus cells, in the leucocytes in certain cachectic conditions, and in the cells of some tumors, not- ably tumors of the kidney and suprarenal (hypernephroma ta), of the cervical portion of the uterus, of the testes, bones, cartilages, and muscles. In all these cases it is probably a result of cell activity. INFILTRATIONS. Amyloid, waxj^ or lardaceous mfiltration is the condition in which there is a deposit of a glassy, wax-like, homogeneous substance in the walls of the smaller blood-vessels. Almost any part of the body may be affected. Amyloid infiltra- tion is most commonly met with in the spleen, kidneys, and liver; less often in the stomach, intestines, heart, IjTuph nodes, suprarenals, and pancreas; rarely in the muscles, uterus, ovaries, and respirator}' tract. DISTURBANCES OF NUTRITION. 195 The exact nature of the infiltration is not entirely understood. It occurs as a secondary disturbance in a variety of ailments, chiefly chronic and infectious, which are accompanied by grave disturbances of nutrition. Thus we get it most commonly in chronic tuberculosis, especially of the lungs, bones, and joints; in chronic suppuration, as in osteomyelitis, pyemia, actinomycosis, glanders; in inveterate syphilis, in chronic dysentery, in prolonged lactation. Local amy- loid infiltration of the kidneys is occasionally met with in chronic Bright's dis- ease. The condition is also sometimes found in connection with leukaemia, car- cinoma, and severe malaria. Ziegler is the authority for the statement that amyloid change may arise in the absence of previous disease. It can be pro- duced experimentally. Czerny caused it in dogs by inducing long-continued suppuration with injections of turpentine. Krawkow produced it in rabbits and chickens by repeated injections, in increasing quantities, of broth cultures of the Staphylococcus pyogenes aureus and the toxin of Bacillus pyocyaneus. In these cases the condition appeared in from one and a half to two months. Thus it is evident that amyloid change is directly related to the disorder of nutrition resulting from chronic cachexia. The more intimate explanation of the process is still to seek. It has been suggested that the parenchjmiatous cells- of the various organs are directly changed into amyloid material, but this is not supported by histological evidence. Amyloid is not found within the cells, but in the interstices of connective tissue and in the walls of blood-vessels. In the early stages it has been found just beneath the endothelial lining of the vessels. This, together with the fact that the vessels are so frequently picked out for the transformation, strongly supports the view, which is now quite generally ac- cepted, that the amyloid, or, more probably, some precursor of it, is circulating in the blood and is precipitated in the walls of the vessels or in the perivascular lymphatics. Possibly we should take into accoimt also the selective properties of the endothelial cells, and the influence of the tissue juices, which may com- bine with the amyloid precursors to form amyloid. We may perhaps here allude to the views of Von Recklinghausen and Czerny. The former has advanced the theory that the cells of the organs excrete a homogeneous substance, which co- agulates in the tissue spaces into the characteristic amyloid deposit. Czerny foimd cells giving the microchemical reaction of am3doid in the pus and blood of animals which later presented amyloid change in the spleen. He therefore thinks that in the early stages the amyloid material is formed in local foci of suppuration and is carried to the internal organs by the leucocytes. Chemically speaking, as Oddi and Krawkow have shown, amyloid is a com- pound of albumin and chondroidin-sulphuric acid. The latter substance is found normally in cartilage and all structures containing abundance of elastic tissue, especially in the blood-vessels. Amyloid does not contain phosphorus. It is practically insoluble in water, is unaffected to any axtent by acids or alkalies, and resists the action of the gastric juice and even of decomposition. There are 196 AMERICAN PRACTICE OF SURGERY. certain chemical tests which give characteristic reactions with amyloid material. To determine the presence of amj'loid in organs removed at autops}', thin slices are taken, the blood is removed bj- washing, and the material is allowed to re- main in a solution of iodine in potassium iodide (iodine 1 gm., potassium iodide 2 gm., water 300 c.c.) for a few minutes. If for any reason the organs are alka- line, it is necessary to soak the tissue first in acetic acid. If amyloid be present, a mahogany-brown, translucent coloration is produced. Thin sections, stained by this method, when viewed under the microscope, show the amyloid as a glassy, transparent substance of a golden-yellow color. More striking still is the reac- tion produced with certain aniline dyes. Microscopic sections are placed for two or three minutes in a somewhat dilute waterj- solution of methjd-violet or gen- tian-violet. The sections are then washed in a weak acid solution, such as acetic or hydrochloric (two per cent), until most of the blue color is removed. If amj'- loid be present, portions of the tissue will assume a rose-pink color, which can also be made out very well under the microscope. The unaffected parts strike a dirty, grayish-blue tint. Organs the seat of advanced amyloid change are usually enlarged, their edges somewhat rounded, and are much increased in consistency, so that they feel like India rubber. On section the amyloid material can often be made out as dots or streaks of a grayish, translucent appearance, or the surface of the organ may look as if smeared over with gelatin. Thin sections on being held up to the light appear to be pale gray and translucent. In the spleen amyloid infiltration begins in the walls of the arteries, capil- laries, and smaller veins, especially those within the Malpighian bodies. These become greatlj' enlarged and appear in the fresh state like grains of half-boiled sago; hence the term "sago spleen." Or, again, the condition may spread, in- volving the vessels and trabeculse of the pulp, giving rise to a diffuse amyloid in- filtration — "waxy," bacony, or lardaceous spleen. In the kidneys the process begins in the walls of the interlobular arteries, afferent arterioles, and glomerular capillaries. The middle coats of the arteries are first and chiefly attacked. The glomeruli in time become largely converted into structureless, translucent nodules. In the liver it appears first in the walls of the intralobular capillaries, mainly in the intermediate zone of the lobules, forming thick, homogeneous bands, be- tween which are liver cells in all stages of atrophy and fatty degeneration. Amyloid infiltration is always of serious import. It is met with only in most dangerous disorders and in the most advanced stages of them. It indicates, then, a bad prognosis where it can be made out. It also aggravates the primary disease by inducing atrophy and fatty changes in the cells with which it comes in contact, and causes marked circulatory disturbances, with all their conse- quences, through alteration in the lumina of the affected vessels. Closely resembling amyloid in general appearance, although differing from it DISTURBANCES OF NUTRITION. 197 in several important particulars, is hyaline infiltration. Like amyloid, this takes place in the walls of blood-vessels and in the interstices of connective tissue. It is also met with in inflammatory exudates. It is distinguished from amyloid by the absence of the iodine reaction and the rose-pink color when treated with aniline dyes. By Van Gieson's method it stains a deep red, while amyloid stains pinkish-yellow or brown. Again, hyaline infiltration is not so regularly distrib- uted in the body as amyloid, nor does it have the same etiological relationship with suppuration and chronic cachexias. The close relationship which exists be- tween hyalin and amyloid is shown by the fact that hyaline deposits are not in- frequently found in organs the seat of amyloid change, and, conversely, amyloid, when introduced into the peritoneal cavity of experimental animals, loses its characteristic staining properties and becomes like hyalin. Hyaline infiltration is found in the walls of sclerotic vessels, in the heart valves when the seat of chronic inflammation, in the connective tissue of the thyroid, ovaries and lymph nodes, and in the stroma of many tumors. Hyaline transformation of the glomerular tufts is often met with in the kidneys in chronic Bright's disease. The cellulo-fibrinous exudate in certain cases of pleu- risy, pericarditis, and peritonitis occasionally undergoes this transformation. This may lead to great thickening of the serous membranes, so that they come to resemble cartilage ("icing" organs, "Zuckergussorgane"). In certain forms of coagulation of the blood, as, for example, in the formation of blood-platelet thrombi, the platelets become fused into a mass resembling hyalin. The so-called "hyaline bodies," or Russell's "fuchsin bodies," are homogeneous, globular masses of varying size, either single or aggregated in clusters. They are found both within and without the cells in glandular proliferations of the gastric mu- cosa and in malignant tumors. They strike a red color with acid fuchsin and dark blue with the Gram-Weigert stain. By some they have been regarded as of parasitic nature. This, however, is now believed to be erroneous. Certain changes in glia cells sometimes produce masses which stain black with the Pal-Weigert method, red with Van Gieson's stain, and bright blue with Weigert's fibrin stain, after fixation in Zenker's fluid. Barker has shown that the material in question forms within the glia cells. So-called amyloid bodies or concretions are also met with in the prostate (Fig. 69), hypophysis, central nervous system, and lungs. Some are homogeneous and others laminated. In the latter case it is not uncommon to find in the centre of the concretions cell debris, indicating that in some cases at least the process is probably a degenerative one, resulting from the cutting off of desquamated cells from their nutritive supply. Occasionally, but by no means invariably, such bodies give the reaction for amyloid. Their exact relationship to amyloid, hya- lin, or colloid cannot as yet be stated. The exact nature of the hyaline change is still unknown. A\nien occm-ring in the connective tissue of certain organs, especially that of the conjunctiva, and in 198 AMERICAN PRACTICE OF SURGERY. inflammatory exudates, hyaline material appears to be more of a degeneration than an infiltration. Theoretically, the connective-tissue elements may be trans- formed into hyaline material containing no nuclei, or the hyalin may be a secre- tion from the connective-tissue cells. In some cases the process appears to be both a degeneration and a deposit, the interstices of the connective tissue being first filled with a clear, homogeneou? material, into which the cells gradually fuse. Calcification and Analogous Conditions. — Under certain conditions there may be a deposit in the body of crystalline, amorphous, or granular salts, derivatives of lime or uric acid. This is called petrifying infiltration. The deposition of lime salts is usually termed calcareous infiltration or calcification. This is of not in- frequent occurrence. The precipitation of these substances may take place into tissues or structures which are normally part of the hoiXj, into structures which Fig. 69. — Corpora (^mvlaiea m the Prostate {LcUz obj No. 3.) (From the author's private collection.) are separated from their normal relationships, or into foreign bodies imported from without. In the last two instances we speak of the formation of concre- tions or calndi. Calcification occurs as a normal change in the formation of bone from carti- lage. In advanced life lime salts are deposited with great regularity in the costal cartilages, in the cartilages of the larynx, and in the walls of the arteries. It is generally believed that this is due to certain involutionary changes in the bone which occur in old age, the lime salts being reabsorbed and deposited elsewhere in the body. In some cases of osteoporosis and osteomalacia the .salts are depos- DISTURBANCES OF NUTRITION. 199 ited in apparently normal tissue, as in the lungs, kidnej's, and gastric mucosa. This process is sometimes referred to as metastatic calcification or lime metastasis. Calcification almost never occurs in normal tissues. It is practically alwa3's preceded by cloudy swelling, fatty degeneration, hyaline transformation, casea- tion, or necrosis. Calcareous deposit occurs not infrequently in connective tis- sue which has become sclerosed or h3-aline; for example, in arteriosclerosis, in the heart valves when the seat of chronic endocarditis, in chronic pleurisy, em- pyema, and chronic pericarditis, and in the thyroid gland. It occurs in tumors, such as uterine fibroids. It is found in necrobiotic and necrotic areas, as in case- ation or coagulation necrosis, in old inflammatory exudates, in thrombi, and in the capsules of animal parasites. Calcareous infiltration may also take place in dead ganglion cells of the brain in cases of shock and softening. It is met with in the renal epithelium in the necrosis resulting from ansemia and from in- toxications, such as those due to corrosive sublimate, aloin, and bismuth. For- eign bodies, such as a dead foetus (lithopcedion), catheters, bullets, pessaries, etc., may become incrusted with lime salts. The exact chemical reactions which occur in the formation of lime deposits are still more or less a matter of debate. The lime is present in the tissues in the form of carbonate and phosphate. "\^^ien strong mineral acids are added to the material, there is an evolution of carbonic dioxide. The problem is chiefly indi- cated in the following questions : How do the lime salts enter the system? In what form do they exist? What brings about their preciijltation? The physiological infiltration of certain tissues with lime salts which occurs in old age is with great probability to be referred, at least in the main, to a transference of the lime from the bones to other parts. The fact, howe^'er, that we find calcification so often in early life would indicate that there must be an- other explanation for its occurrence. We have to believe, then, that the process is intimately bound up with the body metabolism and that the ultimate source of the lime is in the food. A farther point is that calcification does not occur except in tissues that are in a more or less advanced stage of degeneration. There appears to be in such tissues some chemical substance which determines the place of the deposit. In rabbits and ruminants, whose food abounds in lime salts, it is a very common thing to find lime deposits at points where there is local death of tissue. Inasmuch, however, as such local death occurs fre- quently in human beings without calcification supervening, we have to conclude that an excess of lime salts in the food is necessary. These salts, no doubt, are carried throughout the body in the blood and lymph, presumaljly in a soluble form. "V^lien they reach the degenerated tissues it is held by some that they are acted upon by the phosphoric acid and nascent carbonic dioxide and thrown down in an insoluble form, or, what is perhaps more likely, they first combine with the fats in the part to form soaps, which are in their turn decomposed. The salts are thus laid down in solid masses both within the specific cells of the 200 AMERIC\\X PRACTICE OF SURGERY. tissue and in the intercellular substance, and may abound to such a degree as to render the part hard like stone. Microscopically, the lime appears as fine, refrac- tile granules, which are dark and somewhat opaque by transmitted light and white by reflected light. In sections stained by hsematoxylin the granules strike a pm-plish-black color. The condition is essentially one of deposition of mineral matter, and hence is often termed petrifaction, as contradistinguished from ossi- fication, in which, together with the deposition of salts, there is a formation of new tissue. The deposition of salts of uric acid is of great practical importance. In the disease known as gout thej^ are laid down in the articular cartilages, ligaments, tendons, and tendon sheaths, the subcutaneous connective tissue, and in the kidneys. The material is deposited in the form of needle-shaped crystals, some- times trimcated, in the intercellular substance of the cartilage. At first the car- tilage cells do not suffer, but later the deposit may be so great that the cartilage becomes opaque, looking like chalk by reflected light. In the most extreme cases the affected part may actually necrose. As might be expected, the pres- ence of so much foreign material, and that of an irritating kind, leads to inflam- mation of the structures involved. In gout there is evidently a marked disturb- ance of metabolism, in which unusually large quantities of uric acid are formed in the blood. Uric acid is a very insoluble substance, and it has been suggested by Roberts that it exists in the blood as a quadriurate soluble in water. This is broken up in part into sodium biurate, which is the substance precipitated. The uric-acid infarcts found in new-born infants deserve a word. They are observed usually in the first two weeks of life, rarely in the foetus, and appear as yellowish- or reddish-white striated marks in the papillae. They are due to the deposition of urates in the uriniferous tubules, and probably indicate a slight disturbance of metabolism. Calculi or concretions are rounded, nodular, or branched masses of mineral matter formed in the tissue spaces, in the lumina of vessels, in ducts of glands, and in cavities lined by mucous membrane, by precipitation from the fluids or excretions of the body. Some of the so-called "free bodies" are composed en- tirely of organic material, such as certain of the "amyloid" concretions in the prostate and central nervous sj^stem, but as a rule in the organic matrix there is a deposit of insoluble salts. Brain sand is composed of small calcareous masses of this kind, and is found normally in the pineal gland, in certaui tmnors of the dura and pia mater, and of the choroid plexus, hence called psammomata. Similar concretions are at times foimd in the various cavities of the body. Such are the petrifications of old thrombi (arterioliths, phleboliths), calculi in the hepatic and urinary pas- sages, concretions in the pancreatic and salivary ducts, in the nasal (rhinolitlis) and respiratory passages (broncholiths), in the external auditory meatus (oto- liths), fecal accumulations in the intestines, preputial stones. DISTURBANCES OF NUTRITION. 201 Gall stones are among the commonest forms of calculi. They are met with usually after middle life, and are much more, frequent in women than in men (2 to 4: 1). According to their chemical constitution we may recognize four kinds of biliary calculi — cholesterin, bilirubin-calcium, pigmentary, and calcium car- bonate. Various combinations of these may occur. Pure cholesterin calculi are rare. They are often solitary and may form a complete cast of the gall bladder. They are light-colored, often somewhat greenish, are hard, and break with a crystalline fracture. They are made up of radial and concentric laminae. Mixed calculi of bilirubin or biliverdin and calcium salts are more common. They vary greatly in size, are often very numerous and faceted, are hard, and of a dark brownish color. Pigment calculi are small, irregular, and friable. The modus operandi in the formation of gall stones has been fairly well worked out by Naunyn and others. The first requisite for the formation, of biliary cal- culi is an albuminous matrix, and then an abnormal biliary secretion. Catarrh of the biliary passages provides the first condition. This may be brought about by stasis of the bile, such as may be induced by sedentary habits, obesity, tight lacing, and too long intervals between meals. This leads to slight irritation of the mucosa with the liberation of an albuminous secretion and the desquama- tion of some of the lining cells. Or the same result may be brought about by in- testinal or general systemic disturbances, resulting in invasion of the biliary pas- sages by bacteria. The Bacillus coli, the Bacillus typhosus, the staphylococcus, and the streptococcus have been found in the bile passages, and are known to persist there on occasion for months. Both the colon and the typhoid bacillus have been found in gall stones, and typhoid fever is now looked upon as an im- portant etiological factor. Biliary calculi have also been produced experimen- tally by injecting bacteria into the gall bladders of animals. The desquamated cells and albumin tend to fuse together and form the nucleus in and about which the various salts will be deposited. The source of the cholesterin and bilirubin- calcium is not entirely clear, and conflicting opinions have been expressed. Probably Naunyn's view is most widely held. According to this, cholesterin is formed in situ, being produced by the diseased mucous membrane. Increased acidity of the bile appears to have something to do with it. Bilirubin-calcium is not a normal constituent of the bile. Bile salts seemingly have a retarding influence on the formation of bilirubin-calcium, but this inhibitory power is counteracted by the presence of albumin, so that the precipitation of this sub- stance is similarly traceable to the condition of inflammation. The deposition appears to take place, not according to the usual rules of crystallization, but under the influence of the albumin the mineral matter is precipitated in the form of plates. Owing apparently to variations in the local condition of things, the calculus is built up gradually layer after layer, and in radial form. The great variation in the composition of gall stones would, however, seem to in- dicate that there are other factors besides those mentioned. Probably local 202 AMERICAN PRACTICE OF SURGERY. disturbance of the hepatic functions and disorders of systemic metabolism are of importance. Urinary Calculi. — Tl^ese calcuh may be found within the tubules of the kid- ney, in the kidney pelvis, and in ureter, bladder, and urethra. Not infrequently they are formed in one place and carried by the flushing-out action of the urine and muscular activity to some more remote part. Calculi are produced in the kidney (renal calculi) or in the bladder (vesical calculi). By their presence they frequently cause obstruction to the outflow of the urine and inflammatory dis- turbances, with even destruction, of the urinary organs. The chemical constitution of urinary calculi depends, on the one hand, on the composition of the urine, which in its turn is dependent on the general meta- bolic processes of the body; and, on the other, on certain chemical changes oc- curring in the urine after its secretion by the kidneys. As in the case of biliary calculi, we have to recognize both local and general disorders of metabolism. Chemically speaking, urinary calculi may be divided into the following forms: (1) The uratic; (2) the phosphatic; (3) the calcium carbonate; (4) the calcium oxalate; (5) cystin;. (6) xanthin. Calculi are built up gradually, and, owing to variations in the conditions, may present a different composition in different parts, or several calculi of dif- ferent composition may be found in the same patient. The important element in the production of urinary calculi is the disturbance of the general metabolism. This cannot act, however, unless the local conditions are favorable. As we have seen in the case of biliary concretions, an albuminous medium is a necessity. The work of Ebstein, Posner, Naunyn, and Studensky, among others, has shown conclusively that albuminous fluids have the power of determining the precipitating of the crystalline salts from their solutions, much in the same way as in the formation of the hen's egg, where the albumin has the power of separating out carbonate of lime from solutions of calcium salts. To bring about the excretion of albuminous material, the chief factor is of course inflammation. This may be produced by stagnation of urine, alterations in the composition of the urine, local bacterial invasion, fermentative processes, and the like. The lining cells desquamate to some extent and act as a sort of nucleus. As in the case of biliary calculi, catarrhal inflammation is of great importance; but as every catarrh does not result in calculus formation, we must believe that other factors are at work. These are not altogether clear, but are probably to be looked for in some abnormality of general metabolism. Hyperacidity of the urine, due to an excess of uric acid, is a predisposing cause of the precipitation of lU'atic salts and oxalates. When urine becomes alkaline, as from retention and the activity of certain bacteria, ammonio-magnesium phosphate is formed and may be thrown down. Incrustations of phosphates occasionally are formed upon foreign substances which get into the bladder, such as bits of catheters, slate pencils, hairpins, tooth brushes, etc. DISTURBANCES OF NUTRITION. 203 Cystin calculi originate in disturbances which take place outside of the uri- nary organs. Such calculi, which are rare, are due to abnormal decomposition of albuminous substances in the intestines brought about by bacteria. Cystin calculi are yellowish, soft, and waxy. Xanthin calculi are also rare. They are found in the bladder, and are reddish in color, soft, and friable. In cattle, calculi formed of silicates may be met with. Fecal calculi are composed of inspissated fecal matter infiltrated and in- crusted with lime salts. Constipation and the presence of intestinal diverticula favor their formation. Salivary and pancreatic calculi are also composed of lime salts, usually the carbonate. Glycogenous Infiltration. — Infiltration with glycogen is found especially in the case of diabetes mellitus. In this disease both glycogen and sugar are produced in greatly increased amounts. The glycogen may be demonstrated in the leuco- cytes, blood plasma, liver, and kidneys. In the last-mentioned organs the de- posit occurs chiefly in the epithelial cells lining the loops of Henle. It is usually found in hyaline-looking droplets near the nuclei, and may be recognized by the before-mentioned tests. Experimental diabetes, produced by the removal of the pancreas, is followed similarly by a deposit of glycogen in the leucocytes, liver, and kidneys. Pigmentary Infiltration. — We have above referred to a form of pigmentation which is due to metabolic changes in the cells themselves. This has properly been regarded as a true degeneration. There are other forms of pigmentation, however, which, while in some instances the result of disturbed metabolism, are, so far as the affected cells and tissues are concerned, the result of causes op- erating outside of them. Here the pigment which is produced in one part of the body is carried by the blood or lymph to other regions, where it is deposited as so much foreign material. This is pigmentary infiltration. In this class are to be considered the pigmentation which results from breaking down of the red blood corpuscles — hcematogenous pigmentation, and that due to the accumulation of bile in the tissues — biliary pigmentatio7i. In the first-mentioned variety the pigmentation is due to the deposition in the tissues of coloring matter derived from haemoglobin. This may occur as the result of hemorrhages or thrombosis, where the blood cells become, as it were, extravascular, and midergo retrograde changes, or it is due to the solution of the haemoglobin in the plasma and the formation of granules of pigment in the blood. Hematogenous pigments occur in two main forms — hamatoidin and hcemo- siderin. Hsematoidin is found in the form of yellowish or brownish granules, or as reddish rhombic or acicular crystals. It responds to Gmelin's test and is be- lieved to be practically if not quite identical with bilirubin. It does not contain 204 AMERIC.\N PRACTICE OF SURGERY. iron, is insoluble in water, ether, and alcohol, but soluble in alkalies and chloro- form. It is found more particularly in connection with large hemorrhages, espe- cially when they occur into some cavity. In such cases the blood corpuscles are to a comparatively slight extent acted upon by living cells and the supply of oxygen is relatively scanty. Hsemosiderin occurs in yellowish-brown or brown granules, usually within the cells, but also free in the tissue spaces. It is insoluble in water, and differs from hfematoidin in that it contains iron. This may be demonstrated by Perl's test. If a microscopic section containing this pigment be treated with a three- per-cent solution of potassiimi ferrocyanide and then with a weak solution of hydrochloric acid, tlie iron-containing granules take on a bright blue color, owing to the formation of Prussian blue. If treated with hydrogen sulphide, the gran- ules turn black. Hsemosiderin is formed where the blood cells are exposed in small quantities' to the action of living cells and oxygen. Therefore we find it at the site of small effusions of blood, at the margins of larger ones, in small thrombi, and in organs the seat of chronic passive congestion. Hsematogenous pigmentation arises, in general, wherever there is extravasa- tion of blood. The pigmentation is to be attributed to phj^sical and chemical changes in the red corpuscles when out of their normal environment, resulting in a transformation of the haemoglobin. The extravasation of the blood may be due to injury, thrombosis, rupture of vessels, or degenerative changes in the vessel walls, the result of the deleterious action of mineral, bacterial, or other toxins. After an extravasation of blood the red cells are to some extent broken down, and there is an attempt on the part of the cells of the body to remove the debris. The process appears to be as follows : Some of the imaltered red corpus- cles get back to the circulation by means of the hmiphatics; some fragment and disintegrate into brownish or reddish particles, containing haemoglobin; some, again, lose their haemoglobin, which dissolves out in the plasma, and the albu- minous framework of the cells ultimately' breaks down. Part of the liberated haemoglobin passes in the circulation to the organs of excretion, and is eliminated in the urine as methsemoglobin and urobilin. The remainder, together with the remains of the red corpuscles and other detritus, is picked up by the phagocytes or carried by the l}Tnph to various organs, such as the regional lymph nodes, spleen, liver, and bone-marrow, where it is acted upon by the cells of the part or by the oxygen, and deposited in the form of 3'ellowish or brownish granules. The color changes from black to brown, greenish-yellow, and yellow, as maj^ be observed in the familiar instance of the common "black eye." Here the changes m color furnish an external indication of the chemical transformation which occurs in all such cases. Ultimately, the haemoglobin is transformed into haematoidin, haemosiderin, or both. Similar pigmentation occurs from the destruction of the red corpuscles in the circulating blood. This is met with in such conditions as septic infection, per- DISTURBANCES OF NUTRITION. 205 nicious ansemia, leuksemia, and malaria, in poisoning with certain substances, like potassium chlorate, antipyrin, toluylenediamin, fungi, and some bacterial toxins ; and after the introduction, into the circulation of one animal, of the blood of another of a different species. In such cases the hemoglobin may be lib- erated into the plasma (hcEmoglohinceinia) and excreted by the urine, which thus becomes brownish-red or dark red in color (hcemoglohinuria, inethcemoglo- binuria). Up to a certain point the organs of the body directly concerned in the trans- formation are able to deal with the increased amount of hsemoglobin and its de- rivatives which reaches them, but in some cases so much pigment is liberated that the blood-destroying organs become highly colored, or even the whole body may become affected. This is the case in a curious and rare affection, called by Von Recklinghausen hoemochromatosis, in which hEemosiderin is deposited in all the organs and tissues of the body. We have met with one case of this, in which the skin and mucous membranes were of a dark leaden hue. The condition is associated with fibroid changes in the liver (cirrhosis), pancreas (diabete bronze), or in both. The liver is able to change part of the pigment which reaches it into bilirubin, and excretes it in the bile, but any excess in the amount which it is able to transform is deposited in the various tissues, and gradually eliminated by the kidneys as urobilin. In the liver hajmatoidin is usually deposited in the parenchymatous cells toward the centre of the lobules, while hemosiderin is laid down more at the periphery. In extensive hsemosiderosis the iron-containing pigment is laid down in the interstices of the connective tissue of the portal sheaths as well. In the spleen, lymph nodes, and bone-marrow the pigment is chiefly found in the endo- thelial cells lining the blood-vessels. In the kidneys it is to be found in the se- creting cells lining the convoluted tubules, in the endothelium of the vessels, and in the lumina of the tubules. In another class of cases the pigment is produced in some other part of the body by disturbed metabolism, and is then carried by the lymph stream or by leucocytes to the pigmented part. An example of this is the transferrence of melanin from a necrosing melanotic sarcoma to the spleen, lymph nodes, and kidneys. The pigment may appear in the urine, and casts of melanin are some- times to be found in the kidney tubules. The second main form of pigmentary deposit is the biliary. In certain cases of obstruction to the free excretion of bile, it enters the blood and lymph and leads to a yellowish or sometimes greenish discoloration of the whole body. The pigments of bile are produced in the liver and are derived from the haemoglobin of the blood, hsematoidin and bilirubin being identical chemically. Under nor- mal conditions the bilirubin formed in the liver is passed out in the bile into the intestine, where, after effecting certain changes in the food stuffs, it is in part evacuated with the faeces. Part of it, however, is absorbed through the intes- 206 AMERICAN PRACTICE OF SURGERY. tinal mucosa into the blood. Here it undergoes some transformation, the exact nature of which is quite unknown, Ijut eventually it appears in the urine in the form of urobilin. Any condition which interferes with the free discharge of the bile from the liver and bile passages will give rise to jaundice or icterus. Such causes may be at work in connection with the larger bile passages or within the liver itself. In cases of jaundice not only are all the structures of the body stained with bile, but the bile passes out in the urine, in severe cases causing it to assume a dark brownish color. Obstruction of the bile-ducts may be due to catarrhal inflam- mation of the mucous membrane, impacted calculi, the pressure of adhesions, scars or tumors, abscesses, enlarged lymph nodes, cirrhosis of the liver, and tumors within the liver. In some few cases, as in acute yellow atrophy of the liver, some toxin, apparently of an infectious nature, seems to be at work, with- out gross evidences of obstruction to the outflow of bile. When the obstruction is complete no bile reaches the intestines. Consequently, the faeces become pale and clay-colored and very foul from abnormal fermenta- tion. Intestinal digestion is, of course, interfered with. In bad cases delirium, convulsions, coma, and all the features of a profound toxgemia may supervene. . The obstruction to the discharge of the bile leads to dilatation of all the bile- ducts and of the finer bile capillaries within the liver itself. These latter may rupture and the bile may enter the blood directly. Ordinarily, however, it passes into the lymph channels and gets into the circulation by way of the thoracic duct. The liver cells become pigmented, owing to the impossibility of their getting rid of their secretion. All the organs and tissues of the body assume a yellowish or greenish tinge, and under the microscope solid masses of brownish or yellowish pigment in granular form can be recognized, especially in the lymph nodes, spleen, and bone-marrow. In the more persistent and severe forms of jaundice the various organs may contain bilirubin in solid form, or, rarely, in rhombic or acicular crystals. It should be remarked also that the presence of biliary acids in the blood leads to breaking down of the corpuscles and liberation of the haemoglobin. This increases the work of the liver and provides more ma- terial to be converted into bilirubin. Thus a vicious circle is the result. Besides the obstructive form of jaundice just described, there is another very important type, due to the destruction of the red blood corpuscles in the circulat- ing blood. This may be the result of a variety of causes, the most notable being the infections and intoxications. Among these are septicaemia, yellow fever, in- halation of ether and chloroform, snake bite, transfusion of blood, and the exhibi- tion of toluylenediamin. This form of jaundice was formerly termed hcematogen- ous, under the impression that the bilirubin was produced in the blood. We know now, however, from the experiments of Naunyn and Minkowski, that the liver is essential to the production of bilirubin, so that the more correct nomenclature would be limmo-hcpatogenous jaundice. In such cases there must be an increased DISTURBANCES OF NUTRITION. 207 formation of bilirubin in the liver, and this material then makes its way into the general circulation. How this occurs is not certainly known, but some think that the main factor is a catarrhal inflammation of the smaller bile ducts and capillaries in the liver. Allied to jaimdice is the sallow, earthy tint of the skin found in cases of con- stipation and cachexia. Here, there may be an absorption of urobilin from the intestine into the blood, and a moderate grade of disintegration of the red cor- puscles due to toxaemia. Deposition of Foreign Substances. — Foreign material may enter the body from the external world and be deposited in the tissues. Such substances may reach the interior of the body in three ways — by the skin, by the alimentary tract, and by the lungs. Perhaps the commonest foreign substances introduced through the skin are Indian ink and certain aniline colors employed in the process of tattooing. Some of the introduced pigment in these cases remains in the minute scars that form, while some is carried away and deposited in the nearest lymph nodes, which in their turn become pigmented. Explosions may drive particles of gunpowder, coal dust, or dirt into the skin. The chief substances that enter the system through the alimentary tract are lead, arsenic, copper, and silver. The prolonged exhibition of arsenic leads to a brownish discoloration of the skin. In chronic lead-poisoning the lead is depos- ited in the form of a sulphide along the margin of the gums. Copper leads to a greenish pigmentation of the gums. In former days salts of silver were exten- sively used in medical practice, especially for certain nervous affections. After the prolonged use of silver, the metal, presumably in the form of an albuminate, is deposited in the form of brownish or blackish granules in the tissues, which assume a dark leaden gray color (argyria). The silver is laid down principally in the skin, in the kidneys, in the intima of the vessels, in the serous membranes, and in the choroid plexus of the brain. The inhalation of foreign material leads to a deposit of the inspired substance in the hmgs (pneumonokoniosis) . The most usual pigment thus laid down is coal dust (anthracosis) ; next to that, particles of stone {chalicosis, silicosis) ; and next, iron (siderosis). A variety of other substances may on occasion be depos- ited, as cotton, paper, flour, iron ore, tobacco, ultramarine blue. Wlien any of the substances mentioned are inhaled, a portion of the dust is entangled in the mucous membrane of the nasal passages, and to some extent it lodges in that of the upper respiratory passages, from which localities it is grad- ually eliminated by the secretion of the nose and by the act of coughing. If the amount inhaled be not excessive, this may suffice to get rid of all the foreign matter, but as a rule those who are subjected to such unwholesome conditions are operatives who must continue for prolonged periods breathing impure air. In such cases the ordinary means referred to are ineffective, and the for- 208 AMERICAN PRACTICE OF SURGERY. eign material reaches the lungs. It seems fairly established now that in- haled dust does not reach the alveoli of the lung directly, for physical reasons, and we have to seek some other explanation for the occurrence. If we take, for example, the case of the inhalation of coal dust, as it is met with in coal miners or those who live in smoky cities, we find that the excess of coal dust that cannot be eliminated is deposited on the mucosa of the upper respiratory passages, where it sets up a certain amount of irritation, resulting in cough and slight ca- tarrhal inflammation. Phagocytes are attracted to the part, pick up the pig- ment, and carry it along the lymphatics to the recesses of the lungs, where it is deposited in the alveolar walls, the interlobular septa, and in the lower layer of the pleura. In all cases the process follows the course of the lymphatics. From the lungs the pigment is carried to the peribronchial nodes, which become coal-black in color and gritty. As a result of the ij-ritation produced in the tis- sues by the foreign material, chronic inflammation is set up, with the formation of connective tissue. This results in hardening of the lung, especially along the course of the bronchi and the various septa. Coal dust is relatively innocuous, but other substances, such as iron, steel, or marble, are much more irritating and lead to extensive induration of the lung {chronic fibroid 'pneumonia). In very extensive grades of the affection the lungs may become hard, heavy, and may grate under the knife. The lungs may even be unable to retain the great quantities of coal dust which, reach them, so that the coal reaches the general circulation. This takes place either from the dust passing through the entire thickness of the vessels and mixing with the blood, or from the softening of anthracotic lymph nodes, with discharge of their contents into some large vein. The dust may also get into the general blood stream by passing along the lymphatics. Coal dust may thus in time be deposited in the liver, spleen, or bone- marrow. Welch has described a case in which so much coal was deposited in the liver as to give rise to a form of cirrhosis {cirrhosis anthracotica) . The lungs of new-born and young infants are devoid of this coal pigment, so that its absence, or the amount of it when present, gives us approximate informa- tion as to the length of time a person has lived, and therefore may be of some value in medico-legal cases. The great importance of the inhalation of dust ui connection with the health of workers in certain industrial occupations has led most civilized governments to enact laws looking to the providing of efficient ventilation, and in some cases to enforcing the use of proper respirators. NECROBIOSIS AND NECROSIS. Death of cells may be gradual or sudden in its onset. Necrobiosis (indirect necrosis) is a term coined by Virchow to designate that form of death which comes on slowly, the result of slowly acting causes. Necrosis (direct necrosis) is DISTURBANCES OF NUTRITION. 209 immediate death. Both terms apply to a local condition, in contradistinction to death of the body as a whole — somatic death. In the case of necrobiosis, the death of the part is preceded by some retro- grade metamorphosis, such as atrophy, cloudy swelling, fatty degeneration, mu- coid or hydropic degeneration, or by some pathological infiltration. In direct necrosis, or, as it is usually termed more shortly, necrosis, death is rapid and is not preceded by any pathological changes in cellular structure. It is not always easy to draw a hard-and-fast line between these antecedent degenerative changes and the resultant necrobiosis, or between necrobiosis and necrosis. Still it is well to keep the ideas distinct in our minds. The preceding degenerative proc- esses occur so gradually and are so characteristic in their appearances that it is usually thought better to class them by themselves, and to regard them as the causes or, perhaps more correctly speaking, the precursors of necrobiosis, rather than the necrobiosis itself. Necrobiosis usually ends in necrosis, and for prac- tical purposes may be regarded as an incomplete or slowly progressive necrosis. In a sense the normal retrogression of cells incident to katabolic processes and the renewal of tissue is a physiological necrobiosis. It is not pathological, for it does not interfere with function, the dead cells being simultaneously re- placed by new cells of like kind. It may, however, be, and often is, pathological when it takes place independently of the needs of the organism and leads to more or less fimctional disturbance in the part. The causes of necrobiosis are practically the same as those of necrosis — lack of nutrition, uifections and intoxications, traumatic, chemical, thermal, and mechanical influences. Any of these may act separately, or two or more may be combined. In general, we may say that deleterious agencies of slight grade, acting over prolonged periods, are more apt to produce necrobiosis than necrosis. Necrobiosis may, no doubt, in slight grades, be perfectly recovered from, but many cases go on to complete necrosis. If, for instance, necrobiosis has fol- lowed albuminous degeneration, simple necrosis follows ; if there has been ante- cedent fatty degeneration, soft caseation results; if hydropic degeneration pre- ceded, colliquative or liquefaction necrosis is the consequence. The results of necrobiosis are in most cases those of necrosis, as one might expect. Microscopically, the cells undergoing necrobiosis present, in addition to the retrograde manifestations which may have been there, karyorrhexis of the nu- clei, with more or less karyolysis. This passes on into actual disintegration of the cells. Necrosis, then, is death of a cell or a group of cells while they are still a part of the living body. In a pathological sense it includes all those conditions vari- ously known as gangrene, mortification, sequestration, abscess-formation, ulcer- ation, and caries. By surgeons, however, these terms are not generally used syn- onymously. In surgical parlance "gangrene" and "mortification" are usually taken to apply to death of the soft tissues, while death of bone is usually called 210 AiIERIC.\N PRACTICE OF SURGERY. "necrosis." It should be mentioned also that gangrene, mortification, and sequestration always imply death of a part en masse. Gradual, almost imper- ceptible disintegration, or molecular death, is called ulceration in the case of the soft tissues, and caries in the case of bone. As we do not know what constitutes cell life, the true nature of necrosis, or cell death, is in a large measure a sealed book to us. The exact change in the constitution of the cell which mdicates the passage from life to death, and the time at which it occurs, are beyond our ken. The methods of hardening, pre- serving, and staining tissues in vogue at the present time suffice to give us fairly accurate information as to the state of the cells at the time the tissues were placed in the solutions. Of course the cells are killed by such methods, so that we are always studying dead material ; but what we believe to be normal cells, under such circumstances, appear to be so different from others that we are able to infer, with some approxunation to the truth, that certain cells were dead while still connected with the living body. In all cases, however, we are studying post-mortem or post-necrotic appearances, rather than the changes immediately dependent on the necrosis. The exact chemical changes that underlie necrosis are miknown. Histolog- ically, necrotic cells show mmute changes both in the nucleus and in the cyto- plasm. The nucleus apparently breaks up into fragments (karyorrhexis), a form of disintegration shown by Schmaus and Albrecht to be preceded by a peculiar transposition of the chromatin threads. This gives place to dissolution of the nucleus (karyolysis). The cytoplasm loses its fuier structure, becomes more hyaline and opaque, and possibly vacuolated. Ultimately, such cells may fuse into an indistinguishable, structureless mass or may liquefy. In necrotic cells the nuclei stain badly as a rule, and seem to be fading away. In some instances, however, the nucleus contracts and stains more deeply than normal (pyknosis). Thereupon, the cell disintegrates or fragments, and particles of chromatin are liberated, to be disseminated throughout the necrotic area. As a result of this, the dead tissue, at least in the earlier stages, may stain more or less diffusely blue with hfematoxylin. Finally, the whole of the cellular material is converted into a granular debris. The causes of local death of tissue are very various. They, however, may m their essence be reduced to two — lack of nutrition and direct trauma. Traumatic insults, by crushing or tearing the cells, lead directly to death of the part. Or, indirectly, injuries to the blood-vessels may interfere with the adequate supply of blood to a region, and thus necrosis results. Probably in most instances we have to take into account not only direct influence of the in- jury upon the cells, but also more or less disorganization of the ordinary means of circulation. Wherever the blood supply is absolutely cut off, necrosis is in- evitable. Again, cells which are dislocated from their normal environment are very apt to undergo degeneration and necrosis. Injuries do not always produce DISTURBANCES OF NUTRITION. 211 these effects at the exact spot where the injury has taken place. Thus, a cart- wheel passing over a limb may produce extensive laceration of the soft muscles, while the skin remains intact. Or a crushing injury to the trunk may result in tearing of the liver or spleen without any external manifestations. In such cases, if the patient live, necrotic changes in the damaged structures will super- vene. Again, severe blows upon the head may lead to necrosis of the ganglion cells of the brain. Injury to an artery may be from laceration, pressure, or traction. Should the intima be ruptured, a thrombus forms at the site of injury, with ultimate blocking of the vessel and necrosis of the supplied area. This is often serious, for the tissues are sometimes so deteriorated by the injury that a collateral circu- lation cannot be formed. To be classed with mechanical trauma are heat, cold, and caustics. Tissues subjected to a temperature of from 54° to 68° C. for a short time will undergo necrosis. The effects produced by heat depend on its intensity and the length of time during which it is operative. Take, for example, a limb. The least serious result is an active congestion of the part with slight inflammation (burn of the first degree). If the part be exposed somewhat longer, the super- ficial epidermis is elevated into blisters (burn of the second degree). In this case there is necrosis of the epidermis, which is detached in parts from the underly- ing tissues, owing to the accumulation of serous fluid. The cells may show hydropic degeneration. Or, the destruction of substance may extend below the skin (burn of the third degree) ; finally, the whole structure may be charred (burn of the fourth degree). Heat acts by coagulating the albumin of the cells which come under its influence. Cold has an identical effect, the result depending on its degree and on the length of time the part is exposed to it. Cohnheim produced gangrene of a rab- bit's ear by subjecting it for a short time to a temperature of 16° C. Freezing will produce extensive gangrene, especially in those cases where the circulation is not restored gradually and stasis results. The x-rays produce extensive and very obstinate burns in some cases. This is not the effect of heat, but rather of some influence of the chemical rays, possi- bly, as has been suggested, upon the nerve endings. Caustic substances, acids, alkalies, acid nitrate of mercury, chloride of zinc, will cause death of the structures to which they may be applied. The most numerous cases of necrosis are to be traced to defective nutrition. In this connection interference with the circulation is the most important single factor. The blood supply may be partially or wholly cut off through an injury to the wall of the supplying artery, through thrombosis, embolism, arteriosclerosis, ligature, and pressure of tumors or of inflammatory infiltrations and exudates. The return flow may be obstructed, as from pressure, inflammation, or coagulation of the blood. The capillaries may be occluded from similar causes. Prolonged 212 AMERICAN PRACTICE OF SURGERY. stasis of blood will lead to death of the affected parts. A weakened heart action may be a factor of greater or lesser importance in some cases. Familiar instances of necrosis, due in the main to interference with the circulation, are: bed-sores; the local death which follows too tight bandaging, improperly applied splints, or the pressure of an elastic stocking; gangrene of the intestine from incarcera- tion or from torsion of a part. In the cases of tumors the growth may progress far in excess of its nutritive supply, and gangrene will thereupon follow. To some extent mechanical influences play a part, as vessels may be compressed or twisted in the course of the growth of a tumor. This is seen, for instance, in the necrosis which occurs in the pedicles of pedunculated fibromata and lipomata. Ligation of the principal arteries, when they are healthy and in healthy peo- ple, is attended by little danger of gangrene. The effect of ligation is to rupture the intima of the vessel and thereby to induce thrombosis. The circulation is quickly cut off, but usually sufficient time is given for the establishment of a collateral circulation. Toxic agents of a great many kinds may bring about cell death, either by their direct deleterious action upon the cellular protoplasm or by inducing changes in the circulation. Such substances appear to enter into chemical union with the protoplasm of the cells or intercellular substance in such a way as to render life impossible. The most important are the various bacterial toxins, such as those of the staphylococcus, streptococcus, typhoid, diphtheria, tubercu- losis, and cholera micro-organisms. Some few are derived from forms of animal life. Another class includes toxins which result from faulty metabolism within the body. Thus, uric acid, the biliary acids, the abnormal products occurring in diabetes mellitus, the pancreatic ferments, may, under certain circumstances, give rise to necrosis. Inflammation is not infrequently accompanied by necrobiotic and necrotic changes in the tissues. This is due to a variety of factors. We have, for exam- ple, the effect of stasis, alterations in the composition of the blood, the toxic in- fluences of substances derived from bacteria, and the pressure of inflammatory products. Lastly, necrosis may, according to some authorities, originate in the inhibi- tion of impulses from the central nervous system (neurotrophic necrosis). Prob- ably in such cases the death of tissue results more from interference with the vascular mechanism than from simple cutting off of the trophic influences. Moreover, once the vitality of a structure is lowered, bacteria readily make their way into it and their influence must contribute to the final result. The causes just mentioned may act separately, but not infrequently several are combined in a given case. The amount of necrosis resulting depends upon the nature and intensity of the operating cause, the length of time during which it is effective, and the vitality of the affected part. Tissues with weak resisting DISTURBANCES OF NUTRITION. 213 power, such as are found in conditions of old age, general anasmia, cachexia, and marasmus, may undergo necrosis from a trifling cause. The Forms of Necrosis. — The essential changes in the cell which indicate the presence of necrosis are destruction of the nucleus and more or less disinte- gration of the cytoplasm. These are present in every case. These changes may, however, be so modified by or associated with other processes that we are able to recognize different varieties according to the gross or the microscopical appear- ances presented. The form of necrosis depends upon the position and character of the affected cells, the nature and intensity of the causative agent, and the nature of the neighboring tissues. If the dead cells, for instance, are on the sur- face of the body, where evaporation can take place, the cells become inspissated and the part dry and mummified. If there be an abundant supply of fiuid, the cells become hydropic and the part may liquefy. Again, the conditions may be favorable for the coagulation of lymph and the formation of fibrin, either in the cells or in the intercellular substance. Finally, the character of the necrosis may be modified by the occurrence of inflammation and the presence of putrefactive bacteria. The line of demarcation between these various forms cannot, however, be always closely drawn. One form frequently passes imperceptibly into another. We may, however, recognize the following forms of necrosis, which are fairly well to be differentiated the one from the other : (1) Simple necrosis. (2) Coagulation necrosis. (3) Colliquative necrosis. (4) Dry gangrene, or mimnnification. (5) Moist gangrene. (6) Caseation. (7) Fat necrosis. Simple Necrosis. — In this form of necrosis the characteristic features are the disappearance of the nucleus, with hyaline or granular changes in the cellular protoplasm. The cells are often somewhat enlarged, but their general outline is well preserved. Occasionally, the cells seem hyalme and homogeneous. So far as gross appearances are concerned organs so affected are yellowish or grayish in color and diminished in consistency. The condition seems to be an advanced stage of cloudy swelling. It may affect any tissue, but is most commonly found in the specific epithelimn of secreting organs. The liver and kidneys are very fre- quently attacked in cases of infection or intoxication. Thus, the cells lining the contorted tubules of the kidney often show marked necrosis in cases of mineral poisoning and in the cachexia of carcinoma. Large, irregular, necrotic areas of yellowish color are often met with in the liver in cases of appendicitis where in- fection has extended into the portal vein. The so-called "self-digestion" of the pancreas, described by Chiari, presents an accurate picture of simple necrosis, but is in most cases, if not in all, a post-mortem phenomenon. Gastric ulcers and the local necroses following severe binns are probably to be included in this category. The so-called "focal" necroses demand a word or two. These are small local foci of cellular death found in lymph nodes and in the various parenchymatous 214 AMERICAN PRACTICE OF SURGERY. organs, the result of the presence in the blood of bacteria or their toxins. The condition was first observed by Oertel in diphtheria, but is met with in other affections, notably in typhoid, tuberculosis, and in the liver in puerperal eclamp- sia. It has been produced experimentally by the injection of the toxins of diph- theria, of ricin, abrin, and of vegetable toxalbumins. Capillary thrombosis may to some extent aid in the process, but the bacteria or their toxins are believed to be the chief causative factor. Coagulation Necrosis. — There are several forms of necrosis which have con- siderable similarity, so far as superficial appearances are concerned. These are simple necrosis, coagulation necrosis, hyaline degeneration, and caseation. They all are characterized by destruction of the cells and the production of a hyaline or granular structureless detritus. By many simple necrosis is described as co- agulation necrosis. It is perhaps better to reserve the latter term for that form of cell death in which there is a production of fibrin or fibrin-like material (fibri- noid degeneration). That there is such a form of necrosis may be readily demon- strated by the use of Weigert's fibrin stain. Coagulation necrosis occurs only in tissues rich in albuminous substances, and, theoretically, will result whenever, owuag to the cell destruction, fibrin ferment is liberated to combine with the fibrinogen which is present in the lymph. The process is believed to be prac- tically identical with that of coagulation of the blood and the formation of a thrombus. Two forms may be distinguished — intercellular and intracellular. In the former, fibrin is formed between the dead and dying cells. This fibrin may be laid down in the form of threads, granules, or hyaline-looking masses, along with which may be recognized the debris of the original cells. The diphtheria mem- brane may be taken as the type of this form of necrosis, which affects most commonly mucous and serous surfaces (diphtheritic, croupous, or membranous necrosis). All forms of inflammation of mucous svu'faces, associated with the formation of a membrane, are commonly referred to as diphtheritic, but this is somewhat confusing. It is better to restrict the term diphtheritic to diphtheria — that is to say, inflammation due to the Klebs-Loeffler bacillus — and to speak of the other forms as diphtheroid. Focal necroses in the mternal viscera are not in- frequently coagulation necroses, and there is also quite often a formation of fibrin in tubercles. Infarction less frequently gives rise to the production of fibrin. Superficial burns, if extensive, produce areas of coagulation necrosis in the spleen and lymph nodes. The second variety of coagulation necrosis is characterized by the transfor- mation of the parenchymatous cells of an organ or tissue into a solid or semi- solid albuminous substance more or less like fibrin. As an instance of this we may take the so-called vitreous, waxy, or hyaline degeneration of striated mus- cle, known as Zenker's necrosis. This condition is fornid most often in prolonged fevers, such as typhoid, in some anamic infarcts, in muscles which have been DISTUEBANCES OF NUTRITION. 215 subjected to heat or cold or to the influence of toxins, or which have been torn across. In the fevers the abdominal recti, the adductors of the femur, and the ilio-psoas are the parts most often affected. Muscles so affected are semitranslucent and of a pearly-white or grayish color somewhat resembling raw fish. Microscopically, the muscle fibres are swol- len, have lost their striations, and have a hyaline, homogeneous appearance. The exact nature of the process in these cases is somewhat doubtful. Fried- reich, Weigert, and others, look upon it as a coagulation of the muscle plasma; others, as an inspissation of the albuminous constituents. In a few cases coagu- lation necrosis may result from the imbibition of fibrinogen-containing fluids and their subsequent coagulation within the cells. Colliquative Necrosis. — In colliquative necrosis or liquefaction the dead ma- terial undergoes softening and to some extent solution. It occurs as a primary change or secondarily to some other form of necrosis. Colliquative necrosis usu- ally occurs in tissues freely supplied with lymph and containing but little of the fibrin-forming substances. It therefore is found most often in the skin and cen- tral nervous system. Ansemic necrosis of the brain and cord is always associated with softening. The destroyed nerve-material is converted into a soft detritus, consisting of fragments of cell chromatin, droplets of myelin, and fat, which gradually become dissolved in the lymph. The necrotic material is often colored from the admixture of blood or blood pigment (red softening, yellow softening). In such cases absorption of the dead material may take place, with, if the area is small, the formation of a cicatrix. Larger patches of-softening become enclosed in a fibrous capsule, and a certain amotmt of the detritus is absorbed, resulting in the production of a cyst filled with clear fluid. The softening that occurs in thrombi and in the walls of atheromatous vessels is an example of this form of necrosis. Liquefaction is also not uncommonly found in tumors. Primary colliquative necrosis is well seen in burns of the second degree, the first stage of vesication being an outpouring of lymph and a hydropic degeneration of the epithelial cells in the deeper layers of the skin. Liquefaction necrosis may be secondary to simple or coagulation necrosis. Fibrinous exudates, as in pleurisies and in pneumonic lungs, in the later stages imdergo softening, which is an important factor in the process of resolution. Areas of moist gangrene and caseation may imdergo liquefaction. In abscesses liquefaction is a constant feature. Here, not only do we have the effects of the abundant outpouring of lymph, but we have the digestant action of ferments derived from infective bacteria. Conversely, coagulation may follow liquefac- tion, the fibrin-forming substances being derived from the leucocytes. Histologically, areas of colliquative necrosis show, in addition to actual de- struction of the cells, vacuolation, clear spaces between the cells, and a stringy detritus. Caseation. — Caseation is a term applied more or less loosely to designate that 216 AMERICAN PRACTICE OF SURGERY. form of death of tissue which is characterized by the production of material somewhat resembling cheese. It is to be regarded probably as a post-ne- crotic change rather than as a form of necrosis. Simple and coagulation necrosis and moist gangrene may be followed by caseation. Caseation is fomid typ- ically in certain of the infectious granulomata, notably tuberculosis. Somewhat similar changes occur in gummata and in actinomycosis, and occasionally in tumors. Caseous foci are opaciue, grayish-white or yellow, more or less fu-m and granular, and are cheesy in consistence. If they are hard and dry, we speak of the process as fhm or hard caseation; if the imbibition of fluid has occurred, we speak of it as soft caseation. Microscopically, we find more or less extensive areas in which the normal out- FiG. 70. — Caseation (Tuberculous) in the l.uni;. i /,. //; nhj. No. 3.) Area of caseation to the right; the blood-vessels injected to show the avaseularity of the necrotic part. {From the author's private collection.) lines of the cells and tissues are lost, the cells in various stages of disintegration, with liberation of their nuclear chromatin. In the larger areas the central por- tion is converted into a structureless, granular mass, consisting of cellular de- bris, fat, and sometimes calcareous salts. In some cases fibrin is present. In the case of tuberculous caseation, it is believed that the necrotic change is due in part to obstruction of the nutrient blood-vessels, and in part to the influence of the toxins produced by the bacilli (see Fig. 70). Somewhat similar caseation is occa- sionally observed in certain non-tuberculous inflammatory exudates in the lungs. Caseous foci may be completely absorbed and cicatrized. They may soften or become calcified. Allien they tend to heal they become in time surrounded by a fibrous capsule. Fat Necrosis. — This is a curious form of necrosis of considerable mterest to DISTURBANCES OF NUTRITION. 217 the surgeon. In the vast majority of cases fat necrosis is associated with some lesion of the pancreas, such as pancreatitis, although Fitz holds that it may oc- cur in the absence of pancreatic disease. Experimentally it has been produced by the injection of pancreatic extract into adipose tissue, the introduction of certain substances into the pancreatic duct, ligation of the pancreatic vessels, the introduction of pieces of pancreas into fatty tissues or into the peritoneal cavity, and by the action of steapsin upon fat. The necrotic areas vary in size from that of a pinhead to a pea, are opaque, grayish, yellowish, or sometimes black in appearance. They are usually sharply defined, and on section are soft or gritty. Such areas may be found in the pan- creas, in the peripancreatic fat, in the omentum, and also occasionally in the fat of more distant regions, such as the pericardium, liver, bone-marrow, and retro- peritoneal tissues. In some cases the pancreas itself may be free. Microscopically, the parts so affected show that the fat cells are enlarged and the nuclei absent. The cellular substance is granular or presents the appearance of fine needles radiating from the centre. Osmic acid does not stain the necrotic material, while it tinges the healthy fat black or brown. The areas of fat necrosis may liquefy or become calcified. The condition usually ends m the death of the patient, but it may be recovered from. Extensive fat necrosis may be associated with diffuse hemorrhage into the pancreas or with sequestration of large portions of this organ. The researches of Hildebrand and Flexner have shown that fat necrosis is due to the liberation of the fat-splitting ferment of the pancreas. This acts upon the neighboring fat to produce fatty acids, which ultimately miite with the cal- cium salts. Gangrene. — Gangrene, or necrosis of the soft parts, is a term somewhat loosely employed by surgeons to designate certain peculiar changes which occm- in dead tissues. The leading featiu-es of gangrene are that the tissues die in bulk, and that this death is accompanied b}^ putrefactive changes in the affected area. A number of other terms are used also at times to express more or less com- pletely the same imderlying idea — mortijication, putrefaction, putrescence, sphace- lation. Gangrene may be primary or secondary. In primary gangrene the condition is due to the direct action on the tissues of a micro-organism having certain pe- culiar powers, and is to be regarded as a specific infection. In secondary gan- grene the necrosis is due to some other cause, and the affected part is subse- quently invaded by putrefactive bacteria. The etiological factors at work in the causation of gangrene are somewhat varied. The most important single cause is obstruction to the arterial blood sup- ply of a part. Traumatism, or certain toxic agents, or, again, bacteria, may lead to death of a part by direct local action. Other cases are neuropathic in origin. Primary gangrene includes a number of specific affections, such as infection 218 ajmerican practice of surgery. with the B. Welchii, B. oedematis mahgni, B. diphtherise, B. anthracis, B. coh, and some other imperfectly kno-n-n organisms. Under certain circumstances these germs have been known to set up severe local inflanunation followed by gangrene of the part. They appear to be competent to produce gangrene b}^ their un- aided action, but in some cases there may be a combined or secondary infection with putre- factive micro-organisms. On occasion, they may be implicated in the causation of second- ary gangrene. Secondary gangrene is much the more com- mon -^-ariet}'. The original necrosis may be due to vascular disturbances, alterations in the com- position of the blood, pressure, the influence of thermal, chemical, or physical agents, infection, or neuropathic disturbances, the process being characteristically modified by the subsequent entry of parasitic and saprophj^tic micro- organisms. Anatomically we may recognize two main varieties of gangrene — dry gangrene or mummi- ficatioti, and moist gangrene. Both forms are essentially the same, any differences being due to varymg physical conditions. Both are forms of necrosis and both are accompanied by putrefactive changes. Many different forms of gangrene are de- scribed. They may be classified according to etiology, according to their clinical coiu'se, or according to their distribution. According to causes of origin we have : (1) Gangrene from vascular obstruc- tion, (2) traumatic gangrene, (3) inflammatory and infective gangrene, (4) neuro- pathic gangrene, (5) "idiopathic" gangrene. According to the clinical coui'se we may recognize: dry gangrene (Fig. 71), moist gangrene, emphysematous gangrene, putrid gangrene, circumscribed, dif- fuse, spreading, or phagedenic gangj-ene. According to distribution may be differentiated: localized (Fig. 72), multiple, metastatic, S3mimetrical gangrene. Most writers on systematic surgery do not adhere exclusively to any of these modes of classification, but describe the most striking clinical types on then- merits without much reference to the above considerations. It is better, how- ever, to have some logical method. Fig. 71. — Dry Gangrene of the Foot. DISTUEBANCES OF NUTRITION. 219 Among the different forms of gangrene there is only one concerning which we shall take the liberty of making a few remarks — viz., noma. Presumably all the different forms will receive full consideration in the article on Gangrene which is to appear in a later volume. Noma. — Noma (cancer aquaticus, Wasserkrebs) is a particularly rapid and fatal form of gangrene, which usually attacks the face or the pudenda. It is found without exception in debilitated or cachectic children, generally between the ages of two and twelve, and usually attacks those who are already suffering from one of the acute infective fevers. Rarely, it may arise inde- pendently, or as a sequel of acute ulcerative stomatitis. Noma of the face begins usually in the buccal mucous membrane near the angle of the mouth, occasionally in the gums. The affection first makes its appear- ance as a livid, swollen patch. Small vesicles form and the tissues present a grayish-yellow inflammatory in- filtration, which rapidly breaks down and becomes gangrenous. The proc- ess quickly spreads to the "skin of the cheek, so that the whole thickness of the cheek is converted into a black- ish, necrotic substance, about which the tissues are markedly infiltrated and oedematous. (See Fig. 73.) No proper line of demarcation, in the or- dinary acceptation of the term, is formed. The gangrene is usually "unilateral, but may extend to the opposite side and even attack the bones of the nose and jaw. At the vulva the process usually commences at the margin of the labia, and may eventually spread to the clitoris, nymphte, hymen, and urethra. It may even invade the perineum, anus, thigh, and mons veneris, and, like noma of the mouth, seems to have a tendency to penetrate deeply and attack the bone. Noma may be attended with high fever, chills, and great prostration, but the special symptoms are not infrequently masked by those of the previously exist- ing disease. The condition is exceedingly fatal, and the patient usually sinks into a state of profound prostration and rapidly succumbs. Noma of the mouth is said to be occasionally complicated by gangrene of the lungs and enterocolitis. Fig. 72. — Gangrene of the Appendix Vennformis in Acute Appendicitis ; Concretion. (Pathological Museum, McGill University.) 220 AMERICAN PRACTICE OF SURGERY. The affection appears to be almost certainly of infectious nature. It not in- frequently occurs in epidemics and affects parts that are particularly exposed to the action of micro-organisms. The specific cause, if there be one, has not been demonstrated as yet. A bacillus, resembling that of diphtheria, has been de- scribed by Bishop and Ryan and by Schimmelbusch, but is not invariably present. Babes and Zambilovici have isolated from some cases a pathogenic micro- organism capable of mducing gan- grene when injected into rabbits. Ranki and Lingard have also de- scribed a germ which the}^ believe to be specific. Necrosis of Bone. — Death of bone occm's imder two forms — ne- crosis and caries. Necrosis is death of bone en 7nasse, and is analogous to gangrene of the soft tissues; caries is a gradual and almost im- perceptible disintegration of bone into fine particles, which may be compared to ulceration. Necrosis of bone may be due to inflammation, traumatism, interfer- ence with the circulation, thermal or chemical agents. Occasionally the death of the bone substance is direct, but in most cases there is obstruction to the afferent blood supply, however it may be produced. To this we must add in some cases the disintegrating action of bacterial toxins. Necrosis of bone can, in rare instances, be attributed to embolism. The circulation is under normal circumstances fairly active, and should a nutrient artery become blocked, a collateral circulation is readily established. In the few instances where necrosis has followed embolism, the smaller arterioles and capillaries have been obstructed. We occasionally see, in cases of tuberculosis of the long bones, wedge-shaped areas at the ends, having the base of the wedge directed toward the articular surface. This suggests infarction, a view which is strongly corroborated by the experiments of Mueller. It has been showTi, too, that the articular surfaces are supplied by terminal arteries, so that the possi- bility of the occurrence cannot be denied. Volkmann met with an instance of multiple necrosis of the tibia and astragalus in mitral endocarditis. In such a case we probably have to do with multiple capillary emboli. These emboli may be simple or infective. Simple necrosis or an abscess may thus result, or what was at first a simple necrosis may be converted into one of a suppurative or tuberculous nature. Fig. 73. — Noma or Canerum Oris. T. Bazin.) {Case of Dr. A. DISTURBANCES OF NUTRITION. 221 Bones receive their nourishment through numerous freely anastomosing ves- sels situated in the marrow and periosteum.. These are connected with small vessels in the Haversian canals, so that an abundant supply of blood is furnished to every part of the bone. Anything, then, which damages the medulla or peri- osteum, or which obstructs the circulation within the bone itself, may give rise to necrosis. Mere separation of the periosteum does not appear to be competent to produce necrosis, but if the sm-face of the bone be laid open to the external air, or if there be a suppurative process which has extended to the Haversian canals, necrosis will follow. Necrosis, then, may result from suppurative peri- ostitis, osteitis, or osteomyelitis, or from analogous tuberculous or syphilitic lesions. All these conditions, it will be observed, result in compression of the blood-vessels from inflammatory exudates, and may lead to thrombosis or to endarteritis. Suppuration or ulceration of adjacent parts may also extend to the periosteum, and so give rise to necrosis of the bone. Traumatism may produce necrosis, provided that it be of such a nature as to cause the separation of portions of the bone from their natural attachments. If a bone be splintered, the minuter fragments may in time be absorbed. Larger ones may become reunited, provided that the wound remain aseptic, as has been shown experimentally by Oilier, Bergmann, and others. This has an important bearing on the surgical procedure of transplantation of bone. Experiments have proved that detached pieces of bone may be successfully transplanted from one part to another, and even from one animal to another, if suppura- tion do not take place. This does not invariably hold good, for Winiwarter observed total necrosis of the bone to take place in two cases of subcutaneous dislocation of the astragalus, in spite of careful reposition of the parts. Where the bone is extensively crushed, vessels are lacerated or compressed by portions of misplaced bone or blood-clot, and necrosis therefore readily takes place. A good example of necrosis resulting from toxic or chemical agents is the phosphorus necrosis. This is met with in people employed in the manufacture of phosphorus matches, and is due to the injurious action of the phosphorous vapor. Phosphorus necrosis is not so common as it used to be, owing to the more extensive introduction of other kinds of matches and the stricter enforce- ment of hygienic measures. Phosphorus necrosis affects usually the lower jaw, less often the upper. Lack of attention to the cleanliness of the mouth, and the presence of carious teeth, predispose to the condition. The disease usually begins, as Wegner has shown, with inflammation of the periosteum, which, under the stimulating in- fluence of the phosphorus, takes the form of a hypertrophic or productive peri- ostitis. Subsequently, owing to the action of micro-organisms, infection takes place with the production of suppuration and secondary necrosis between the periosteum and the new bone or between the new and the old bone. Rarely, the 222 AMERICAN PRACTICE OF SURGERY. disease begins more acutely without the preliminary h}^perostosis. In time the whole of the lower jaw may become necrotic. The Mechanism of Bone Necrosis. — \Mien a portion of a bone dies, it is grad- ually separated from the living tissues and may in time be completely separated or exfoliated. This process is called sequestration, and the separated bone a se- questrum. Sequestration results from a process kno^m as lacimar resorption. The ordinary breaking do^\Ta of bony substance takes place through the agency of certain large cells called osteoclasts (mj-eloplaxes). These are situated in the bone marrow and the deeper layers of the periosteum, and erode their way into the bone, giving rise to minute excavations, known as Howship's lacunse. In the pathological conditions of bone under consideration, these osteoclasts are greatly increased in numbers and lie closely packed together. Therefore, rarefy- ing osteitis, as it is called, leads to rapid destruction of the dead material, and may succeed, in the case of the smaller fragments, in completely removing it. The process of lacunar resorption begins at the line between the living and the dead material, and results in the formation of a line of demarcation. The peri- osteal surface of the sequestrum often remains smooth, while the margins are rough and uneven. The process proceeds centripetalh^, resulting in the loosen- ing of the fragment and a more or less marked diminution in its size. Inas- much as the dead bone is to all intents and purposes a foreign substance, there is a certain amotmt of reactive inflammation in the neighborhood which tends to hasten the process. If, as is so often the case, the necrosis be due to inflamma- tion, we may have the formation of pus, which accumulates in and about the se- questrum and in time makes its way to the surface of the body. In this way communication is established between the site of the necrotic process and the external air (sinus, fistula, cloaca). Through such fistulse portions of the dead bone, if lying free upon the surface of the bone, may make their way to the ex- terior and be cast off, and healing will in many cases result. Sequestra, however, which lie in the interior of the bone, if not absorbed, remain incarcerated unless removed by operation. Coincidently with the separation and removal of the dead material, in cases where repair is possible, there is an attempt at the restoration of the damaged part through reactive bone formation. The osteophytes of the periosteum are stimulated to increased activit}^, so that a capsule of newly formed bone is pro- duced around the sequestrum (involucrum). This is particularly well seen in cases of total destruction of the shaft of a long bone, where a complete new diaphysis may be developed from the inner layer of the periosteum, which gradually restores the continuity and configuration of the bone to such a degree that eventually no deviation from the normal can be detected. This formation of new bone is most marked in the case of young and vigorous subjects. Where a suppurative in- flammation is going on, pus may escape from the cavity through the fistula). If it be pent up, however, it may in its turn lead to further necrosis, even of the DISTURBANCES OF NUTRITION. 223 newly formed bone. In long-standing cases, where the power of repair is very marked, the inflamed bone in the neighborhood of the necrotic part becomes hard and eburnated (sclerosing osteitis). Sequestra may be divided, according to their situation, into external, or pe- ripheral, and central. The variety termed by Blasius "necrosis tubulata" is very rare. The chief characteristic is a tubular sequestrum, the internal axis of which is formed of living bone connected with the old bone. Dead bone is dry, light, devoid of fat, and of a whitish color, owing to anae- mia. It may be porous or, on the other hand, sclerosed. ULCERATION AND CARIES. Closely allied to the conditions we have been describing, and, from the pa- thologist's standpoint, practically identical with them, are ulceration and caries. The terms gangrene and necrosis connote, as we have pointed out above, the idea of death of tissue in bulk ; ulceration and caries, as these names are ordina- rily employed, signify death by the more gradual process of molecular disintegra- tion. Authorities differ radically in their ideas as to what constitutes an ulcer. Billroth defines it as "a loss of substance, with no tendency to heal." Golding Bird holds it to be "a limited area of granulation tissue on the surface of the body." To my mind both definitions are defective, in that they are not suffi- ciently comprehensive, while to a great extent they are mutually exclusive. An ulcer is none the less an ulcer because it is healing, and, in fact, we are constantly hearing the term "healing ulcer." The second definition is too restricted, inas- much as it excludes all ulcers which are not granulating, such as phagedenic and the so-called "croupous" ulcers. Pathologically speaking, we cannot very well separate the condition known as a granulating wound from a healing ulcer, but in the surgeon's mind there is nevertheless an underlying thought which distin- guishes ulcers from all other superficial losses of substance. This appears to be the idea of erosion. Perhaps we can come very near to what is usually meant by the term "ulcer," if we define it to be a superficial loss of substance of the skin or a mucous membrane, which at some or other has shown a tendency to enlarge its boundaries. This definition would include those cases excluded by the other definitions referred to, and would exclude healthy granulating wounds resulting from traumatism, while it is at the same time non-committal on the question of etiology. Ulceration is the process by which ulcers are produced. Etiology.— VlceTS may be brought about by a great many different factors, which may operate singly or in combination. We may consider the subject con- veniently under the headings of (1) predisposing causes and (2) exciting causes. Predisposing causes are general or local. General Predisposing Causes.— Age is of no great importance in determining 224 AMERICAN PRACTICE OF SURGERY. the frequency of ulceration. One might expect that ulcers would be relatively more common in those past middle life, considering the prevalence of retro- gressive changes m such persons; but this, in a sense physiological, tendency to ulceration in the aged is more than counterbalanced by the frequency of tuber- culosis and syphilis in the yoxmg and middle-aged, and of traumatism in the active period of life. Tlcers are said to be three times more prevalent in men than in women. This is probably due to the greater liability to traumatism in the case of males, lack of cleanliness, and the ravages of alcohol and syphilis. All occupations which expose to trauma and promote dirt would, of course, predispose. Many constitutional diseases and those which lower vitality tend to invite ulceration. Diabetes, gout, anaemia, scurvj^, tuberculosis, and syphilis are im- portant in this connection. General obesity and disturbances of the cardio- vascular system have also to be mentioned. Local Predisposing Causes. — Of these, perhaps the most important is im- paired circulation. Atheroma of the arteries, embolism or thrombosis in the arteries, veins, or capillaries, often lead to ulceration by cutting off the nutrition of the part. Small areas of ischsemic necrosis may be converted into ulcers. Stasis in the venous circulation, especially if accompanied by oedema, is a potent factor in bringing about ulceration. Thus, ulcers form on the extremities in ob- structive valvular disease of the heart and varicose veins. In what way ulcers of the lower part of the leg should be connected with varicose veins has been a matter of debate. Varicose veins do not inevitably lead to ulceration, so that some other factor must play a part. Some find the connectuig link in gout; others in a local nem^itis. Probably it is more correct to find it in the phlebitis and periphlebitis which so often come on in the case of varicose veins, while from the superficial position of the lesion infection from the skin is readily brought about. Rupture of a vein with extravasation of blood into the sur- rounding tissues might cause ulceration in one whose tissues possessed a low re- sisting power. Generally, too, these conditions occur in the obese, in whom the circulation is feeble. Obstruction to the lymphatic circulation may also lead to ulceration. This is seen occasionally in cicatricial closure of the lymphatics of a part after opera- tions and in elephantiasis. Trophic disturbances in the central or peripheral nervous system may also be provocative of ulceration. Exciting Causes. — These are direct and local in their character. Chief among them should be mentioned traumatism of all kinds, various forms of in- fection, caustics and other toxic substances, and malignant disease. Traumatism. — One of the most common direct causes of ulceration is injury in some form or other. The effect of an injury will, of course, depend upon the nature of that injury and the character of the part affected. Thus the skin era DISTURBANCES OF NUTRITION. 225 mucous membrane may be destro3^ed by a contusion, laceration, the operative removal of substance, by friction or by a burn. In many cases healing will begin immediately and will progress by the formation of healthy granulations. If, how- ever, infection should be superadded, or should it have existed from the begin- ning, the womid may take on unhealthy action and tend to spread by molecular disintegration. On the other hand, a much slighter injury, occurring in a person of lowered vitality or in one the subject of constitutional disease or poor circu- lation, or with deranged nervous mechanism, may be followed by ulceration. Besides sudden losses of substances mechanically produced, we have to men- tion ulceration resulting from pressure, extreme heat or cold, x-rays and caustics. Pressure, either from within or from without, if continued for a length of time, may produce ulceration, partly by the direct action on the cells and partly by cutting off the nutrition. Bed-sores, ulcers from improperly applied splints or orthopedic apparatus are well-known instances of this. Pessaries or other for- eign bodies m the vagina, calculi in the urinary bladder or the biliary passages, impacted fseces and fecal concretions in the appendix and bowel, hard substances introduced into the nasal passages, not infrequently cause ulceration. Deposits of various salts beneath the skin, as in cases of gout, tumors growing from below into the skin or a mucous membrane, the filaria medinensis or guinea-worm, lead to ulceration of the skin. In badly-performed amputations the flaps may ulcerate from pressure of the end of the bone or from too tightlj' drawn sutures. Caustic substances, such as acids, alkalies, and certain acid salts, act by di- rectly killing the part to which they are applied. Unless their effects are cjuickl}' neutralized, the cells for a considerable distance outside of the direct field of action may suffer in vitalit)^ and subsecjuently die, thus leading to a spreading ulcer. Infection. — Theoretically it is possible to conceive of ulceration in the ab- sence of infection. Practically, however, since ulcers are found in the skin and mucous membranes — in other words, on the surfaces of the body which are ex- posed to the attacks of micro-organisms — ulceration and infection ahva3's go to- gether. The infecting agents act by converting what would otherwise be a gran- ulating or healing lesion into one of a disintegrating and destructive character. The germs at work aie usually the ordinary pj^ogenic or saprophytic organisms. In an analysis of one hundred cases of ulceration of the leg, Bukovsky f omid the B. pyocyaneus most frequently present. Other germs were staphylococci, strepto- cocci, B. coli, B. proteus, and B. Friedlanderi (one case), besides a few other relatively unimportant forms. Of course there are several forms of ulceration due to specific micro-organisms, — forms which are not represented in this analysis, and which usually receive separate consideration, such as syphilis, tuberculosis, actinomycosis, Madura foot disease, glanders, leprosy. Rapidly spreading ulcers, termed phagedcenic, are due to a particularly virulent infection 226 AMERICAN PRACTICE OF SURGERY. in the case of a debilitated subject. Of this type are the hospital gangrene and the phagedsena which attacks venereal sores. We have to bear in mind that infection may be the primary cause of ulcera- tion, as in the specific diseases just referred to, in typhoid, and in chancroid, but not infrequently it is superadded to necrosis originating in another way. Thus traumatic losses of substance may become secondarily infected. Certain skin diseases, such as herpes, eczema, ecthyma, and pemphigus, if situated in parts of the body which are subjected to friction and imperfectly cleansed, often lead to infection and intractable ulceration. The eczema that so often accom- panies varicose veins is an instance of this. Ulceration may also be produced on mucous surfaces by the direct action of organisms like the B. typhi, B. dysenterite of Shiga, B. diphtherise, Amoeba coli, and the Plasmodium of malaria. Parenchymatous inflammations, when not progressing satisfactorily toward healing, may result in ulceration. A good instance of this is seen in the some- what common event of an abscess making its way to the surface of the body, or "pointing," as it is called. An abscess is a deep-seated focus of suppurative in- flammation. The tissues disintegrate and there is formed a cavity filled with pus. This tends to increase in size in the direction of least resistance. The effect of the pus is to produce, first, pressure, then distention and stretching, and, eventually, molecular disintegration of the structures which bar its way. Finally, in favor- able cases, the pus reaches the surface of the body or is discharged into some hollow viscus. In this way healing is not infrequently accomplished. The process in question may properly be regarded as an ulcerative one, inasmuch as there is a molecular death of tissue which tends to spread. In some cases the nature of the infection is such that healing does not take place, except by the aid of art, or else the whole track of the suppurative process becomes specific- ally infected and a more or less permanent external ulceration results. Syphilis in all its stages is a potent cause of ulceration. The chancre is usu- ally ulcerative in character and is an example of ulceration from a primary in- fection. In the secondary stage mucous patches and the various cutaneous lesions may in weakly and uncleanly individuals be converted into ulcers. The most typical syphilitic ulcer is, however, found in the tertiary period in the breaking-down gumma. Tuberculous ulceration is found both in the skin and in the mucous mem- branes. Thus, we may have primary infection of the tongue, fauces, larynx, bronchi, stomach (rarely), and intestines. The skin also may be directly in- vaded by the tubercle bacilli. Again, botli skin and mucous surfaces may be infected secondarily through the blood, or a tuberculous abscess may extend to the surface and there discharge, forming a more or less intractable ulcer. Tu- berculous ulcers are usually indolent, with irregular, thickened edges and uneven base. The discharge consists of caseous detritus and, usually, pus. DISTURBANCES OF NUTRITION. 227 In the case of glanders, soft nodules form in the mucous membranes, such as that of the nose, or under the skin, and these nodules break down, forming irregular ulcers which discharge a glairy pus. The adinoviyces bovis and actinomyces of Madura foot disease give rise to similar lesions, inflammatory granulomata, which, oAving to secondary infection, soften and suppurate, and when near the surface often discharge externally, forming ulcers. The ulceration so characteristic of leprosy is due either to breaking down of lepra nodules, to neurotrophic disturbances, or to the antesthesia produced, which renders it impossible for the patient to perceive and avoid injury. Toxic Ulceration. — Certain drugs in the course of their elimination through the emunctories may set up inflammation and, finally, ulceration. Such are mercury, which produces ulcerative stomatitis, gingivitis and colitis; and phos- phorus, which causes ulceration of the buccal mucous membrane. Ulceration in Tumors. — Benign tumors may undergo necrosis and ulceration. This occurs when the tumor is so large that its nutrition is impaired, or when its pedicle is kinked or twisted, thus interfering with the blood supply. Large pe- dunculated fibromata and lipomata not infrequently undergo ulceration. In the case of the lipomata, owing to the liberation of fatty acids, very foul ulcers are produced. Malignant tumors, carcinomata and sarcomata, regularly break down, and, if on the surface of the body, ulcerate after they have attained a certain size. Good examples of this are found in the epitheliomata of the skin and mucous membranes, rodent ulcers, chancroids, and melanotic sarcomata. Secondary malignant growths may extend from the deeper parts to the skin and mucous surfaces, and then undergo necrosis. The Locality and Distribution of Ulcers. — In general, ulcers are apt to be found in those parts of the body which are exposed to injury or infection, and in which the circulation is poor. Therefore we find them on the uncovered por- tions of the body, at the orifices, in the mucous membrane of the alimentary tract, and on the extremities. Those due to metastatic infection, carcinosis, or sarcomatosis, are usually multiple, and may, of course, develop anywhere. Ulcers are, therefore, common on the cornea, at the junction of the skin and mucous membranes, as, for example, at the angles of the mouth and at the anus, on the nipples, in the stomach, intestines, the urinary and biliary passages. The Pathology of Ulceration. — The pathological process at work in ulcera- tion is in the main the same in all cases, although it differs in minor details ac- cording to the causative factor. There are two opposing forces in operation : First, disintegration of tissue ; and secondly, in most cases a more or less perfect attempt at repair, which manifests itself after a variable period. All cases are accompanied by the phenomena of inflammation. We may recognize two great classes of ulcers — one in which the destruction of tissue is the direct result of cir- 228 AMERICAN PRACTICE OF SURGERY. culatory disturbance or trauma, to which an inflammatory process is subse- quently superadded; the other in which inflammation is the primary cause of the cellular disintegration. The first class of cases, which are pathologically and etiologically related to atrophy and degeneration, is represented by the ulceration which is produced by ischsemic necrosis and gangrene, passive congestion and oedema of tissues, contusions, the pressure of tumors or surgical appliances. The second class of cases includes such conditions as the ulceration which re- sults from infected wounds, diphtheritic inflammation, and the specific granu- lomata. Owing to the great variety of the causes that produce ulceration and the dif- ferences in the local reaction, it is impossible to give one description which will apply to all cases. It will therefore be better to indicate the chief types. We may classify ulcers according to their etiology or according to their appearance and clinical course. According to etiology we can recognize traumatic ulcers, ulcers from stasis, inflammatory, gouty, scorbutic, neuropathic, and malignant ulcers. It is perhaps more usual in practical works on surgery to classify ulcers ac- cording to their clinical features. Thus we have the simple, healthy, or healing ulcer, the rveak or oedematous ulcer, the mflamed ulcer, the chronic callous or indolent ulcer, the fungous ulcer, the irritable or painful ulcer, the sloughing or -phagedcenic ulcer, varicose, eczematous, gonty, scorhitic, specific, and malignant ul- cers. These terms indicate in part the particular causes of the ulceration, and in part their special characteristics, due to local conditions and surroundings. The local conditions are, however, liable to change from day to day, so that various gradations occur between the various forms of ulcers, and even the type itself may change from time to time. For example, a callous ulcer may be trans- formed into a phageda^nic one. The Simple Ulcer. — This may be taken as the type of all ulceration. Others differ from it merelj' in detail, and all ulcers tend when healing to approach this form. The base of the ulcer is level or nearly so, and covered with healthy gran- ulations. The edges are smooth and shelving. The newly formed epidermis, destined to cover the damaged area, can be seen at the borders as a thin, bluish- white film. The discharge is creamy, inodorous pus, or possibly, if the ulcer be kept clean and dressed antiseptically, serum. Microscopicall}', the base of the ulcer consists in the main of inflammatory round cells, together with some spheroidal and epithelioid cells. On the surface may be pus cells, fibrin, cell debris, and dried serum. Deeper down we find greater amounts of connective tissue, with, if the ulcer be healing satisfactorily, young fibroblasts. Newly-formed capillaries are also present, in the form of ver- tical sprouts and loops extending in the direction of the surface. Round about the ulcer will be found a variable amount of connective tissue or scar tissue, DISTURBANCES OF NUTRITION. 229 which contracts as the ulcer heals. At the margin the epithelium is proliferating by division of the cells. In the case of the skin proper, the papilla? are not repro- duced nor are the hair follicles and various glands. As the process of healing progresses, more of the round cells are produced than necessary, and are cast off in the discharge. Loops of blood-vessels are abundantly produced and carry along with them numerous fibroblasts, which are to be converted into cicatricial tissue. Fibrous tissue is produced in in- creasing amount, and the epithelium gradually extends over the raw surface until the loss of substance is made good. Finally, many of the blood-vessels disappear, and the scar contracts, becoming firm, pale, and ansemic. The Weak or (EdemaMis Ulcer. — Any ulcer may become weak if healing be too long delayed. This form is generally found in connection with tuberculous bones and joints. The edges and tissues about the ulcer are generally healthy, but the granulations on the surface are abundant, flabby, semitranslucent, cedematous, and friable. The discharge is watery and free. The Fungous or Exuberant Ulcer. — Here the edges are healthy, but the gran- ulations rise above the surface, are tumid, dark red, redundant, and easily bleed. The condition is usually due to some obstruction in the return venous circula- tion. The Inflamed and Inflammatory Ulcer. — In these ulcers inflammation is the most striking feature. The inflammation may result from some constitutional vitium, as from alcoholism, improper and insufficient food and other causes of impaired nutrition, or from any local cause of irritation. Inflammatory ulcers are irregular in shape; the edges are ragged and shreddy or sharplj^ defined. The base is dry, dull red, devoid of granulations, covered with serous or sanious discharge, sometimes with yellowish sloughs. The surrounding tissues are swol- len, red, and hot. The Sloughing or Phagedenic Ulcer. — This is a more intense form of the in- flammatory ulcer. The destructive processes are greatly in the ascendant, and the inflammation is of quickly spreading and infective character. The base is devoid of granulations, secretes an ichorous discharge, and is converted into an ashen-gray or black, sloughy material. The edges are irregular, swollen, and undermined. The process appears to be clue to a specific micro-organism, as the ulceration proceeds with extraordinary rapidity unless checked by appropriate measures. There is usually also considerable constitutional disturbance. This form of ulceration is seldom seen except in connection with venereal disease in those with broken-down constitutions. The Chronic, Callous, or Indolent Ulcer. — An ulcer may become indolent as a result of long-continued irritation. The edges of such an ulcer are smooth, white, hard, rounded, and insensitive, and they are indurated from the pres- ence of inflammatory products, so that the circulation is impaired and healing prevented. The neighboring tissues are congested, and the skin is often excori- 230 a:\iericax practice of surgery. ated or eczematous. Granulations are either absent or are scanty, small, and badh' formed. The discharge is thin and sanious. Indolent ulcers are com- monly fomid m the lower third of the leg, may exist for years, and are attended by but little pain. They may be small or may gradualh' extend round the limb. Sometimes the}- become adherent to the fascia, periostemri, or bone. \Mien verj' old or when subjected to constant irritation, they maj' take on epithe- liomatous action. The Irritable or Painful Ulcer. — Any ulcer may be irritable and painful or may become so, but the term "irritable" is generalh' restricted by surgeons to painful fissm'es about the anus and to a small, superficial, congested ulcer,Jound usually in women after middle age, near the ankle. The pain is extreme and is believed to be due to involvement of the nerve endings. Varicose and Eczematous Ulcers. — This form of ulceration, as the names im- ph% is associated with varicose veins and eczema. Both conditions are not infrequenth^ foimd together. Gouty Ulcers. — Goutj- ulcers are fomid over uratic deposits. They are small and superficial, and the discharge contains sodium urate, which it deposits as a chalk-like material about the ulcer. The Scorbutic Ulcer. — The sm'face of a scoi'butic ulcer is covered with a spong}^, dark, adherent, fetid crust. "\^lien this is removed the surface bleeds freely and the same material is reproduced. Specific Ulcers. — These include tuberculous and syphilitic ulcers. The former are generalh^ multiple and often confluent. In the neighborhood can sometimes be formd traces of former ulcers in the form of scars and depres- sions. Tuberculous ulcers are generally due to the breaking do'mi of tuberculous nodes, with discharge of their contents externalh^ The granulations are pale, cedematous, protruding, and bleed freely when touched. The discharge is scanty, thin, and yellowish-green in color. The edges are pale, thin, and undermined. Lupus, or tuberculosis of the skin, is described elsewhere. Syphilitic ulcers, with the exception of the prmiary sore, are divided into superfi.cial and deep. The superficial are usually associated with syphilitic erup- tions. They are circular or crescentic in shape, or, when several have coalesced, .serpiginous or annular. Thej' spread by their convex aspect, while the older portions tend to heal. The base of such ulcers is but slighth^ depressed, of dark reddish color, and is covered with a scab or slough. The edges are sharply cut and surrounded by a dull reddish areola. Deep syphilitic ulcers are due to the breaking down of gummata. They are oval or circular in shape. The base is depressed and covered with a yellowish slough resembling wet wash-leather. The edges are steep, well-defined, slightly excavated, and of a dull reddish appearance. Malignant Ulcers. — These include epithelioma, carcinoma, sarcoma, and rodent ulcers. They are described elsewhere. In general it may be said, how- DISTURB.\NCES OF NUTRITION. 231 ever, that benign growths may produce ulceration from pressure on the skin arising in the course of their growth, or from impairment of the circulation within them. In the case of malignant tumors, "when ulceration occurs, it is clue to the breaking dowm of the cells proper of the growth. The surrounding tissues may in time be invaded by the new growth, and this freshly formed material may in its turn break down. Usually in such cases there is more or less inflam- mation, with its ordinary phenomena superadded. Both primary and second- ary new growths may attack the skin and mucous membranes and undergo necrosis. Chronic ulcers in elderly people and lupous patches may at times undergo epltheliomatous transformation. There are a few forms of tropical ulcers, mostly of uncertain etiology, about which a word or two may not be out of place here. Veldt sores are a form of ulcer common among the British troops during the recent war in South Africa. The sores are found on the exposed parts of the body, the hands, forearms, and feet. They appear to begin in the deeper layers of the epidermis, and at first resemble a bleb abrasion. Later, a slowly spread- ing, chronic ulcer is formed. The etiology is still imder discussion. Delhi sore is met with in India, Central Asia, the Levant, Algeria, and the Malay peninsula. It is found on some exposed portion of the body, and begins as one or more papules, which become pustular and finally develop into ulcers. The ulcers may be multiple and may fuse together. The base is usually irregu- lar, healing in one place and spreading in another. The edge is thickened, ragged, and surrounded by an areola of inflammation. The ulcer runs a very sluggish course. Wlien it heals it leaves a depressed scar, puckered in the centre, and of a bluish-brown color. Annani ulcer is a variety of phagedtena found m Annam, Aden, Cochin China, and Mozambique. It usually begins on the foot or leg as an area of infection. This sloughs and a more or less rapidly spreading ulcer is produced. The base is covered with unhealthy granulations, which bleed at the slightest touch, or with a grayish pseudo-membrane, and discharges fetid pus. The edges are undermined. Both base and edges may be extensively gangrenous, and the ulcer may penetrate deeply. The cause is unknown, but syphilis, antemia, bad hygienic conditions, are believed to predispose. Gaboon ulcer is found in natives of the Gaboon. It occurs on the limbs and is similar to a syphilitic ulcer. Dracuncular ulcer is endemic in parts of India, Ai'abia, Bokliara, Turkestan, tropical Africa, and South America. It is due to the Filaria medinensis, or Guinea-worm, a species of thread-worm. This is a very large filaria, averaging three feet in length, but may be as much as six feet long. It lives in the sub- cutaneous tissues. The female worm, which is the one that causes the trouble, as she approaches maturity, works her way to the surface, usually in the leg, foot, or ankle. She then discharges her eggs and penetrates the skin, forming a 232 AMERICAN PRACTICE OF SURGERY. sort of bulla on the surface. This becomes infected, breaks down, and forms an ulcer with a minute hole in the centre, through which part of the worm may- protrude. Complications and Sequelss of Ulceration. — Cellulitis or erysipelas may at- tack the tissues about an ulcer. Hemorrhage from an ulcer is not uncommon, especially in varicose cases. It has been fatal. Wlien an ulcer has healed, the resulting cicatrix may be the cause of serious trouble. Thus, it may lead to un- sightly deformities and distortion when on the face or neck ; when it is situated near a joint, more or less ankylosis may result. Keloid may also develop in the scar of an ulcer. Ulceration may lead to destruction of important struct- ures, such as bones, cartilage, joints, muscles, and it may also cause infection of lymphatic vessels and nodes. Profound constitutional disturbance and weakness may result. Ulcers affecting the hollow viscera, such as the stomach and intestines, may perforate, giving ri,se, unless protective adhesions be formed, to fatal peritonitis. Chronic ulcers, or those which have healed, may cause stenosis of the lumen of the bowel. Caries of Bone. — Analogous to ulceration of the soft tissues is the molecular disintegration of bone known as caries. Caries is a chronic process of gradual softening or breaking down of bony substance, and is in all cases the result of inflammation. Infective agents are brought to the bone by the blood stream, and are deposited in the smaller vessels in the bone spaces. The ordinary phenomena of inflammation result, save that swelling cannot occur, owing to the unyielding nature of the tissue. Pressure, interference with the nutrition of the part, and the toxic emanations from the bacteria, all combine to bring about the death of the part. The products of in- flammation are thrown off, mixed with calcareous matter and particles of decal- cified bone in the form of sand or grit (molecular necrosis of bone — von Volkmann). Actual loss of substance thus occurs. Caries is met with most commonly and typically in connection with tuberculosis, syphilis, actinomycosis, acute and chronic osteomyelitis, and in suppurative processes extending to the bone. When there is a dry, cheesy sort of detritus produced without pus, we have what is known as caries sicca. Or, the carious process may so extend as to encircle a considerable area of bony substance, which it thus deprives of nutrition. As a result a large sequestrum is formed. This is termed caries necrotica. Molecular necrosis is met with more particularly in association with acute suppuration and where the granulation tissue is of low vitality, direct death of small particles of bone resulting. The finer details of the process in caries are largely a matter of speculation. Billroth thought that the essential factor was the resorption of the bone by the cells of the granulation tissue. Von Volkmann believed that the bone is disintegrated by the chemical solution of the ground substance with the liberation of the calcareous salts. A similar obscurity befogs the subject of ulceration of the soft tissues. DISTURBANCES OF NUTRITION. 233 Ulceration cannot take place in healthy tissues. There must be some previously existing disturbance which impairs vitality.. If inflammation be not the dis- turbing factor in the first instance, it quickly becomes associated with the process. Breaking down of tissue is for a time at least in excess. How is the dead material disposed of? Two methods are conceivable. Either it may be disintegrated and cast off externally, or it may be absorbed. No doubt both methods are at work, but the former seems to be by far the more important. In- asmuch as material to be removed, such as portions of epidermis, fragments of bone or of soft tissue, are usually cast off rather than absorbed, we may infer with some certainty that the same general rule holds good in regard to ulceration and caries. It is, in fact, not uncommon to recognize small particles of bone or other tissue in the discharge from ulcers, while in certain cases considerable areas of dead tissue — sloughs, as they are called — are produced, which, when they are cast off, leave an ulcerating surface beneath. Thus we have all possible grada- tions between an impalpable disintegration of tissue (molecular necrosis, or ul- ceration in the strict sense) and the separation of visible particles or larger masses (sloughing or gangrene). The importance of the external discharge of dead material is seen particularly well in the case of abscesses, which may in a sense be regarded as concealed ulcers. Wherever possible, the pus burrows its way to the surface of the body or to some hollow viscus, and is there evacuated and removed. Healing in many cases will then occur spontaneously. If this do not occur, in many cases the abscesses are not absorbed, but go on extending. Indeed, only the smaller foci of suppuration can be removed by absorption, and that often imperfectly. With regard to the cjuestion of absorption, we cannot altogether deny that it is of some importance. No doubt the excretions or discharges from certain ul- cers, inasmuch as they contain enzymes derived from bacteria, are competent to bring about solution of the tissues, although it is not likely that this invariably occurs, as Rokitansky used to think. Now if such discharges be pent up, the disintegration process often proceeds apace, as we have so often opportunity to note clinically, and in some cases the products of disintegration, together with septic matter, are absorbed into the circulation, partly through the lymph stream and partly through the agency of the phagocytes. Proof of this is fovmd in the cases of cellulitis, erysipelas, and septico-pysemia which occasionally complicate ulceration. The removal of inflammatory products in other forms of inflamma- tion — a process which is so constant an accompaniment in the process of repair — would induce us to think that a somewhat similar state of affairs is present in ulceration. DISTURBANCES OF THE CIRCULATION. The circulation of the blood throughout the body is carried on by means of a muscular force and suction pump — the heart, — with which is connected an elab- 234 AMERICAN PRACTICE OF SURGERY. orate system of more or less elastic tubes — the arteries, capillaries, and veins. Within the vascular system the blood pressure is dependent, first, on the force of the contractions of the heart muscle, and, secondly, on the amount of resist- ance manifested in the peripheral vessels. The blood pressure is greatest within the heart dxiring systole, and falls gradually in the arteries, capillaries, and veins, in the order named. It is least at the venous orifices of the heart during dias- tole. The blood pressure is also governed to a large extent by the elasticity of the vessels and the degree of their tone. The amount of blood in any part de- pends, in addition to the influence of muscular action and elasticity, upon the vasomotor nerve mechanism, which determines the calibre of the vessels, their distensibility, and, hence, their capacity. The circulation is apt to be feeblest in those parts of the body which are most remote from the heart, and in the dependent portions. Under ordinary circumstances, the blood pressure and the amount of blood in any given part vary according to the nutritive and functional needs. The circulation may be deranged by causes which interfere with the on- ward flow of the blood and lymph. These may be systemic or local in their operation. Or the blood itself may be altered in amount or in quality. Hypersemia, or Congestion. — The amount of blood in any given part varies considerably even within physiological limits, according as to whether the func- tion of the part is active or in abeyance. Should the amount exceed or fall below these limits, owing to causes other than physiological ones ; or should the varia- tion persist for an abnormal length of time, then we speak of pathological disor- ders of circulation. An excess of blood is called hypermmia or congestion; lack of blood is called anmnia, or, more correctly, ischamia. Hypersemia may be general or local. General hypercemia, or plethora, as it is called, is rare, if it can be said to occur at all. Now and then we meet with in- dividuals whose circulatory system seems to be overfilled. Especially do we see this in those who have died from obstructive heart affections. There seems to be more blood than usual in the body, although it is certainly not normal blood. During life, however, any excess in the total quantitj^ of the blood is quickly compensated by increased activity of the emunctories. Local hypercemia may be due to an excessive supply of arterial blood — active hyperemia; or to some obstruction to the outflow of venous blood — passive or venous hypercemia. Active hyperaemia results from a variety of causes, among which may be mentioned increased heart action, dilatation of the arteries of a part, stimula- tion of the vasodilator nerves, paralysis of the vasoconstrictor nerves, the diminution of extravascular pressure. It is seen particularly well in the first stages of inflammation. Irritations of all kinds, such as those produced by traumatism and by chemical, thermal, and mechanical influences, are competent to produce congestion. Local ana-mia, when continued for any length of time, is usually followed by hypersemia. The removal of long-continued pressure upon DISTURBANCES OF NUTRITION. 235 blood-vessels is succeeded conimonly by arterial dilatation and congestion. Thus, the application of an Esmarch bandage is followed by arterial dilatation on its removal. The sudden removal of fluid from the chest or abdomen is followed by local active hypersemia, which may be so extreme as to cause faintness, owing to the collateral ansemia of the brain that results. Closure or narrowing of an artery leads to collateral hypersemia of the adjacent parts. The pressure of tumors, of enlarged lymph nodes, or of inflammatory products upon the sympa- thetic nerve ganglia or fibres, sometimes causes arterial hypersemia, owing to paralysis of the vasoconstrictor nerves. A part affected by arterial hypersemia, if on the surface of the body, is of a more or less deep red color, and is somewhat warmer than the siurounding structures. In many instances nutrition is stimulated, and probably function is increased. Local venous hypersemia, or passive congestion, is due to some interference with the outflow of the blood from an organ or tissue. The obstruction may be due to causes situated in the heart, mediastinum, or lungs, or to more strictly local and circumscribed conditions. A great variety of causes might be men- tioned, such as the external compression of the efferent veins by tumors, aneu- risms, ligatures, inflammatory infiltrations and exudates, cicatricial bands; closure of the lumen of veins by ingrowing tumors, thrombosis, or embolism; pressure in the abdominal cavity from timrors, effusions, and the pregnant uterus; constriction of the veins of the intestine by the neck of the sac in strang- ulated hernia. The result depends, of course, upon the extent of the obstruction, its site, and the presence or absence of a collateral vascular sj'stem. If the part be sup- plied with anastomosing branches, occlusion of a vein is followed by only a tem- porary overfilling of the veins on the distal side of the obstruction. If, however, comnumication with other veins is slight or lacking, then more serious and last- ing disturbance will arise. The pathological changes which result from the complete obstruction of the return flow through the veins of an organ or tissue have been fairly well deter- mined from experiment and clinical observation. The veins and capillaries on the distal side of the obfetnaction are greatly distended with blood. The distinc- tion between the axial and peripheral currents in the veins is lost, the plasma gradually disappears, and the vessels become filled with closely packed red blood corpuscles. In an hour or two the blood has stopped in the veins and capillaries (stasis), and a few red cells find their way from the vessels into the neighboring tissue spaces. If there be any anastomoses with other vessels, capillaries hitherto unseen open up and an attempt is made at re-establishing the circulation. The effect of all this is that a rise of pressure occurs in the veins and capillaries, causing them to dilate. The blood becomes still more venous, owing to the stasis, and this interferes with the vitality of the endothelial cells 236 AiIERIC.\N PRACTICE OF SURGERY. lining the vessels. Then, owing to the distention of the vessels and the lowered nutrition of their walls, transudation of the fluid part of the blood occurs. The process is in part compensated by contraction of the arterioles in the congested area, which is secondary to the diminished amount of blood flowing through the part. This tends to prevent an excessive increase m the intravenous pressiu-e, to limit the amoimt of transudation, and to give time for a collateral circulation to be established. To gross appearance, a region the seat of passive congestion is swollen, dusky red or purplish-red m color (cyanosis), cooler than normal, and its func- tional activity is diminished. The final results of passive congestion depend upon the extent and duration of the condition. Temporary congestion may lead to no permanent changes. Congestion continued for a longer period causes pressui'e upon the cells, which become fattily degenerated, hydropic, and atrophied. In the more advanced conditions many cells, especially the more highly differentiated, such as the parenchymatous cells of glands, disappear and are replaced by fibrous tissue. The disintegration of the red corpuscles which have passed into the tissues leads also to the deposit of blood pigments (brown induration). In the most severe cases, where the circulation is absolutely and permanently stopped, hemorrhagic infarction of the part may occur, followed by gangrene. (Edema. — Mention has been made of the fact that in passive congestion the plasma passes out from the vessels mto the interstices of the tissues. Should the lymph circulation be inadequate to carry it away, it accumulates in the part and leads to the condition Icnown as ccdema or dropsy. This transudation and accumulation of the fluid portion of the blood maj- take place in various parts of the body. It may occur in the peritoneal cavity, and is then Icno'mi as ascites. Effusion into the pericardial and pleural cavities is spoken of as hydropericar- diwn and hydrothora.v, respectivel}''; into the tunica vaginalis, as hydrocele; into the subarachnoid space, as external hydrocephalus: into the ventricles of the brain, as internal hydrocephalus. Generalized cedema of the subcutaneous and intermuscular connective tissue is called anasarca. (Edema occm-s in the earlier stages of inflammation — hence called inflamma- tory oedema — and, as we have seen, in passive congestion. Three factors are of importance in determining the production of transudation mto the tissues, namely, pathological variation in the blood pressure, alterations in the composi- tion of the blood itself, and changes in the structure and function of the vessel walls. Whether oedema will result or not, in cases of transudation, depends entirely on the ability of the lymph channels to cope with the increased supply of fluid in the tissues. Obstruction to the current in the lymph vessels does not usually cause oedema, inasmuch as the anastomoses are verj^ abundant, and any excess of fluid may be reabsorbed by the veins. Complete obstruction of all the IjTiiph vessels of a part may, however, lead to a pure lymphatic oedema. The DISTURBANCES OF NUTRITION. 237 same thing is seen in cases of obstruction of the thoracic duct ("whether from tumors or from other caxises), which results in what is known as pseudo-chyloiis ascites. Increased pressure within the arteries does not give rise to oedema, provided that the return flow through the veins be unimpaired. Increased pressure within the veins, such as occurs in passive hypersemia, is, however, an important factor. Thus, oedema and effusions into the various cav- ities of the body are common in cases of general passive congestion, the result of obstructive valvular disease of the heart and of certain pulmonarj' and renal affections which interfere with the circulation. In such cases the oedema usually begins in the dependent or more peripheral parts, where we encounter the in- fluence of gravity or of a weak circulation. Local oedema may follow local passive congestion, as in the production of ascites in portal obstruction, or as the result of the pressure of tumors, inflam- matory exudates, splints or other surgical appliances, on the veins of a part. Increased pressure within the veins seems to predispose to transudation, ow- ing to thinning of their walls and the presence of a vis a tergo. Probably, also, long-continued distention and imperfect nutrition lead to impaired elasticity of the extravascular tissues, so that the lymph tends to accumulate. More than this, however, seems to be necessary. Certain oedemas are met with in which the main condition appears to be some alteration in the secreting powers of the endothelial cells lining the vessels. Such are the cedemas formerly called hy- drsemic, and those due to the injection into the circulation of such substances as peptone and the enzymes of the various digestive secretions. At any rate, sufficient evidence has accumulated to show that transudation is not a mere question of pressures, filtration, and osmosis. The secretory activities of the cells lining the vessels must be taken into account as well. This leads us to con- clude that there is not so much difference between the transudates and inflam- matory exudates as used to be thought. The old view was, that transudates passed through the healthy vessel walls by a simple process of filtration or osmo- sis, while in the case of inflammatory exudates there were serious alterations in the vascular walls. This distinction cannot now be said to hold good, except in the most general wa}^ The vital secretory powers of the vascular endothelimn have to be taken into account in all cases. Passive effusions or transudates are clear, usually colorless, of low specific gravity (from 1.006 to 1.012), and relatively poor Ln albumin. A few leucocytes and red corpuscles are usually present, and also swollen and fattily degenerated endothelium. Inflammatory exudates are usually turl^id, sometimes mixed with blood, of high specific gravity, and rich in proteids. Spontaneous clotting may take place. A relatively larger mmiber of leucocytes is present. Inflammatory oedema is found in the neighborhood of inflammatory foci or may be caused 238 AMERICAN PRACTICE OF SURGERY. directly by the local action of various toxic, thermal, and traumatic agencies. It no doubt represents the first stage in the formation of inflammatory infiltration. CEdematous tissues and organs present a characteristic waterlogged appear- ance, owing to the accumulation of fluid in the interstices. The part is swollen, pits on pressure, and, if an incision be made, clear, watery fluid exudes. On sec- tion, the tissue is juicy, of a semitranslucent appearance, and drips watery fluid. In the case of an extremity the skin is greatly stretched, is shiny, thin, and may present livid scars. In cedema due to passive congestion the part may be con- gested, at least in the earlier stages, but later becomes ana?mic, owing tc the pressure of the fluid. Effusions into the body cavities lead to dilatation of the cavity, with com- pression of the viscera contained within, and, in time, to thickening of the serous lining. Microscopically, cedematous tissues present some enlargement, with more or less dissociation of their elements. In the more extreme forms the cells and fibres are swollen, hydropic, and vacuolated. The results of oedema depend upon its localization and extent. Effusions into the body cavities may lead to serious consequences, owing to pressure upon or dislocation of important organs. Transudation into the brain substance, or its ventricles, or into the subarachnoid space may lead to paralysis and death. (Edema of the glottis is a dangerous and often fatal complication of certain affections, such as Bright's disease, laryngitis, cervical cellulitis. Prolonged ojdema of the skin and subcutaneous tissues leads to lowered vitality of the part, and may result in ulceration or gangrene. Infection readily occurs, and the con- dition may be complicated by erysipelas or cellulitis. Anaemia. — The term "anajmia" literally means absence of blood. To a cer- tain extent the term as ordinarily used is a misnomer, inasmuch as complete absence of blood does not occur in the animal organism, except in the most cir- cumscribed areas. Further, we speak of a person as being "auEemic," when we mean that his skin and mucous membranes are pale and apparently bloodless. This pallor, however, need not depend on a complete or partial deficiency in the amount of blood in the part, but may be due to changes in the blood itself. The blood may be there in normal quantitj', but may be lacking in red corpuscles or the corpuscles may be poor in haemoglobin. It would, therefore, be more strictly correct to speak of a diminution in the total quantity of blood in the body as "ischsemia," and to keep the term "angemia" for the purely local disturbances associated with deprivation of the blood supply, to a part. Alterations in the quality of the blood should be given other designations. Probably, however, the word "anemia" has been so long employed in this loose way that it will continue so to be used. It is well, however, to qualify it when necessary, so as to promote precision of language. DISTURBANCES OF NUTRITION. 239 General systemic ischiemia will be discussed elsewhere, and we will confine our remarks here to the consideration of loca,l ana?mia and ischa^mia. The supply of blood going to a part may be diminished or cut off completely in a variety of ways. The total quantity of blood in the body may be less than normal, so that a smaller quantity reaches the various parts ; or some local con- dition may prevent the blood reaching the part. Thus, the lumina of the afferent arteries, arterioles, and arterial capillaries may be diminished or occluded by pressure from without, spasm, or alterations in the structure of their walls. Local anisemia, for example, may be produced by the compression of an extrem- ity by an Esmarch bandage, the ligation of the principal arteries, the pressure of a tumor, of an inflammatory exudate or effusion, or of a contracting, cica- tricial band. The artery may also be more or less completely occluded by end- arteritis, sclerosis, or the invasion of malignant growths; or its lumen may be obstructed by thrombi or emboli. Disturbances of the vasomotor system may produce local ischsemia. Brown-Sequard showed that stimulation of the cervical sympathetic is followed by contraction of the arterioles of the same side of the head. An excess of blood in any part, as in some cases of passive congestion, may result in a deficiency of blood in some other region. This is called collateral ancemia. A good example of this is seen in the ordinary "faint." Under the influence of pain, emotion, or fright, a nervous disturbance takes place, which determines large quantities of blood to the abdominal viscera. This leads to ischaemia of the brain and loss of consciousness. In certain parts of the body, such as the heart, brain, spleen, kidneys, some portions of the long bones, and the retina, there are what are known as " ter- minal" or ''end" arteries; that is to say, arteries which do not connect with anastomosing branches. Should such an end artery be occluded, complete anae- mia of the part ordinarily supplied by that vessel will result. This leads to the so-called ancemic necrosis or infarction. The condition is met with typically in the kidney, where we find more or less wedge-shaped areas of an opaque, yellow- ish color, devoid of blood, and showing microscopically coagulation-necrosis. At the apex of the wedge can be demonstrated the occluded vessel. Such an infarct is called an ancemic or white infarct. Blood may, however, make its way in time from the neighboring capillaries into the anfemic part, thus converting the white into a red or hemorrhagic infarct. In the case of the brain, infarction is followed by colliquative necrosis (red or yellow softening). Infarcts are most commonly produced by emboli. If infection take place, we get suppuration in the affected part. If the affected part remain aseptic and if it be not of vital importance, the dead tissue is in time absorbed and replaced by fibrous tissue. The results of a circumscribed anaemia depend upon its extent and upon the locality which it occupies. Complete deprivation of the blood supply in certain areas produces, as we have seen, death of the part. In other regions, where a collateral circulation is present or can be established, less disturbance is mani- 240 M'lERICAN PRACTICE OF SURGERY. fested. Provided that the circulation be cut off for only a short time, no lasting results follow. More severe distiu-bance may result in minor degenerative changes and atrophy of the cells of the affected part. Where large vessels are obstructed it is not uncommon to find new channels of supply opened up, and previously existing anastomosing branches enlarge and dilate to meet the altered conditions of nutrition. ALTERATIONS OF THE BLOOD. These are chiefly of interest to the physician. They will, therefore, be dealt with here only in a sketchy way, but an attempt will be made to indicate, as far as may be, the bearing of disorders of the blood on surgical practice In brief, the blood consists of a fluid part — the plasma — and certain formed elements — the red corpuscles, leucocytes, haematoblasts or blood platelets and " haemokonien " or "dust bodies." The blood may manifest abnormal changes in regard to its total quanti y. It may be excessive in amount (plethora) or diminished (ischcemia, oligmnia) ; or the relative proportions of plasma and corpuscles may be altered. Thus, there may be an absolute or relative increase in the plasma, while the corpuscles are normal in numbers and character (hydrcemia) ; or, again, the plasma may be di- minished in amount, so that the blood becomes more concentrated (polyqjthwmia). Foreign substances may gain entrance into the blood, or substances which are normally present in small amovmt may be abnormally increased. Thus, bile, melanin, coal pigment, calcareous salts, fat, sugar, glycogen, toxic substances of many kinds, portions of tmnors, necrotic tissue, gas, bacteria, and animal para- sites may be foimd in the blood. Finally, the corpuscles may be altered in number, both absolutely and rela- tively to the amount of plasma, or they may vary in their relative percentage to one another, or, again, in their quality and characteristics. The red cells may be diminished in numbers, as in most forms of anaemia, or increased. They may be deficient in hsemoglobin, as in chlorosis, or certain of them may contain an excess of this substance, as in pernicious ansemia. The leucocytes may be increased (leucocytosis) , or diminished (leucopenia) , in numbers; they may be altered in the proportions which one form bears to the other; or, finally, certain abnormal forms ma}^ make their appearance, as in leukaemia. By an extension of the idea, the term "anaemia" is commonly employed to designate changes in the number and character of the corpuscles, as well as diminution in the total amoimt of blood. It is usual to divide the anaemias into ■primary and secondary. The primarj^ are : chlorosis, pernicious anaemia, leukae- mia, and pseudo-leukaemia. The secondary anaemias result from a great variety of caases, such as loss of blood, impaired nutrition, cachexia, the presence of intest'inal parasites, infection, toxaemia. DISTURBANCES OF NUTRITION. 241 The Primary Anaemias.— CVi/orosis.— The main changes in the blood are as follows : The specific gravity is reduced. The number of the red cells is normal or nearly so. In neglected cases they may, however, sink to 1,500,000 per cubic millimetre (Stengel). Not infrequently they are increased (7,100,000 in one of Cabot's cases). The average would be about 4,000,000 or slightly over it. The diagnostic point is the diminution of the htemcglobin out of proportion to the diminution of the red cells. It may be reduced to twenty per cent or xmder, but on the average is about forty-one per cent. The number of the leucocytes is about normal. Rarely, they are somewhat increased, especially during rapid convalescence. The hsematoblasts are always increased. In severe cases the red cells are somewhat diminished in size. In mild cases the size is unaltered. Only in the severer forms is poikilocytosis observed. Rarely, normoblasts may be seen. The disease is found almost excmsively m girls and young women, develop- ing with the onset of puberty or shortly after. Thrombosis of the cerebral si- nuses and of the veins of the extremities is a not infrequent complication. Pernicious Anemia. — The striking peculiarity in this disease is extreme dim- inution in the number of the red cells, with a relative increase in the amount of the hemoglobin. The red cells usually fall to between 2,000,000 and 1,000,000 per cubic millimetre. The lowest count on record is in a case of Quincke's — 143,000. The total amount of htemoglobm is, of course, much below the normal, but is relatively increased per corpuscle. The color index may reach as high as 1.7. With regard to the size of the red cells, the average diameter is increased, but normocytes, microcytes, and macrocytes are to be seen. Usually poikilocy- tosis is marked. The formation of rouleaux is absent or slight. The blood clots slowly. Basophilic degeneration may sometimes be seen in the red corpuscles. Nucleated red cells, normoblasts, and megaloblasts are usually to be found in considerable numbers. The leucocytes are usually greatly diminished in severe cases. There is a relative increase in the lymphocytes. Rare myelocytes may be met with. The blood platelets are diminished. Leukcemia. — The most important of the primary ansemias, from the surgeon's point of view, is leukemia. This disease is manifested in two well-marked forms, the lymphatic and the myelocytic. According to the predominating type — for mixed forms are not uncommon — the most striking external featvues are en- largem.ent of the lymph nodes, enlargement of the spleen, and pain in the bones. For the relief of these conditions the surgeon is occasionally consulted, and, if unwary, may be led seriously astray, to the great detriment of the patient. A careful blood examination is called for in all cases of ansemia associated with enlargement of the lymph nodes or spleen, and will reveal the true nature of the case. Operative measures are uncalled for in such cases, and, in fact, are very liable to end fatally for the patient. 242 AMERICAN PRACTICE OF SURGERY. Leuka?mia is characterized by the appearance, in the blood and tissues, of enormous numbers of leucocytes. According to the appearance of the blood and the condition of the organs, we can differentiate lymphatic leuksemia, both acute and chronic, and myelocytic. Mixed forms also occur. The cause is still un- known, but, whatever it may be, it certainly stimulates greatly the formation and cell division of the leucocytes, and increases the facilities for these leucocytes to enter the blood. Acute lymphatic leukamia, or acute lymphocythtemia, generally occurs m young persons between the ages of eleven and twenty-four. It may rarely be found in very young children, and has been observed at birth. It begins acutely with fever, a rapidly progressive antemia, hemorrhages from the mucous mem- branes, purpuric spots upon the skin, and slight or moderate enlargement of the lymph nodes, spleen, and liver. The affection ends fatally in five or six weeks as a rule. Rarely, it may terminate in a few days. Occasionally it may last some weeks or even months, and then becomes chronic. Vomiting and diarrhoea occur, ulcerations take place in the mouth and gastro-intestinal tract, the patient becomes rapidly exhausted, and passes into a "typhoid" state, in which he dies. Delirium, convulsions, and coma may be observed. Chronic lymphatic leukcemia, when typical, begins more gradually, with local manifestations in the form of enlargement of the various lymph nodes, to which general symptoms are superadded only in the later stages. The disease lasts some months or for several years ; on the average, from nine months to two years. The nodes most often affected are the cervical, then the inguinal, retro- peritoneal, mesenteric, and axillary. Ultimately all become involved. The spleen and liver are moderately enlarged. Moderate anemia, emaciation, and progressive loss of strength are the leading features. Later, a tendency to hemorrhages into the skin and viscera, and from the various mucous surfaces, manifests itself. With regard to the blood, there is a marKecl leucocytosis, the white cells reaching from 100,000 to 300,000 per cubic millimetre in the chronic form, and 100,000 or less in the acute. The leucocytosis is therefore much less than in the myelocytic type. The leucocytosis is further characterized by the enormous pre- ponderance of the mononuclear forms. In healthy blood the lymphocytes are somewhat less than thirty per cent of the total number of leucocytes, but in lymphatic leukjemia they may amount to more than ninety per cent. In the acute form the large lymphocytes tend to predominate, while in the chronic it is the small. Myelocytic Leukajnia. — This is the form of leukfemia most commonly met with, and is the usual type found in the adult. In the vast majority of cases it comes on gradually. The general health begins to fail, the skin becomes pale and muddy, there is a gradually increasing enlargement of the abdomen, and possibly a dragging pain in the left flank. A diurnal rise in DISTURBANCES OF NUTRITION. 243 temperature may be the first symptom in some cases. Priapism may also be an early sign. Myelocytic leukaemia is, as a rule, a chronic affection. Rarely it begins acutely with fever and hemorrhages. The result is invariably death. The symptoms are at first slight, and patients usually seek medical aid some time after the disease has become well established. A sense of weight or actual pain in the abdomen, due to the enlarged spleen, is sometimes complained of, and the patient may himself discover the existence of a tumor in the abdomen. The progressive enlargement of the spleen is the most constant and conspicuous feature of the disease, and is often associated with enlargement of the liver. In such cases the protuberant abdomen contrasts greatly with the emaciation of the thorax. The various lymph nodes are usually slightly enlarged, but not ob- trusively so. Tenderness over the bones is experienced in some cases. The skin and mucous membrane are somewhat pale and earthy in appearance, but the outward evidences of anaemia need not be striking. There are general lassitude and weakness, and there may be dyspnoea, palpitation of the heart, and faint- ness on exertion. The patient gradually emaciates, and there are occasional elevations of body- temperature. The average duration of the disease is from one to three years. A rare form of myelocytic leukaemia, but one which undoubtedly occurs, is the so-called myelogenous., in which the spleen, lymph nodes, and liver are not enlarged, at least to physical examination, the characteristic changes of the disease being confined to the bone-marrow. The blood changes are, however, identical with those of the ordinary, or spleno-myelogenous, form. The blood in myelocytic leukaemia shows a diminution in the red cells and a great increase in the white. The hajmoglobin content of the blood is diminished. The red cells usually average about 3,000,000 per cubic millimetre, but may be reduced to 1,000,000 or less. Ordinarily the white cells exceed in number 100,000 per cubic millimetre, and may reach 1 ,000,000 or even more. Cases have been known where the white cells were as numerous as the red. The character of the white cells present in the blood is the most important diagnostic feature of this disease. Not only are the ordinary leucocytes in- creased in numbers, but certain abnormal forms, chiefly derived from the bone- marrow, make their appearance in great abundance. Three types of myelo- cytes, one or other of which may predominate, are to be found — the eosinophilic marrow cell, the neutrophilic marrow cell (Ehrlich's Markzelle), and the marrow cell of Cornil. Occasionally cells with coarse basophilic granulations may be found (Mastzellen). All the forms just mentioned are mononuclear. Dwarfed forms of the various white cells are often to be found. The red cells usually show all the changes peculiar to a severe primary anaemia. Nucleated forms, generally normoblasts, but also megaloblasts, may be noted. Basophilic degen- eration also occurs, and sometimes there is poikilocytosis. 244 AMERICAN PRACTICE OF SURGERY. It is important to remember that an intercurrent inflammatory process may greatly modify tlie blood picture of leukaemia. In such cases the tendency is for the blood to approximate to the type of the ordinary febrile leucocytosis. The total number of leucocytes is diminished, and the ordinary pol3'morphonuclears begin to predominate. Nucleated red cells and myelocytes are, however, never entirely absent. Under the continued use of arsenic, too, there may be at times a similar reduction in the number of the white cells, and the blood picture may change to one closely resembling primary pernicious anaemia. Such remissions, if such they may be called, are but temporary. The cause of leukaemia is as yet unknown. Opinions are also divided as to whether the disease is allied to the malignant tumors or is to be regarded as a specific infectious leucocytosis. The enlargement of the spleen is not an essen- tial feature of the disorder, nor is this organ primaril}' at fault. Therefore re- moval of the spleen, as has been advocated and practised, is unscientific and imjustifiable. The operation is, moreover, usually fatal. Pseudo-leiikcEmia, or Hodgkin's disease, occasionally comes under the obser- vation of the surgeon, with a view to possible operative interference. To exter- nal appearance this disease is practically identical with chronic lymphatic leu- kaemia, but the characteristic blood changes of the latter affection are not present. In Hodgkin's disease there may be a polymorphonuclear leucocytosis or even a slight lymphocytosis. Extreme lymphocytosis is not observed. Inasmuch as patients suffering from Hodgkin's disease occasionally develop leukaemia, there is some reason for thinking that leukaemia and pseudo-leukaemia are simply phases of one and the same pathological process. The surgeon may be called upon, in Hodgkin's disease, to remove nodes which are pressing upon important structures. The Secondary Anaemias. — Besides the grave forms of anaemia just referred to there are others, less severe and often temporary, which result from affections other than those of the blood itself or blood-forming organs. The causes are very varied. Chief among them are hemorrhage, malignant disease, chronic suppm'ation, acute and chronic infectious diseases, nephritis, dj'sentery, heart disease, tox£en:ia of all kinds, prolonged lactation, myxoedema, rickets, Addi- son's disease, and any condition which leads to disintegration of the blood cells. In general, it may be said that the red corpuscles are more or less dmiinished in numbers. The red cells may be deformed or of small size. In some severe cases the blood may resemble in many particulars that of chlorosis or that of pernicious anaemia. Normoblasts occur, but are scanty. Megaloblasts are encountered still more rarely. Ivaryokinesis and karyolysis may be observed. Leucocytosis may or may not be present. The white cells are usually in- creased in number in cases of malignant disease, in tuberculosis with ulceration, and in suppurative processes generally. The increase is, as a rule, in the poly- morphonuclear form. DISTURBANCES OF NUTRITION. 245 The Ancemia from Hemorrhage. — The subjective and objective phenomena of sudden and extreme loss of blood are well known and need not be described here. With regard to the blood itself, there is, of course, a more or less pronounced diminution in its total quantity, involving all its components. The red cells are diminished in numbers, and there is a corresponding reduction in the amount of ha}moglobin. If the hemorrhage be recovered from, the loss in bulk of the blood is compensated by a reabsorption of plasma from the interstices of the tissues and by contraction of the vessels. The blood thus becomes more watery. The red cells are not altered in appearance. Shortly after the loss of blood, a tendency toward restoration of the former condition manifests itself. The red cells gradually increase in numbers, and young forms, microcytes and macro- cytes, make their appearance, with also nucleated forms. The haemoglobin is not so quickly replaced as the cells, so that many of them appear to be chlorotic. Very shortly, too, after the occurrence of the hemorrhage, regenerative changes become strongly marked in the leucocytes, which are notably increased in number. This post-hemorrhagic leucocytosis is a constant and characteristic feature. The blood thus gradually becomes more concentrated, and finally as- sumes its normal condition. The length of time required for complete return to the normal depends upon the amoimt of blood lost, the age and idiosyncrasy of the patient, the character of his food, medicinal measures, and so on. Small losses of blood may be re- paired in from two to five days; larger ones may require a month. Young chil- dren stand hemorrhage badly and take longer to recover. The blood picture after repeated small hemorrhages is quite different. Such hemorrhages may be the result of nose-bleeding, htemoptysis, lijematemesis, melgena, hemorrhoids, haemophilia, the hemorrhagic diathesis, certain uterine disorders, intestinal parasites. Small hemorrhages, as we have seen, are quickly compensated and repaired. Should they be repeated before restoration to the normal can take place, we get the picture of chronic ansemia. The extent of this will, of course, depend upon the number of the hemorrhages, their severity, and the vitality of the patient. The main changes may be summed up as follows: The red cells are diminished in numbers and the blood becomes more watery; the haemoglobin is diminished in proportion to the diminution of the red corpus- cles, but may be even more reduced in severe cases; microcytes, macrocytes, and poikilocytes may be found; nucleated red corpuscles are not uncommon; the red cells show sometimes polychromatophilism; the leucocytes (usually the polynuclear) at first are often increased, but in advanced cases may be dimin- ished. In the most extreme cases the blood may resemble very closely that of primary pernicious anaemia. Leucocytosis. — Leucocytosis is an increase in the number of leucocytes pres- ent m a given quantity of blood removed from a peripheral vessel, above the number normal for the individual concerned. Leucocytosis usually concerns 246 AMERICAN PRACTICE OF SURGERY. the polymorphonuclear leucocytes, but the others, lymphocytes and eosmophiles, may be at times affected. Therefore, in determining leucocytosis it is wise to make a differential count of the forms present. Leucocytosis may be physiological or pathological. Physiological leucocytosis is met with in the young infant, and also in adults during digestion, during pregnancy, just before death, after violent exercise, after massage, after short cold baths or prolonged hot ones. Digestion leucocytosis amounts to an increase of about one-third in the mmi- ber of the white cells. The normal percentages of the various cells may remain the same, or the lymphocytes may be absolutely or relatively increased. In chronic gastric troubles and gastric cancer, digestion leucocytosis may fail to occur. In infancy the lymphocytes are relatively and absolutely increased — a fact which should not be forgotten in the examination of those of tender age. Pathological leucocj^tosis ma}- be due to hemorrhage, inflammation, intoxi- cations, infection, or malignant disease, or to the exhibition of certain chemical substances. Post-hemorrhagic leucoc}- tosis has already been sufficiently dealt with. Inflammatory leucoc3'tosis is met with in inflammations of almost all kinds. Its degree seems to depend upon the balance existing between the inflammatory process and the resisting power of the patient. The character of the infection is also important. Leucocj^tosis is most marked in lobar pneumonia; moderate in most infective processes, including suppuration due to pyogenic cocci; but may be absent, as in typhoid fever, malaria, influenza, measles, acute miliarj^ tuber- culosis, leprosy. The occurrence of leucocytosis in a disease which ordinarily should present none maj^ at times be of value to the surgeon, in indicating some suppurative complication. The increase of the leucocytes in inflammatory afi"ec- tions is usuallj' in the poljaiuclears. Extensive malignant disease is associated with an increase in the number of the polymorphonuclear leucocytes. This may possibly be due to ulceration and secondary infection, at least in many cases. Toxic leucocytosis is met with in poisoning by ptomains, illuminating gas, ether, quinine. The administration of drugs, such as the salicylates, pilocarpine, ergotin, the antipyretics, and tuberculin, and the injection of normal saline, will raise the number of the white corpuscles. Lymphocytosis may be found at times in rickets, syphilis, scurvy, malaria, chlorosis, pernicious anaemia, malignant disease, and cachexias. Eosinophilia, or increase in the number of the eosinophiles, is found in some diseases due to animal parasites, such as trichinosis and ankylostomiasis, and in malaria; in osteomalacia; in some cases of sarcoma; in certain skin diseases, as pemphigus, pellagra, dermatitis herpetiformis. DISTURBANCES OF NUTRITION. 247- ON CERTAIN PRODUCTS OF INFLAMMATION. Under this heading we propose to deal with the question of the origin and nature of inflammatory exudates, more especially in regard to lymph and pus. The proper apprehension of this subject presupposes a knowledge of the principles exemplified in the process of inflammation. As this phase of the matter has been thoroughly discussed in article No. 1 we may proceed at once to the consideration of the question in hand. Perhaps the simplest form of inflammatory exudation is that known as serous exudation. Instances of this are met with in the fluid contained in blisters pro- duced by cantharides or by heat, in the effusion into joints or hernial sacs, which have been injured and become immediately inflamed. Such effusions are rare in inflammation, except in its mildest form, but are a common result of passive congestion. As we have already seen, there is no essential difference in composi- tion between the so-called passive effusions or transudates and inflammatory exudates. The only practical distinction, and that a somewhat rough one, is that the latter contain more cellular elements and are much richer in fibrin- forming substances. The fluid from a simple transudate will not usually clot on removal from the body, while an inflammatory exudate will. At most, in pas- sive effusions of long standing we may find a few flakes of fibrin floating, and even here it is open to assume that a low grade of inflammation has been present. We have to recognize, therefore, that there are many intervening stages between a simple serous effusion, the result of a passive transudation, and the cellular, more fibrin-containing exudate characteristic of inflammation. In many of these serous effusions, so long as the fluid remains within the body, clotting does not occur; but, as soon as it is withdrawn, fibrin is formed in considerable amount. Again, we have inflammatory exudates, and these are the commoner and more characteristic ones, which are so rich in fibrin-forming substances that when re- moved from the body they clot promptly and firmly, or they may even clot within the body. These exudates constitute what is usually known as plastic or coagulable lymph. The term "lymph" is somewhat unfortunate in this connec- tion, as it is apt to lead to confusion with the lymph which flows within the lymphatic vessels. This, of course, has nothing necessarily to do with inflam- mation. By preflxing the word "inflammatory" we probably render the mean- ing sufficiently evident, and long usage has by this time sanctioned the error. Plastic or Coagulable Lymph. — This is the exudation produced in what may be called "healthy" or "constructive" inflammation. It is in the main a fluid having properties not unlike the liquor sanguinis, more particularly in that it tends to coagulate. The amount of fibrin-forming substances is, however, some- what variable, being at one time, as we have seen in the so-called serous exu- dates, comparatively trifling; at another, sufficient to produce a dense, thready, firm, coagulum, even during life. The number of the contained corpuscular ele- _MS AMERICAN PRACTICE OF SITRGERY. ments, or leucocytes, is also variable. These are practically absent, or at least quite scanty, in serous exudations, more abundant in the ordinary inflammatory exudations, so that in some cases it is difficult to distinguish the exudate from pus, save in its faculty for coagulating. Such IjTnph is met with on the surface of recent wounds, in the neighborhood of many inflammatory foci, on abraded surfaces, and upon mucous and serous membranes. In the case of the serous cavities, where considerable quantities of exudation may collect, we can differ- entiate several forms, according to the relative proportions of the fluid part and the cellulo-fibrinous material. Thus, if the exudate be largely fluid, we speak of a serous exudate ; if mixed with considerable fibrin and more numerous cells, we speak of a sero-fibrinous exudate; if mainly fibrin and cells, we have a plastic or fibrinous exudate. Inflammatory exudates are not without import, and, indeed, subserve many useful purposes. First, the passage out of fluid and cells through the vessel walls lessens the congestion and diminishes the distention of the vessels of the inflamed part; secondly, the exudate tends to dilute any irritating substances, such as bacterial toxins or disintegrating tissue, which may be present; thirdly, it tends to flush out the part, and, by reducing toxic materials to a soluble and labile form, to promote the removal of such irritating substances from the part through the lymphatics and blood-vessels ; fourthly, it in some cases helps to limit the inflammatory process; fifthly, in the case of uninfected wounds it forms a bland and unirritating natural dressing and tends to promote adhesion of inflamed surfaces and hasten the reparative processes; lastly, in certain cases it appears to possess bactericidal properties. The importance of coagulable lymph in connection with the repair of injuries can be well seen in the study of a simple incised and uninfected wound, such as may be inflicted by the surgeon's knife. The first effect of the incision is to di- vide the tissues, vessels, nerves, and other structures of the part. At first a little blood will be effused from the severed vessels. This soon stops unless a large ves- sel be cut and left unsecured. Now when the cut surfaces are brought into close and accurate apposition, we have an instance of a reparative inflammation with the least possible amomit of reaction. The divided cells for the most part die, at least if their nuclei be destroyed; the injured vessels retract, close, and become thrombosed, and an outpouring of serum takes place, which glues the two sur- faces together and exudes slightly upon the surface as a clear, transparent fluid, that ultimately dries into a delicate membrane of fibrin known as the "scab." This effused serum is an admirable medium for the growth and development of new cells, as it contains all the necessary pabulmn. Leucocytes pass out from the vessels into the injured region and into the lymph, so that in a few hours there may be a considerable aggregation of granular cells. Next, by a process not as yet fully understood, the adjacent capillaries send out buds from their sides, which gradually become hollowed out and permeable for blood. These DISTURBANCES OF NUTRITION. 249 extend into the effused lymph until they meet similar buds from other vessels, with which they unite, forming loops of vessels. With them certain cells also in- vade the part, derived to some extent from the proliferation of the pre-existing connective-tissue elements about the walls of the vessels, or possibly, as some hold, also from the germination of the leucocytes. These are known as fibro- blasts, and in time they become converted into dense, fibrous connective tissue. Thus, the jelly-like cement substance originall}^ present is transformed by the proc- ess of organization into a firm connecting substance, cicatricial tissue, which binds the formerly dissevered surfaces together and to this extent makes good the injury. This process is called union by "first intention." As a rule, the more highly specialized cells, such as nerve cells or those of glands, are only incom- pletely restored, if at all, and the damage is repaired by more or less inert con- nective tissue. This ultimately contracts, many of its vessels become obliter- ated, and we get a dense, white scar or cicatrix. Where the epidermis is severed, the epithelial cells grow inward over the wound, and its continuity is restored in all parts. In the case of an abrasion or superficial wound, when of limited extent, the exuded fluid coagulates upon the denuded surface, where it dries, forming a tough, somewhat flexible crust or scab. The effused lymph is gradually organized in the way just described, and the epidermis grows inward beneath the scab, which eventually falls off, leaving a slightly reddened, smooth surface, that in course of time pales and becomes scarcely distinguishable. This is known as healinr under a scab, and is a very simple and effective method where it is practicable. If micro-organisms be present, as they so often are, healing by the two methods Tnphoid cells ; 4, plasma cells ; 5, fibroblasts, or newly formed connective-tissue cells; 6.. new inter- cellular fibrils. {Original.) 272 AMERICAN PRACTICE OF SURGERY. leucocytes, as is the case in aseptic wounds. The infectious organisms also ex- tend rapidly into the tissue at the edges of the wounds, cause a marked solution of those tissues, and enlarge the interval between the edges. If the infection occurs early the exudate maj' be discharged between the sutm-es, but if it occurs after the edges are sealed together by fibrinous exudate the woimd rapidly is converted into an abscess cavity, which ultimately may open upon the surface at some point in the original incision; or the entire margin of the wound, includ- ing the epidermis, may become dissolved, and the closed wound may be con- verted into an open wound. In either case the extent of the wound is very much enlarged, and the amount of tissue to be replaced is much increased and the time required for repair correspondingly prolonged. In case the closed wound becomes infected by organisms which produce ne- crosis without marked solution of tissue, i.e., an acute inflammation of the phleg- monous type, the process of repair also is affected. In such cases the pyogenic organisms extend into the lymphatic clefts of the tissue adjacent to the woimd and produce necrosis of tissue, and the necrotic area becomes infiltrated with a purulent exudate. The necrosis may extend over an area many times greater than that of the original wound. After the infection has ceased or the wound has been artificially drained, a large slough, usually but not always subcutane- ous, is formed about the woimd, and this necrotic tissue must be replaced by granulation tissue, the time required for this replacement corresponding to the extent of the necrosis. In such cases the area of granulation tissue is many times greater than that which would be inferred from the line of the original incision, and maj^, as in the case of a limb, lead to the formation of a very extensive subcutaneous scar, which may surround the entire limb as a buskin of scar tissue, which, by its pressure and contractility, may lead to verj' great im- pairment of the functions of underh'ing muscles. In open wounds the result of an infection is similar to that in closed wounds. An open wound infected with organisms which produce suppuration and solu- tion of tissue maj^ have its original area enormously increased, while the time required for healing is correspondingly lengthened. An open wound infected with organisms which produce phlegmonous inflammation not only has its superficial area increased to a considerable extent, but also becomes surrounded by a subcutaneous slough which leads to the same complications as are seen in infected open wounds. Principles of Treatment of Wo^lnds. From a consideration of the process of repair of wounds certain simple fundamental principles of treatment are obvious. Surgical cleanliness is the most important factor, and is practically trader control. This cleanliness applies to the field of operation, to the hands of the operator, instriraients, sponges, sutures, dressing, and to all materials which in PROCESSES OF REPAIR. 273 any way are brought into contact with the wound. If perfect surgical cleanli- ness (asepsis) is obtained, the amount of tissue to be repaired is dependent solely upon the size of the original wound. If pyogenic infection occurs the destruction of tissue depends upon the extent of infection, and in all cases the extent of the wound and the length of time required to replace the defect are increased, to say nothing of the dangers of septicsemia, etc.' Avoidance of manipulation is also extremely desirable. In wounds in which long-continued or violent manipulation is carried on, the destruction of tissue extends very widely beyond the mere limits of a surgeon's incision, and in such cases the amount of tissue to be replaced is much greater than the mere incision would require. Even in incised wounds the extent of the reparative process beyond the line of incision is much greater than usually is appreciated. For this reason it is desirable for the surgeon to make free, sweeping incisions, rather than a series of little cuts. Perfect and complete ha?mostasis also is necessary to obtain rapid healing of wounds. The greater the amount of hemorrhage between the edges of aseptic wounds the greater the length of time required for healing. The hemorrhage separates the edges of the woimd and increases the area to be organized by gran- ulation tissue. Excessive amoimt of blood in a closed wound also furnishes an excellent culture medium for the growth of pyogenic organisms, if any are present. Accurate closure and approximation of the edges of wounds in which an at- tempt is made to obtain primary union are essential. The approximation should affect not only the superficial edges, but especially the deeper layers of the wound. Even in the case of careful operators it is astonishing to see, on examin- ing sections with a microscope, how very imperfect the closure of the wound is. The more accurately the epidermis is approximated the less the surface to be covered by proliferating epithelium. The quicker the wound is covered by epi- thelium the less the liability of infection. The more carefully the deeper layers are approximated and dead spaces are obliterated the less the amount of in- flammatory exudate and blood to be removed and organized by granulation tissue, and the smaller the scar. Aseptic protection of the wound is essential during the early days of the reparative process. The danger of secondary infection is over when the wound is covered by epithelium and the exudate is entirely replaced by granulation tissue. The power of resistance to infection possessed by a wound covered with granulation tissue is much greater than that which it possesses in the earlier stages before the formation of granulation tissue. Fixation of wounded tissue also is essential if it be desired to protect fresh or granulating edges of the wound from further injury. This fixation may be obtained in a variety of ways. In regard to open wounds there are certain special precautions. Surgical asepsis is as desirable in them as in closed womids, but perfect asepsis is not 274 AMERICAN PRACTICE OF SURGERY. feasible in wounds which remain open for long intervals. The reason why ex- tensive open wounds do not oftener become seriously infected is that healthy granulation tissue has a marked power of resistance to absorption of pyogenic organisms. On the surface of open wounds, in the early stages, masses of necrotic tissue ("sloughs") often are present. It is better not to attempt too vigorous removal of these, as their forcible removal leads to repeated traumat- ism of the young granulation tissue beneath them, with a consequent prolonga- tion of the time of healing and increased danger of pyogenic infection. In open wounds also it is desirable to keep the granulation tissue below the level of the advancing epithelial edge, as epithelium often is unable to cover over exuberant granulations. In many cases of extensive open wounds the epithelium ceases to advance over the granulating area, and in such cases it becomes necessary to cover in the epithelial defect by small isolated grafts, plastic flaps, or Thiersch grafts. Regulation of the blood supply always is desirable in open wounds. Venous stasis always appears to interfere both with the formation of granulation tissue and with the advance of the epithelium. Prevention of venous stasis can be obtained by pressure, by removal of varicose veins, or by position. B. Sutures and Other Foreign Bodies. Various substances are used for approximating, supporting, and holding in position the edges of wounds. These mechanical supports must be retained in the tissue until the process of repair along the line of incision is so advanced that the new tissue can support the tension upon the wounded area. Usually, when the wound is superficial the ends of the suture are left visible, and the suture is removed when the repair of the wound is sufficiently advanced, al- though occasionally even skin sutures are buried. In deep wounds or in wounds of the various body cavities, sutures or ligatures may be buried, and cannot be removed after healing is completed. The material used as sutures may be of animai origin, and therefore capable of being ultimately dissolved by the tissues. Other varieties of sutures cannot be dissolved. Of the soluble sutures those most commonly used are catgut, both plain and chromicized, and various animal tendons. The common insoluble su- tures are silk, silkworm gut, horsehair, celloidin, and various metallic wires. The character of the reaction produced in the tissues by sutures depends partly upon whether the suture is soluble or insoluble. The primary effect of the introduction of a suture is the production of a minute wound, which is , filled by a foreign body. The soluble sutures, of which catgut may be taken as a type, at first act as a foreign body, but after a time are dissolved by the tissues, and the gap left by their removal becomes filled with scar tissue. Insoluble sutures, such as silk, persist indefinitely unless removed, and finally are sur- rounded, infiltrated, and encapsulated by scar tissue. PROCESSES OF REPAIR. 275 Soluble sutures. The introduction of the suture produces a minute wound. Along the track of the suture, extending into the tissues for some distance beyond it, and also extending into the clefts of the suture itself, comes an in- flammatory exudate. The suture itself becomes swollen and fibrillated, and finally begins to dissolve. By the third day a la3'er of granulation tissue appears about the suture. In this granulation tissue very few, if any, giant cells are seen. The granulation tissue advances, while the suture disappears, and the exudation is absorbed, until finally no remnant of suture can be seen and the ti'ack of the suture is occupied by granulation tissue, which becomes fibrillated and is con- verted into a white scar. The length of time required to effect the complete removal, of absorbable su- tures is variable. Small-sized, plain catgut requires approximately twelve days; larger sizes take somewhat longer. Chromicized catgut takes a variable time, dependent upon the degree of chromization, and in some cases the suture may be rendered practically insoluble and may persist for months or even years. Soluble sutures which become infected by pyogenic organisms are absorbed much less rapidly than sutures which remain aseptic. Insoluble sutures. As in the case of the soluble sutures, the first effect is the production of a minute wound containing a foreign body. Into this wound comes an inflammatory exudate. The exudate extends for some distance into the surrounding tissues and also into the meshes of the suture. In a few hours granulation tissue is formed at the periphery of the woimd and extends toward the suture, and finally the exudate disappears and the granulation tissue sur- rounds and extends between the fibres of the suture. In this granulation tissue are many giant cells. These giant cells may persist for months or years. In the case of superficial sutures, which are removed at the end of ten or twelve days, there is left a minute wound lined with granulation tissues, and this wound in a very short time is filled with new granulation tissue. Insoluble sutures, which are fibrillar like silk, are surrounded ana everywhere enmeshed by the scar tissue which penetrates between the fibres. Sutures like wire, horsehair, or silkworm gut are not fibrillar, and no enmeshing by the scar tissue takes place. C. Wounds of the Intestine. When any portion of the intestinal tract is wounded, it is essential that the wound be closed at once in such a way as to render the wall of the intes- tine watertight as soon as possible, so as to prevent leakage of the infectious contents. Consequently, many methods have been devised for securing me- chanical closure as perfect as possible — it is, however, never absolutely perfect; and the serous surfaces of the cut edges always are approximated, because, if mucous-membrane surfaces are brought together, repair does not begin imtil the epitliel-ium has been sloughed off; while, when the external (serous) sur- 276 AMERICAN PRACTICE OF SURGERY. faces are approximated, the production of fibrinous exudate is very rapid, and in a very few liours the wound is rendered watertight, provided it be not sub- jected to too much mechanical tension. Many methods of suture have been de- vised for closing the mtestine. In some cases the suture may penetrate all the coats of the gut, but these sutures are, as a rule, applied merely to give fixation of the wounded edges. The sutures which approximate the serous surfaces of the intestine should not extend from the lumen of the intestine to the peritoneal cavity, for if they do they make a wound that is connected with the infected intes- tinal canal, and infection along the suture may lead to infection of the general peritoneal cavity. The best suture is one which gives the strongest and_ most perfect immediate mechanical closure of the wound without allowing any con- nection of infected intestine with the peritoneal cavity, and also gives the most perfect approximation of the edges of the external serous coat without diminu- tion of the calibre of the intestine. It may be said that without doubt the best suture material is, on the whole, silk or celloidin, as animal sutures soften so early that they do not maintain perfect approximation mitil the wound is com- pletely organized. Mechanical devices should be used only for special clinical reasons. The process of repair is the same, no matter what mechanical method is used, but the process which I have described above is such as is seen after suture. In intestinal wounds the mucous membrane is inverted and the serous sur- faces are approximated. The interval between the approximated serous sur- faces thereupon quickly fills with inflammatory exudate, and all layers of the cut intestine are infiltrated. In a few hours the endothelium of the serous mem- brane becomes necrotic between the sutured edges, as well as for a considerable distance beyond the line of incision, and the latter can no longer be recog- nized. Exudate covers the external surface of the gut for a considerable dis- tance beyond the wormd, and thus in a few hours the wound becomes imper- meable to fluids, if too much tension be not applied. The inverted mucous membrane becomes necrotic, and always is more or less infected. Through a process of necrosis the invaginated portion of the gut becomes dissolved. In a very few hours (twenty-four) a marked proliferation of the connective tissue, chiefly of the subserous connective tissue, takes place, together with a new formation of blood-vessels. This granulation tissue very rapidly extends into the exudate between the inverted serous surfaces, and in a relatively short time, often by the seventh day, the exudate is entirely removed and re- placed by granulation tissue. Wliile this is taking place, the inverted edges have sloughed, forming an ulcer on the inner surface of the gut, beneath which granulation tissue also forms. The intestinal epithelium at the edges of this ulcer proliferates and extends over the surface of the ulcer, just as does epithe- lium in ulcers of the surface of the body. Wliile these changes are taking place inside the gut, the exudate on the outside also has been replaced by granulation PROCESSES OF REPAIR. 277 tissue. Finallj^, the granulation tissue between the inverted serous surfaces be- comes dense scar tissue, and the internal ulcer is covered by intestinal epithe- lium, which even may form imperfect glands. In time, the restoration is so complete that it may be impossible to find the site of the wound by gross examination. The healing usually proceeds more rapidly than it does in wounds of the sur- face of the body. The wound is sealed by fibrinous exudate within a very few hours, although, of course, the fibrin can easily be displaced under great tension. In many cases the organization of the exudate is completed in seven days, al- though it is to be remembered that granulation tissue at this time still is very fragile. Rapidity of union is favored by accurate approximation of serous sur- faces and by avoiding, as far as possible, any manipulation that might disturb the approxuTiated edges. D. Repair of Tendons. Tendons, aponeuroses, and ligaments are special types of connective tissue. What has already been said about the repair of connective tissues in wounds ap- plies in a general way to the repair of tendons, but tendons are connective tissue with a special function and a special structure, and the details of the process of repair, in these structures, vary somewhat from the process as seen in, e.g., sub- cutaneous connective tissue. It will, therefore, be proper to make special men- tion of some of these details. To understand the process of repair it is necessary to bear in mind the anat- omy of a normal tendon. Tendons are composed of the densest sort of fibrous tissue arrayed in parallel bundles, closely connected, with relatively few elastic- tissue fibres. Surrounding the tendons is a layer of loose areolar tissue (the peritendineum), from which septa run into the tendon, dividing it into larger (secondary) and smaller (primary) bundles of dense fibres. These dense fibres appear, under the microscope, wavy from contraction, and anastomose more or less with one another. Between the fibres are cells which on long section are oval or rectangular, but on cross section are stellate, and are united to other similar cells by processes, thus separating the fibres into bundles. When a tendon is divided there always is considerable retraction of the di- vided ends. This is due partly to contraction of the muscle of the tendon, and partly to contraction of the fibres of the tendon itself. The peritendineum sel- dom retracts to the same extent as the tendon, but becomes markedly fibrillar and folds over the retracted end of the tendon. Into the interval between the retracted tendon ends comes an inflammatory exudate, with perhaps some hemorrhage. The mesh of the peritendineum is filled with exudate, but this exudate extends only a little way into the cut ends of the tendon itself. Very early there begins a rapid proliferation of connective-tissue cells from the connective tissue of the mesh of the peritendineum, not only between the re- 278 AMERICAN PRACTICE OF SURGERY. tracted ends of the tendon, but also from the peritendineum outside the tendon ends, thus forming a spindle-shaped swelling much like the callus of a fracture. At the same time new blood-vessels are formed. In this spindle of granulation tissue intercellular fibrils appear very early to an extent much more marked than in ordinary connective tissue. The cells of the tendon take very little part in this process of proliferation, and the original dense fibres of the tendon not at all. There is, however, marked proliferation of the connective-tissue cells of the connective-tissue septa of the tendon, which extend between the dense fibres of the tendon proper. As the proliferation continues the exudate disappears, and finally the cut ends are joined by a spindle of granulation tissue. The blood- vessels disappear very early, granulation-tissue fibrils are formed in large amounts, and a spindle of dense, fibrous tissue joins the cut ends. In time, the new intercellular fibrils cannot be distinguished from the original tendon fibres, the new tissue becomes of the same size as the original tendon, and cannot be distinguished by the naked eye from the uninjured tendon. The time required for the process is variable, depending upon the size of the tendon and upon the amount of separation. The formation of completely or- ganized, dense, fibrous tissue in smaller tendons is completed in about two weeks. In larger tendons the process covers a somewhat longer period of time. In practically every case the tendon is sufficientlj^ regenerated to allow passive motion in about three weeks. In some cases tendons fail to unite or may unite imperfectly. If the cut ten- don ends are too widely separated, the connective tissue reproduced by adjacent connective tissue may interpose, and the gap be filled with ordinary scar tissue instead of with connective tissue arising from the peritendineum; or again, even if the two tendinous ends become united with new tendon derived from the peritendineum, the new tissue may become adherent to the new connective tissue of the adjacent skin, etc., and thus imperfect function may result. Also, where several tendons are divided in one wound, e.g., in accidental wounds about the wrist, especially if the tendons are divided in some place where the tendon sheaths are not sharply defined, the newly formed tissue between the ends of adjacent tendons may unite into one common mass, thus leading to very im- perfect function. In the same way, even when only one tendon is divided, it may adhere to the connective-tissue wall of its sheath. In the case of tendons lying m sharply defined sheaths, a large amount of separation is possible. In cases where several tendons lie close together, less separation is possible. In such cases it often is better to fill the gap by some one of the many methods of splicing the tendon, in order to be sure that the line of the tendon is main- tained by peritendineum from which the new tendon is to be formed. PROCESSES OF REPAIR. 279 E. Repair of Fractures. The bones, like the tendons, are essentially a modified connective tissue with special functions, the first of which is to furnish support ; the second is connected with the function of production of the blood corpuscles. The supporting part of the bones is a modified connective tissue, in which lime salts are deposited. To understand the process of repair of injuries to bone, it is necessary to bear in mind the minute anatomy of the bones. The bones consist of a supporting framework, rigid from the presence of lime salts, and of a soft central portion, the marrow. On the external surface of the bone is a thin layer of peculiar structure, corresponding to the "bast" of a tree — the "periosteum." This external la}^er is one of the two actively growing por- tions of the bone. Lining the inner surface of the supporting, portion of the bone are cells which have the same function of bone production as the deeper cells of the periosteum, the "endosteum." The calcified portion of the bone forms an external dense shell, or "cortex," surrounding the more or less open central "marrow cavity." From the inner surface of the cortex irregular beams or "trabeculte" of bone extend inward, especially near the articular ends of the marrow, forming an irregular meshwork of rigid beams, which adds to the strength of the bone and serves as a support. The trabecule make an irregular meshwork of bone, but the spaces of the mesh are not closed spaces, but irregu- lar spaces connecting one with another, although the course of the communica- tion may be very devious. The relative amount of supporting trabeculse varies in different bones and in different portions of the same bone. In the flat bones of the skull, and in the short bones, the meshwork of the trabeculse is relatively large and is fairly uniformly distributed. In the long bones, in the articulating end, the trabeculse are numerous, and form a rather dense internal meshwork of bone, which adds to the strength of the structure. The trabeculse in this portion of the bone are not arranged irregularly, but are distributed in such a way as to give the maximum of strength, l^eing arranged roughl}^ along the lines of " stress and strain," much as an engineer would arrange the structure of a bridge or der- rick. The character of the marrow varies at different ages, and in different bones at the same age. In infants and young people the marrow is red and con- tains many hemopoietic cells. In adults the marrow of the long bones is yellow, and consists chiefly of fat cells. The marrow of the short bones more closely resembles the red marrow of children. In old people the marrow often is of a myxomatous structure. The marrow consists of a framework of connective tis- sue, supporting blood-making or fat cells. The periosteum is a membrane sur- rounding the cortex, composed of a deep layer of polygonal cells, which have the power of depositing bone, while the outer layer is fibrous, much like dense fibrous tissue. The periosteum is the seat of the peripheral growth of bone. The inner surface of the cortex and the trabecule are lined with a membrane of cells (the 280 AilERICAN PRACTICE OF SURGERY. endosteum), which have the same function for the internal surface of the sup- porting frameworlv that the periosteum has for the periphery. Under normal conditions the endosteum may be undemonstrable in ordinary sections, but in bone that is undergoing repair this internal osteogenetic layer is clearly visible. The cortical bone has a laminated structure, and at intervals between the 1am- inai are open spaces, or "lacuna," in which lie living bone cells, or "bone cor- puscles." The lacuna? communicate one with another by delicate canals, or "canahculse," in which run processes of the bone corpuscles. In places in the cortical bone are open canals of larger size, surrounded by concentric bone lam- ins, "Haversian canals," in which blood-vessels and nerves run. The spaces be- tween the trabeculfe are the "alveolar spaces." The bones develop in different ways. Most of the bones are preformed in cartilage, arising from mesoblastic cells, and finally become converted into true bone. This process of ossification in the long bones begins at the middle of the shaft, and extends in both directions toward the ends of the bone. Consequently the ends of the bone persist as cartilage long after the shaft is ossified. These cartilaginous ends form the "epiphyses." The intermediate line between the epiphysis and the ossified shaft, or diaphysis, is the so-called epiphyseal line, and is the point at which new bone is formed to increase the length of the bone. Some of the bones, notably the bones of the vault of the cranium, are not preformed in cartilage, but are formed directly from mesoblastic cells, without the intervention of cartilage. These are the so-called "membranous bones." The process of repair by the osteogenetic tissues, although essentially the same as that which takes place after a fracture of bone or after its partial or complete removal, differs from it, nevertheless, in certain details ; hence the two processes will be described separately. Fractures. If a bone is fractured, usually the broken ends are more or less displaced, fragments of bone may lie loose in the tissues, and there usually is more or less stripping of the periosteum, and crushing of the adjacent soft parts, with some hemorrhage ; i.e., there is not only an injury of the bone, but also a more or less extensive injury of the soft parts. After a few daj's a fusiform mass (cal- lus) is formed about the broken ends, and persists for a variable length of time, constantly becoming more rigid and dense. After the ends of the bone are firmly imited, the callus disappears more or less completely, and, if the broken ends have been accurately approximated, the external appearance of the bone be- comes normal. The details of the reparative process are best studied in bones in which a loss of tissue has been produced without dislocation or displacement of fragments, e.g., by drilling a small hole vertically into the shaft of a bone of an animal. In this way the process can be studied in its simplest form and the more compli- cated process of repair in complete fractures will then be more easily understood. In experimental drill holes the first result of the injury is hemorrhage into PROCESSES OF REPAIR. 281 the hole, followed in a few hours by an inflammatory exudate of leucocytes, serum, and fibrin. By the second day a proliferation of periosteal cells and of the endothelium of adjacent blood-vessels begins, both on the outside of, and within, the cortex of the bone. The proliferation of cells external to the cortex arises from the cells of the periosteum at the periphery of the drill holes, and results in the formation of a mass of tissue, thickest over the hole and thinnest at the edges. Among these proliferated periosteal cells are numerous young blood-vessels. This mass of new cells and vessels forms the earliest stage of the " external cal- lus." The internal proliferation arises from the layer of cells of the marrow which lies next to the cortex and trabeculae (endosteum); it forms a mass of cells about the drill hole, and is thickest opposite the hole. This is the so-called " in- ternal" or "myelogenous callus." In this callus also may be numerous new blood-vessels. Besides the proliferation of osteogenetic cells (periosteal cells externally and the endosteal internally), there is a proliferation of ordinary connective tissue. The cells derived from this ordinary connective tissue can- not at first be distinguished by their appearance from the cells of osteogenetic origin. (See Plate A.) By the fourth day, in both the external and the internal callus, there ap- pears, between the osteogenetic cells, a homogeneous intercellular substance. This homogeneous substance ("ostoid") marks the beginning of new-formed trabeculse, for in a short time lime salts are deposited in this material. As the process continues, some of the proliferated cells are retained in the mass of cal- cified material and become bone corpuscles. Other cells, at the periphery of the calcified, homogeneous material, deposit successive layers of osteoid tissue upon the external surface of the young trabeculae, producing a steady increase in size. These bone-depositing cells are the osteoblasts. The spaces between the newly formed trabecule (marrow spaces) are filled with spindle-shaped yoimg connec- tive-tissue cells, probably not of osteogenetic origin. At this stage the old cor- tical bone takes practically no part in the process of proliferation, but the drill hole is filled with granulation tissue derived from the periosteum and endosteum. By the end of a week the exudate usually has almost entirely disappeared. Numerous well-developed young trabecule are formed in the external and in- ternal callus. The drill hole is filled with granulation tissue of osteogenetic origin, one part of it arising from the external callus and growing inward, while the other arises from the internal callus and grows outward. In this granulation tissue osteoid tissue appears between the cells and forms the basis of new trabec- ulte, which are to replace the defect in the cortex caused by the drill. The corti- cal bone itself remains practically inert and does not assist in the formation of new bone. The trabecule at this period are arranged, in a general way, at right angles to the course of the laminae of the cortical bone. The surface of the trabeculae is studded with osteoblasts. Other cells, larger than the osteoblasts, with many nu- clei, are fairly numerous at this time. These giant cells or osteoclasts usually lie 282 AMERICAN PRACTICE OF SURGERY. in little bays or depressions on the surface of the new trabeculae, and have the power of dissolving or destroying the bony tissue of the new trabeculte. As a re- sult of the activity of these two varieties of cells— osteoblasts and osteoclasts — two processes are going on at the same time in the bony portion of the callus : bone formation by osteoblasts, and bone destruction by osteoclasts. Consequently, the form of any given trabeculae. is constantly changing. The tendency of the two processes is so to arrange the new bone that it shall take up weight to tlie best ad- vantage with the smallest amomit of bone. Finally, in the course of three or four weeks, the new trabecular which are formed in the granulation tissue between the broken cortical ends become attached to the cortex, and completely fill the de- fect caused by the drill hole. The external callus, therefore, no longer is neces- sary to maintain the strength of the bone, and by the action of the osteoclasts is absorbed and nearly or entirely disappears. The same is true of the internal callus. The trabeculte in the drill hole, by the combined action of osteoblasts and osteoclasts, come to be arranged in the same general direction as the trabec- ulge of the original cortex, and repair is practically completed. The bone which fills the drill hole continues to become denser for many months after the injury, and finally it replaces the old bone so perfectly that it is difficult to determine the point of injury. (See Fig. S3.) In the simplest process of repair of an experimental drill hole, the transition from granulation tissue of osteogenetic origin to bone is direct, without the in- tervention of cartilage. This process corresponds roughly to the formation of bone as it is seen in the so-called membranous bones. In many cases of simple injury of bone by the drill, however, the process produces granulation tissue of osteogenetic origin, as already described: but this granulation tissue becomes at first converted into cartilage. In this case some of the cells become sur- rounded by a homogeneous, intercellular material, in which lime salts are not deposited. Some of the cells included in this matrix take on the appearance of cartilage cells, and in this way both external and internal callus may at first be formed of hyaline cartilage to a greater or less extent. Later, as the process advances, this cartilage becomes converted into bone. In fractiu-es in animals, in which the fracture is complete, and probably in all human fractures, this forma- tion of bony callus via cartilage is always the course of a greater or less part of the callus. In complete fractures of bone the general process of repair is the same as that observed in experimental drill holes, Ijut the details vary somewhat. In complete fractures the ends of the bones are nearly always somewhat dislocated, so that perfect approximation of the ends seldom occurs, and as a rule the injury to the soft parts is excessive. ^Yhen cell proliferation begins it arises internally from the endosteum ("medullary callus"), and externally both from the periosteum and from the connective tissue of the adjacent soft parts ("external callus"). The external callus appears relatively nmch largei' than in drill-hole fractures, and EXPLANATION OF PLATE A. Repair of Fractures. (Experimeiital.) Transverse section through a vertical drill-hole in the femur of a rabbit. Condition after the lapse of eight days. 1, Drill-hole filled with loose fragments of bone and granulation tissue; 2, remnant of fibrin from inflammatory exudate; 3, margin of drill- hole in cortical bone — no proliferation of this dense bone: 4, internal callus, arising from endosteum; 5, 5, external callus, arising from periosteum, and being partly preformed cartilage and partly a direct bony formation; 6, scar tissue in marrow canal, coming chiefly from reticulum of marrow; 7, 7, cor- tex of-femur. (Original.) AMERICAN PRACTICE OF SURGERY PLATE A ri,"V'^ PROCESSES OF REPAIR. PROCESSES OF REPAIR. 283 forms a large, fusiform mass, including the fractured ends. At first no distinc- tion can be made between the cells which arise from the periosteum and those which arise from the soft tissues. WHren ti'abeculce form in the callus they may form directly from the osteogenetic granulation tissue, as in the simplest form of drill-hole fracture ; or, more often, the first step is a conversion of the granu- lation tissue into hyaline cartilage. As the process advances, the deeper layers of this cartilage — those nearest the cortical bone — are converted (metaplasia) into bone, and the process continues until the greater portion of the callus be- "P^^i^^ c*.'^yT>«a^.«^ Fig. S3. — Repair of Fractures. (Experimental.) Transverse section tlirougli a \'ertical drill- "hole in tlie femur of a rabbit. Condition after tlie lapse of twenty days. 1, Drill-hole filled with newly formed trabeculce, derived from external and internal callus ; 2, external callus wliich has under- gone partial absorption; 3, internal callus partly absorbed; 4, new bone which replaces lost bone, adherent to original cortical bone : 5, similar condition, artificially separated from original cortex, showing that union is insecure for some time. Notice that new trabecul^e are beginning to assume a position like that of the original bone. (Original.) ■comes bone. The same process may be seen, although usually not so well marked, in the internal callus. As in experimental fractures, the cortical bone of the fractured ends remains practicalh^ inert, and takes no part in the pro- duction of the new trabeculae, which arise almost entirely from the periosteum and endosteum. The trabecule from these two bone-forming layers extend between the broken ends, and finally become attached to the cortical bone, and more or less completely restore the line of the cortex. At first, this new bone is composed of young trabeculse, studded with osteoblasts and osteoclasts, with narrow spaces between the trabeculfe filled with spmdle-celled connective 284 AMERICAN PRACTICE OF SURGERY. tissue. The trabecular often are arranged at right angles to the line of the laminae, of the cortical bone. Ultimately, the narrow spaces disappear as the trabecule increase in size, and by growth of the trabeculse new dense cortical bone is formed to replace the defect caused by fracture. By the combined ac- tion of osteoblasts and osteoclasts, the laminae of this new dense cortex resume the same general direction as the laminae of the injured cortex, provided the fractured ends have been accurately approximated. The ultimate fate of the bone of the external callus depends upon the accu- racy of approximation of the fractured ends of the bone. If they are so ap- proximated as practically to restore the original contour of the bone, after a time there is marked or complete absorption of the external callus, and the bone resumes its original contour. If, however, the dislocation of the fractured ends is extreme and is not reduced, much of the external callus persists after bony union has taken place, and the laminae of the callus which persists are not paral- lel to the laminae of the unbroken cortex, but are arranged in such a way as to take up weight to the best mechanical advantage. A persistence of a marked amount of external callus always indicates malposition of the fractured ends. This fact is of great clinical importance. The time required to repair any given fracture depends upon the size of the fractured bone, upon the accuracy with which the ends are approximated, and upon the care and perfection with which they are immobilized. In some cases bony union is delayed for long periods, or, indeed, may never take place. In many cases the reason for failure to unite is not clear. Some- times it appears to be due to the inclusion of soft tissues between the broken ends, thus preventing the union of the two sides of the external callus. This cause, however, certainly is a rare one. In other cases tissue having the struct- ure of bone (osteoid tissue) forms an external callus, but no deposit of lime salts takes place. The cause of this is unknown. In some cases the fractured ends are united by dense scar tissue only, without any bone formation. This pro- duces a flail-like joint, or "syndesmosis." Or one fractiu-ed end may enlarge and form a false socket, while the other end forms a false head, both contained in a capsule of dense fibrous tissue, forming a sort of synovial cavity, or false joint, ("pseudo-arthrosis"). The two articulating ends generally are covered with a layer of dense fibrous tissue, and not with cartilage. Sometimes, when two adjacent bones are broken, the two calluses may unite to form one single callus, and thus the two bones are firmly united ("synostosis"). The gross appearance about a fracture corresponds to the histological condi- tion already described. The swelling of the soft parts which appears at the end of a few hours is due to the presence of an inflammatory exudate in the injured soft tissues. The blebs and bullae which may appear in a short time are due to elevation of the superficial layers of the skin by the fluid exudate, which extends toward the surface. If the injury to the soft tissues is severe, the overlying skin PROCESSES OF REPAIR. 285 may be discolored bluish at once from deep hsematoma, or it may become black and blue after a few days from disintegration of a deep hemorrhage, with diffu- sion of blood pigment. As the exudate diminishes the tissues about the broken ends become thickened from cell proliferation, and form a spindle-shaped thick- ening (granulation-tissue external callus), composed of ordinary granulation tissue and of granulation tissue arising from the periosteum. At first, this callus is firm and elastic, but not bony. After about two weeks the callus obviously becomes harder and more sharply defined (ossification of deep portion of callus derived from periosteum). At this time the fragments, which at first are freely movable, are much less so, and move only under strong pressure. After a vari- able number of weeks, depending upon the site and severity of the fracture, mobility entirely disappears (restoration of cortical defect), although the callus persists. At this time the bone is strong enough to bear weight. In the course of months the callus progressively becomes smaller, and finally may largely or entirely disappear if the bones are in perfect position. The amount of callus which persists is proportional to the amount of deformitj^ There are certain principles of treatment of fractures which depend upon the above-described conditions. The first essential is to secure as perfect as possible approximation of the frac- tured ends. The more perfect the position of tlie fracture, the smaller the exter- nal callus and the shorter the time required for completion of repair of the bone. The more perfect the position, the less is the interference with the soft tissues, and in all fractures it is to be remembered that there is injury not only of bone, but of soft tissues. As regards the reduction of the deformity, it should be borne in mind that attempts at reduction more than two weeks after injury are likely to give poor results. During the earlier stages the callus is soft and not ossified. After the second week bone formation is well advanced, the ends of the bone are included in the spindle-shaped callus, are not freely movable as at first, and forcible correction causes injury to the newly formed bone and prolongation of the process of repair. Perfect immobilization also is essential. The less the callus is interfered with, the greater is the rapidity of repair. In case of fracture about tendons or into the articular surfaces of joints, other mechanical problems enter in, so that early mobility may be necessary and the importance of rapid ossification may hold a secondary place. Regeneration of bone. As has been said already, growth in diameter of bone is dependent upon the periosteum. The calcified bone itself is practically inert. In cases in which there has been extensive destruction of bone, advantage may be taken of the power of the periosteum to produce new bone to replace loss. Oilier has shown that if the entire shaft of a healthy bone of an animal be removed subperiosteally, leaving the periosteum intact, the periosteum will produce new bone exactly similar in outline to that portion of the bone which 286 .\iIERICAX PRACTICE OF SURGERY. has been removed. In the .same way, if an enthe diaphysis, e.g., of a long bone, is destroyed by disease, e.g., by acute suppurative infection (acute suppurative osteomyeUtis), advantage can be taken of this fact to bring about a complete regeneration of bone to replace the lost tissue. The vitality of calcified bone is very much lower than that of the surroimding periosteum. Various diseases (osteomyelitis, tuberculosis, sarcoma) may cause the death of a considerable portion of any bone. The dead bone loses its power of performing its function of supporting weight. In that case the periosteum surrounding the necrotic bone proliferates to form new bone to take up the weight-carrying fimction. The dead bone persists as a foreign body, while the periosteum forms a cylindrical layer of new bone, of a structure like that of the bone seen in the external callus, about the dead bone. The dead bone persists as a "sequestrum," surrounded by a cylindrical " involucmm" of new periosteal bone. The involucrum at first is soft, like the early external callus, and contin- ues to thicken until the diameter of the new bone equals or somewhat exceeds the diameter of the original shaft. As the involucrum becomes older it becomes denser, like ordinary cortical bone, which, as has already been sho^-n, has very limited power of repair. The sequestrum usually is coimected with the surface of the body by various "sinuses," which perforate the involucrum at various points. At any of these stages, i.e., early necrosis, early periosteal proliferation, or in the stage of involucrum and sequestrum, it is possible to take advantage of the regenerative power of the periosteum and endostemn to bring about com- plete regeneration of bone. In all cases it first is necessary to remove the necrotic bone, which acts as a foreign body. After the necrotic bone has been removed, the intact periosteum should be approximated so as to bring the internal surfaces together and to leave no central cavity. The growth of the periosteum is peripheral, and new bone, like the external callus, is formed, until there is produced a shaft of perios- teal bone which slightly exceeds in size that of the original shaft. As the bone becomes harder as it grows older, there is some absorption of the bone, mitil ulti- mately the new bone is of the same size as the original shaft. The new bone at first is solid bone without a marrow canal, but finally, so far as can be judged from x-ray pictures, there is an absorption of the bone in the centre of the shaft, and a new marrow canal is formed. The notable thing about this proc- ess of bone regeneration by the periosteum is that the new bone is of exactly the same shape as the original bone, and cannot be distinguished from it even by touch, sight, or the .r-ray. This suggests that the shape of the bones of the human skeleton is due to two causes— heredity and environment, or function. Hence when a bone is removed the new bone which is formed is of the shape which performs function to the best advantage. This is true of very compli- cated bones, and even of complicated joints which are excised subperiostealh^ In some cases in which the involucrum is old it has limited power of repair, PROCESSES OF REPAIR. 287 and in such cases both involucrum and sequestrum must be removed, to give the periosteum a chance to form an entirely new bone. F. Repair of Muscle. After a wound of striated muscle there comes, as in all injuries of the soft tissue, an Lnflammatorj' exudate. In the cotirse of a few hours there arises a new growth of granulation tissue from the adjacent connective tissue and also a peculiar series of changes in the muscle itself. Some of the muscle fibres next to the wound become necrotic; they are invaded by polynuclear leuco- cytes and endothelial cells, dissolved, and removed. In some of the other muscle fibres there occurs an increase in the number of the nuclei, which arise not by mitosis, but by direct nuclear division. These nuclei arrange themselves in the ends of the muscle fibres, and, instead of having a mural arrangement like that of the nuclei in normal muscle fibres, are situated in the middle of the fibre. The fibre itself loses its strise, and becomes more or less fibrillated longi- tudinally. The greater portion of these cells finally disappear, so that in the granulation-tissue scar only an occasional club-ended -fibre is left, and the defect in the muscle is replaced by granulation tissue, which ultimately becomes scar tissue. If the ends of the muscle are accurately approximated, the scar is a small one and Interference with muscle fimction is slight. If the ends of the muscle are widely separated, there may be great impairment of function. G. Repair of the Heart. In wounds of the heart the muscle fibres take no part in the process of re- pair, but the defect is filled by granulation tissue, which finally forms a scar. Adhesion to the pericardial walls is common. H. Repair of Blood-\'essels. Wounds of vessels of large size present a condition somewhat different from that of woimds of other tissues, since the walls contain no small vessels except in the adventitia coat, so that the early adhesion of the edges of the wound is not produced by an inflammator}' exudate in the ordinary sense of the word, but is due to fibrin which arises from the circulating blood in the vessel itself. The conditions vary somewhat in arteries and veins, and -with the character of the injur}-, i.e., whether there is complete division of the vessel, or a lateral wovmd, or a rupture of the internal coat. In arteries complete division of the wall by a sharp instrtmient of course leads to ■\.aolent hemorrhage, which may cause death in a short time. In complete di- vision of an arterj' by tearing or by similar \'iolence, however, extensive hemor- rhage as a rule does not take place, and may be absent even in clean cuts, because the ends of the vessel retract into the surrounding tissues, while the walls of the vessel become occluded by the formation of a clot, composed of fibrin derived from the blood in the vessel and enclosing red blood globules and a few leuco- 288 AMERICAN PRACTICE OF SURGERY. cytes. In wounds in the wall of an artery the hemorrhage takes place into the soft tissues about the point of injury, and coagulates, so that finally the edges of the vessel wound are sealed together by a layer of fibrin. Within the lumen of the vessel there may be simply a thin peripheral clot at the point of injury, covering the wound; or in other cases, especially if the endothelium is exten- sively injured, a thrombus may form, of such size as to occlude the vessel. In ligature of a vessel which is completely divided there is formed, at the point of ligature, a clot, the size of which is variable, depending upon the rapidity of cir- culation, the amount of injury to the endothelium, and the perfection of the asepsis. After the formation of the thrombus the later stages are like those of any wound; i.e., the clot, which is essentially- an inflammatory exudate, in which red blood globules are overwhelmingly predominant, becomes converted into organized tissue. If the clot is a small one, situated peripherally, the surface may be covered by newly formed endothelial cells, while the deeper layers of the clot are replaced by newly formed connective tissue derived from the media and adventitia. If the clot is of large size and completely fills the lumen of the ves- sel, the surface of the clot toward the blood stream is covered with endothelium growing from the walls of the vessel, while the clot itself becomes organized by granulation tissue. The lumen of the vessel beyond the point of obstruction undergoes a slow diminution in size through an obliterative endarteritis. In some cases, in which the wound in the vessel is a lateral one, a large clot forms about the point of injury and pushes the surrounding soft tissue.s to one side, until the pressure becomes so great that no further hemorrhage takes place. The effused blood coagulates, and finally the periphery may become organized by granulation tissue arising from adjacent connective tissue. In some cases the centre of this area may remain patent and contain fluid blood, connected with the circulating blood in the patent vessel through the interval in the wall made by the wound, thus forming a false traumatic aneurism. In complete division of veins the divided ends usually are filled with a blood clot which becomes covered by endothelium, while the clot itself comes to be re- placed by dense scar tissue derived from the media and adventitia. In some cases, however, the amount of terminal clot is exceedingly small. In case of a lateral wound of a large vein, it often is possible to prevent severe hemorrhage by ligaturing the wound in the vessel. In that case the inner wall of the veins is puckered by ligature, and may be covered with a thin, peripherally placed clot, which may become organized without the formation of an obstructing and ob- literating thrombus. In all lateral wounds of vessels absolutely perfect asepsis is essential if one expects to obtain healing without complete thrombosis and obstruction. The presence of even a slight amount of infection is practically certain to cause suffi- cient injury to the endothelium to produce complete obstruction. In suturing PROCESSES OF REPAIR. 289 of vessels it is said that the projection of perfectly aseptic sutures uito the lumen of the vessel through the endothelium does not necessarily produce thrombosis, but that in many cases the sutures are very early covered with new endothelium. I. Peripheral Nerves. Section or destructive injury of a peripheral nerve causes an immediate traumatic local degeneration of the nerve at the point of injury. This is fol- lowed by a degeneration throughout the extent of the nerve peripheral to the point of injury, and a degeneration of the fibres proximal to the point of in- jury, extending no farther than the first few nodes of Ranvier. There also occur changes in the cells of origin of the degenerated nerves, resulting in an effacement of the granular structure of the nerve cell body, with displacement of the cell nucleus to the periphery of the cell — the so-called "axonal reaction" of Nissl. Following the degeneration occur regenerative changes in the nerve, which may lead to a restoration of function. The eictent to which this regeneration may occur depends somewhat upon the amount of injury to surrounding soft parts. If the injury is one which destroys the integrity of the nerve fibre, with- out destroying the continuity of the nerve sheath — e.g., crushing injuries — the regeneration of the nerve is more rapid and certain. If the nerve is cut across and the ends are sutured together, regeneration is more likely to occur than it is if the ends retract and become widely separated, or if suppuration occurs so that the ends are separated by a wide zone of granulation tissue. If the peripheral end of a nerve is entirely removed, as, e.g., in an amputation, a peculiar partial regeneration of the proximal portion may occur, resulting in an "amputation neuroma." After the receipt of an injury there comes a traumatic degeneration of the nerve in the immediate vicinity of the injury. The amount of this degeneration depends upon the character of the injury, being, e.g., slight in a clean-cut wound and more extensive after a crush. Immediately after this change there comes a secondary ("paralytic") degeneration of the nerve, extending in either direc- tion from the point of injury. On the central side of the injury the degeneration extends upward to the nearest nodes of Ranvier. On the peripheral side the degeneration extends throughout the entire extent of the nerve. The degenerative changes produce a fragmentation and fibrillation of the axis cylinder, and a fragmentation of the medullary sheath. Very early there also arises marked proliferation of the cells in the sheath of Schwann. The regenerative process begins after the degenerative process. It is difficult to say just how the new axis cylinders are produced, there being dispute upon this point; but the new axis cylinders extend gradually into the peripheral end. Most observers believe that the process of growth is like that in embryonal development, i.e., there is a constant peripheral growth. Others believe that the 293 AMERICAN PRACTICE OF SURGERY. new formation is, partly at least, the result of activity of cells in the sheath of Schwann. As a practical matter, the new fibres in the adult always arise from the central stump and extend peripherally along the track of the original nerve. The new fibres, as they arise from the central stmnp, tend to split into bun- dles of small neuro-fibrils, of which the original nerve is supposed to be com- posed. The direction of the new fibres may be modified by various mechanical obstructions, and also by an apparent attraction of the distal nerve remnant for the proximal nerve fibres. The fibres at first grow in the interstices between the cells of the scar ("neurotization of the scar"), which lies between ends of the nerve. If the scar between the ends is too dense, the new fibres may grew into the tissues in various directions, and never may be able to get into contact with the peripheral stump. In such cases no restoration of nerve fimction takes place. The tendency of the proximal axones to join the peripheral stump can be favored by various mechanical means, e.g., by the introduction of catgut sutures or hollow tubes, along the tract of the nerve, or by means of neuro- plastic flaps. Regeneration is obstructed by secondary infection with excessive formation of granulation tissue. The rate of regeneration varies somewhat, but is approximately at the rate of 1 mm. per day. J. Central Nervous System. As regards regeneration or repair of injuries to the central nervous system, while theoretically possible to a very slight degree, the amount of regeneration is so slight as to be of no surgical importance. The cause of the lack of power of central nerves to regenerate is obscure, but it is claimed to be due to the fact that the central nerve fibres do not possess a sheath of Schwann, which is es- sential in some way to the new formation of axis cylinders, and also to the fact that the neuroglia fibrils offer a mechanical obstruction to the advance of nerve fibres. TUMORS AND TUMOR FORMATION. Bij ALBERT G. NICHOLLS, M.D., CM., Montreal, Canada. Definition. — The term tumor in its literal sense means swelling. Any swell- ing, therefore, irrespective of its cause, might be called a tumor. Swelling, how- ever, as we know, is merely an external symptom and may be brought about by a great variety of causes, such as congestion, oedema, hemorrhage, inflammatory infiltration, deposits of various kinds, and the new formation of tissue. All the conditions mentioned have this in common, that the part is enlarged. In the old days, before the publication of "Die krankhaften Geschwiilste, " the wildest speculations were rife as to the causes of pathological phenomena, so that we are not surprised that many essentially unlike conditions should have been confused together. The word "tumor" was conveniently broad and noncommittal and, like charity, was made to cover a multitude of sins. It is curious how tradi- tional modes of expression will persist, for even yet we not infrequentl}^ speak of tumor albus, the ivhite swelling or tumor, when we mean tuberculous synovitis with effusion. The appearance, in 1863, of Virchow's epoch-making work, with its insistence on the doctrine of what is commonly known as the " cellular path- ology," laid the foundation of and pointed the way to a more adequate concep- tion of pathological processes, particularly cell proliferation. From this time modern pathology may be said to date. With the improvements in microscop- ical technique many additional facts have been recorded, and while many of Virchow's conclusions have been shown to be partial and even erroneous, the fundamental principles which he laid down have been confirmed and strength- ened. The result has been to restrict the term tumor to pathological new-forma- tions of tissue. But here a difficulty was soon encountered, a difficulty that cannot be said to be entirely cleared up even yet. This is, that certain inflammatory processes give rise to local swellings and some of the other phenomena that we usually associate with the idea of a tumor. Thus, in typhoid, malaria, and some other infectious diseases the spleen may be greatly enlarged as a result of prolifer- ation of tissue. The most notable example is, however, to be found in the so- called "infective granulomata." In tuberculosis, syphilis, actinomycosis, lep- rosy, and some forms of animal parasitism, we get localized nodules, associated often with great proliferation of cells, with central necrosis, which tend to spread and may even give rise to similar growths elsewhere. The resemblance to a tu- mor is therefore striking. More thorough investigation has served to draw a dis- tinction between cell proliferation, due to infective and other forms of irritative 291 292 AMERICAN PRACTICE OF SURGERY. inflammation, and tissue neoplasia due to none of these causes. What, then, con- stitutes the difference between an inflammatory neoplasm or granuloma and a tumor, using the latter term in its more restricted modern sense? An inflamma- tory granuloma can be traced to a definite cause, usually some micro-organism; it is reactive and its purpose benign, in so far as it is an attempt to neutralize the effect and repair the damage caused by the invading element ; the process goes on only so long as the cause is operative, and ceases when it has come to an end. A true tumor, on the other hand, is a new formation of tissue, due to no demon- strable cause; the vegetative power of the cells composing it is excessive and appears to be inherent ; the growth takes place Avithout regard to the neighbor- ing structures and is, therefore, a law unto itself; finally, it subserves no useful purpose in the body. We may, therefore, with Thoma, define a tumor shortly as an autonomous or indepeiident neiv-growth. The peculiar features of tumors are the following: (1) The majoritj' begin at some one point in an organ and subse- quently spread to neighboring parts. (2) They reproduce with more or less modification the tissues from which they spring. (3) They differ in physiologi- cal function from the part in which they are fovuid. (4) They cause pressure- atrophy and dislocation of the adjacent structures, or, again, lead to destructive infiltration. (5) They are particularly liable to retrogressive changes. (6) The tumor cells in many instances, when transplanted to distant parts, give rise to secondary tumors resembling in properties and appearance the original growth. Etiology. — Notwithstanding the fact that of late years our information in re- gard to tumors and tumor formation has been steadily increasing, the question of etiology still remains largely an unsolved problem. We know to some extent the general laws governing the proliferation of tissue. We are familiar with the ap- pearance and minuter structure of the various tumors. We can apprehend in some degree their mode of origin and method of extension. We have made some progress in differentiating the various forms. But, when all is said and done, it must be confessed that the essential cause has up to the present eluded discovery. We are still puzzling over the question. What is the force that in the first instance determines the cell proliferation in tumors? I do not propose here to enter the arena of controversy and discuss the various theories that have been advanced to explain tumor formation. This has been done very fully and competently in another portion of this work. I will, therefore, content myself simply with drawing attention to a few points that are of considerable practical importance. Leaving for the moment the benign tumors out of consideration, the surgeon is confronted by two undeniable facts. Carcinomata develop most frequently at the so-called ostia of the various portions of the alimentary tract, the lips, tongue, cardia and pylorus of the stomach, the ileo-c£ecal valve and anus; in ducts and hollow viscera, as, for instance, the bile ducts, the gall bladder, theurinar}' bladder, TUMORS AND TUMOR FORMATION. 293 and the uterus. Tissues in all these places are subject to considerable meclian- ical and other irritation. We may conclude, therefore, that the influence of ex- ternal traumatism, using that term in its widest sense to include irritation from mechanical, thermal, chemical, and infective causes, is by no means unimportant. A great deal of evidence has accumulated to support this position. Carcinomata have, for instance, been known to develop in the cicatrices of burns, in the neighborhood of setons, in the bases of chronic ulcers and lupus patches, and at the orifices of sinuses. The irritation of soot (sweep's cancer), tar, and paraffin in the clothing occasionally sets up carcinoma of the scrotum. Epithe- liomata of the lip and tongue are not infrequently associated with irritation of the part by a pipe; carcinoma of the biliary passages is often accompa- nied by cholelithiasis; a chronic ulcer of the stomach may become malignant. Again, constant or repeated irritation may convert a benign growth into a malig- nant one. Yet, when we consider how often irritation of the same kind and in- tensity fails to produce tumor growth, we have to admit that irritation can only be the exciting cause, and that at the back of it all is some unknown force that deter- mines the fact of cell proliferation. The second point is, that many tumors arise in parts of the body where there are transition of epithelium, complicated infoldings of tissues, and the closure of devel- opmental fissures. At such places the cell equilibrium appears to be unstable. As examples may be cited : cystic tumors and epitheliomata occurring in the neck in parts where normally epithelium does not exist, in consequence of defective closure of the branchial clefts ; hypernephromata ; the heterologous tumors, such as chondromata of the mamma, parotid, and testis ; dermoid cysts of the ovary and testis, and other teratoid growths. In many cases it can be shown that the neoplasm originates in misplaced embryonic cells or " rests." With the increase in our knowledge of tumors, this class of growths has been greatly enlarged, and the " developmental" theory of tumor formation has probably the greatest number of adherents among pathologists. None, however, give it the wide application that Cohnheim has done. Not a few tumors have not as yet been satisfactorily accounted for on this basis, and in any case, even were the theory universal, the ultimate cause of the neoplasia remains unknown. The Gross Appearance of Tumors. — Tumors vary greatly in size. Some are microscopic, others may exceed in weight the individual in whom they are found. The shape is also variable, being in large part governed by external conditions. Tumors on free surfaces grow in all directions and tend to assume a rounded form. Those occurring in closed cavities accommodate themselves to the space in which they lie. Tumors may, therefore, be tuberous or nodular, lobulated, fungoid, polypoid, papillary, sessile, or diffuse. In regard to consistence, some are soft, friable, juicy, and brainlike; others firm, hard, fibrous, or stony. Differences in consistence and texture may be found in different parts of the same tumor. 294 MIERICAN PRACTICE OF SURGERY. Most new growths are white or gra3'ish-white in color. Some, however, are reddish, yellow, brown, green, or even black. As a rule, the substance of a tumor is sufficiently unlike that of the part in which it is found to render its detec- tion easy. Yet some, like the gliomata of the central nervous system, are with difficulty distinguished from the healthy tissues. The benign neoplasms are provided with a more or less complete capsule, while the malignant ones are badly defined and infiltrating in character. On section, tumors may present the features above mentioned, but may also in parts show evidences of retrogressive processes, fatty degeneration, caseation, liquefaction, hemorrhagic extravasation, colloid transformation, or even sup- puration. The Classification of Tumors. — There are few subjects in the realm of pathol- ogy more fraught with difficulty than this. For, as in so many other branches of science, so here, improved methods of investigation and more extensive informa- tion have resulted in the replacement of the crude ideas formerly in vogue by much more complex conceptions. Yet we cannot say that the steadily increas- ing knowledge we are gaining from day to day with regard to the structure and histogenetic development of new growths has been attended by a corre- sponding advance in our views as to the true nature of these formations. Various classifications, as numerous as the definitions of what constitutes a tumor, have been proposed, all of which have, in the light of modern investigations, been proved to be faulty in one or more important particulars. Four methods of classification appear to be possible: (1) According to etiology, (2) according to clinical peculiarities, (3) according to morphology and histogenetic development, and (4) on the basis of embryological differentiation. A classification on etiological principles, were it possible, would be strictly scientific, but it is hardly necessary to say that, in view of the obscurity that enwraps the question of the essential cause of neoplastic growth, such a classifi- cation is not at present practicable, nor, indeed, in my opinion, is it likely to be so useful as some others that might be devised. We may, then, dismiss this part of the subject without more ado. The clinical behavior of tumors enables us to lay down certain broad gen- eralizations that are unquestionably of value and convenience in any consider- ation of the nature of neoplastic growth. I refer to the common division of neoplasms into henign and malignant. A benign tumor may in general terms be defined as a slowly growing tumor, often encapsulated, which does not tend to invade neighboring structures, does not produce secondary growths in distant parts, and produces its symptoms chiefly by its bulk. A malignant tumor, on the other hand, is usually rapid in its growth, invades and destroys the adjacent tissues, is apt to form secondary growths in other organs, tends to necrose or ul- cerate, frequentl)' recurs after removal, and, finally, produces certain grave con- stitutional disturbances commonly included under the term cachexia. This class- TUMORS AND TUMOR FORMATION. 295 ification, while to a certain extent it subserves a useful clinical purpose, is open to the objection that it lays stress on a somewhat inconstant feature of tumors as a means of differentiation, to the exclusion of much more fundamental characters. As a consequence, tumors that have little in common in point of structure are brought into the same category. We know, for example, that chondromata and adenomata, both of which are usually regarded as benign growths, may, excep- tionally, give rise to secondary growths, which, however, do not markedly tend to infiltrate. In other words, they occasionally exliibit a limited tendency to malignancy. Again, certain tumors, notably pigmented moles, may be practi- cally identical in histological structiu'e with melanotic sarcomata and carcino- mata, and yet may persist for years without taking on excessive growth, though they may do so in time, when irritated. Their malignancy is, as it were, latent. Their place, therefore, seems to be intermediate between benign and malignant growths. The classification in question is, in fact, too wide to be accurate and is, moreover, as artificial and unscientific as the Linnsean classification of plants. Much more can be said in favor of the grouping of tumors on a morpho- logical basis, and this is the method which, in some shape or other, is the most popular among pathologists at the present time. With the advent of the newer "Cellular Pathologie" it became possible for the first time to attempt the classification of new growths on a rational basis, and with the improvements in technicjue, and the enormous increase in knowl- edge that has resulted therefrom, the principles originally enunciated by Virchow have been in a large measure placed upon a solid substratum of fact. Virchow, among other things, as a result of his investigations, pointed out that certain tumors conform more or less accurately, so far at least as their structure is concerned, with normal forms of tissue, while others show deviations, chiefly in the direction of being more cellular. The latter for the most part are malig- nant in nature with all the peculiarities which this implies. According to Vir- chow, then, we can recognize two main groups, the cellular tumors and the less cellular tumors. In the former, the component cells are greatly increased as com- pared with the corresponding normal tissues. This includes forms which are now termed sarcoma and carcinoma. The latter group was subdivided by Virchow into the histioid and organoid tumors. Histioid tumors are made up for the most part of cells resembling one of the normal tissues, while organoid tumors are com- posed of several tissues, normal in regard to their structure, and arranged after the fashion of an organ. This classification is important chiefly because it clearly indicates the agreement between normal and autonomous tissue formation. More complete study has shown, as Thoma has pointed out, that no tumor con- sists of only one tissue. All, for example, are provided with blood-vessels, and many of them with nerves, while at some part there is invariably a certain amount of connective tissue to be found. Hence, histioid tumors always have an arrangement similar to that of an organ, if it be only to a limited degree. The 296 AMERICAN PRACTICE OF SURGERY. distinction between histioid and organoid tumors may properly, therefore, be allowed to drop. From somewhat different considerations, Virchow again recognized two great classes of tumors: the homoplastic growths, which in structure closely resemble the normal tissues from which they arise, and the heteroplastic, which deviate widely from the normal. More complete investigations have shown, however, that perfect homoplasia never really exists, and that all true tumors — and in this category we would not of course place ordinary tissue hypertrophies — are to a greater or less degree heteroplastic. If it be granted — and for these conclusions we have ample proof — that every cell or group of cells is derived from some pre-existing cell ancestor, and, as a corollary to this, that every new growth has its prototype in a normal tissue, then it is possible to classify tumors according to their origin, and this is the funda- mental principle underlying what may be called the embryological method of classification. It is now well recognized that at a very early period in the development of the embryo the almost entirely undifferentiated cells of the morula become arranged into two layers, the primitive epiblast and hypoblast, indicating the future epi- derm and endoderm. Very soon the hypoblast, or innermost of the two primitive layers, proliferates and gives rise to a mass of cells, the mesoblast, which lies inter- mediate between the primitive epiblast and hypoblast. To these three primitive layers, epiblast, mesoblast, and hypoblast, can be traced the origin of all the tissues of the body. This being so, it is quite logical to classify tumors in the same way, and this in fact has been done, notably by Waldeyer, who recognized tumors of epiblastic, mesoblastic, and hypoblastic derivation. It was quickly found, too, that epiblastic and hypoblastic tumors presented many striking points of similarity, so that they have now come to be classed together under the designation of tumors "of epithelial type," as contradistinguished from those of mesoblastic origin and "connective-tissue type." Thus, both on embryological and on histological grounds, we can recognize two great classes of tumors, apparently sharply differentiated the one from the other, those of mesoblastic origin and connective-tissue type, and those of epithelial and glandular origin and of epithelial and glandular type. This is the most popular classification among pathologists at the present time, is withal practical and, so far as it goes, scientific. Both groups may be divided into benign and malignant. The benign connective-tissue growths include the 'fibroma, myxoma, lipoma, myoma, chondroma, osteoma, glioma, neuroma, ha:mangioma, lymphangioma. The malignant are the various forms of sarcoma, and the malignant myomata. The benign tumors of epithelial type include the papilloma, the adenoma, and cystadenoma. The malignant are the malignant adenoma, the adeno-carcinoma, carcinoma, and epithelioma. TUMORS AND TUMOR FORMATION. 297 To these may be added certain mixed forms, consisting both of epithehal and of connective-tissue elements, one or other of which may predominate. Such are the papillary fibroma, the papillary cystadenoma, the ade^io- fibroma, and similar growths. It may be remarked en passant that the majority of epithelial tumors are, in a sense, of mixed type, for, with the possible exception of the epithelioma, most of them show evidences in some part or other of a new formation of fibrous tissue. The objections that have been brought forward to this mode of classification are that there are not a few cases to be met with which do not fit into the scheme. The first great type embraces the tumors of mesoblastic origin and connective- tissue type. Now, the gliomata, which are of connective-tissue type, and, there- fore, are generally classed with the fibromata and other tumors of this group, are not mesoblastic, but epiblastic. To include them with the fibromata and homologous growths is, to say the least, artificial. Again, certain tumors of the kidney, suprarenal, ovaries, testis, and uterus, while histologically of epithelial type, in that resembling the carcinomata, are really of mesoblastic origin. If, therefore, we are to preserve the embryological method of classification, some method must be devised of grouping like with like, and bringing histological structure into harmony with embryological derivation. This has been attempted by Prof. J. G. Adami in an important contribution to the subject, entitled "On the Classification of Tumors" (Journal of Pathol- ogy and Bacteriology, June, 1902). He recognized that in early fcetal exist- ence we have two differentiations of the primitive cell layers, leading to the production of two sets of tissues. One he calls lepidic or lining-membrane tis- sues; the other, hylic or pulp tissues. The lepidic tissues form the lining endo- thelium of blood-vessels, lymphatics, serous membranes, and the acini of various glands. They have this in common, that there is an absence of stroma between the members of the cell groups. The pulp tissues are composed of an intercel- lular ground substance, either homogeneous or fibrillated, separating the specific cells of the tissue, and constitute the supporting stroma. On this basis, and in accordance with the principles just enunciated, Adami would classify blastomatous tumors after the following scheme : I. LEPIDOMATA OR "RIND" TUMORS. A. Primary Lepidomata. 1. Epilepidomata. Tumors whose characteristic constituents are overgrowths of tissues, derived directly from the epiblastic lining membranes, or true epiblast. (a) Typical. — Papilloma, epidermal adenomata (of sweat, salivary, seba- ceous, and mammary glands, etc.). (b) Atypical. — Epithelioma proper, carcinoma of glands of epiblastic origin. 298 AMERIC.IX PRACTICE OF SURGERY. 2. Hypolepidomata. (a) Typical. — Adenoma and papilloma of digestive and respirator}^ tracts, thjToid, pancreas, liver, bladder, etc. (b) Atypical. — Carcinoma developing in the same organs and regions. B. Secondary Lepidomata. 3. ilesolepidomata. Tumors whose characteristic constituents are cells derived in direct descent from the persistent mesotheliiwi of the embryo. (a) Typical. — Adenoma of kidney, testicle, ovary, urogenital ducts; ade- noma of uterus and prostate ; adenomas originating from the serous membranes, "mesothelioma" of pleurae, peritoneum, etc. (b) Atypical. — Cancer of the above-mentioned organs: squamous endothe- lioma, so called, of serous surfaces ; epithelioma of vagina. 4. Endothelial Lepidomata. Tumors originating from the endothelium of the blood- and lymph-vessels; endothelioma, perithelioma. II. HYLOMATA OR "PULP" TUMORS. 1. Epihylomata. Tumors whose characteristic constituents are overgrowths of tissues derived from the embryonic pulp of epiblastic origin. (a) Typical. — True neuroma, glioma. (b) Atypical. — " Glio-sarcoma. " 2. Hypohylomata. Tumors derived similarly from embryonic pulp of hypoblastic origin. (?) Chor- doma. 3. Mesohylomata. A. Mesenchymal Hylomata. — Derived from tissues originating from the per- sistent mesoblastic pulp or mesenchjine. (a) Typical. — Fibroma, lipoma, chondroma, osteoma, myxoma, leio-myoma. (b) Atypical. — Sarcoma (derived frommesenchymatous tissues), with its vari- ous subdivisions, fibro-sarcoma, spindle-cell sarcoma, oat-shape-cell sarcoma, chondro-sarcoma, osteo-sarcoma, myxo-sarcoma, melanotic sarcoma, etc. B. Mesothelial Hylomata. — Tumors which are overgrowths similarly of tis- sues derived from embryonic pulp of definitely mesothelial origm. Rhabdomyoma. It will, perhaps, be an aid to the proper understanding of a somewhat abstruse part of the subject, and make clear the virtues of the new classification, if we TOIORS AND TUMOR F0R:\IATI0N. 299 enumerate the various tissues and structures derived from the primitive germ layers. I. EpIBLASTIC STRrCTURES. The skin and its appendages, epidermal glands, hair, nails, enamel of the teeth, the lens of the eye, the epithelium of the cornea, olfactory organ, the mem- branous labyrinth of the ear, the epithelium of the mouth, salivary glands, buccal portion of the hj^pophysis cerebri ; the epithelium of the anus and male urethra, with the exception of the prostatic portion; the central, peripheral, and sympa- thetic nervous systems; the retina; neuroglia. II. Hypoblastic Structures. The notochord; the epithelium of the digestive tract and associated organs, oesophagus, stomach, intestines, liver, pancreas; the specific cells of the tonsils, thymus, and thyroid glands, parathyroids, pharynx, and Eustachian tube; the epithelium of the respiratory tract, larynx, trachea, and lungs, of the bladder, female urethra, and the prostatic portion of the male urethra. III. Mesoblastic Structures. 1. Mesothelium. The lining cells of the pleura^, pericardium, and peritoneum; the specific cells of the suprarenals, kidneys, testes, ovaries (Graafian follicles); the epi- thelium and glands of the Fallopian tubes, uterus, vagina, vasa deferentia, vesic- ulse seminales; striated muscles, including that of the heart. 2. ]\Iesenchyma. Fibrous connective tissue, cartilage, bone, reticulum of lymph nodes, bone marrow, fat, unstriated muscle, spleen, the endothelium of blood-vessels and lymphatics, blood corpuscles, the endotheliiun of the arachnoid, synovial, bur- sal, and corneal spaces; nerve sheaths. I. Tumors of Epiblastic Origix. Adenomata and cystadenomata of the epidermal glands and epithelimii of the tooth papillEe; epidermoids (cholesteatoma) and inclusion dermoids; epi- thelioma; neuroma; glioma. II. TuiioRS OF Mesoblastic Origin'. (a) Mesothelial. — Adenoma and cystadenoma; carcinoma; rhabdomyoma; hypernephroma. (b) Mesenchymatous. — Fibroma, myxoma, lipoma, chondroma, osteoma, leio- myoma, angioma, myeloma, endothelioma (perithelioma) of blood- vessels and lymphatics; sarcomata of all kinds. III. Tumors of Hypoblastic Origin. Papilloma, adenoma, chordoma (?), carcinoma. 300 AMERICAN PRACTICE OF SURGERY. The accompanying figure (Fig. 84), taken from Adami's paper above referred to, illustrates in a graphic way the differentiation of the various embryonal tis- sues, at the same time indicating their function and relative position. We pass on now to the consideration of the special varieties of tumors. In- asmuch as this is a work for practical surgeons, I have not ventured to adopt Adami's classification, though I believe it to be the most scientific that has hith- erto been devised. It involves, however, the use of a new terminology, and Fig. 84. — Scheme of Tissue Relationships. (Adami.) Lepidic tissues : 1, Epiblast (ectoderm and glands) : 2, hypoblast (entoderm and glands) ; 2', noto- chord (hypoblast); 3, mesothelium (hning body-cavity), with derived glands; 4, endothelium (hning vessels). Hylic tissues: 5, Epiblastic (forming nervous tissues) ; 6, mesothelial (forming striated muscles) ; 7, mesenchyme; 8, pleuro-peritoneal cavity; 9, lumen of alimentary canal. until this becomes generally understood any other course would be liable to create confusion. Nevertheless, in view of the importance of the subject, I have introduced as alternative designations the terms employed in this latest attempt at the classification of new growths on embryological principles. By a refer- ence to the schemata given above, the subject will be made sufficiently plain. TUMORS AND TUMOR FORMATION. 301 I. TUMORS OF NON-EPITHELIAL TYPE. These may be benign or malignant. For the most part they are mesoblastic and mesenchymatous, though notable exceptions occur. Histologically, they manifest this important peculiarity, namely, that the component cells are em- bedded in an intercellular matrix, and vessels penetrate between many of the cells. In general it may be said that they consist of connective tissue or its homologues. The following tumors come under this category : ' Fibroma. Myoma. Lipoma. Chondroma. ^ Osteoma. Benign. '-'»)■ ^H^Av>f^« ^^^^^1 ^^^^B -' '' ^,^1 Hk^' wH ^^;;-'\^^^ ^^^^^^V '^SHHI ^^IP~^^' '^^^^H ^^^^l»^' ^ 'inP^^ Wfi ^-'riH ^^HHt 1^ "'^pii jnjk 4.">^^^l ^^H^^- 'v*^x W ' •' hP^^''"'*^^^^!^h i kJ^^^ Fig. 94. — Myomatous Enlargement of the Prostate , obstruction to the outflow of urine caused by the overgrowth of the so-called middle lobe; consecutive hypertrophy of the wall of the bladder. (Pathological Museum of McGill University. portion is of fibrillated texture, firm, and of a shining white color; the muscular part is pinkish or bright grayish-red. Histologically, the muscle fibres may be recognized by the fact that they are long spindles arranged somewhat regularly into bundles, and possess elongated rod- shaped nuclei (Fig. 93). The character of the cells can usually be ascertained on macerating some fresh material for from twenty to thirty minutes in from three TUMORS AND TUMOR FORMATION. 319 to four per cent, caustic-potash solution and then teasing it out with needles. Degenerative changes, fatty degeneration, softening, cyst formation, and calcifi- cation are not uncommon events in leiomyomata. Occasionally, the muscle fibres may atrophy, thus converting the tumor into a simple fibroma. Leiomyomata are benign tumors and develop during adult or advanced life. Very exceptionally leiomyomata have been observed during the first few years of life. With regard to their mode of origin, it may be said in general terms that they may arise wherever there is unstriped muscle. In the case of uterine myomata and certain myomata of the skin, the muscle bundles can often be made out to be arranged around the vessels, the ramifications of which they more or less follow, suggesting that the growth has originated from the muscular walls of these ves- sels. In other parts of the body, myomata are also sometimes found in the walls of the blood-vessels, particularlj^ the veins. Some of the myomata of the skin have been shown to be derived from the arrectores pilorum. Now and then epi- thelial elements, in the form of cell masses or imperfect acini, have been foimd in uterine myomata. They have been variously explained as being remnants of the Muellerian or Gaertner's ducts, or of the Wolffian body. Possibly, they are only portions of the uterine mucosa which have been pinched off and have become embedded in the tumor. The clinical results produced by myomata depend mainly upon their size and position. Myomata of the uterus lead to distortion and displacement of that organ, and to pressure or tension on the other pelvic viscera. Myomata of the prostate often start from the so-called middle lobe, and may, by encroaching upon the urinary passage at the neck of the bladder, result in obstruction to the outflow of urine with 'all that this condition implies. (Fig. 94.) Multiple myomata of the skin are occasionally very painful (tubercula dolorosa). In rare instances, leiomyomata undergo sarcomatous transformation and give rise to metastases. Angiomata. Under this caption are included a number of tumors and tmnor-like forma- tions the chief peculiarity of which is that they are composed mainly of vas- cular channels, either blood or lymph vessels. These vessels may be newly formed, or may consist of the pre-existing vessels of the part more or less altered, either in the direction of enlarged calibre, or in that of increase in length or hypertrophy of their walls. Tumors consisting mainly of blood-vessels are termed hoemangiomata, or angiomata, this term being used in a restricted sense; those composed of lymph channels are known as lymphangiomata. A hsemangioma consists of arteries, capillaries, and veins, which are sup- ported and held together by connective tissue or by tissues homologous with it, such as adipose and mucoid tissue. We can, therefore, recognize mixed forms of vascular tumors, such as teleangiedatic fibroma, lipoma, myxoma. When we 320 AMERICAN PRACTICE OF SURGERY. have a cellular variation Ln the direction of malignancj', we may speak of angio- sarcoma. According to the character of the vessels that go to make up the tiunor, it is customary to distmguish several subvarieties. In hoemangioma simplex (hsemangioma teleangiectaticum ; teleangiectasia) there is an excessive development of capillaries, with a relatively scanty forma- tion of arteries and veins. Ho'mangioma arteriale (tumor vasculosus arterialis) is mainly composed of small arteries, with a relatively small proportion of capillaries and veins. Hcemangioma cavernosum (cavernoma ; tumor cavernosus) presents numerous large vascular spaces or sinuses, lined with endothelium, resembling the' struc- ture found normally in the corpora cavernosa of the penis. The best known example of the simple hgemangioma is the nmvus vasculosus, one of the forms of "birth-mark." This is found commonly in the skin and is present at birth, though it may attain its greatest development somewhat later. In these cases we caimot always speak of the condition as a true tumor, for the vascular area may be badly defined, without any elevation of the skin, but in other instances the area is well localized, penetrating into the subcutaneous tis- sues, associated with undoubted new formation of fibrous tissue, and covered with hypertrophic epithelium. In still other cases regular warts or flattened tubercles are formed. The simple, smooth ntevus appears in the skin as a bright red (ncemis f.am- meus) or bluish-red patch (nsevus vinosus: "port-wine stain"). At the periph- ery, many smaller vascular spots may often be seen. The red color is due to the presence of mmierous wide and dilated vessels filled with blood, situated partly in the corium and partly in the subcutaneous fatty tissue. Occasion- ally, similar formations are met with in other structures, such as the mamma, liver, bones, brain, and spinal cord. The abnormality consists mainly in a cir- cumscribed dilatation of pre-existing or newly formed capillaries. The dilatation may be spindle-shaped or cylindrical, or, again, saccular, or all three. The dilated vessels may be separated from one another by normally constituted capillaries or by capillaries only slightly dilated. The vascular walls are usually thin, or at any rate not specially thickened. In the variety of simple hsemangioma known as the angioma simplex hypei-- trophicum the capillaries are exceedingly numerous and held together by rela- tively little connective tissue. The lumina of the vessels are only moderately dilated and the walls are thick and cellular, resembling arterial walls. In a few cases it happens that the endothelial cells proliferate and thereby encroach on the lumina. The tumor is divided into lobules by connective tissue in such a way that each lobule is made up of a highly convoluted tangle of capillaries with thickened walls. Here and there atrophied remains of sweat glands may be sometimes detected. TUMORS AND TUMOR FORMATION. 321 The hoemangioma venosum is composed chiefly of veins, the capillaries being only slightly if at all enlarged. The dilatation of the veins is cylindrical, am- puUiform, or saccular. The vascular walls are sometimes thickened. The hoemangioma arteriale consists of numerous small arteries, with a com- paratively small development of veins and capillaries. A curious variety of this is the angioma arteriale racemosum (cirsoid aneurysm ; angioma arteriale plexi- forme; Rankenangiom). Here the arteries of a particular district, such as the forehead or scalp, are dilated, thickened, and highly convoluted. The tumor feels on palpation somewhat like a bag of worms. The blood can usually be squeezed out of the vessels, but they quickly fill up again so soon as the pressiu-e is removed. A bruit can usually be heard over the affected area. The cavernoma (tumor cavernosus) consists of large, irregularly shaped sinuses, lined with endothelium, and separated one from the other by a more or less cellular connective tissue. The various blood spaces may here and there be 3een to communicate with one another. Cavernomata are found usually in the skin and subcutaneous tissues, but occasionally m the viscera, especially the liver (Fig. 95), more rarely in the kidney, spleen, uterus, intestine, bladder, muscles, and bones. In the skin they form bluish-red, somewhat elevated or warty elevations {mcvus prominens), or may lead to a uniform and extensive enlargement of the part, constituting one form of elephantiasis. The histogenesis of hsemangiomata is extremely interesting. Many of the cases are present at birth or appear during the earlier years of life, and are met with in situations corresponding to the embryonic lines of fusion, such as the fa- cial and branchial clefts. The angiomata foimd at the orifices of the body, in the face, neck, and upper part of the breast, are of the nature of fissural angiomata. Certain of the naevi vasculosi, or "mother's marks," though not all, come under the category of fissural angiomata. Many of the angiomata belonging to this class are at first little more than teleangiectases, but, after a more or less prolonged period of latency, they may increase in size, and m time be trans- formed into large projecting masses, resembling a cock's comb. Other htemangiomata appear to have some connection with the nervous mech- anism {neuropathic angiomata). Such are the teleangiectases which begin as small red spots on the skin and then gradually spread over the surface in an area corresponding to the peripheral distribution of some cutaneous nerve. Certain multiple, nodular hsemangiomata are occasionally met with in old people, and are often termed senile angiomata. Thoma would place the caver- noma of the liver, which also occurs in advanced life, in this group. Traumatism is an important factor in some cases. Of this nature are some cicatricial tumors or keloids which appear after injury and are particularly rich in vessels. VOL. I.— 21 322 AMERICAN PRACTICE OF SURGERY. It must be admitted that the above classification of the angiomata is by no means complete, for many forms, and not the least important, such as certain vascular tumors of the skin, muscles, glands, and intestines, cannot be explained on the grounds mentioned. Possibly here congenital anomalies of development, though this is a simple conjecture, may have to be taken into account. Thoma has drawTi attention to the important part that physical and mechan- ical principles play in determining the origin and development of angiomata. This investigator has shown that the new formation of capillaries is related to the blood-pressure within the capillaries of a part and to the condition of the sur- roimding tissues. The normal intravascular pressure is dependent on the strength of the cardiac impulse and the resistance of the extravascular tissues. An increase of pressure so that it exceeds the normal will result m the production Fig. 95. — Cavernous Angioma of the Li^cr. Winekel No. 3, without ocular. Normal liver tissue is shown above and to the left. The fibrous trabeculaj of the blood tumor are well seen. (From the author's collection.) of new capillaries. This may be explained as an attempt on the part of the tis- sues to establish an equilibrium. Disturbances of the blood pressure, as can readily be understood, might easily be brought about by errors of development and derangements of the vasomotor mechanism. Further changes are depend- ent on the rate of the blood flow. If the rate be under the normal, capillaries with narrow limiina are formed ; if it be greater, the capillaries will become more or less dilated. The rise in blood pressure, which must occur at some time in the process, will lead, m accordance with well-known pathological prin- ciples, to increase in the thickness of the capillary and lesser arterial walls. The lym-phangioma, or angioma lymphaticitm, is m most respects analogous to the hemangioma, save that the vascular spaces contained therein are lymph TUMORS AND TUMOR FORMATION. 323 channels instead of blood-vessels. The supporting stroma in which the vessels are embedded may be fibrous, fatty, or mucinous. Three anatomical forms are recognized : the Ixjmphangioma sim-plex or telean- giectasia lymphatica, the lymphangioma cavernosum, and the lymphangioma cys- toides. In simple lymphangioma the lymphatic vessels in a more or less circum- scribed area are dilated and their walls thickened. In the cavernous variety the lymph channels are very numerous and much dilated, so that the structure, on section, has a somewhat spongy texture. The supporting stroma is scanty, thin, delicate, and transparent. In the last-mentioned form cysts varying in size from that of a pea to that of a walnut or larger may be produced. As in the case of the htemangiomata, developmental anomalies are of great etiological moment. Many of the lymphangiomata are fomid in connection with the sutures and fissures of the body. Of this nature are the lymphangiectasias met with in the tongue (macroglossia) , gums, lips (macrocheilia), neck (hygroma colli congenitum), skin (ncevus lymphaticus) , subcutaneous tissues, and vulva. A diffuse cavernous dilatation of the lymphatic channels of the skin or subcuta- neous tissues, as, for instance, in the thigh and scrotum, gives rise to one form of elephantiasis. Some of the lymphangiectases of the skin, subcutaneous tissues, peritoneum, and mesentery, appear late in life and are acquired rather than con- genital. Lymphangiomata of the mesentery contain chyle and, hence, are some- times called chylangiomata. Cystic lymphangiomata are sometimes met with m the peritoneum, but are rare. Some authorities would class certain of the pig- mented nsevi, pigment patches, freckles, and fleshy warts with the lymphangi- omata. Lymphangiomata in the course of their growth may extend widely and dis- locate or enclose portions of the neighboring tissues. They may reach the surface of the body and there discharge, forming lymph fistulse and causing lymphor- rhoea. Both the hfemangiomata and the lymphangiomata are to be classed with the benign growths. As, however, they contain newly-formed endothelial elements and connective tissue, we occasionally find that they take on malignant action, becoming extremely cellular (perithelial or endothelial angiosarcoma). Lymphangiomata may attain a considerable size, and the cavernous and cystic forms are often multiple. On section, these tumors exude lymph, which may be clear, or cloudy from admixture with lymph corpuscles or blood. The contents of the cysts may be fluid, or, again, partially or completely coagulated. Histologically, the lymph spaces are lined with endothelimn and held to- gether by a rather cellular fibrous tissue. Almost any tissue may, however, at times, enter mto the composition of the stroma. Here and there m the support- ing substance collections of lymphoid cells may be fomid. 324 AMERICAN PRACTICE OF SURGERY. Gliomata. Gliomata are tumors derived from the neuroglia or supporting stroma of the central nervous system. The}' are limited, therefore, to the brain and cord, and to those parts of the peripheral nervous system which represent prolongations of the primitive cerebral vesicles, namely, the retina, optic nerve, and olfactory bulbs. Gliomata may be single or multiple, and vary considerably m size, though they never become very large. As a rule they resemble more or less closely the nervous tissue in which they are found, and indeed cases are not infrequently met with where we are onh' able to infer the presence of a tumor from the fact that there is a local swelling of the brain substance and that the normal distinctions between the various parts of the organ are obliterated. On section through a glioma we find that it is usually badly defined, infiltrat- ing the surrounding tissues; it is sometimes grayish in color, moderately firm and somewhat translucent, resembling the normal gray matter of the central nervous system; it may be grayish-white, rather dense and hard; or, again, it may be grayish-red or dark red, owing to the presence of numerous vessels. Hemorrhage into the substance of the tumor, fatty degeneration, softening, and necrosis are not infrequent accompaniments. Histologically, ,a typical glioma is composed of a meshwork of delicate refrac- tile fibrils, among which can be seen embedded more or less numerous rounded or oval nuclei. These nuclei, on closer inspection, are found to be surroimded by a small quantity of cell protoplasm (Fig. 96). On macerating the tissue and teasing it out with needles the cells referred to can be shown to be bipolar and stellate in shape and to possess shorter or longer, sometimes branching, processes. The blood-vessels are often abundant and may be dilated {glioma teleangi- ectaticum). The relative proportions of cells and fibrils vary in different cases. Some gliomata are cellular (glioma moUe), others are more fibrous [glioma durum). We can better understand the histogenesis of the gliomata if we remember the way in which the neuroglia normally develops. The glia, like the specific nerve elements, is of ectodermic origin, being derived from the undifferenti- ated epiblastic cells heaped up about the primitive dorsal groove. These cells eventually are separated from the superficial ectoderm and become aggregated about a central space, the neural canal, which is Imed with cells that permanentl}' retain their epithelial type. Wliile certain cells undergo marked differentiation, and eventually are converted mto the highly complicated nerve structures, others remain more primitive and assume many of the characteristics of connective tissue. The latter, the glia cells, originate, both in the highest and lowest ver- tebrates, in the ependyma cells, which are now known to belong to the supporting structures. In certain of the more primitive animals, such as the amphioxus, the supporting stroma is composed entirely of ependymal cells, but higher in the scale we find that the principal part is taken by stellate cells (astrocytes). In TUMORS AND TUMOR FORMATION. 325 the case of mammals it is believed by some that the astrocytes are not derived directly from the ependymal cells, but from intermediate forms, which may be termed astroblasts. All glia cells, whether provided with long or short processes, brush cells or stellate cells, are therefore, ultimately derived from the same pre- cursors. It has usually been taught that the various processes are closely related to the cell bodies, being, in fact, protoplasmic prolongations of the latter, an opinion based upon studies conducteil with the Golgi method of staining More recent methods, notably those of Weigert, Mallory, and Beneke, have proved, however, that this is not altogether correct. According to Weigert, the cells of human Fig. 96. — Glioma, from Cerebral Cortex. Winckel No. 6, without ocular. (From the author's foUection.) neuroglia possess protoplasmic processes only during embryonic life. Adult neuroglia is made up of cells and fibrils, the latter greatly predominating. Bearing these facts in mind we are able to get a more adequate conception of the various forms of gliomata that we actually meet with. Thus, we have: (1) The glioma durum, or fibrillary form, corresponding to mature glial tissue; (2) the astrocytic glioma, composed of Deiters' spider and brush cells; (3) a highly cel- lular form, resembling a small round-celled sarcoma, possibly derived from a still more undifi'erentiated type of cell, namely, the astroblast; (4) gliomata composed of cells of ependymal type. It must be admitted, however, that while the more recent methods of investigation have proved of great value in differentiating the various forms of glioma one from the other, in another direction they have per- haps proved more confusing than helpful, for the relationship of such conditions as sclerosis of the central nervous system, nodular gliosis, and the central gliosis of syringomyelia remains still cjuite obscure. 326 AMERICAN PRACTICE OF SURGERY. A word or two with regard to the ghomata of the retina may not be out of place. These tumors are met with only in childhood, usually in the earlier years. One or both eyes may be attacked, and more than one member of a family may be affected with the disease. The timior may originate in any of the layers of the retina, but usually in the deeper parts. It grows more or less rapidly, extends forward into the vitreous humor and invades the uveal region, or it may perforate the sclerotic posteriorly and attack the orbit and brain. Eventually, the whole eye is destroyed and we have a large vascular, fmigating mass which projects exter- nally and leads to destruction of the neighboring soft tissues and bone. Second- ary growths are formed in the regional lymph nodes and in distant organs. _ His- tologically, we may recognize several varieties, which are strictly in accord with the classification of the other gliomata indicated above. The most common form is a highly cellular growth, composed of midifferentiated cells, resembling closely the small round-celled sarcoma. Less often the growth is composed of closely aggregated cells with processes, or astrocytes. In other cases we find curious rosette-like formations, so that the tirnior resembles in some degree the cells of the layers of rods and cones. The layer of rods and cones corresponds histoge- netically with the epithelial cells lining the central neural canal, and, therefore, is to be regarded as of ependymal nature. Flexner, therefore, would term such tumors ependymal gliomata. In consideration of their histological appearance and the physiological function of the cells from which they are derived, they are often called yieuro-epitheliomata. The relationship of glioma to sarcoma is at present a somewhat debatable question. The fact that gliomata are embryologically of ectodermic origin, while sarcomata are mesodermic, would of itself suffice to indicate that there are fimda- mental differences between these two forms of new growth. It is a fact, how- ever, that the vessels in gliomata are provided with sheaths of mesoblastic fibrous tissue, and it is, therefore, theoretically possible that a cellular variation of this mesoblastic structure might on occasion give rise to a true sarcomatous neopla- sia. Such tumors would, therefore, be mixed m character, consisting both of newly formed glial and sarcomatous elements. As we have seen, however, cer- tain gliomata are derived from relatively imdifferentiated glial cells, and their resemblance to romid-celled sarcomata is so close that we are often at a loss to make the differential diagnosis. This being the case, we are hardly justified, in my opinion, in speaking of new growths of this histological tj'pe as "glio-sarco- mata," even in view of the fact that they are often malignant. \^^ien we con- sider that tmnors of this type are composed of relatively undifferentiated cells, cells which according to well-known pathological prmciples must be endowed with great proliferative capacity, it is not surprising that they at times take on excessive and aberrant action. This view is supported by what we have already learned in connection with other tumors composed of relatively immature cells, such as the soft fibroma, myxoma, and chondroma, which, as we have seen, may TUMORS AND TUMOR FORMATION. 327 occasionally produce both local and distant metastases. We shall, I think, be more logical if, for the time being at least, we speak of the forms in question as "malignant gliomata," until microscopical investigation shall have proved beyond cavil that the round cells present therein are derived from the meso- blastic vessel sheaths. Some interesting points come up, too, in regard to the ependymal gliomata. It cannot now be denied that we occasionally meet with tumors composed of cells resembling somewhat closely cells of ependymal type. Flexner, for exam- ple, records a brain tumor composed of cells resembling for the most part the ependymal cells found in the embryonic human cord. These cells were arranged in a radial fashion around the blood-vessels, toward which their processes were directed. The processes came together at a point somewhat short of the vessel wall, so that a small space existed between them and the wall. It is conceivable that more fully developed or adult ependymal cells might be competent to give rise to tumors. One point to which attention should be directed is that the cells of the ependymal gliomata may assume more or less perfectly an epithelioid type. In cases where the cells are of this character, or are spindle-shaped, especially if they be grouped about the vessels, the resemblance to the endotheliomata and peritheliomata is striking. With regard, therefore, to tumors originating in por- tions of the brain containing ependymal elements, as for instance the pituitary, which resemble endothelial and perithelial formations, it would be well always to consider the possibility of their being glial and ependymal in nature. It is quite possible that the gliosis occurring in the condition known as syrin- gomyelia, which has proved such a puzzle to investigators, may be explained on the lines indicated above. Flexner {Journal of Nervous and Mental Disease, May, 1898) mentions having seen a case of syringomyelia in which the tumor mass was composed largely, if not entirely, of cells of an early ependymal type. In view of the fact that our ideas in regard to gliosis and gliomatosis are in a transition stage, and that our ignorance on many important points is not slight, it is not surprising that but little is to be said on the subject of the remote etiology of these growths. Certain of the ependymal gliomata, and the gliomata met with in childhood, are probably to be referred to some developmental anomaly or aberration. Trauma has been held by some to play a part. Possibly, also, toxic and infectious agents will be found to be of some etiological importance. Gliomata produce their effects in accordance with their size and position. Those in the central portion of the brain give rise to no clinical symptoms save those of pressure. Others, when situated in areas functionally important, both by pressure and destructive infiltration damage the neurons and interfere proportionately with the origination and conduction of impulses. Thus we may get muscular paralysis, disturbances of sensation, interference with muscular tone, pain, and paresthesia;. 328 AMERICAN PRACTICE OF SURGERY. Neuhoxiata. The term neuroma is used somewhat loosely b}' surgeons to designate almost any tumor arising in connection with nerves. In this category would come the so-called "amputation neuroma," multiple cutaneous neuromata, and the plexi- form neuroma. To which may possibly be added the neuroma or neuro-glioma ganglionare. All these forms have this in common, that they consist of nerve cells or fibres held together by a fibrous or neuroglial matrix. It should be re- marked, however, that in the strict sense of the term the word " neuroma " should be applied only to growths consisting wholly or in part of newly formed nerve elements. Of course it is difficult in many cases to decide, when nerve cells or fibres are discovered in a tumor, whether these are newly formed or not, and this is the whole point at issue between the pathologists. A large number of growths occupy debatable ground, but more careful study, connected with modern tech- nique, has served greatly to circumscribe the class of nerve tumors, though it has undoubtedly proved that neuromata, in the true sense of the word, do exist. The so-called amputation neuroma belongs to what has been called the trau- matic neuromata. It is perhaps the most common form of the false neuromata. As its name implies, the condition is found in connection with amputation wounds. In some cases of this kind the ends of the nerves within the stump are found to be swollen like clubs and firmly adherent to the cicatrix. Microscopic exam- ination shows that these nodes are composed of medullated and non-medullated nerve fibres, irregularly interlacing, embedded in a dense scar tissue. Properly, such growths should not be classed with the neuromata, for they represent sim- ply the ordinary process of regeneration modified by an unusual physical condi- tion. The dense scar prevents the nerve fibres from growing straight forward in the axis of the nerve trunk, so that they become diverted and bend and inter- lace in a confused manner. The new formation of fibres is, therefore, not au- tonomous. Traumatic neuromata are occasionally met with in connection with injuries other than amputation. Division or compression of a nerve sometimes results in the formation of nodules composed of newly formed nerve fibres and connective tissue at the seat of injuiy. An interesting class of cases is that which includes the nuiltiple nodes some- times found upon the peripheral nerves. These tumors are found not only on the trunk of the nerves, but also on their peripheral terminations and may affect a large part of the body, or, again, may be confined to a particular nerve dis- trict. Not uncommonly the tumors are situated in the skin where they form numerous, smaller or larger, visually soft nodules. They are often painful, ow- ing to pressure upon the sensorj^ fibres (tubercula dolorosa). Further investiga- tion has shown that some of these cutaneous nodules are leiomyomata containing nerve fibrils, but the majority of them are to be regarded as fibromata (q. v.). The smallest nodules are only of microscopic size, but the larger ones may attain the size of a pea, a marble, or even a man's fist. TUMORS AND TUMOR FORMATION. 329 The so-called plexiform neuroma (Rankenneurom) has already been tlealt with (see p. 305). Suffice it to say here that mo.st authorities hold it to be simply a peculiar form of fibroma of the nerve sheaths, though a few good ob- servers still maintain that the nerve fibres to be seen in this growth are newly formed, and that, therefore, the tumor is a true neuroma. Plexiform neuromata are found upon the head, trunk, and extremities, and lead to a condition re- sembling elephantiasis. The multiple cutaneous neuromata found by Knauss in j'oung children seem to be true neuromata. Here we find branching ganglion cells together with numerous medullated and non-medullated fibres, having no anatomical conti- nuity with the nerves of the part. "Neuromata" of the central nervous system have been described. In some of these, tumor-like masses of nervous substance have been found. Probably some of them are simply a misplacement or abnormal arrangement of the normal layers of the central nervous tissues, due to an anomaly of development. Or they may be merely artefacts, as Lubarsch has suggested. Inasmuch as certain of the forms just mentioned contain ganglion cells, they have been included with the neuro-glioma or neuroma ganglionare. Ganglionic neuromata have been met with in the thoracic, lumbar, hypogas- tric, solar, and adrenal plexuses of the sympathetic system. Microscopically, they consist of a more or less dense glia-supporting stroma, in which can be seen irregularly distributed ganglia, and nerve fibres. They are probably true neuromata. Papillo.m.\ta. Strictly speaking, the term " papilloma," as applied to tumors, refers to their external appearance rather than to peculiarities of histogenetic structure. Any tumor, in fact, which projects above the general surface of the tissue in which it is found, and has a convoluted, villus-like appearance, may properly be termed a papilloma. Such tumors illustrate particularly well the "organoid" character supposed to appertain to the benign growths we have been describing. Papillomata consist of a central core of vascular, connective, or mucoid tis- sue, covered with one or more layers of epithelium. They are found springing from the skin and mucous surfaces and occasionally from the interior of cysts and the ducts of glands. They are' rounded, cylindrical, lobulated, or cauliflower- like in appearance, or highly convoluted and villus-like. They may be sessile and attached by a broad base, or, again, may have a relatively narrow pedicle. The nature of the epithelium with which they are covered varies somewhat, but conforms more or less closely to that of the part from which they arise (Fig. 97). Many cutaneous warts belong to the class of papillomata, as do certain con- genital excrescences on the surface of the body, papillary najvi. Papillomata of the mucous surfaces are found especially in connection with 330 AMERICAN PRACTICE OF SURGERY the larjqix and trachea, the stomach and intestines, the urinarj- bladder, and the genitaha, as, for example, the penis, vulva, vagina, uterus, and Fallopian tubes. One of the most important types is the papilloma of the bladder, which takes the form of a cauliflower-like growth, composed of an aggregation of numer- ous delicate branching papilUe. These papillse are composed of a small amount of vascular connective tissue covered with cjdindrical epithelium. Papilloniata of the bladder are usually situated at the fundus of the organ and are often mul- TUMORS AND TUMOR FORMATION. 331 tiple. They are of importance to the surgeon in that thej' frequentlj' cause ob- struction of the urine, with all that implies, give rise to ha^maturia, and may, occasionally, assume malignant action. The most potent single factor in the causation of papillomata is irritation in its widest sense. Papillomata of the larynx are found m singers, public speakers, and others who strain the voice. Chronic congestion may be of importance here. Chronic catarrh accounts for many papillomata of the mucous surfaces, as, for example, "venereal warts" (condylomata acuminata). Many of the warts of the skin are properly to be referred to the effects of irritation. It is perhaps ques- tionable, where chronic inflammation is the chief etiological factor, whether the new formation of tissue thereupon resulting should properly be classed with the autonomous new formations. It has probably more affinities with the simple, irritative hyperplasias. The papillary excrescences found in connection with many cystic adenomata may with much more reason be classed with true tumors. Sarcomata (Atypical Meso-hylomata). We have up to this point been considering a series of neoplasms, benign in character and of more or less perfect organoid type, which have this in comnron, that they reproduce the features of normal adult connective tissue, that is to say, fibrous tissue and its homologues. They are of mesoblastic origiii, with the ex- ception of the neuromata and gliomata, which are epiblastic, and the papillomata, which are partly mesoblastic and partly epiblastic. Corresponding with most of these, and forming a cellular variation of them, we have another set of tumors, commonly known as sarcomata. Sarcomata may be defined as malignant tumors of mesoblastic origin and con- nective-tissue type, having for the most part this peculiarity, that they are com- posed of cells that more or less completely fail to attain the morphological perfec- tion of adult cells. These cells are immature or comparatively undifferentiated and are consequently endowed with great proliferative capacity. We find, therefore, as we might expect, that the sarcomata are the most malignant of tumors, that is to say, they grow rapidly, tend to recur locally after removal, form early and exten- sive metastases, and, finally, are apt to break down and ulcerate. The occur- rence of local metastases accounts for the lobulated structure that so many sar- comata present. Sarcomata arise from all forms of connective tissue and in any part where such structures are found. They develop, therefore, from fibrous tissue, fatty tissue, mucoid tissue, cartilage, and bone (Fig. 98). There are certain parts, however, where they are more conunon than elsewhere. They are met with oftener, for example, in the skin, fascia, intermuscular connective tissue, peri- ostexmr, bone, brain, and ovaries than in the lungs, liver, mtestines, and uterus. The gross anatomical appearance of sarcomata varies considerably according to circumstances. No one description applies to all. Many sarcomata, especially 332 .AJilERiaiX PRACTICE OF SURGERY. those comiected with bone and periosteiun, attam a large size, others ai'e almost microscopic. In color, they may be whitish, pinkish, or grayish-white, glistening and semitranslucent, at other tmies bro\s'nish, black, bluish, green, or slaty, from the deposit of pigment. In regard to consistence, some are soft, juicy, and bram- FiG. 98. — Sarcoma of the Shaft of tlie Humerus. (.Pathological iluseum of ilcGill ITniversity.) like (mechiUarij sarcomata); others, firmer, denser, and more fibrous; still others are of almost stonj' hardness. Blood-vessels are more or less nimierous, and ma}- be dilated {teleangiedatic sarcomata). The vessels usuallj' possess a regular wall, well defined from the tumor substance, but in some mstances it is composed of the proper cells of the new growth. TUMORS AND TUMOR FORMATION. 333 Retrogressive changes, fatty and mucoid degeneration, hemorrhage, coHi- quative necrosis, caseation, gangrene, and ulceration are not uncommon. As Ave have seen in the preceding pages, not a few of the benign, so-called organoid tumors ma}- on occasion undergo at some point or other malignant, that is to say, sarcomatous, transformation. We may thus recognize, on the basis of etiology, fibro-sarconiata, lipo-, myxo-, chondro-, osteo-, osteoid, and angio- sarcomata. The sole exceptions are the neuromata and gliomata. The neuro- mata are excessively rare and not well understood, but so far as we know have no malignant cellular derivative. A malignant form of glioma is known, the so- called "glio-sarcoma," but we have elsewhere adduced reasons for thudving that the majority of these are not true sarcomata, unless we are prepared to use this term in the widest sense. Sarcomata may, however, arise directly from con- nective tissues without passing through the intermediate stage of benign neoplasia. For descriptive purposes it is usual to classify the sarcomata according to the character and arrangement of the cells composing them. Perhaps the arrange- ment adopted by Ziegler is as convenient as any. He recognizes: (1) Simple sar- comata, tumors composed of a uniform aggregation of cells of connective-tissue type, but immature; (2) tumors which, owing to the peculiar arrangement and grouping of their component parts, more closely approxmiate the organoid type, in some cases resembling tumors of definitely epithelial type; and (3) tumors presenting secondary changes in their specific cells, stroma, or blood-vessels, changes that give them a peculiar and characteristic appearance. Simple Sarcomata. — The simple sarcomata may be divided according to the shape of their cells into small and large round-celled sarcomata, small and large spindle-celled growths, and mixed forms. All gradations exist between the soft, highly cellular, and malignant medullary tumor and the more slowly growing, firm, fibrous sarcoma. At one end of the scale we have the small round-celled sarcoma, at the other the fibro-sarcoma and recurrent fibroma. Small round-celled sarcomata are found more especiall}- arising from the con- nective tissue of the locomotor apparatus and from connective-tissue stroma. They are met with also in the skin, lymph nodes, testis, and ovaries. They are soft and rapidly growing. On section, they are whitish or grayish-white in color, brainlike, and a milky juice can be scraped from the surface. Not infrequently they present necrotic, caseated, or softened areas. Histologically, they consist almost entirely of round cells and blood-vessels. The round cells are small and delicate, with relatively little cytoplasm, and con- tain round or oA^ate, somewhat A^esicular, nuclei. (Fig. 99.) BetAA'een the cells is a variable quantity of delicate granular and fibrillar stroma. It is usually quite scanty and may, indeed, be difficult to demonstrate. The A^essels may be recognized as thin-walled channels coursing betAA^een the specific cells of the tu- mor. Here and there lymphoid cells can be made out Avhose nuclei stain more intensely than those of the tumor proper. 334 AMERICAN PRACTICE OF SURGERY. One particular form of small round-celled sarcoma deserves special remark. This is the so-called lymphosarcoma. It is very difficult to place this tumor, for pathologists are by no means agreed as to its nature. The enlarged lymph nodes in Hodgkin's disease are bj' some regarded as the result of a true autonomous neo- plasia, thereupon termed lympho-sarcoma ; others think that the condition is a simple inflammatory tissue hyperplasia. There is, undoubtedly, a new growth of the lymph nodes, which leads to local infiltration and the formation of distant met- astases. It has the microscopical appearance of a small round-celled sarcoma (Fig. 100). Such a growth might arise from the connective tissue of the nodes (sar- coma of the lymph nodes) or by proliferation of the lymphoid elements (true l}Tiipho-sarcoma) . Fig. 99. — Small Round-Celled Sarcom.a oi tlio Cervix Uteri. Winckel No. 6, without ocular. (From the author's collection.) Large rouml-celled sarcomata resemble closely the small-celled t3'pe and develop in the same situations. They are somewhat firmer and less malignant than the latter. The cells are larger, richer in cytoplasm, and possess one, two, or more large vesicular nuclei. Between the specific cells, and dividing them more or less definitely into groups or alveoli (alveolar sarcoma), there is a delicate fibril- lated stroma containing here and there spindle and branching cells. The vessels are generally thin-walled. Spindle-celled sarcomata are among the commonest forms of sarcomata. As a rule they are firmer than the round-celled form, and may appear on section even somewhat fibrous. Still, medullary forms occur. They are grayish or yellowish white in color, somewhat translucent, or, if vascular, may have a pinkish tinge. The cells lie for the most part side by side with their long axes pointing in the same TUMORS AND TUMOR FORMATION. 335 general direction. Tliey may compose a large area of the tumor after this fashion, but are perhaps more commonly aggregated into bundles, which run in different directions, and, indeed, may to some extent interlace. Not infrequently there is a definite relationship to the vessels, the bundles being grouped about them after the manner of a sheath. On teasing out a sarcoma of this kind, the spindle cells composing it are found to assume various types according to the tumor. Some are oval or oat-shaped, others are short spindles, while still others are provided with long processes, so that they approximate closely to the type of the normal fibrous- tissue cell. The supporting stroma is often scanty or may be scarcely, if it all, recognizable. In other cases it is more abundant and presents a fibrillar character. Those Fig. 100. — Lympho-sarcoraa. Winckel No. 6, without ocular. (Froni the author's collection.) spindle-celled growths which contain a relative abundance of stroma are usually termed fibro-sarco7nata (Fig. 101). The mixed-celled sarcomata are composed, as the name implies, of cells of sev- eral different types. It is not uncommon to find sarcomata, both of the round- celled and spindle-celled type, which on closer inspection are found to contain in addition oval, pyramidal, prismatic, stellate, or irregularly shaped cells. These cells may possess one or more nuclei. The most important variety is the giant- celled sarcoma. This form is one of the most interesting to the surgeon, inasmuch as it develops in connection with the bones, occasionally in the breast, and may reach a great size. The shafts of the long bones and the alveolar process are the parts ordinarily attacked. The growth usually starts from the bone marrow, whence the term sometimes applied to it, myeloid sarcoma (Fig. 102), and in the course of its growth 336 A-AIERICAX PRACTICE OF SURGERY. leads to great rarefaction and destruction of the bone. The denser outer shell is thinned out and can be found over the surface of the tumor in the form of thin plates, that on palpation give a curious sensation like thecnimplingof an egg shell (egg-shell crackle) . In the alveolar process the giant-celled sarcoma forms one va- riety of the tumor known to surgeons as epulis. It is in this situation a dense, firm, sessile or nodular gi-owth, tending to envelop the bone. It sometimes also originates in the antrum of Highmore. On section, giant-celled sarcomata are firm, some^yhat fibrous, and frequently present a brick-red color from parenchy- matous hemorrhage. The growth is one of the least malignant forms of the sar- comata. Microscopically, there is usually a good deal of fibrous tissue here and there, so Fig. 101. — Spindle-celled Fibro-sarcoma. Winckel No. 6, without ocular. (From the author's collection.) that the growth might be regarded as fibro-sarcoma. The specific cells are of mixed variety, round, oval, spindle, or irregular, but the characteristic feature is the presence of relatively enormous multinucleated cells. Small patches of hem- orrhage can usually be made out in various jmrts (Fig. 103). Sarcomata of Definitely Organoid Type. — In this group we place all those sarco- mata that, from the peculiar arrangement of their cells, remintl us somewhat of on organ. Thus, the cells may be aggregated into definite clusters or nests, surrounded by connective tissue {alveolar sarcoma) ; others have a tubular appear- ance not unlike that of a gland (tubular sarcomata) ; still others have a stratifietl appearance recalling the skin or a lining membrane. The type is not necessarily maintained throughout, it should be remarked. Thus a certain tumor may at one point present an organoid structure, while in other parts the appearance is rathev TUMORS AND TUMOR FORMATION. 337 that of a simple, diffuse, round-, spindle-, or mixed-celled sarcoma. Again, some of the new growths coming under this category, consisting of large spindle, round, or cylindrical cells of epithelioid appearance, closely resemble the carcinomata, for which many of them have been mistaken, particularly if they have an alveolar ar- FiG. 102.— Sarcoma of the Lower End of the Shaft of the Femur. The soft parts have been removed by maceration to show the rarefaction and expansion of the diaphysis. (Patho- logical Museum of McGill University.) rangement. In not a few cases careful examination will show a gradual transition from a carcinomatoid to a definitely sarcomatous appearance in the same tumor. It is not surprising, therefore, that this class of tumors has led to much confusion of ideas and many erroneous deductions. Standing, as regards their histological ap- pearance, on the border Ime between the carcinomata and the sarcomata, they have VOL. I.— 92 338 AMERICAN PRACTICE OF SURGERY. been classed by different investigators in accordance with tlieir individual bias as carcinomata or as sarcomata, while others have boldly met the difficult)' bj^ ignor- ing it and calling them sarco-carcinomata. I would like to emphasize here what I have said before, that it is far more scientific to go right to the root of the matter and classify these according to their origin and mode of development rather than on the basis of mere superficial resemblance. With careful study and the use of serial sections, the nature of these puzzling growths can usually be made out, though it may be freely admitted that the difficulties cannot always be cleared up. The chief forms which we have to consider in this connection are the angio- sarcomata and the endoiheliomata. Under the term angio-sarcoma we may include any highly vascular sarcoma. Two main types may be recognized, though mixed forms and modifications occur, namely, the angiomatous sarcoma and the periihelial sarcoma. Fig. 103. — Giant-Celled Sarcoma, from tlie Periosteum. Winckel Xo. 0, mthout ocular. (From the author's collection.) The first-mentioned may perhaps be regarded, at least in many cases, as a cel- lular variation of the angioma. It consists of numerous blood capillaries, be- tween which are dense aggregations of sarcoma cells. The latterariseas a sarcom- atous metamorphosis of the connective tissue forming the supporting stroma found in all angiomata. Owing to the abundance of the blood capillaries, such tumors often present a more or less distinctly alveolar arrangement, which may cause them to be mistaken for carcinomata. In the perithelial sarcoma the structure is still more alveolar in appearance. The tumor is extremely vascular and the cells composing it are large, round, spindle-like, or cylindrical in shape; they are derived from the proliferation of the connective tissue or perithelium forming the adventitia of the vessels. TU-MORS AND TUMOR FORxMATION. 339 Thus, larger or smaller cell clusters are found grouped around the -vessels, the intervening spaces being filled with connective or mucoid tissue, ordinary sarcoma cells, or a finely granular debris (Fig. 104). The perithelial sarcomata are found in the kidne3's, suprarenals, prostate, thyroid, parotid, and elsewhere. They are extremely malignant and tend to in- vade the veins of the neighboring parts. Numerous metastases may be formed. When the growths are superficial their extreme vascularity is manifested by rhyth- mical pulsation corresponding to the systole of the heart and by a blowing murmur on auscultation. The blood can often be squeezed out of the growth, only to return when the pressure is removed. Care should he taken not to confuse such Fig. 104. — Perithelial Angio-sarcoma of the Pituitarj' Body. I.eitz objective No. 7. (From the author's collection.) angio-sarcomatous metastases with cirsoid aneurisms, arterio-venous aneurisms, or phlebectasise. While on the subject of angio-sarcomata I would point out that, as Flexner's case above referred to (p. 327) proves, there is a striking resemblance be- tween the perithelial angio-sarcomata and certain tumors of the central nervous system, regarded as being probably ependymal glioma ta, so that further studj' of brain tumors of this general type may result in considerable modification of our present ideas. Some new-growths, therefore, at present classed with the peri- theliomata, may eventually turn out to be gliomatous in origin. Under the term endothelioma we include all tunrors derived from endothelial cells, whether of blood-vessels, lymphatics, perivascular lymph spaces, or of the larger serous cavities. The specific cells of such tumors are romid, flattened, or cuboidal, and bear a strong general resemblance to epithelial cells. When we 340 AMERICAN PRACTICE OF SURGERY. remember this and also take into -account tlie fact that the cells are not infre- quently arranged in alveoli, bands, nests, and tubules, it is not surprising that certain of the endotheliomata should have been mistaken for carcinoma ta. The error is more likely to occur if only an isolated portion of the growth be examined ; careful search, however, will often show at some point or other the direct conti- nuity of the cells of the tumor with those of some lining membrane, and reveal the true nature of the growth. The finer histological details of endotheliomata vary considerably according to the character of the structure from which they take their rise. In those origi- nating in the endotlielium lining blood-vessels, the specific tumor cells often show a definite relationship to the vessels, which may be so large, numerous, and tor- tuous as to give the tumor a highly complicated and peculiar structure {angiosar- coma plexiforme). In parts it may be possible to detect the remains of the vessel walls which have been destroyed by the proliferating endothelium. Within the spaces formed by the more or less imperfectly formed tubules can sometimes be seen blood corpuscles, suggesting the origin of the growth from blood-vessels. Endotheliomata derived from the lymphatic channels present a very similar ap- pearance. Those originating from the lining membranes of serous cavities and tissue spaces are apt to have a more alveolar character, clumps, nests, and anasto- mosing bands of epithelioid cells being embedded in a more or less abundant stroma of connective tissue. There may be but little ground-substance of a finely fibrillar character, it may form a well-defined stroma or, again, may be so dense and abundant that it gives a distinct scirrhous character to the growth. The stroma in some cases exhibits peculiar secondary transformations. It maj' present mucinous degeneration, forming one variety of myxo-sarcoma ; or there may be a hyaline change in the vessel walls and portions of the stroma, pro- ducing the curious growth known as the sarcomatous cylindroma. Certain endotheliomata of the dura are intensely fibrous and contain lami- nated calcareous concretions, similar to those found normall}' in the pineal gland and meninges (brain-sand). They have, therefore, been termed j)sammomata (Fig. 105). As will be gathered from the above remarks there is a striking similarity be- tween certain of the more vascular endotheliomata and forms which I have already described under the group of angio-sarcomata. This has led to some confusion in the terminology. It would be well if, with Waldeyer, we should restrict the term angiosarcoma to tumors originating from the adventitia of blood-vessels, and should include under endothelioma only such tumors as originate from endo- thelial lining membranes, whether vascular or not. It would be still more precise if we were to call tumors derived from the adventitia perithelial angiosarcomata or malignant peritheliomata. The chief difficulty with this is that histologicall}^ the endotheliomata originating in the periA'ascular lymph spaces are almost iden- tical with tlie p(>rithelial angio-sarcomata. In the case of the latter growths it TUMORS AND TUMOR FORMATION 341 ought to be possible to deiuonstrate the direct continuity of the ceUs nearest the blood-vessels with the adventitia, but this is often a matter of great difhcult3^ Endotheliomata are found usually in connection with the serous sacs, the meninges of the brain and cord, and connective-tissue spaces, occasionally in the peribronchial connective tissue, the parotid, skin, and pituitary body. Thej' form nodular or flattened sessile growths, tending to extend superficially. The denser, more fibrous forms, especially those of the meninges, are not particularly malignant, inasmuch as they infiltrate comparatively slowly and do not form dis- tant metastases. The softer cellular forms are, however, often highly malignant. The etiology is practically unknown. Irritation appears to play a part in some cases. I have met with two instances in which endotheliomata of the dura Fig. 105.— Endothelioma (Psammoma) of tlie Jlrain. Winckel No the author's collection.) .3, without ocular. (From mater appeared to be due to the influence of a sharp spur of bone projecting from the inner surface of the calvarium. Sarcomata Presenting Peculiar Secondary Characteristics. — Under this heading we will discuss the pigmented sarcomata and certain forms presenting mucoid, hyaline, and calcareous transformation. The melanotic sarcoma (melanosarcoma; melanoma; chromatophoroma) is a pigmented sarcoma, found usually in the uveal tract of the eye or in the skin. The growth varies in size and shape and is usually soft and friable. Its most striking feature is its color, which may range from yellow, brown, or gray to the most intense black. The coloration is not always uniform, and some forms may even be speckled. The vascularity may be great, and in that case it is not unusual to find areas of hemorrhage in the substance of the growth. 342 .4.MERICAN PRACTICE OF SURGERY. ^Melanotic sarcomata generally originate in structures that are normally pig- mented, though there are occasional exceptions to this rule. Those foimd in the skin can usuallj- be traced to pigmented naevi which have taken on aberrant growth. These growths are highly malignant and quickl}" produce metastases in various parts of the body, as the liver, lungs, intestines, muscles, bones, and skm. In some cases the secondary growths are exceedingly numerous, and often varj- greatly in size, some being almost microscopical, others as large as a cherry or walnut. Tlie primary' tumor may be quite small and unobtrusive. Proba- bl}' some of the cases reported as primary in the viscera are really secondarj^, the original growth having been overlooked. Histologically, there are two t3'pes of melanotic sarcomata, the spindle-celled and the alveolar. The pigmented sarcomata that arise in the choroid of the eye are usualh' of the former variety', those occurring in the skin and in nae^i are more apt to be alveolar. The pigment is called melanin. Its nature is not thorough!}- understood. The old idea was that it was derived from the coloring matter of the blood, but this is imlikel}', as it contains no iron. It is known, moreover, to contain a consid- erable proportion of sulphur. Probably the composition of the pigment differs in different cases, and it is altogether likely that it is autochthonous in nature and produced b}' the metabolism of the chromatophores. The pigment takes the form of fine dust-like particles, granules, or lumps, both withui the cells and in the in- terstices of the tissue (Fig. 106). It is highly refractile in appearance and of a yel- lowish, bro\^•nish, or black color. In the alveolar growths the pigment tends to accumulate in the cells at the periphery of the clusters and in the neighborhood of the blood-vessels. In the choroidal tumors the coloring matter is more imi- formly distributed. The amount may be so great as to mask the true nature of the specific tiunor cells. In fact it ma}^ so interfere with nutrition that liquefac- tion and necrosis result. It is a curious fact that the metastases often present a different degree of pigmentation from that presented by the original growth, and sometimes, indeed, they are quite colorless. The exact status of these timiors is still not quite settled. Unna, Gilchrist, and others hold to the epiblastic nature of the forms arising in connection ■nath pig- mented n£e^'i, while Ribbert contends that the}' arise from pigmented mesoblastic cells (chromatophores). On this point depends the question whether we are to class the melanomata with the carcmomata or with the sarcomata. In the case of the eye, the chromatophores, as Ribbert points out, are undoubtedly of meso- blastic origm. Another pigmented growth of a somewhat remarkable nature is the chloroma. This is a rare tumor which develops in connection with periosteimi, more espe- cially that of the skull, A'ertebrae, and humerus. Its peculiar feature is its color, a green or greenish- j'ellow. This is most mtensewhen the tumor is freshly cut, and fades somewhat on exposure to the air. TUMORS AND TUMOR FORMATION. 343 Histologically, the chloroma is composed of round cells, resembling large and small lymphocytes, held together by a delicate fibrous reticulum. The pigment occurs in the form of small, highly retractile granules within the cells, and is best made out in frozen sections or in teased-out material. There is still much doubt in regard to the true nature of these tumors. Many hold them to be a form of lymph-adenoma and, therefore, related to leuktemia and Hodgkin's disease. The coloring matter gives some of the micro-chemical reac- tions of fat and is, probably, to be classed as a lipochrome. Of the other secondary manifestations which sarcomata may undergo we may simply mention hyaline changes and the deposit of calcareous material in the stroma {sarcoma petrificans) Fig. 106. — Melanotic Sarcoma. Winckel No. 6, without ocular. (From the author's collection.) Sarcomatous Tumors of Mixed Type. — Under this caption we can conveniently discuss those forms of sarcomata which represent cellular variations of the simple benign tumors. In the fibrosarcoma the connective-tissue nature of the growth is quite evident. As in the fibroma there are cells of connective-tissue type together with a homo- geneous and fibrillar intercellular substance. In the fibro-sarcoma the cells are more numerous, the nuclei plumper, and the fibrillar substance less in evidence. As may be imagined, it is not easy in many cases, from the histological appearance alone, to draw the line between the benign fibroma and the fibro-sarcoma. It is well known to surgeons that a tumor which has existed for a long time and has been regarded as an innocent fibroma may recur after removal, exhibiting a limited degree of malignancy (recurrent fibroma). The transition from the fibroma moUe to the fibro-sarcoma is, in fact, almost imperceptible. In another form of fibro- 344 AMERICAN PRACTICE OF SURGERY. sarcoma the structure is not so uniform, liut there are more or less dense fibi'ous septa enclosing spindle-shaped sarcoma cells. The niyxo-sarcoma resembles the myxoma, except that the round and stellate cells are more numerous, while the nuicoid and fibrillar intercellular substance is relatively more scant}^ The lipoma may also be transformed in part mto myx- oma and subsequently into lipo-myxo-sarcoma. The cho)idro-sarcoma is a highly cellular tumor derived from the chondroma. It consists in the main of closely aggregated round, o^'al, or fusiform cells with rel- atively little cement substance. But the true nature of the growth can be made out bj^ recognizing here and there islets of unaltered cartilage. Like the lipoma, the chondroma not infrequentlj' undergoes myxomatous and, later, sarcomatous change — chondro-myxo-sarcoma. The osteosarcoma is a tumor consisting of bone, the medullar}- spaces of which contain, not marrow, but sarcoma cells. The osteoid sarcoma is similar, bony plates and spicules being formed which, however, are not ossified. Not infrequently subsequent calcareous deposit will convert the osteoid sarcoma into the osteo-sarcoma. These tumors are usually found in connection with the ]3eriosteum. The formation of bone is probably due to the action of the periosteal osteoblasts, which are in some wa}' stimulated into activity, and, possibly, are carried out into the substance of the growth. The supporting stroma of an angioma maj' occasionally undergo sarcomatous transformation (angioma sarcomatodes). Myosarcoma, a tumor homologous with the fibro-sarcoma, myxo-sarcoma, and chondro-sarcoma, composed of undifferentiated muscle cells, is theoretically possible, but little is known about its actual occurrence. The vast majority of tumors described as myo-sarcomata are either rhabdo-myomata or else myoniata presenting secondary sarcomatous transformation of the intermuscular fibrous supporting substance. They are more properly termed myoma sarcomatodes. Some rare muscle tumors, forming metastases in the internal viscera, have been described in connection with the uterus, and are believed by those recording them to be composed of immature muscle cells. These would be the true myosarcomata. II. TUMORS OF EPITHELIAL TYPE. Under this heading we would include all tumors whose most notable feature is that they contain epithelial elements. There is invariably, however, more or less connective tissue present which serves as a supporting stroma or matrix, so that in a sense some at least of these growths may be regarded as being of mixed type. The proportion of connective tissue varies in different cases. In some instances the main mass of the growth is composed of connective tissue which is definitely proliferating, the epithelial structures simply keeping pace to form an external covering. Such tumors have more in common with the fibro- mata and myxomata than with the epithelial growths. In others, the epithelial TUMORS AND TUMOR FORMATION. 345 elements are in such excess that a highl}' celhilar tumor is produced. A good example of the former is the papilloma; of the latter, adenoma and carcinoma may serve as examples. Strictl}^ speaking, before we should regard a given tumor as of epithelial type, we must be certain that there is a primary autono- mous new formation of epithelial structures. It is in man}^ cases, of course, diffi- cult to be sure of this. Where, for example, epithelial structures are present in small amount, it is not impossible that they may not be newly formed, but sim- ply entangled in the course of the excessive proliferation of the fibrous stroma. Therefore, there are not a few tumors whose status is somewhat doubtful. They are, consequently, discussed here largely as a matter of convenience. As we have seen above (p. 329), papillo7nata assume varying forms and are of diverse etiology. Many of them have affinities with the inflammatory hyper- plasias rather than with the true neoplasms; others are fibromata, lipomata, and myxomata which have come into special relationship with epithelial structures. Still others are definitely the result of the proliferation of epithelial elements. The first two classes have been sufficiently dealt with already (pp. 303 et seg.), but the last-mentioned demands further attention. This subject will be more con- veniently discussed, however, in connection with the adenomata and cystomata. Adenomata. Adenomata are tumors arising from glands or gland-like structures, the structure of which they more or less perfectly reproduce. When in the viscera, they form circumscribed, nodular masses usually encapsulated. On free sur- faces they are apt to be compound, polypoid, villous, or papillomatous. As a rule they grow slowly and rarely attain a great size. Adenomata are moderately common and are found more especially in the mamma, kidney, liver, suprarenal, thyroid, uterus, and the mucous membrane of the alimentary tract; occasionally, also, they originate in the sudoriparous, salivary, and lachrymal glands. I have been fortunate enough to find and report a unique adenoma of the pancreas arising from an island of Langerhans {Journal of Medical Research, November, 1902). Structurally, the adenomata consist of an epithelial part and a connective-tissue part. The epithelial cells usu- ally resemble somewhat closely those of the gland from which they arise, and in a general way are arranged so as to reproduce the acini and ducts, but here the resemblance usually ends. The regular structure of the normal gland and the relative proportion of its parts are considerably departed from. The connective tissue forms a stroma supporting the glandular portion and in different cases varies greatly in amount. It is usual to divide the adenomata into two classes, according to their histo- logical appearance, namely, the tubular adenomata and the alveolar adenomata, to which may possibly be added a third, the papuliferous adenomata. In the first-mentioned variety the epithelial cells are in large measure arranged after 346 AMERICAN PRACTICE OF SURGERY. the fashion of tubules or ckicts possessing definite lumina. The alveolar or acinous adenoma reminds one of the normal acini of the gland, save that they are much more numerous, and are apt to be larger and more highly convoluted. In the case of the papuliferous form, the connective tissue forming the walls of the acini or ducts proliferates actively and, pushing the epithelial cells before it, encroaches upon the cavities, which often become dilated, in the form of polypoid or papillary protuberances. Adenomata are formed, probably, much in the same way as glandular struc- tures are normally produced, namely, by the proliferation of the epithelium, which penetrates the connective-tissue stroma and assumes the form of acini and tubules. These structures are, however, produced in excess, and in some in- stances there is evidence that the stroma is not entirely passive, but partici- pates in the overgrowth also. Certain of the adenomata are of considerable practical importance to the surgeon. Of these may be mentioned the adenomata of the manmia, kidney, suprarenal, thyroid, prostate, testis, and uterus. Fig. 107. — Fibro-adenoma of the Mamma, of the Acinous Type. Winckel No. 3, without ocular. (From the author's collection.) The adenomata of the breast take the form of notlular masses, the size of a hazelnut or larger, which are movable, elastic, and moderately firm. On section they are lobulated, and the lumina of the dilated gland tubules and acini can be recognized on the cut surface. Occasionally, areas of softening and cystic degen- eration can be detected. They are of slow growth, do not cause retraction of the nipple, do not involve the axillary nodes, and do not recur after removal. Histologically, several varieties may be recognized. Certain of the fibromata of the breast, above described, contain a more or less notable amount of glandular TUMORS AND TUMOR FORMATION. 347 structure. This may in some cases be an accidental admixture, but not infre- quently with the overgrowth of the fibrous tissue there is undoubted new forma- tion of glandular acini. Such tumors are often termed adeno-f-bromata and fibro-adenomata, according to the relative proportions of the two elements present (Fig. 107). Pure adenomata of the mamma are somewhat rare. In some instances the newly formed glandular tissue results in the production of new terminal acini, associated together in groups, and lined with cubical epithelium, resembling somewhat closely the structure of the normal functioning gland. In others the growth is erratic, presenting irregular tubules lined with cubical and cylindrical cells. The various tubules and acini are bounded externally by a doubly refractile basement membrane. The recognition of this structure is im- portant, for so long as it remains intact the growth is benign. Should the gland- ular elements proliferate irregularly and appear outside the basement membrane the tumor would be called a carcinoma. Many carcinomata of the breast origi- nate in a simple adenoma and are hence called adeno-carcinomata, though there is no doubt that some arise directly from the glandular epithelium. Fig. 108. — Foetal Adenoma of the Thyroid. Winckel No. 3, without ocular. (From the author's collection.) Adenomata of the kidney are well-defined, rather soft, growths, of whitish col- or, which may be microscopic in size or may attain that of a walnut. Histolog- ically, they are tubular, acinous, or papuliferous. The epithelium resembles more or less closely that of the secreting tubules. Some of the renal adenomata, however, have been shown to originate in misplaced suprarenal "rests" (benign hypernephromata). The adenomata of the kidney may become malignant. Glandular benign tumors of the thyroid are of three types, simple, foetal, and 348 AMERICAN PRACTICE OF SURGERY. papuliferous adenomata. The simple adenoma consists of follicles filled -with col- loid, resembling those of the normal thyroid. The epithelium lining the follicles is cuboidal or somewhat flattened. In the supporting stroma can be seen here and there islets of similar cells, resembling embryonic thyroidal structure. The growth may be diffuse (colloid struma) or localized and encapsulated. In some cases the colloid increases in amount, the follicles enlarge, the intervening walls atrophy and rupture, and thus cysts filled with colloid result (cystic goitre). Simple adenomata are usuall}' single, but ma}^ be multiple. The foetal adenomata resemble in structure the foetal thyroid. The cells are arranged in solid columns and clusters, in Avhich occasionally minute lumina-may Fig. 109. — Adenomatous Enlargement of the Prostate. An " amyloid body " may be seen at tlic lower part of the section. Winckel No. 3, without ocular. (I<>om the author's collection.) be discovered, hut colloid is not present. The tumor is usually encapsulated, is whitish or reddish in color, and of soft consistence. As a rule it is quite vascular. (Fig. lOS.) The papilliferous adenomata usually originate in the walls of old cysts, but very rarely they are true paiiilliferous adeno-cystomata, comparable to those of the ovary. Adenomata of the suprarenal capsule are quite common, but rarely attain any size. It is interesting that misplaced suprarenal tissue may give rise to adeno- mata in unlikely situations sucli as the kidney, peritoneum, and broad ligament. The enlargement of the prostate that so often occurs in old age is due to an overgrowth of the glandular portion, the fibro-muscular stroma, or both. When the glandular elements are increased the prostate is enlarged, spongy, and moder- ately soft, and on pressure a fluid rich in cells can be expressed. The overgrowth TUMORS AND TUMOR FORMATION. 349 is usually generalized, but nodular masses may be formed. Microscopically, the acini of the gland are increased in numbers, are enlarged, tortuous, and often di- lated. They frequently contain concretions (Fig. 109). There issome doubt as to whether the condition should be regarded as a simple glandular hyperplasia or a true tumor formation. The importance of the condition lies in the fact that the overgrowth leads to encroachment upon the urethra, which it obstructs. This is particularly apt to be the case when the so-called middle lobe is enlarged. As a consequence the bladder becomes hypertrophied, later dilated, and at times in- flamed (Fig. 94). Even the ureters, the pelvis of the kidneys, and the kidney proper may become dilated from the excessive pressure. Adenoma of the testis originates in the seminiferous tubules and may be solid or cystic. When present, the cysts are filled with a clear mucoid material {cyst- adenoma mucosum) or with a cheesy detritus (cystadenoma atheromatosum) . In the latter variety the cysts are lined with a thick, somewhat keratinized epithe- lium. Cartilage and muscle fibres are not infrequently present, suggesting the teratoid nature of the growth. In a few cases there may be a sarcomatous transformation of the stroma {adeno-sarcoma or cystadeno-sarcoma testis). In determining the nature of a glandular overgrowth occurring in connection with the lining membrane of the uterus considerable difficulty is encountered. In the uterus the mucosa lies directly upon the muscular wall without the interven- tion of a submucosa. The uterine glands also occasionally penetrate into the muscle. In inflammation, as for example in endometritis proliferans, the tubules are enlarged, often dilated, and increased in numbers, sometimes forming inter- communicating spaces. The resemblance to a tumor is close. Moreover, round- celled infiltration which might in other cases be of diagnostic value is present in both. In making the differentiation between endometritis and adenoma on the one hand, and between adenoma and adeno-carcinoma on the other, regard must be had to the extent of the glandular proliferation. In many cases, however, we must be in doubt. Some authors describe an adenoma of the uterus consisting of numerous enlarged, dilated, and uitercommunicating tubules held together by a somewhat scantj' stroma. The tubules are lined by a single layer of irregular, compressed-looking cylindrical cells, often ciliated and showing mitoses. The tumor is apt to infiltrate and forms a connecting link with the adeno-carcinomata (adenoma uteri malignum). From what has just been said on the subject of adenomata of the prostate and uterus, it may be inferred that there is a close resemblance between simple gland- ular hyperplasia and adenomatous new formations, and this is, indeed, the fact. Structurally, the appearances in both are practically identical, any difference be- ing merely that of degree. If we take, for example, the mucous membrane of the stomach and intestines, it is not unusual to find, in the neighborhood of chronic inflammatory patches and especially ulcers, that the tissues are undergoing marked hyperplasia. This must be regarded as an attempt at regeneration, but 350 AMERICAN PRACTICE OF SURGERY. while in some cases it leads to the repair of the injury by the formation of normal mucous membrane, it not infrequently occurs in excess and produces tumor-like polypoid outgrowths. Histologically, such structures conform in appearance to tubular glands, but deviate somewhat from the normal in that the glandular ele- ments are more irregularly disposed and branched. In a certain sense there is an atypical glandular formation. The overgrowth may also be so active that the glands are dilated and we get a kind of papillary excrescence. Such formations occur also in the absence of any pre-existing inflammation, and in these cases must be regarded as true hypertrophies. Here we begin to enter the region of the adenomata. Irritation of some kind would seem to be of some importance in the etiology of these growths. The fact that they are sometimes found at birth sug- gests in some cases the influence of developmental anomalies. An interesting confirmation of this is found in those adenomata which are traceable to misplaced portions of the suprarenals and thyroid gland. These can hardly be attributed to anything but the proliferation of cells or remnants of organs which have in the course of embryonic development been dislocated from their natural environ- ment. The adenomata are usually considered to be benign tumors. They may, how- ever, take on atypical and aberrant growth, and may, therefore, pass on into car- cinoma. There would appear to be a gradual transition of forms between the simple adenoma and the frankly malignant adeno-carcinoma. This, again, has led to some confusion of terms and ideas. There are certain tumors, that histo- logically must be classed with the simple adenomata, which on occasion are com- petent to produce distant metastases. The secondary growths in their turn pre- sent the structure of a plain adenoma. In a sense they are comparable to the chondroma, which acts occasionally in a manner sunilar. Such are some of the adenomata of the thyroid, the intestinal tract, the ovary, and the uterus. It is perhaps a matter of taste whether we term these, with certain authors, adenoma malignum or carcinomatoswn , or carcinoma aclenomatosum. CYSTOMATA. Closely allied on the one hand to the fibromata and on the other to the adeno- mata are certain forms of cystic growths known as epithelial or proliferation cys- tomata. It would be well here to keep constantly in mind the distinction that exists between a cyst and a cystoma. In a broad way a cyst may be defined as a patho- logical cavity containing fluid or semifluid material. The term does not connote any new formation of tissue. As examples we may cite the degenerative cysts that often are met with in tumors and inflammatory infiltrations, the result of necrosis and liquefaction of the substance, retention cysts, the developmental cysts occurring in connection with the embryonic fissures, and parasitic cysts. A TUMORS AND TUMOR FORMATION. 351 cystoma is a true tumor, resulting from the proliferation of a matrix that tends to form cavities. It is possessed of powers of independent growth. The true cystomata generally arise in structures that contain epithelium. When occurring elsewhere they must be derived from "cell rests" or misplaced embryonic tissue, and should, therefore, be classed with the teratomata {q. v.). The cavities in a cystoma are single, multiple, or multiloculated, and are lined by epithelial cells. The material contained within the cysts is fluid or semifluid, presumably the result of the secretory activity of the lining cells, or in part a tran- sudation from the lymph- and blood-vessels. The fluid often, also, contains cholesterin, fatt}^ and caseous matter, blood, pigment, and cell detritus. With regard to the gross structure these tumors may be largely cysts or, again, they may be partly solid and partly cystic. Histogenetically, they are found to have aflfinities with the adenomata and the papillomata. Favorite sites for proliferation cysts are the thyroid, breast, ovary, kidney, liver, broad ligament, wall of the uterus, and vagina. The first method by which cystic tumors may develop from the adenoma is well illustrated in the case of the thyroid gland. Here, in the lobules of the gland new acini containing colloid are formed, constituting an adenoma or colloid struma. The colloidal secretion gradually increases until the walls of the acini become greatly distended and finally rupture, many of them thus becoming confluent. In this way there are sometimes formed cystic cavities of consider- able size containing colloid and often blood. This might be termed the gland- ular type of cystoma. The second type is the papilliferoiis cystoma. A good example of this is to be found in the intracanalicular papilloma of the mamma. This originates in a fibro- adenoma of the organ. Such tumors usually contain at some part or other some- what dilated ducts and acini (tubular adenoma). The interstitial stroma of con- nective or mucoid tissue proliferates, forming papillary processes that project into the glandular spaces, gradually distending them. These outgrowths are covered with epithelium and may become highly complicated and exuberant in their career, in some cases even extending through the ducts of the hippie and appear- ing externally. The ovarian cystomata are, too, of great practical importance, being among the most common neoplasms affecting these organs. They are unilateral or bilat- eral, unilocular or multilocular. They produce symptoms largely by their size and weight, but one variety, the papillary cystadenoma, exhibits a marked tend- ency to become malignant. The most frecjuent variety is the simple cystoma. This is commonly unilat- eral and is composed of one cyst of relatively large size, together with sev- eral smaller subsidiary cysts. The cyst wall is tough, thin, and translucent, and the cavities are filled with a viscid, mucinous fluid, either clear and colorless or 352 AMERICAN PRACTICE OF SURGERY. mixed with cell detritus and blood. The cyst Avail is composed of two layers of fibrous tissue, the outer dense, the inner vascular and more cellular. The lining membrane of the cavities is usually composed of a single layer of high cylindrical cells, but, in the larger cysts, of short columnar, cuboidal, or even flattened cells. The lining epithelium often extends outward into the wall of the c}^sts, forming simple or compound gland tubules. It is rare for the epithelium to be stratified. Occasionally the epithelium is ciliated. A second, but rare form is a pedunculated multilocular cyst of moderate size, usually unilateral, lined with cylindrical epithelium. The contents of the cysts are thin, more serous than in the first form, light yellow or greenish in color, and rich in albumin. The most important type, however, is the papillary cystoma, or cystadenoma papilliferum. This is a multilocular or, occasionally, unilocular cyst, which is apt to be bilateral. The cysts are usually smaller than those of the simple cystade- noma and are more or less filled with warty, villous, or tree-like formations of con- nective tissue covered with ciliated epithelium (Fig. 110). In a few cases cilia are absent or are present only on the papillte. The growth extends between the lay- ers of the broad ligament or forms a pedunculated mass springing from the sur- face of the ovary. The fluid contained within the cysts is thin, watery, often dark colored, and more serous than that of the simple cystadenoma. Not infre- quently the cauliflower-like excrescences appear externally, either because the outer wall of certain of the cavities has given way or because of an actual inva- sion of the wall by the new growth. This form of cystadenoma has a great tendency toward excessive and inde- pendent growth. According to Pfannenstiel about one-half the cases in time be- come malignant. In rare cases the tumor spreads along the peritoneum, forming local metastases that reproduce the cystic and adenomatous character of the pri- mary tumor. The pathogeny of ovarian cystadenomata is not at all clear. As Orth has pointed out, all sorts of transitional forms exist between the simple and the papil- lary varieties. This, together AA'ith the fact that in all varieties the cysts may be lined with ciliated epithelium, suggests that the ovarian cystadenomata have a common origin. This is by no means necessarily so, however, for it has been shown that under certahi circumstances non-ciliated epithelium may acquire cilia. Theoretically, ovarian cystadenomata may arise from the epithelium of the follicles, from the superficial germinal epithelium, from certain tubules of the paroophoron (Waldeyer), from displaced "rests" of the ciliated tubal epithelium (Kassmann), or from remains of the Wolffian body (Koelliker). The develop- mental origin of many of them is supported by several observations. Cystadeno- mata are usually met with during the period of sexual activity and, often, in both ovaries. Cases have been reported where sisters or mother and daughter have been affected, suggesting a hereditary peculiarity. Again, it is not uncommon to TUMORS AND TUIVIOR FORMATION. 353 find the combination of a cystadenoma and a dermoid. Autliorities are not agreed wliether to assign the same mode of origin to the simple cystadenomata and the papiUiferous forms. Orth is inclined to attribute the majority of them to the same precursor, the germinal epithelium. The cystomata of the kidney rarely attain a large size. The congenital cystic kidney is in some cases probably to be regarded as a true tumor or cystadenoma. Certain of the smaller ones may be traced to misplaced suprarenal "rests." The alveolar, tubular, and papillary adenomata of the kidney occasionally give rise to cystic growths not unlike those of the ovary in outward appearance. Multiple cysts of congenital origin have been foimd in the liver. The condi- tion is often associated with congenital cysts of the kidney. Little is known posi- tively about them. They are probably to be regarded as true cystomata, com- FiG. 110. — PapiUiferous Cystoma of the Ovary. Leitz objective No. 3, without ocular. (From the author's collection.) parable in most respects to those of the kidney. Some of them may possibly start from suprarenal " rests " in the liver, inasmuch as suprarenal tissue has occa- sionally been found there. Carcixomata (Atypical Epi-, Meso-, and Hypo-lepidomata). Just as we have malignant new growths that are cellular variations of con- nective tissue and are known as sarcomata, so we can recognize malignant neo- plasms of epithelial origin — the carcinomata. We may pursue the parallel fur- ther. As we get sarcomatous transformation of tumors derived from fibrous tissue and its congeners, as for example in fibromata, myxomata, chondromata, osteomata, so we may have carcinomatous metamorphosis of the benign epithelial growths — the papilloma, adenoma, and cystoma. VOL. T _93 354 AMERICAN PRACTICE OF SURGERY. A carcinoma may be defined as a malignant tumor arising from epithelium. It possesses a remarkable tendency to local infiltration, sooner or later undergoes partial necrosis, and commonly produces secondary new growths in distant parts (metastasis). Carcinomata arise wherever epithelium is found, from the super- ficial epithelium of the skin, from the epithelium lining the alimentary tract and lungs, and from the invaginations of epithelium constituting the secreting glands. Carcinomata occasionally, also, manifest themselves in structures where epithe- lium is not normally present, as, for instance, deep down in the neck (in con- nection with the branchial clefts) and in the walls of dermoid cysts. Such an occurrence does not invalidate the general rule, for in such cases the tumorn orig- inate from embryonic epithelium which has become displaced and separated from its proper environment in the course of development. From the standpoint of embryology the epithelium from which carcinomata are developed may belong to any of the three primitive cell aggregations — ectoderm, entoderm, or mesoblast. Histologically, carcinomata resemble the epithelial or fibro-epithelial struct- ures from which they spring, with one important difference to be referred to anon. We find masses of epithelial cells of varying size and shape enclosed in spaces or alveoli, and supported by a connective-tissue stroma carrying the blood-vessels for the support of the tissues. The connective tissue and the blood-vessels never penetrate the epithelial-cell masses. We can best understand, perhaps, the nature of carcinoma and the sequence of events that give rise to it if we consider for a moment the normal proliferation of epithelial structures. Epithelial tissues are among the most active in the bodj^ Owing to the demands of function and their exposed position they are subjected to a great amount of wear and tear. This is quickly made good. The reparative powers of epithelial cells, however, are not only sufficient for these lesser calls, but are competent to replace extensive losses of substance. Moreover, under certain circumstances, as, for example, under the influence of irritation, large masses of tissue, composed principally of epithelial elements, can be produced. In addition to the proliferation of the epithelial cells in such cases there is a new formation of connective tissue, which acts as a supporting stroma and carries the blood-vessels. Such a structure repeats somewhat closely the appearances of the original tissue from which it sprang and is, therefore, called typical. Of this nature are certain papillomatous and polypoid outgrowths, warts, and condylomata, before referred to, that stand in an intermediate position between the simple inflammatory hy- perplasia! and the true tumors. But we may go further than this. If we take, for instance, a chronic ulcer of the skin and subcutaneous tissues, it is not unusu- al to find marked evidences of proliferation of the epithelial cells of the cutis at the periphery of the lesion. The epithelium is thickened and tends to penetrate deeply into the loose connective tissue resulting from the inflammatory action. In fact, the ordinary histological features of the epithelioma or epidermal carci- noma are simulated with remarkable accuracy. Such a growth must, therefore, be TUMORS AND TUMOR FORMATION. 355 termed atypical. There is, however, this important fact to be noted : the down- ward extension of the superficial epithelial cells only extends as far as the confines of the altered connective tissue, and ceases so soon as the source of irritation is removed. In other words, the new growth is not autonomous. In the carcinomata, on the other hand, while the proHferating epithelial cells retain a somewhat close resem- blance to those from which they are derived and with which they are in anatom- ical continuity, they grow wildly and without regard to the neighboring struct- ures. The orderly arrangement of the original tissues from which they spring is departed from. Structurally speaking, there is no normal prototype of the carcinoma. This, then, is the crucial point in the differentiation of carcinomata from other forms of epithelial-cell proliferation: the overgrowth is not only atypical but it is aberrant. Inasmuch as the proliferation appears to be the result of forces inherent in the epithelial cells themselves, the carcinomata, like other tumors, are autonomous formations. To illustrate. Let us take the case of carcinomatous transformation of the adenoma of the breast, an occurrence that is by no means uncommon. In the adenoma we have a more or less abundant new formation of acini, ducts, and tubules, closely resembling those of the normal functioning gland, enclosed in an orderly fashion within a basement membrane. The glandular nature of the growth is quite evident. The epithelial cells of such an adenoma may at times take on excessive action. They proliferate more rapidly, are heaped up in places, and finally break the bounds of the limiting membrane and appear in the intervening fibrous stroma. Here they form rounded, oval, elongated, or irregular solid clusters, in which the arrangement into acini and ducts can no longer be traced. These masses are, however, in direct continuity with the epi- thelial elements of the original tumor. Such an atypical and disorderly growth of the epithelial cells constitutes a carcinoma. In a similar fashion papillomata, especially those of an adenomatous character, such as the papillomata of the bladder and rectum, and certain cystomata, may take on malignant action. In the cases just cited, the carcinoma originates as a cellular variation of a tumor of organoid type. But this is not the only way. Carcinoma may originate directly from epithelium without going through an intermediate organoid stage. This occurs, for instance, in the skin and mucous surfaces. In the development of squamous-celled carcinoma or epithelioma of the skin, the part is first enlarged owing to the simple hyperplasia of the Malpighian layers, the follicles, and glands. But soon the aberrant character of the growth becomes evident. The proliferating cells begin to penetrate the subjacent fatty and connective tissue as frnger-like processes and strands of cells, which in parts coalesce, forming a sort of network. The normal relationships of the various tissues entering into the part are quickly obliterated, as the growth becomes exuberant and erratic (Fig. 111). In a sim- ilar way, carcinomata of the mucous membranes, as of the stomach and bowels, begin with hyperplasia of the glandular elements, the cells of which increase in size and numbers, penetrate the basement membranes, burst through the muscu- 356 AMERICAN PRACTICE OF SURGERY. laris mucosffi, and eventualh- appear in the muscular wall. The term adeno-car- cinoma, so often employed, refers to a carcinoma that reproduces the glandular tj^e in a recognizable degree. The large majorit}' of carcinomata are adeno-car- cinomata. Having considered the manner in which carcinomata originate, we may prop- erly inquire into their mode of growth. This depends in large measure on the nature of the supporting stroma of the part involved. In the case of connective tissue we haA-e a mesh work of fibres, between which lie the cells proper. The spaces form an interconimunicating system and are the radicles of the lymphatic chan- nels. Now, if a mass of epithelial cells begins to proliferate, and does not extend to the surface after the manner of a typical growth, it extends downward and at once enters this system of tissue spaces, where it continues to grow. J.:/- mr-^^t^-^P^ n'-*^'" mT- '■ Fig. 111. — Epithelioma. Tliis section shows very -well the aberrant downward growth of the super- ficial epithelium of the skin. Winckel No. 3, without ocular. (From the author's collection.) The epithelial-cell clusters invariablj' lie within the Ijmiph spaces and extend by way of the lymph channels. In hardened sections, in which the epithelial cells have shrunk away from their boundaries, it is often possible to detect a layer of endothelium lining the alveolus, similar to that lining the lymphatics. In a general way, the cells forming a carcinoma resemble those of the epithelial structures from which they arise. Close study, however, will reveal some nota- ble differences. The carcinoma cells are often larger and possess larger nuclei ; there is considerable variation in shape; and degenerative changes are often to be observed in the protoplasm. Single cells of relativelj' great size, containing a sin- gle large nucleus, can occasionally be seen; or, again, cells may be seen which con- tain a multitude of nuclei. The nuclei are rich in chromatin and stain deeply. The process of cell division is, moreover, abnormal. In place of simple division TUMORS AND TUMOR FORMATION. 357 of the nuclei, we get the most compUcated and irregular nuclear figures. Some of the cells contain vacuoles filled with fat or hyalin and appear to be phago- cytic, for they may enclose leucocytes, red corpuscles, or plasma cells. In fine, the differences taken together indicate an overplus of vegetative energy. The degenerations so commonly found are a natural accompaniment of this, the cells growing so fast that they cannot obtain sufficient nourishment. The clumps of epithelial cells, lying in the alveolar spaces, present great varia- tions in size and shape. As a rule, the newly formed epithelium forms a solid mass which ramifies in the connective tissue, not unlike the roots of a tree. At the periphery of the main mass, small isolated clusters of cells may often be found, having no visible connection with the rest. The distinction between cells and stroma is usually weW preserved, but if the stroma be loose and cellular it is hard to determine the limits of the new growth. In the case of loose connectiA'e tissue and fat the epithelial cells grow wildly in all directions, so that the alveolar arrangement is lost. We often find the carcinoma cells extending in long rows as a somewhat diffuse infiltration. It should be noted that the carcinoma cells preserve, so far as may be, the physiological characters of the epithelium from which they are derived. If we take the case of the epithelioma of the skin, the finger-like processes that invade the deeper tissues are composed of cells that develop, grow old, and die, just as do those of the superficial epithelium. We find, for example, that the cells at the periphery of the cell masses correspond with those of the Malpighian layer. As we proceed toward the centre the cells gradually become flattened and are converted into keratohyalin. This gives rise to curious translucent bodies having a concentric lamination resembling the layers of a pearl or onion. These are the " epithelial pearls " or " cell nests " that are so conspicuous a feature of the epithe- liomata of the skin (Fig. 112). The same tendency is manifested in the columnar- celled carcinoma of the rectum. The proliferating epithelial cells come to be arranged side by side, their long axes pointing in the same general direction. As a result we get the columnar cells grouping themselves about a central lumen, thus reproducing more or less faithfully the original tubules and acini. The regu- larity of this formation is often, however, lost in consequence of the exuberant growth, so that groups of cells become forced into the cavity and there form acini, solid masses, and complicated loops. Pressure, too, of the rapidly growing cells will naturally modify the arrangement. Carcinomata of the thjToid also give rise to secondary growths that assume the alveolar structure of the normal gland and may even produce colloid. This tendency to retain the original char- acteristics of the parent cells is, as one would expect, most marked in the case of slowly growing tumors, while it is lost in the more exuberant growths. It may, moreover, be present in one part of a tumor and absent in another. Mention has been made above of degenerative disturbances which are not infrequently present in the specific cells of carcinomata. These take the form of 358 AMERICAN PRACTICE OF SURGERY. simple coagulation, of colliquative necrosis, or, again, of colloidal and hyaline transformation. Necrosis is apt, of course, to occur in rapidly growing tumors, where the vascular mechanism is unable to keep pace with the epithelial pro- liferation. Necrosis usually occurs in the centre of the cell masses, or, in other words, at the point most remote from the nutrient blood-vessels. From the histologist's point of view the appearance of the cells constituting a carcinoma forms a ready means of classification. Thus we may recognize a squa- mons-celled carcinoma (carcinoma plano-cellulare), a round-celled carcinoma (carcinoma globo-cellulare), and a cylindrical-celled carcinoma (carcinoma cy- lindro-cellulare). It should be remarked, however, that while the carcinoma cells tend to reproduce the characters of the epithelial cells from which they spring, yet they do not always perpetuate these. The more rapidly growing the tumor and Fig. 112. — Epithelial Pearl or "Cell-Nest," from an Epithelioma of the Lip. W^inckel No. 6, without ocular. (From the author's collection.) the farther removed its cells from their original progenitors, the more widely do the specific carcinoma cells deviate from the type. Thus, a carcinoma of the cylin- drical-cell type may in parts consist of clusters and off-shoots of round cells. This has been by some termed metaplasia of epithelium. It is more likely, how- ever, that the round cells are merely young and immature forms of cylindrical cells. This is often well illustrated in the case of metastases which may be quite unlike the parent growth. The sqiiamous-ceUed carcinoma (epithelioma) may arise in any part of the body where stratified pavement epithelium is found. It occurs, therefore, in the skin, especially that of the face and lip, in the buccal mucous membrane, the tongue, oesophagus, anus, vulva, vagina, vaginal portion of the cervix uteri, penis, and TUMORS AND TUMOR FORMATION. 359 conjunctiva. Rarely, epitheiiomata may arise from papillary warts and ntevi, from atheroma cysts, and from dermoids, ^'ery exceptionally, a squamous-celled carcmoma may originate from parts that contain no squamous cells. This is known to occur in the uterus. "\'on Rosthorn and Zeller have described a meta- plasia of the columnar cells lining the uterine cavity into pavement cells, and from these a squamous-celled epithelioma may develop. A squamous-celled epithelioma results from the invasion of tissues and organs by proliferating epithelial cells deri-\'ed from stratified pavement epithelium con- stituting a protecting membrane or lining a cavity. Histologically, it consists of a supporting stroma usually of connective-tissue or muscle, or both, in which are alveoli filled with cells of epithelial type. The cell clusters usually appear to be distinct and isolated, but serial sections show that they are united at various levels by lateral processes, so that the epithelial masses have really a plexiform arrangement. In the epitheiiomata of the skin, the cells at the periphery of the alveoli are round, cubical, or short columnar, and are placed at angles to the surface of the stroma, in this resembling the germinal cells of the rete Malpighii. Many of them can be recognized as " prickle ' ' cells. As we approach the centre, the cells become more flattened and spindle-shaped, and gradually lose their nuclei. The central cells, as before mentioned, retaining their physiological peculiarities, are gradually transformed into an almost struct- ureless keratohyalin material. The concentrically arranged cell masses may cal- cify at the centre, liquefy, or swell up, or may become converted into colloid. They are not always found in epitheiiomata, or, if they are, they are present in very small numbers. Carcinomata of this type are particularly apt to break down on the surface, thus forming an ulcer, the edges of which are soft and swollen. A special form of epithelioma of the skin, that demands a word or two, is the so-called "rodent ulcer." This begins as a small ulcer of the skin, not infre- quently on the face near the eyelids. It spreads irregularly at the periphery, while the older parts cicatrize and heal, again becoming covered with epithelium. The growth is essentially chronic and may last many years. Histologically, it is a superficial epithelioma of the skin, but must be regarded as the least malignant form of this type of cancer. The rotrnd-celled carcinoma is composed of spaces filled with round cells or cells which have been rendered polyhedral from pressure. Since the various diame- ters of the cells are approximately equal they have been termed isodiametric. Round-celled carcinomata arise in glands, like the mamma, salivary glands, and liver, and in glandular tumors, that contain isodiametric epithelium. Occa- sionally, they may arise from the cylindrical epithelivim of mucous surfaces and glands, the cells of which have been transformed into the isodiametric type. Histologically, we may recognize a large alveolar round-celled form, in which the spaces contain a large mmiber of isodiametric cells closely packed together, 360 AilERICAN PRACTICE OF SURGERY. and a s77iaU alveolar round-celled variety, in which a smaller number of cells, iisually from two to ten, are to be found. The cylindrical-celled carcinoma originates in mucous membranes, glands, ducts, and tubules provided with cylindrical epithelium. We find it, therefore, very commonly in the stomach and intestines. In a typical case, the alveoli con- sist of cylindrical cells arranged so as to enclose a central cavity, in this suggest- ing the normal structure of the gland. Certain of the cells in question are goblet cells. The lumina generally contain fluid, mucin, and disintegrated cells. The cells lining the alveoli may form a single layer, or, again, they may be strati- fied. Here and there the smaller alveoli can be seen to contain masses of round cells, which are solid buds of young growing cells springing from the cylindrical cells lining the spaces. These may be so numerous as to constitute the tvunor a transition form between the C3dindrical-celled and the round-celled carcinoma. The shape of the epithelial cells closelj' resembles that of the cells of the normal mucous membrane, and it is curious how faithfully the glandular appearance of the new growth is preserved. A reference to Fig. 113 will show how closely such a carcinoma may resemble the simple adenoma. Certain features, however, will aid us in making the differential diagnosis. Thus, cylindrical-celled carcinomata usuallj' ulcerate early, much earlier than do the adenomata. The important clincliing point is, however, the presence of epithelial cell masses in parts where normally epithelium is not present. In the adenoma, say of the intestinal mu- cous membrane, cell masses and alveoli are produced which closely resemble the growing processes of the carcinoma. There is this important difference, how- ever, the proliferation of the cylindrical cells in the adenoma is entirely confined to the muco.sa ; in other words, it lies above the muscularis mucosie. In the cjdindrical-celled carcinoma, on the other hand, the cells soon break these bonds, pass into the submucosa, and eventually invade the muscular la}'ers and the neighboring structures. Goblet cells, which are so important a feature of the gastro-intestinal mucous membrane, are fairly numerous in the adenoma, while they are much rarer in the carcinoma. Having discussed the nature and appearance of the epithelial cells that con- stitute a carcinoma we pass on to consider the character of the supporting stroma. This also presents considerable variations. ^^Hiile it forms part of the tmiior mass and grows with it, it camiot be said to be an integral part of the timior. The stroma of the tumor represents in part the normal tissues of the locality that has been invaded by the epithelial cells. Thus, in an epithelioma of the skin the stroma consists of the subcutaneous connective tissue and fat together ^^•ith seba- ceous and sudoriparous glands. As the tumor grows there is undoubtedly a new formation of the interstitial connective tissue advancing -pari pass^l with it. This may possibly be interpreted as an attempt to form a vascular tissue competent to carry nutriment to the growing epithelial structures. Possibly, too, it is to some TUMORS AND TUIVIOR FORMATION 361 extent a reaction on the part of the stroma resulting from tlie irritation produced by the presence of cells foreign to the normal tissues. The stroma usually consists of fibrous connective tissue, though in excep- tional cases it may be composed of muscle, as in carcinoma of the uterus, or of bone, as in secondary carcinoma of bone. Here and there in the stroma can be seen isolated clumps or, sometimes, a diffuse infiltration of round cells, resem- bling the h'mphoid cells of the lymph nodes and the lymphocytes of the blood. Plasma cells are present also, but are somewhat less nvunerous. With this there are evidences of proliferation of the connective-tissue cells proper, but this is usually in the background. Occasionally the proliferation is so marked that the interstitial stroma comes to resemble a sarcoma. Occasionally giant cells can Fig. 113. — Columnar-celled Adeno-carcinoma of the Rectum. Winckel No. 3, without ocular. (From the author's collection.) be seen in the stroma, similar to those sometimes found in the neighborhood of foreign bodies. The relative amounts of epithelial-cell masses and of stroma varj- greatly in different tumors and even in different parts of the same tumor. This forms a convenient basis on which to divide carcinomata according to their gross appearances. If the fibrous connective tissue greatly predominate we speak of a scirrhous carcinoma. In such cases the epithelial-cell clusters are small, often attenuated, and atrophic-looking. If the epithelial cells be numerous and arranged in small clusters bounded by a delicate connective-tissue wall, we have an alveolar carcinoma. If the stroma be scarcely apparent so that we get a soft brain-like growth, we call it a medullary or encephuloid carcinoma. A carcinoma in which stroma and epithelial elements are about equally divided is termed a simple carcinoma. 362 AMERICAN PRACTICE OF SURGERY. The margin of a carcinoma is rareh' sliarp. The greatest growth is at the peripherj^, and the tumor extends in lines into the adjacent tissues. There is never any attempt at the formation of a capsule. In the neighborhood of the growth can often be seen small foci of epithelial cells either separated from the main mass or attached to it by a delicate thread of tissue. The invasion and destruction of the healthy tissues in the immediate vicinity of the growth are a marked feature. The destruction of the tissues seems to be brought -Carcinoma of the Lesser Curvature of the Stomach, with Ulceratii Museum of McGiil University.) (Pathological about, not so much by pressure or by phagocytic action of the carcinoma cells, as by simple lack of nutrition, all the available pabulum being appropriated by the tumor. Secondary Changes in Carcinomata. — I have above mentioned the fact that degenerative phenomena are commonly to l^e found in carcinoma cells, ^^^^en the growth is of any size these become quite marked. Thus, in the centre of the cell clusters, we get fatty degeneration, vacuolation, atrophy, and even necrosis. In this way large portions of the alveolar contents are destroyed. The nuclei disintegrate, the cytoplasm fragments, and we get a dirty-looking granular TUMORS AND TUilOR FORMATION. 363 detritus that stains badly. 'N^lien the necrosis is superficial it leads to ulcera- tion (Fig. 114). In internal carcinoma ta, ag for example those of the liver, the detritus is in part absorbed, and the nodules formed by new growth soften and become depressed in the centre, or "umbilicated" as it is called. Certain of the degenerative changes are so striking that they stamp the tumor as something out of the ordinary. An instance of this is the colloid or gelatinous carcinoma, foimd most often in the alimentary tract and mamma, less often in the ovary. It forms a nodular growth or a diffuse infiltration. On section the tumor shows in some part or other, or possibly throughout, a characteristic trans- lucent, gluey, or gelatinous appearance. This is due to a mucinous or gelatinous degeneration of the epithelial-cell clusters. The carcinoma cells may in time entirely disappear, and the spaces are then filled with a homogeneous, glassy Fig. 115. — Colloid Carcinoma. Winckel No. 3, without ocular. The carcinoma cells are greatly degenerated and have been replaced by colloid, which can be recognized as long stringy fibrils. (From the author's collection.) substance that under the microscope appears as structureless fibrils striking a purple color with h^ematoxylin (Fig. 115). In other cases the fibrous stroma undergoes myxomatous transformation — carcinovia myxomatodes, — either alone or with mucinous transformation of the epithelial cells as well. Thus the whole growth may become translucent and gelatinous. A rarer form of carcinoma is that in which hyaline transformation of certain of the epithelial cells or of the stroma takes place — carcinoma, cylindromatosiim. It occurs in the skin, the mtestine, and in glands. Pigmented carcinomata — melano-carcinomata — have been described, but are still rarer. The pigment lies partly in the epithelial cells and partly in the stroma, giving the tumor a gray, brownish, or black color. 364 AMERICAN PRACTICE OF SURGERY. Methods of Extension and Metastasis. — If we examine a growing carcinoma, we find tliat it is sending out at tlie periphery processes of epithelial cells into the tissue spaces, spaces that, as we have alreadj' seen, are to be regarded as the ulti- mate radicles of the lymph chamiels. This is termed extension by infiltration (Fig. 116). Some few carcinoma ta are almost as sharply defined at the margins as a benign growth, but in most there is undoubted infiltration of the surrounding soft parts, and in some this may be quite far-reaching. Sometimes, also, we find small nodules at some little distance from the periphery, similar in appear- ance to, but quite distinct from, the primary growth. These are the result of minute emboli of carcinoma cells within the l3''mphatic channels leading from the part. This is known as extension by dissemination. -Carcinoma of the Stomach. This spc muscular wall with epithelial cells ui'ii sh()\vs very clearly the infiltratii (_Frorn the author's collection.) Small clusters of epithelial cells ma}' also break away from the main mass of the growth and be carried by the lymphatics or, occasionally, by the blood stream, to distant parts, where they set up independent foci of disease. This phenomenon is called metastasis. In general the first manifestation of metastasis occurs in the regional lymph nodes nearest the primary growth (Fig. 117). If we examine one of these nodes in the early stage of the process, we find small foci of epithelial cells at the periphery of the node in close relationship to the afferent lymphatic channels and sinuses. At first, one sees the lymphoid cells between the epithelial- cell masses, but soon they atrophj^ and their place is taken by connective tissue. The metastases in general resemble the primary tumor, except that the}' are not so apt to retain the functional peculiarities of the cells from which they are ulti- mately derived. Thus, in metastases from an epithelioma of the skin we do not so often get the formation of the epithelial "pearls," and in adeno-carcinomata TUMORS AND TUMOR FORMATION. 365 the glandular appearance of the original growth is not so completely preserved. When the regional lymph nodes are thoroughly infiltrated, the masses of carci- noma cells pass out by the efferent lymphatics and invade the system of nodes next in order, or cancerous emboli may pass through the first series of nodes without involving them, and attack those more remote. Metastasis by the blood stream is rather uncommon in the case of the carci- nomata, though it is the rule with the sarcomata. Carcinomata of the stomach and intestines, however, commonly spread to the liver through the portal system, (Fig). 118, and carcinomata of vascular regions, like the penis, may extend through the blood sinuses and vessels. The new growth may directly invade the vessels destroying the wall and appearing within the lumen, or may reach the Fig. 117. — Secondary Invasion of a Lymph Node with Columnar-Celled Carcinoma. Winckel No. 3, without ocular. (From the author's collection.) blood through the lymph-vascular system. Generally speaking, emboli from car- cinomata of the gastro-intestinal tract reach the liver, those from tmnors situ- ated elsewhere reach the lungs. Exceptionally, invasion may take place in a direction opposite to the course of the lymph stream — retrograde embolism. Extension of a carcinoma may also take place by implantation. In carcinoma of the kidney, secondary tumors may arise along the ureter and in the bladder. In carcinoma of the ovary, secondary nodules may appear in the Fallopian tubes and in the peritoneum. In the intestine, small secondary growths may be found in the mucosa below the original mass. In all these cases the dissemination of the growth appears in large part to be determined by gravity. Carcinoma in its extension always takes the line of least resistance, and we find it spreading along the tissue interstices, and along the perineural and perivas- cular lymphatics. 366 AMERICAN PRACTICE OF SURGERY. III. THE TERATOID TUMORS. In the foregoing pages we have had under discussion tumors that are members of the great family commonly known as the Blastomata. It remains for us to con- sider the second main group, the Teratomata. The blastomata have been dealt with at considerable length, comprising as they do the vast majority of tumors commonly met with. The teratomata, being much rarer, are of not so much practical importance to the surgeon, though they are of the greatest importance in regard to the question of tumor formation. We will, therefore, in this place consider them only in a sketchy way. A teratoma is a tumor the characteristic feature of which is that it is com- posed of cells or tissues that normally do not occur in the affected part, or at least are not present at the period of bodily development at which the growth mani- FiG. lis. — Secondary Carcinoma of the Liver. Winckel No. 3, witliout ocular. (From tlie autlior's collection.) fests itself. The simplest form of teratoma is represented by a single tissue or a cyst {simple teratoid tumor or cyst), but as a rule more than one tissue and more than one germ layer are represented (mixed tumor). The term "teratoma" is often applied in a narrower sense to the more complex growths, while tumors consisting of derivatives of all three primitive cell-layers are called embrijoid tumors or einbryomata. The tissues entering into the composition of teratomata arise either from the Anlage of the affected individual {monogerminal, endogenous, or autochthonous teratoviata) , or from those of a second individual (bigerminal ectogenous teratomata; fa'tus in fwtu). Occasionally, sarcomatous or carcinomatous transformation may occur iu the tissues of a teratoma, constituting a malignant teratoma. TUMORS AND TUMOR FORMATION. 367 As all teratomata are due to proliferation of misplaced or redundant cells, it is evident that we may meet with all degrees- of complexity, from the simplest epidermoid or implantation cyst to the most complicated malformation and mon- strosity. For information on the latter phase of the subject the reader is referred to works on teratology. Warthin gives the following classification of teratomata, which is as simple as any: 1. Simple teratoid tumors. f n . [ Ectodermal. •' 2. Simple teratoid cysts. -{ Mesodermal. Teratomata : \ (. Entodermal. 3. Complex teratomata and teratoid cysts (embryoid tumors and embryoniata). 4. Malignant teratomata. Simple teratoid tumors consist of a single variety of tissue or at most of only a few forms of tissue. Tumors belonging to this group are the hypernephro- mata, rhabdo-myomata, chondroma of the mamma, salivary glands, skin, testis, etc.; adeno-myoma of the uterus and broad ligament; leiomyoma of the kidney; osteoma of muscles, skin, mamma, tongue ; lipoma of the meninges ; coccygeal and lumbo-sacral lipomata and myo-lipomata. Most of the tumors of this group are to be regarded as heterotopic tumors, arising from autochthonous foetal " Anlage," but some possibly may be bigerminal inclusions. Simple Teratoid Cysts. — Ectodermal teratoid cysts include cysts lined with stratified squamous epithelium, without other skin structures (epidermoid cysts), and cysts whose wall contains hairs, glands, and fat (dermoid cysts), in this resem- bling skin. Epidermoids are sometimes due to injury, as in the so-called implan- tation dermoids. I have met with one such case where the penetration of the palm of the hand with a blunt piece of wood was followed by the formation of a small cyst of epidermoid character. One of the most interesting forms of epider- moid is the cholesteatoma, fouird in the meninges, the hypophysis cerebri, and the middle ear, among other places. It is a spherical or nodular tumor, varying in size from that of a pea to that of an orange, and on section has a glistening, waxy appearance. Histologically, it is composed of flattened, scale-like cells, devoid of nuclei, arranged in a laminated fashion. The central portion tends to degen- erate and is often filled with a pultaceous mass containing plates of cholesterin. Mesodermal and entodermal cysts originate in misplaced entodermal and mes- odermal "Anlage," or the persistence of foetal ducts and glands. They are lined with columnar epithelium, sometimes ciliated, and are found most frequently in the female genital tract, less often in the peritoneal cavity, intestine, close to the trachea and bronchi, and in the lungs, pleura, tongue, neck, liver, and kidneys. 368 AMERICAN PRACTICE OF SURGERY. Complex teratoid tumors and cysts are found in the same situations as the forms above described but are commonly met with in the sexual glands and about the coccyx. They consist of a great variety of cells and tissues, squamous and columnar epithelium, ciliated epithelium, skin, nerve, fat, striped and unstriped muscle, cartilage, bone, and glands. The tissue represented may be adult or im- mature. The ovarian dermoid may be taken as a type. This is a thick-walled cyst filled with a fatty, pultaceous substance, lanolin, and sometimes wisps of hair. At one point of the inner wall is a prominence cov- ered with hairs and occasionally containing teeth. This may contain masses of bone, suggesting a jaw. The prominence referred to consists of all the structures of the skin. The cyst is lined in places with ciliated epithelium. In the cyst wall derivatives of all the three primitive germinal layers may be found. Malignant Teratomata. — Any of the above-mentioned tumors and cysts may undergo secondary malignant transformation. Some behave as malignant from the first. The more complicated solid growths, especially those of the genital tract and mediastinum, are those most apt to exliibit this tendency. A word or two should be said about the chorio-epitheliovia malignum, some- times called deciduoma malignum.. Inasmuch as this tumor is derived from the cells of one individual proliferating within the tissues of another, it can properly be included with the teratomata. Chorio-epithelioma malignum is a new growth originating in the foetal epiblast of the chorionic villi. It grows rapidly, infiltrates, and forms metastases. The growth is polypoid or fungous, projecting into the cavity of the uterus, is of red- dish color, and of soft, friable texture. Microscopically, the tumor resembles a carcinoma or sarcoma, or both, but there may be in addition syncytial or plas- modial masses, or even \\\Y\. The growth originates in the proliferation of the syncytiimi and the Langhans' layer of the chorionic villi. The syncytium is thick- ened and the cells of the Langhans' layer tend to grow toward the surface. The deeper parts present an alveolar arrangement. The resulting tumor has no stroma and no blood-vessels. Hemorrhage into the growth and necrosis are common features. THE RESULTS OF TUMOR FORMATION. All tumors produce effects by their size and weight. The neighboring struct- ures are pressed upon and as a result undergo atrophy, or, if movable, they may be dislocated. Pressure upon blood-vessels leads to obstruction of the circulation, oedema, thrombosis, embolism, or necrosis. Pressure upon nerves causes pain and may lead to paralyses. Pressure upon the ducts of glands may result in retention of secretion and dilatation of the organ. Tumors on the extremities may interfere with locomotion and the free action of joints. Pedun- culated growths, especially when of large size, are apt to undergo necrosis and ulceration, owing to the interference with nutrition that eventually takes place. TUMORS AND TUMOR FORMATION. 369 Secondary infection may result in local inflammation and even generalized septic manifestations. Malignant tumors, in addition to the conditions mentioned above, which are largely the result of mechanical forces, and, therefore, are particularly well exem- plified in the case of the benign growths, possess the power of infiltrating and destroying the structures in which they may be growing. Their power of metas- tasis has already been referred to. When superficial, carcinomata may ulcerate and become inflamed. The malignant growths also give rise to a peculiar form of generalized marasmus, known as cancerous cachexia. This is manifested by great weakness, wasting of substance, and an earthy color of the skin. It owes its origin in part to the pain and discomfort caused by the growth, and in part to the interference with the functions of the body, notably digestion; it may also in some measure be attributed to septic absorption ; and, finally, it should to some extent be considered a systemic manifestation of poisonous substances emanating from the new growth. THEORIES OF TUMOR FORMATION. By THEODORE A. McGRAW , M.D., LL.D., Detroit, Michigan. True tumors or neoplasms have been aptly defined as "new growths of tis- sue which have no physiological connection with the body." The essential features of this definition have been generally accepted, but there is hardly a pa- thologist of note who has not tried to improve it by variations in the mode of statement or by explanatory additions. These efforts have generally ended in failure, for the reason that it is impossible to define exactly and minutely condi- tions which we do not imderstand. We speak of the physiological connection of normal tissues with the organism of which they form part, because we have become assured, from observing certain constant phenomena, of the existence of physiological laws, which are violated in the growth of every neoplasm, but our knowledge is so vague and indefinite, and the mechanisms by which vital processes are carried on are so_ beyond all human understanding, that we cannot formulate them in terms which convey exact ideas. We cannot, how- ever, understand the abnormal without having first obtained more or less clear conceptions of the normal; and it is necessary, therefore, on entering upon the study of tumors, to inquire into the nature of the law which is violated in their growth, even though we may not hope to account for its existence or explain the method on which it acts. We may do this, perhaps, to best advantage by considering briefly certain facts in embryonal and post-embryonal life. Every animal organism begins life in the impregnated egg. From this cellu- lar unit spring an enormous number of cells, whose generation takes place with a predestined order. In millions of individuals of the same species there comes almost precisely the same sequence of changes, from which there is, only in rare cases, any deviation whatever. The original cell divides by a process of segmen- tation into a cluster of cells, which soon proceed to arrange themselves in layers, assum etheir proper relations to each other, become differentiated, and event- ually develop into various tissues and organs under a compulsion the nature of which is absolutely mysterious and inscrutable. On studying these manifestations of Adtal energy, we soon come to see that every animal organism becomes such by virtue of its own inherent force. In it- self lies the power which compels every cell within its limits to expend its en- ergies only in such ways as will contribute to the general good. The environment has an influence on the development and growth of the cell, for it affects those external conditions of protection, temperature, nutrition, etc., 370 THEORIES OF TUMOR FORMATION. 371 on which every living thing is dependent; but it has no power to initiate the evolution of the embryo nor to keep the proliferating cells in proper control. To a complex organism, however, the existence of a governing power within itself is a primal necessity, for if its constituent units should multiply without regard to its necessities, if it could neither limit their propagation nor get rid of them when they had become useless, it would necessarily die from its own weak- ness. Accordingly we find in every normal animal body evidences of the exist- ence of just such a controlling force, and, if we study carefully the changes which occur in the growing embryo and in the nutritive processes of the adult, we may distinguish two modes of action by means of which it produces the necessary re- sults. By the one it forms continually new cells and tissues and sometimes new organs, while it removes by the other all debris, destroys all cells, tissues, and organs which have accomplished their end and become effete, and causes the disintegration and absorption of all living matter which has become useless or obstructive. There is nothing more wonderful in nature than the working of this imseen and unobtrusive force. We see in the embryo masses of cells form themselves into organs, which perform some obscure function and then disap- pear. The Wolffian body has for the most part diminished to nothing at the close of the sixteenth week of gestation, but one portion, that destined to form the sexual organs, has increased in size and importance. In the formation of the vagina we see the same processes of tissue building and tissue destruction going on simultaneously, the Mueller's ducts coalescing in the middle line and the cen- tral cells disintegrating and disappearing. If we watch the growth of bones, we find taking place together a growth of bone and a destruction of cartilage. Everywhere we see the exercise of a controlling power which compels all cellular action to proceed on certain defined lines. We may say, in a certain sense, that Nature abhors a cellular anarchy. Sometimes she is betrayed in the processes of evolution into an excess of en- ergy, and more germinal material is formed than can be utilized; but she will then try to regain her normal standpoint by the destruction and removal of the superfluous mass. A notable example of this tendency may frequently be seen in cases where extra fingers and toes are found on newborn children. In many cases the useless members are well formed, but so located as to be of no use to the organism. The effort to remove them may be noted in the absorption of the tissue which connects them to the extremity, for in the majority of instances they hang to the hand or foot by a mere thread of skin. We see similar evi- dences of a governing power in adult life, where there is constant loss of organic units which must be met by a corresponding regeneration. The useless and ef- fete cells are destroyed and new ones appear to perform their functions. Large organs even may be formed to replace defects produced by disease or injury, as when, after removal of the thyroid, the subsidiary thyroids which exist in some persons develop into large and active glands, or as when a kidney doubles in size 372 AMERICAN PRACTICE OF SURGERY. to compensate for the loss of its neighbor. The processes by which these results are obtained are never obtrusive in normal conditions, and may often be best studied when the vital operations are accentuated by disease or when in wounds they are exposed to the eye. In the latter case we may see manifest evidences of the twofold action : First, proliferation of cells ; and, second, their eventual destruction or disappearance ; and, in addition to these, the exercise of an inhib- iting force which limits a cellular proliferation, after it has reached its proper limit. In a deep wound we may see granulations forming with great rapidity, but with this enormous cellular growth there goes a contraction of the new tissue, which lessens the area of the wound and draws its walls together. Finally, when the granulations have reached the surface they cease to multiply and become passive, and give place to a new kind of cellular activity, that of the adjacent epidermis, which then grows over the wound surface and gives it its protecting mantle. This accomplished, the new tissue gradually changes into a hard, dense scar, with the disappearance of the cells whose activity produced the healing. Thiersch imagined that this subsidence of connective-tissue formation on reach- ing the level of the skin was due to a power residing in the local tissues, which enables them to repel the encroachment of cells of a different kind on their do- mains. This idea has been modified in various ways, especially by German authors. All of them recognize local influences which limit the germination and growth of cells by opposing to the cellular activity the active or passive resist- ance of a living environment. The resistance may take the form of pressure, or of secretions unfavorable to cellular growth, or of monopoly of nutriment. Other authorities, extending this idea until it embraces the entire organism, imagine that the organic solidarity is due solely to a balance maintained between antag- onistic tissues. It seems to me more reasonable to believe that behind all the phenomena of generation, growth, and nutrition there exists in every complex organism some unconscious intelligence which directs and controls the vital processes. I cannot conceive how any balance could long exist between constantly changing tissues and organs which may lose their powers of resistance by any chance disease or injury, unless there is some regulating force inherent in the organism as a whole. It is only by means of such a controlling power that that perfect co-operation and co-ordination of the cells of an organism can be maintained which are the very essence of physiological unity. Upon the perfection of this controlling force depends the perfection of the individual. It is when this force is weakened or lost that we see groups of cells develop into those useless and destructive masses which we call timiors. When we call in review these facts of organic life, the question inevitably arises whether any tumor, even the most innocent, can be regarded as a mere local affair. If the power of control is normal, no tumor can grow; if lost over any portion of the body, this loss may indicate a vital defect. THEORIES OF TUMOR FORMATION. 373 Before the days of Virchow, the word "constitutional" was used to designate certain diseases which were supposed to arise from morbid conditions of the blood. Since the advent of cellular pathology and the demonstration that all maladies originate in perverted cellular action, the word has lost all meaning to the pathologist. As regards neoplasms, the expression used by W. Roger Williams, of Bristol, England, " that nobody nowadays thinks of wasting his time in discussing the obsolete riddle as to whether these diseases are of local or constitutional origin," represents, doubtless, the present attitude of the professional mind; and yet, this much may be said on the other side, that no riddle is obsolete that is im- solved. Pathological societies may put such questions on the shelf as imworthy of attention, but they will, nevertheless, reappear for discussion until the human mind has found a satisfactory solution. We may not say that tumors or cancers are constitutional in the old sense of that word, but when we are confronted, again and again, with certain phenomena for which we cannot account, we are compelled to ask ourselves whether the local manifestations represent the whole morbid action, and whether preceding that local affection and accompanying it, there may not be some unknown quantity of far greater importance. We have to ask ourselves, then, what is the nature of the force which co-ordinates all nor- mal cellular activity, and how it is that it becomes paralyzed and inert. The growth of a tumor may indicate either that a single group of cells have become emancipated from the general control, or, on the other hand, that the power of the organism as a whole to govern its constituent units has become impaired. In the first case, the tumor may be of only local significance; in the second, we have a condition that involves the Avhole body in a common danger. The appearance, then, of even the most innocent neoplasm may have in it some- thing portentous. There are reasons for believing that this constitutional defect acts much more frequently as a cause of tumors than is generally believed. There are, first of all, the numerous cases of heredity, where neoplasms of various kinds appear in a family through several generations. There is no other way of accounting for these cases except on the theory that such families labor under defects of devel- opment and growth. Then, again, there are those cases where many and diverse tumors appear on the person of the same individual — cases difficult to under- stand on the theory of local origin. The fact that in old age, when the vital forces are weakened, tumors become common, points also to some general cause for their occurrence. The most unanswerable argument for such a belief, however, may be found in the study of the metastases of malignant tumors. A melanotic sarcoma makes its appearance in some locality, and thence infects the whole system by sending its cells or their nuclei through the blood-vessels to all parts of the body. The cells lodge and multiply, and a secondary tumor is evolved, precisely like the 374 AMERICAN PRACTICE OF SURGERY. primarj' growth in structure. No tissue in the person so affected can withstand the invasion, and in the course of a few months the patient dies. In this history we see two violations of organic law. The first is the original growth of useless cells in the organism. This, however, might be accounted for on the theory of local severance of that group of cells from their physiological connection. The second is the repeated and successful implantations of these morbid cells in spots all over the body. The normal organism would resist the growth of such intruders and destroy them. This, in fact, is what occurs in ar- tificial implantations of such growths in healthy animals; the graft either dies at once or undergoes speedy degeneration and disappears. It is only occasion- ally that an animal can be found which is susceptible to the inoculation of a true tumor, even from one of its own species. While auto-inoculation of such growths is the rule, the successful implanta- tion of such cells, in individuals other than the patient, almost never occurs. Surgeons and medical students may bury their hands in such neoplasms, carry away fragments under their finger-nails, and rub the pulpy mass into cuts and crevices of the skui, without ever showing the slightest symptom of the disease. If we reason at all about the pathology of malignant tumors, we have no other choice than to assume that from the very beginning of such a disease there is a loss of control which involves the whole organism. 'Whether we should apply the word "constitutional" to such a weakness or defect is another question. Cohnheim's Theory. The most brilliant hypothesis regarding the origin of tumors ever advanced is that of the German pathologist Cohnheim. Like all other new ideas, how- ever, this theory was an almost inevitable consequence of certain positive ad- vances in knowledge, which enabled the student to look upon his subject from a novel standpoint. With the advance of embryological and histological science, the theory had become generally accepted that the three blastodermic layers represented perma- nent divisions of tissues. It was believed that the ectodermal and entodermal layers would give rise only to cells of an epidermal or epithelial type, and that the mesodermal layer would produce only cells with peculiar characteristics of connective tissues. It was, however, a continual struggle to reconcile this theory with the fact that epithelial structures are frequently found embedded among the muscles and fascia in the form of dermoid cysts, that cartilage is found in tu- mors of the parotid gland, mammary glandular tvmiors in the ax-illa, etc. The question continually arose, whether, under the stimulus of morbid conditions, there might not occur a metaplasia of cellular elements which would entirely change their character. The study of these conditions led to a possible solution of the problem, by the hypothesis of displaced or wandering germs. It was suggested that during the THEORIES OF TUMOR FORMATION. 375 period of embryonic development, in the many changes in the relations of tissues and organs, cells might occasionally become pushed out of their proper place and remain attached to other structures in abnormal positions and environments. If we assume that such cells survive their uncongenial surroundings, overcome the resistance of neighboring structures, and multiply and grow into masses of tissue, we have a plausible explanation of heterologous tumors. The enchon- droma of the parotid appears, then, as a growth from cells which have been de- tached, in the formative stage of the embryo, from the germinal substance of the ear and have become attached to the parotid ; the adenoma or mammary glandu- lar tumor of the axilla springs evidently from detached portions of the nascent mammary gland ; the dermoid cysts of the neck have originated from ectodermic cells which have accidentally been turned into the depths during the coalescence of the branchial arches. In this last instance a corroboration of the theory has been obtained from the history of those cases of dermoid cysts in the fingers of sewing-women, which are caused by implantations of minute portions of the epidermis by needle punctures. This theory of displaced germinal matter is so plausible and explains so many otherwise inexplicable pathological conditions that it has met with general acceptance. Cohnheim, however, evolved from this class of facts a theory covering the etiology of all neoplasms. He assumed that in most healthy animals more germinal matter is formed during the evolution of the embryo than can possibly be used for purposes of development, and that these superfluous cells might persist indefinitely in the organism long after the period had passed when , they could enter into physiological relations with the rest of the body. He supposed that such redundant germinal matter might date from any period of embryonic life, from the earliest period after impregnation to the full completion of development, retaining in its latent condition the same capacity for multiplication as that possessed by embryonal material in the same stage of organization. Reasoning by analogy from the normal to the abnormal, he instanced the life history of the uterus. This organ, when impregnated, begins to grow, form- ing new muscular tissue, until it measures, after the expulsion of the foetus, four or five times its original volume. It then undergoes the process of involution, when the superfluous uterine tissue disappears, leaving the organ slightly larger than the virgin uterus. This sequence of events occurs in every successive preg- nancy, the growth after impregnation being followed by the destruction of the new tissue after childbirth. Cohnheim urges that there is only one explanation of these events possible. There must exist, in the uterus, germinal matter which responds to the stimulus of pregnancy and then develops into adult tissue. In every pregnancy some of this store of embryonic material is used up, and finally the supply, after repeated pregnancies, becomes exhausted. In case pregnancy should not occur, these germs, responding to some other stimulus, may develop 376 AMERICAN PRACTICE OF SURGERY. abnormally into those fibro-muscular tumors so common in old virgins and in barren women. Like the supposititious germs of the uterus, so, too, the hypothetical super- fluous germs, left stranded in the tissues after the wave of evolution had passed by, might, under favorable circumstances, develop later in life into tumors. If they were pushed out of the vital current at an early stage of development, before the cellular masses had become differentiated into tissues, they would re- tain that enormous generative energy which is common to that stage of life. Thence would originate those terrible cellular growths which we class together under the name "sarcoma," or, if residual from the ectoderm or entoderna, the various forms of cancer. The aggressive powers of such neoplasms are due, ac- cording to Cohnheim, to the unexpended embryonic energy bottled up in such residual cells. On the other hand, those tumors which originate from germinal matter at a later period, when this force has abated, after the tissues have become differen- tiated and fixed, would partake of a histoid character and grow more slowly and be less infectious. As regards the development of such germs into tumors, two factors are nec- essary: one is the destruction of the resisting power of the normal tissues in which the germs are embedded, which would otherwise inhibit the growth of the abnormal cells; and the other is the application of some stimulus which would arouse the latent germinative energy. While this theory may be accepted with some reserve in explanation of those congenital heterologous tumors due to the persistence and growth of displaced germinal matter, there are reasons for doubting its applicability to neoplasms of a different character. In view of the fact that one of the positive laws, in a com- plex animal organism, is that which determines the degeneration and ultimate destruction of all tissues which have neither present nor potential utility, it is difficult to believe that embryonic germs, subject like all cellular vmits to the action of this law, could persist for years together in a hostile environment, neither disappearing nor enlarging until the time came for them to grow into tumors. It seems more probable that adult cells may, under pathological condi- tions, change their nature and undergo a degeneration marked by great activity in the production of a low grade of offspring. Borst raises the question whether persistent dislocated germs are in reality more disposed to the heteroplastic de- velopment than others, and answers the question in the negative. Many of the examples he quotes, however, do not seem to me altogether pertinent. Acces- sory thyroids and suprarenal capsules, even though out of normal position, might, if able to perform the functions of those glands, have a perfect physio- logical connection with the organism. As regards accessory thyroids, there can, in fact, be little doubt that they have in some cases of loss of thyroid saved the patients from myxcedema. Indeed, it has been stated on good authority that THEORIES OF TUMOR FORMATION. 377 patients have even been cured of cachexia strumipriva by the successful implan- tation of thyroid tissue in the abdomen. Borst is, however, undoubtedly right when he asserts that neither the aber- ration nor the persistence of supernumerary germs suffices in itself to produce neoplastic growths. There must, in addition, be added an unknown element which has thus far escaped all analysis. We may say, however, of this theory of Cohnheim's that it is the only one advanced since the days of humoral pathology which has even attempted to ac- count in a comprehensive and rational manner for the occurrence of neoplasms. It has acted as a wonderful stimulus to the whole profession in their studies of this dark subject, and, if it has not solved the whole riddle, it has, nevertheless, thrown great light on many of the questions nvolved. In the opinion of this great pathologist the cells from which tumors arise are from the very beginning abnormal. It is interesting to note that the best men of to-day are adopting generally this point of view. They differ, however, from Oohnheim in this, that they do not regard embryonal aberration and persistence as the only abnormal condi- tions which are capable of producing the result. There is reason to think that under certain unknown conditions adult cells may undergo metaplasia, or, if you please, an anaplasia — a process of degeneration in which they so far simulate em- bryonic tissue that they acquire the power of rapid multiplication, although, un- like embryonal material, they are incapable of developing differentiated cells of a high grade. The cell progeny, even in histoid tumors, is badly formed and abnormal, while in the more malignant growths it represents the lowest form of undifferentiated cells. It always is marked by an absence of purpose and a uselessness, which are the most certain criteria of a true tumor. Ribbert derives the beginning of a tumor from the disruption of the physiological relations of a cell or group of cells to the organic whole. He believes that, whatever unknown forces may cause the disruption, when a cellular unit — either in embryonic or in post-uterine life — undergoes this change, it thenceforward leads a life of its own, regardless of all organic laws. He denies to these elements the power of produc- ing in neighboring cells a similar metamorphosis, but asserts positively that they grow into tumors from their own inherent wild energy, by the multiplication of their own cells, pushing tissues aside and compressing them, or forcing their way into every crevice, and, in the malignant varieties, destroying the component cells. In this respect Ribbert differs from some other pathologists, who ascribe to the original morbid elements a quality which enables them to cause in their sister- cells, by mere contact, similar morbid tendencies. In their view the tumor, orig- inating in some great disturbance in cellular relations, grows by constant accre- tions from without, as one cell after another yields to the morbid impulse. Max Borst, who has considered the subject exhaustively from all standpoints, concludes that the causes of neoplasms must be sought in the internal conditions 378 AMERICAN PRACTICE OF SURGERY. _ of the tissues in which they originate. He assumes the existence, in every case, of some congenital pathological quality of cells or tissues as the foundation for the formation of a neoplasm. Among the anatomical conditions for considera- tion in this connection he mentions, first, gross disturbances in the development of a region or organ or system; second, displacements of embryonal germs or disruption of such germs from their physiological connections without displace- ment; third, formations of superfluous germs in foetal life; fourth, abnormal persistence of tissues which, in normal course, should have disappeared; and, fifth, failures in the differentiation of cells and minute disturbances in their idio- plastic development. Cheyne, of Edinburgh, assuming that every cell carries within itself a male and a female element, fancies that a disturbance of their relations may account for the formation of tumors, the female element becoming ungovernable and de- veloping without physiological purpose. This theory lacks that foundation on established facts which alone can give a theory recognition by scientists. In the most of these theories the main element in the production of the abnormal growth is sought for in the aggressive action of the tumor cells, but some authors are dis- posed to lay the principal stress on the loss of resisting power in neighboring tis- sues. Thus Thiersch regards the atrophy of the connective tissues in old age as the primary cause of epithelioma, the epithelium growing wildly and irregularly because it is no longer checked by the conservative resistance of the tissue under- neath. Regarding the organism as held together by a mutual balance and, to some extent, by antagonism between the various structures and organs, he con- ceives the loss of that balance to be of primary importance in the causation of all irregular cellular proliferation. In all of these theories we may recognize the perception on the part of pa- thologists that there is something monstrous and portentous in the useless and aimless growth of cells which we class together under the name of true tumors or neoplasms. They occupy a peculiar and unique place in biology, for in no other class of vital processes can we witness the component units of an organism separating themselves from the organic whole and fastening themselves upon it as parasites and enemies. The criterions on which we base our diagnoses of true tumors are, then, the evidences which we see of an organic rupture which endangers the very life and being of the animal. There can be no other symptom which indicates such a profound disturbance of a complex organism as the wild generation of useless cellular masses. In this common feature lies the mystery of all tumors, innocent and malignant. The essential nature of a lipoma or fibroma or osteoma is closely allied to that of a sarcoma or cancer. The same law is broken in the growth of one as in that of the other, and whether the result is a comparative innocuous- ness or a virulent malignancy would seem to be a matter of degree in morbid action rather than one of kind. THEORIES OF TUMOR FORIIATIOX. 379 Before proceeding to the consideration of those theories which seek to explain the phenomena presented by tumors and cancers by the action of microscopic parasites, it may be well to tm^n our attention for a moment to the pathology of that most virulent class of neoplasms which are termed par excellence malignant. If we study the natural history of tumors with exclusive attention to the two ends of a long series, we may divide them into two classes, innocent and malig- nant, the first of which — although its members may cause damage by pressure or weight or mechanical interference with the blood supply or nerve conduction — is not in itself dangerous to life, while the second is primarily and always viru- lent and destructive. If, however, we take a more general view of the subject, and, instead of occupying ourselves solely with the extremes of the series, exam- ine all with reference to their action upon the human body, we become convinced that the innocency or malignity of a tumor is not that which, biologically speak- ing, is its most marked characteristic. We shall find that, while the quality of virulence is much more marked in some tumors than in others, there is hardly any kind of neoplasm which may be said never to show it in some degree. There are many tumors, too, considered quite innocent, which have a tendency in time to change their characteristics in this respect and become malignant, either by a metaplasia of tissue or by offering a favorable soil for the growth of other neo- plasms, ilalignancy in a tumor is but another name for a tendency to make metastases. The cells, multiplying rapidly, cling no longer to their original hab- itat. Some of them push their way in long lines which may be traced, in epi- theliomas, from the surface through crevices in the underlying tissues far into the depths; others, getting into the lymphatic spaces, are carried through the lymphatic vessels into the neighboring lymphatic nodes. Thence they reach, in time, the deeper lymphatics, and finally are discharged into the blood current. Others, again, as in sarcomas, involve the capillaries and veins at an early stage of the disorders, fill up the Imnen of these vessels, and are sooner or later carried away as malignant emboli to lodge and grow in some distant part of the body. "Where such ttmiors grow into the intestines or urinary passages, detached frag- ments may pass dowTi with the excreta and become implanted lower do'mi in the canals. A^Tien projecting into the serous cavities, they fall to the lower levels and cause numeroas secondary growths. Mrchow long since pointed out the conditions which favored metastasis. They are, first, a tissue formation which permits the easy detachment of cells. In histoid tumors, like lipomas, fibromas, etc., the cells have become differenti- • ated, multiply slowly, and have firm coimections with the intercellular sub- stance. Such cells are torn with difl[iculty away from their attachments, and metastases of such tumors are, of necessity, rare, and occur only when through some metaplastic change they have become more cellular and when the bonds of the cells to the stroma have become less rigid. It is evident that the drier and firmer tissues are, the more permanent they are in form. For this reason the 380 AMERICAN PRACTICE OF SURGERY. tendency to metastasis increases with the succulency of the tissues. The greater the amount of fluid contained in a tumor, the less stable are its component ele- ments. The size and shape of the tumor cell also have an influence upon its ten- dency to metastasis. A small cell can more readily pass through a narrow channel than a larger one, and a round or spindle-shaped cell than one that is irregular or angular. More potent, however, than all of these qualifications for malignant growth is the possession of a great proliferating energy. Neither loose connec- tions, small size, nor round shape could endow a fat cell with the aggressive force which enables a cellular unit to supplant and destroy its normal neighbors. There must be an inherent energy such as we see manifested in normal condi- tions only by embryonal cells. Whether malignant growths spring from persist- ent embryonic germs, as Cohnheim affirms, or whether there is a reversion of adult cells to an embryonal form and condition, as some assert, or whether, finally, without undergoing that kind of retrograde change, certain adult cells, when their physiological bonds are broken, may acquire the power of generating great quantities of a low-grade progeny, are questions which in the present state of biological science cannot be decided. As regards the secondary tumors, it must be remarked that they invariably are composed of the same type of cells as that of the primary growth. The sec- ondary tumors of a squamous-celled epithelioma are composed of squamous cells, those of a columnar-celled cancer have columnar cells, and the metastatic growths of a sarcoma invariably show their mesoblastic origin in the character of their cellular elements. While adhering to the same type of structure as that exhibited by the pri- mary growth, the metastatic tumors may, nevertheless, deviate from it in some particulars. The secondary and tertiary tumors will sometimes be more sviccu- lent than the primary and hasten more rapidly the disintegration, but, while the cells of such tumors undergo a metaplasia to a lower grade of development, they do not lose their distinctive equalities. The course followed by malignant growths in their dissemination throughout the system is so similar to that pursued in infections of various kinds in which the active agent is a microscopic parasite that many pathologists have come to regard them as diseases of allied nature. Long before the days of cellular pathology, men were disposed to look upon cancers as parasites on the human body, and, while the grosser conceptions of a hundred years ago have been discarded, the belief has lingered in the human imagination. Of late years this view, modified to meet the present conditions of science, has been pressed upon the profession by many enthusiastic advocates who never tire in citing the various points in which cancer and sarcoma resemble the infectious granulomas. In all these maladies the disease has a local origin ; in all it spreads through the body by the same channels ; in all it generates new foci in continuous and THEORIES OF TUMOR FORMATION. 381 contiguous tissues; in all the active agents which carry the disease to distant parts of the body are carried to their destination in the lymph and blood currents. San Felice, Roncali, Plimmer, and other scientists in Europe, and in this country Gaylord, have found in microscopical sections of cancerous tumors pe- culiar figures which seemed to them to be different from all cells found in the normal tissues of the human body, and also from any form of cell degeneration known to the pathologist. They affirm that they have been able to grow these so-called Plimmer's bodies in cultures and to have caused fatal growths in the lower animals which have been inoculated with the germs. Plimmer regards these bodies as probably saccharomycetes, and is confident that they are the parasitic organisms which are responsible for the occurrence of cancerous tumors. These views, however, have not met with general acceptance. There is one point especially which distinguishes malignant growths of all kinds from those tume- factions which are caused by microbic infection. In the infectious granuloma the organism which conveys the infection is always and invariably the patho- genic microbe. The human tissue which nature builds around the focus of in- fection to wall it in, and if possible to destroy the infectious germs, is a granula- tion tissue. It is not a true tumor, but a false tumor, and the newly formed tissue is built up by the organism in its own interests as a defence against the invasion. Of widely different character is the pathology of a true tumor. In the human subject it springs from human cells which in some mysterious way have lost their physiological connections. From the multiplication of these cells arise the pri- mary and all of the secondary tumors. If metastases are formed, it is because cells or their nuclei, which have been separated from the original growth, have floated away in the lymph or blood channels, have lodged elsewhere in the body, and have generated here and there a numerous progeny which compose new tumors. This new tissue is not formed in the interests of the organism, to pro- tect it, but is itself the invader. It always shows in the character of its cells a likeness to the cells from which it is derived. When we study these conditions with reference to a possible parasitism as the causal factor, we have to ask our- selves whether it is possible for any parasite, animal or vegetable, so to act upon the human tissues as to break up their physiological bonds and cause their cellu- lar units to grow into tumors, and, wandering from their primary seat, to estab- lish colonies of the same kind in various parts of the body. The burden of proof of a proposition of this kind, which is opposed to all of our experience, rests with those who advance the theory ; but as yet it has not, in one single instance, been demonstrated. There are other considerations, too, which apply with almost equal force against this hypothesis. There is a rela- tionship between tumors of all kinds which cannot be ignored. Malignancy is not confined to cancer or sarcoma, but is an attribute of many and various kinds of tumors. In our studies we may not limit our researches to cancer and our finds to Plimmer's bodies, but we must study the problem of malignancy wherever we 382 AMERICAN PRACTICE OF SURGERY. find it. If it is the result of parasitic infection, we have to ask whether this pe- culiar power over animal cells is limited to .one kind of parasite or is common to many; whether the same protozoa or blastomycetse which produce cancer also cause the phenomena of adenoma, malignant enchondroma, sarcoma, and other neoplasms with malign tendencies. It is evident that, if this were so, every malignant tiunor would be a mixed tumor; for the parasites which attacked the epithelium would inevitably come in contact with other tissues, and, as the dis- ease progressed, with all kinds of tissue. The lodgment of the parasite in the mammary ducts, for example, would first affect the epithelium and connective tissues of the breast ; after that, as the disease progressed, the underlying mus- cles, and then the cartilages and bones, all of the various cells of these tissues being stimulated to a malignant and prolific generation of their own kind of cellular units. It is evident that this hypothesis could not bear criticism. On the other hand, there are difficulties in assummg the existence of a lai-ge variety of parasitic forms each of which is gifted with the power of causing a wild cell proliferation in some particular tissue for which it has a predilection. As the matter stands to-day, the theory of a causal parasitic infection in the eti- ology of tumors has not been sustained. The results of inoculations with Plim- mer's bodies have not been convincing, and all other phenomena which are relied on to sustain the hypothesis can be better explained on other grounds. One of the most original of the theories in support of the doctrine of para- sitism is that advanced by Kelling, of Dresden. It occurred to this author that the existence of cancer might be explained by the invasion of the human body by embryonal cells derived from other than human sources, and that these cells, more or less altered in character by their environment, might be the progenitors of the cancer cells. Having a foreign origin, they could not enter into physio- logical relations with the organism, but would multiply, grow, and destroy after the manner of parasites. He fancied that such cells might get into the human tissues from various sources, as, for instance, from embryonal tissues of pigs, lambs, fish, snails, etc. ; but that the most frequent cause of trouble was due to the ingestion of raw impregnated hens' eggs which are used so commonly as food, the living cells obtaining entrance into the human tissues through some crevice or some ulcer in the alimentary canal. He examined many carcinomas from human subjects biochemically, in order to determine the nature of the contained albumin, and obtained reactions which indicated the presence of the albimiin peculiar to fowls in about one-third of the cases. He chose for these investigations patients with gastric cancer secondary to gastric ulcer, who had, on account of the last-named disease, been fed with raw eggs. As a further test, he injected embryonal material from animals into animals of a different species, and produced thereby tumors which eventually caused death. He regards these tumefactions as true tumors of a malignant type. He further advances the opin- ion that the profession may hope, from the development of these biochemi- THEORIES OF TUMOR FORMATION. 383 cal examinations, to obtain a new and trustworthy method of diagnosticating cancer. His ingenious tlieory and tlie conclusions whicli lie draws from his experi- ments have not been considered by pathological experts as warranted by the facts. Like all hypotheses which would explain the origin of tumors on a basis of parasitism, this of Kelling meets with an insurmountable obstacle, in the his- togenetic relations of all tumors and cancers. The cells of all tumors and their metastatic progeny are of the same type as the tissues from which the primary growth took its origin. The cells in human cancers could never, as Ribbert as- serts, have arisen from the cells of a hen. Ribbert, whose pre-eminence in histo- logical work no one can gainsay, denies positively the cancerous nature of the growths produced by Kelling's experiments, and regards them as enlargements due to irritation. From the biochemical side Kelling has been equally unfor- tunate, the investigation which Fuld conducted, with the purpose of obtaining the reactions of hen albumin from human carcinomas, having yielded only nega- tive results. Among the theories relating to the origin of tumors there remains yet to be mentioned one which is not new and which has not met with many advocates. The theory that tumors might be due to nervous disturbances was broached by Schroeder van der Kolk in the middle of the last century. There seemed at that time few facts to support it. Since then the study of acromegaly, in which dis- ease enlargement of the bones has been associated with disease of the pituitary body, has given warrant for the hypothesis that there may be nervous centres whose function it is to regulate growths. Recklinghausen has shown that the spots of pigment which are often in num- bers on the body, appear at the ends of nerves and are associated with very mi- nute fibromas. Not infrequently cancers and sarcomas develop from these spots. It would seem that the relations of the nervous system to tumors of all kinds might deserve a thorough and minute investigation. Should it ever be demon- strated that cellular generation and growth depend upon some as yet unknown nervous centre, the inference that the occurrence of tupiors might be due to de- fects or diseases of that centre would not be unreasonable. It is not impossible that even before any nervous system comes into being the development of the embryo may be regulated by certain governing cells. If such hypotheses seem like idle speculations, it must be remembered that the solution of the problem, if it ever takes place, must come through the careful and patient investigation of every suggestion which may have in it a possibility of success. There are many questions which arise with reference to neoplasms, which admit of answer only on a basis of accurate statistics. This phase of the tumor question has come recently into prominence through the intense interest excited by the statements of certain authors to the effect that cancer is greatly on the increase. The importance of establishing the truth or error of this opinion can 384 AMERICAN PRACTICE OF SURGERY. be hardly overestimated, and it is well, therefore, to ask whether there are any statistics, covering three or four decades, sufficiently trustworthy to warrant such a positive expression. The reliability of medical statistics depends upon the competency of the great mass of physicians who make the diagnoses and furnish the death certificates. It is evident that, as in every profession there are great numbers of badly educated, stupid, and indifferent men, there never can be any medical statistics which are absolutely exact. The utmost that can be hoped for, under the most favorable circumstances, is the attainment of results which are approximately correct. This consideration should, of itself, inspire caution in accepting any very positive statements based upon statistical reports. When, however, as in the case of the relative prevalence of cancer in different decades, the statistics have been compiled under constantly varying conditions, the profession should subject such statements to the severest criticism. There has never been a period in the history of medicine when such radical changes have been effected as in the last forty years. During that period of time the profession has abandoned the old humoral theories of disease and has sub- scribed to the doctrines of cellular pathology. In surgery Lister's discoveries have caused a revolution in ideas and practice which can be described only as tremendous. Preventive medicine has become a science in itself, and health boards have been established all over the civilized world as permanent additions to the social organizations. In fact, the whole situation has so altered that the perusal of a medical book written before 1860 is like reading a work of Hippoc- rates or Galen. The profession, responding to the stimulus of the new ideas, has grown in stature. Its members have never before been so generally enthusi- astic, and have never in the same lapse of time made advances in so many direc- tions. The changes have taken place so rapidly that no two decades show pre- cisely the same point of view on any medical subject. The doctrines relative to malignant diseases especially have been revolutionized, and the pessimism of the old humoral pathology has given place to hopes based on the theory of local origin, and the bias of the profession toward these diseases has become reversed. The general practitioner who formerly admitted with reluctance the existence of cancer when it was beyond hope is now disposed to regard every obscure malady as possibly malignant and to recommend operative procedures as a cure. The laity, participating in the confidence of the profession, are even too eager to seek in surgery a remedy for every ill. The operations on the abdomen have disclosed new pathological conditions and made clear what was dubious and uncertain. It was inevitable that these changes should become reflected in the health re- ports, and that the general advance in intelligence, in insight, and in efficiency should manifest itself in more accurate diagnoses. These changes in the patho- logical conceptions and in the methods of diagnosis and treatment, so widely adopted by the profession, are of themselves sufficient to account for an appar- ent increase in cancer, as shown by the health reports of a few cities ; but, in THEORIES OF TUMOR FORMATION. 385 addition, we have to recognize tlie existence of other factors which also influence the character of statistical reports. One of these is the greater efficiency of the health boards of later over those of the earlier years. This is especially noticeable in some of the German reports. It is not many years since that the records of deaths in most civilized countries were kept in the most slovenly and careless manner. Even now the methods in vogue in many places are not beyond improvement. In Wuertemberg, for instance, according to Weinberg and Caspar, in 1899, thirty-eight per cent of all deaths had occurred without the attendance of qualified practitioners. Of the deaths in Stuttgart, in 1879, thirty per cent of the deaths of men and twenty-seven per cent of those of women had taken place without competent medical attendance, but in 1901 this per- centage had diminished to sixteen per cent of men and fifteen per cent of women. Another element to be considered in estimating the character of the death certificates of the various decades is the increasing tendency of patients suffer- ing from surgical maladies to seek relief in the hospitals; and still another is noticed by German authorities in the greater relative number of physicians at the present time — a change which has insured to the poorer patients more thor- ough examinations and more careful diagnoses. After examining very carefully all the literature which I have been able to get bearing on this subject, I have come to the conviction that we have as yet no trustworthy statistics on which the most painstaking investigator could base a just opinion as to the relative prevalence of cancer in the last three decades. The same criticism may be made about other very positively expressed opinions. Statements have been made as to the relative prevalence of cancer in hot and cold countries, among savage and civilized peoples, among meat-eaters and vege- tarians, and on certain geological formations, which statements cannot be sup- ported by anything like scientific testimony. The inherent difficulties in the way of getting correct data on a large scale in regard to tumors are so great that we cannot accept without scrutiny any statements which are based on doubtful statistics, or on the impressions of travellers, or even of surgeons in large prac- tice. These difficulties may never be altogether overcome, but it may be pos- sible, by getting the profession sufficiently interested, so to lessen the causes of failure as to get approximately correct results. Until that is accomplished we must be content to suspend our judgment on many questions. What we ur- gently need at the present time is, not hasty generalizations from limited experi- ences, but correct information, carefully and systematically acquired, as to the conditions which influence tumor growth. A review of the numerous hypotheses and theories which have been advanced to account for the existence of tumors does not inspire the student with the feel- ing that the problem is near solution. Those which seem most rational, like Cohnheim's, and Ribbert's modification of Cohnheim's, impress one rather as exaggerated statements of certain facts than as serious attempts to explain them. VOL. I. — 25 386 AMERICAN PRACTICE OF SURGERY. There can be little doubt that there are certain defects in development which are characterized by the formation of superfluous cells ; that in some cases these cells suffer displacement ; and that in some they persist and develop abnormally in intra-uterine or post-uterine life. The riddle is not solved by these state- ments, but is differently presented. We have still to learn the natvire of that physiological bond which makes the existence of complex organisms possible — the bond which is broken whenever and wherever a tumor exists. PARASITICAL RELATIONS OF CAKCER. By HARVEY R. GAYLORD, M.D., Buffalo, N. Y. The belief that the cancerous process is due to some parasite has come down to us with our earhest knowledge of this affection. In the minds of the earlier observers this was due to the frequent confusion of cancer and certain of the in- fectious granulomata, especiallj' tuberculosis. The clinical course of many of the sarcomata and the difficulty frequently met with in distinguishing sarcoma in its clinical aspect from such processes as Hodgkin's disease, which is undoubtedly infectious, have sufficed to keep alive, in the minds of many clinicians, the belief in the infectious nature of the malignant processes. It is obvious that a purely clinical point of view may be one-sided, but there is little doubt that manj' of the theories which have been advanced by pathology have not sufficiently considered the clinical aspects of the disease or else have ignored them entirely. The major- ity of pathologists are at present distinctly opposed to the belief that any parasite exists which could fulfil the role of a parasite for cancer. It is obvious that no ordinary parasite could fulfil this role. Therefore, when, in 1886, Scheuerlin, and later Schill, detected bacteria in cancer, it was not long before these organ- isms were found to be simply harmless saprophytes. This also may be stated to have been the case with the yeast organisms or blastomycetes, which have been more recently described by San Felice and others as occurring in carcinomata. INCLUSIONS IN CANCER. Since the earliest histological investigations of cancer, there have been ob- served in the cells certain objects, as to the significance of which much discussion has taken place. It is not profitable to consider here the question whether or not these bodies are parasites. It is interesting to note, however, that as early as 1847 Virchow described these objects, believing them to be metamorphosed nuclei or degenerative changes, of a fatty character, in the protoplasm of the cancer cells. They were again described in 1889 by Thoma, who believed that they were proto- zoa ; in 1890 by Sjobring and Siegenbeck van Heukelom ; in 1891 by Steinhaus ; in 1892 by Soudakewitsch, Borrel, Foa, Kursteiner, Podwyssozki, and Sawtschenko; 387 388 AIMERICAN PRACTICE OF SURGERY. in 1893 by Ruffer and Walker and Ruffer and Plimmer; in 1894 by J. Jackson Clarke and Cattle; in 1896 by Pianese; in 1898 by Bosc; in 1901 by E. van Ley- den and Gaylord; in 1902 by Feinberg, Greenough, Nosske, and Posner; in 1903 by Apolant and Embden; and in 1904 bj^ G. N. Calkins. Of these observers, Pianese, Greenough, Nosske, and Apolant and Embden believed that the bodies in question are not parasites. The others held them to be protozoa or allied or- ganisms. Calkins holds that, although they have not been proven to be so, they may nevertheless be parasites. The forms in question have come to be known as "Plimmer's bodies," or Van Leyden's "bird's-eye inclusions," or the "x-bodies" of Behla. They are spherical structures, which var}^ in size from four to forty microns. They have a delicate limiting membrane and a central, highly refrac- tive body. The space between the central body and the margin sometimes con- tains a fine protoplasmic structure, while at other times granules are regularly distributed between the periphery and the central bod3\ They have been ob- ser\^ed in the nucleus and in the protoplasm, and in the intranuclear forms they present an appearance not unlike the similar inclusions which have been observed in smallpox and in vaccinia. These bodies have been seen in the fresh state, but thej^ are best demonstrated by complicated hardening and staining methods. There is no direct proof that these bodies are parasites, although many ob- servers have maintained the belief that they are such. On the other hand, those who have attempted to show that they are not parasites have been forced to employ the same methods of reasoning, and it can be fairly stated that to-day neither those who hold that they are of a parasitic nature nor those who hold that they are not, are in a position to prove their contention. The preponder- ance of opinion is opposed to the view that these bodies are of a parasitic nature, but this is, to no inconsiderable extent, due to the fact that the majority of pa- thologists hold, on a priori grounds, that cancer is under no circumstances an infectious process. There are some observers, however — notably Borrel — who hold that cancer is an infectious process, that these inclusions are not parasites, but that there is an infective agent in cancer which is either undemonstrable or ultra-microscopic. Perhaps the best arguments in favor of the inclusions being parasites are these: Their similarity in appearance to a known organism — Plasmodiophora brassicse — and the fact that in certain respects they resemble certain forms of the smallpox organism. CANCER AND THE ACUTE EXANTHEMATA. Although at first thought there would scarcely appear to be any relation between the cancerous process and the acute exanthemata, yet this analogy between the two groups of diseases has been strongly advocated, principally by Bosc, Gaylord, Borrel, and von Wasielewski; the first two observers basing their PARASITICAL RELATIONS OF CANCER. 389 advocacy on the ground of the similarity of some of the inclusions in the two processes, and Borrel and von Wasielewski on more general grounds. It will perhaps be of interest to follow more closely the relation which exists between the two processes. Those who discovered a resemblance between the inclusions found in cancer and those observed in smallpox and vaccinia were the first to call attention to the analogy between the two processes. It was Gorini, namely, who first detected points of similarity between certain larger forms of the vaccine body as they appeared in the inoculated corneas of rabbits and the cell inclusions of cancer. This similarity applies only to certain larger forms of the vaccine body which had been previously described by L. Pfeiffer, Guarnieri, and Clarke, but Gorini was able to trace a gradual transition between the larger typical vaccine bodies and these larger inclusions, which resemble the inclusions in cancer. In 1900 the writer observed a similarity between certain of the can- cer inclusions and certain forms of the vaccine organism, and from this observa- tion it was inferred by him that if the inclusions in vaccine were parasites, then in all probability the inclusions in cancer were of the same nature. On the same day of the same year Bosc published an article in which he advanced exactly the same idea. At the same time he called attention to the fact that in the le- sions of sheep-pox also there were bodies which bore a close resemblance to some of the cancer inclusions. Sheep-pox is characterized by the development of both epithelial and connective-tissue nodules in the subcutaneous tissue. Bosc found, in the exudate from fresh pustules, characteristic epithelial cells containing highly refractive bodies surrounded by a clear zone of protoplasm; in other words, inclusions closely resembling those described in the epithelial cells of can- cer. Similar inclusions were found in the cells forming the connective-tissue nodules. A sheep's cornea inoculated with the virus of sheep-pox presented le- sions very similar to those resulting from the inoculations of the rabbit's cornea with vaccine, and Bosc believed that sheep-pox represented an infection lying midway between the malignant epithelial processes and the infectious exan- themata. It is unnecessary to state that the parasitic natvue of these inclusions cannot be proved by histological methods alone; and the experiments thus far made with cancer have failed to bring any proof of its specific qualities. On the other hand, the work of Councilman and Calkins and of Bosc and Howard has again brought the significance of the vaccine and variola inclusions into the fore- ground, and it must be recognized that if these last inclusions — which are ap- parently incapable of cultivation and which are demonstrated by methods simi- lar to those employed in the case of cancer inclusions, but which present more specific characteristics than do the latter — are ultimately shown to be parasites, then there is a prospect that future investigation may show that the inclusions ioimd in cancer are also of the same nature. Arguments in favor of the parasitic factor in cancer can, however, be adduced without the aid of these inclusions. 390 AMERICAN PRACTICE OF SURGERY. GENERAL ARGUilENTS IN FAVOR OF THE INFECTIOUS NATURE OF CANCER. Transplantation Experiments. Experimental methods in cancer research have opened a new era. This has been made possible by the discovery of the transplantability of tumors in animals of the same species, the first extensive demonstration of which we owe to Hanau, who succeeded in transplanting to the third generation a carcinoma of the rat. Before Hanau, however, as early as 1875, Nowinsky succeeded in transplanting a medullary carcinoma taken from the nose of a dog, successfull}^ in two out of forty-two inoculated clogs. Wehr in 1883 succeeded in transplanting a medul- lary carcinoma from the vaginal mucosa of a bitch into a number of dogs. Most of these tumors retrograded, but in one animal the tumors grew to con- siderable size and produced metastases in the adjacent lymph nodes. Follow- ing Hanau, Morau in France, Leo Loeb in America, Jensen in Copenhagen, Borrel in Paris, Ehrlich in Frankfurt, Bashford in London, and the New York State Cancer Laboratory in Buffalo have all experimented with the trans- plantation of primary tumors — mosth^ in mice, Loeb's first observations being on a sarcoma of the rat. The extent to which this work is now being car- ried on can be appreciated when it is stated that one tumor alone, that of Jensen, is now being worked upon in at least seven laboratories, and that this tumor has been transplanted to somewhere near the eightieth generation. The attention which has been attracted to the occurrence of primary tumors in mice has led to the discovery of a large number. Thus Ehrlich has succeeded in collecting tumors in 154 white and 10 gray mice; Bashford collected 9; Loeb has recently detected a spontaneous tumor in a mouse ; and the New York State Laboratory is in possession of 8 primary tumors. Borrel has secured in Paris 30 examples of spontaneous tumors in mice, and Haaland speaks of 62 cases known to the authorities of the Pasteur Institute. The latter authority calls attention to the fact that the 62 spontaneous tumors observed in Paris were all in elderly females, and that all of the tumors were adenocarcinomata, involving the ab- dominal aspect, the axilla?, the groins, or the neighborhood of the anus or the vulva of these mice. They were all derived from the breast. Ehrlich likewise calls attention to the fact that, of 164 spontaneous tumors observed in his lab- oratory, all occurred in aged females and were all positively derived from the mamma. Eight out of nine of Bashford's mice were elderly females, and the tumors were likewise all derived from the breast; in the one exceptional case — that of a male — the tumor was situated near the root of the tail and presented the same characteristics as the other tumors. Of the eight tumors observed in Buffalo, seven were in females, the sex of the eighth having been unfortunately overlooked. They all presented characteristics similar to those observed in the recognized adenocarcinomata derived from the breast in the mouse. PARASITICAL RELATIONS OF CANCER. 391 The fact that all of these tumors were derived from the breast, and the fur- ther fact that the mouse appears to be much more frequently affected by carci- noma than are other small animals, can only be explained, as Ehrlich has pointed out, by the facts that all of these mice were obtained from dealers who were en- gaged in raising white mice for the market and that all the females are employed for breeding purposes. The fact that almost all of the tumors have appeared in elderly females certainly points to the probability that the tremen- dous demands made upon the mammary tissue of these animals explain the almost exclusive appearance of this form of the tumor. In connection with these facts, the observation of Borrel that healthy mice, when kept for a sufficient period of time in the same cage with infected mice, may develop spontaneous tumors, is of the greatest importance. It has likewise been observed that wherever one spontaneous tumor developed in any particular locality where the mice are being bred, either simultaneously or later, mice with similar tumors have been found. COMMUNICABILITY OF CaNCERS IN MiCE. The most striking example of the endemic occurrence of cancer is described by Borrel, who, in the course of two years, observed in one breeding place twenty cases of carcinoma of the breast. All of these mice had, at one time or another, been in the same cage. He observed further, in a second case, in the course of ■one year, five or six cancer mice, all of which developed in one cage. A similar endemic occurrence of cancer in the rat was observed by Hanau, who first suc- cessfully transplanted cancer in this animal. He observed in the course of six years three cases of squamous epithelioma of the vulva. There were in all about one hundred rats, all the offspring of two pairs. Perhaps the most striking evi- dence of cage infection is found in an observation recently made in the State Cancer Laboratory, combined with a previous observation made by Leo Loeb. Loeb states that in January, 1900, there developed in a group of cages containing rats in the Chicago Polyclinic Laboratory a spontaneous sarcoma of the thyroid. In November of 1901 a second case of sarcoma of the thyroid developed in the same group of cages, and in the autumn of 1903 a third case. The rats had been moved about from cage to cage and were all the offspring of a certain limited nimiber of rats. The tumors presented identical histological characteristics. The first and second rat tumors were vised for transplantation, in both cases successfully. On transplantation the tumor presented the characteristics of spindle-celled sar- coma, which in many animals produces characteristic regional and organal metastases. Sections of this tumor have been repeatedly shown at scientific meetings, and there is absolutely no question as to its being a genuine spindle- celled sarcoma. The spring and summer of 1902 were spent by Dr. Loeb at the State Cancer Laboratory in Buffalo. He was provided, for the accommodation of his animals, with two large and a number of small cages. He brought with him a number of rats which had been inoculated from his second sarcoma of the 392 AMERICAN PRACTICE OF SURGERY. thyroid obtained in Chicago. During the period of his stay in Buffalo ne carried out a number of successful transplantations. On leaving the laboratory in Sep- tember he took with him a number of rats with tumors, but these became in- fected, and later the tumor was so infected as to be no longer transplantable. After Dr. Loeb's departure all rats were removed from the laboratory. The smaller cages were sterilized in the hot-air sterilizer, but the two larger cages which he had employed, being too large for such steriUzation, were simply cleaned and put away. For a period of several months after Dr. Loeb's depart- ure there were no rats of any kind in the laboratory. In the summer of 1903 some rats were purchased in Buffalo for other purposes than tumor transplanta- tion, and a number of them were placed in the two large cages mentioned. In the spring of 1904 there was found in one of these cages a rat with a tumor the size of a horse-chestnut in the subcutaneous tissue of the right abdominal aspect. This tumor was removed by operation, and proved to be a fibro-sarcoma. It was transplanted to other rats, but without success. The occurrence of the development of this sarcoma in the rat was noted and the cage was- marked. There were then introduced into the cage a number of adult rats, but, owing to an epidemic of itch among them, it was found necessary to remove the cages containing them to the basement to prevent the possible spread of this infection to the hundreds of mice which occupied the regular animal space in the labora- tory. During the summer of 1905 there were found in this cage two adult rats, both males, one with a large fibro-sarcoma in the right abdominal aspect and the other with a large sarcoma of the thyroid. The latter rat died early in October. Sections of the tumor showed it to be identical in appearance with the three primary sarcomas of the thyroid described by Loeb, which developed in the cages in the Chicago Polyclinic Laboratory. In the middle of October an opera- tion was performed upon the other rat. Sections showed that the tumor was a fibro-sarcoma of identical appearance with the one which had appeared in the cage a year before. A number of rats had died during the course of the summer with tuberculosis, so that at the time of the development of the tumors there were but four adult rats in the cage, the two with the tumors and two without. No other tumors have developed in rats in any of the other cages in the labora- tory, although the small cages employed by Dr. Loeb and subsequently sterilized have now had rats in them for a period of two years. Aside from the three cases of primary sarcoma of the thyroid developed in Chicago and described by Dr. Loeb, during the period of three years since his departure from the laboratory with his inoculated rats no other author has described sarcoma of the thyroid in the rat, and none has been known to develop in any of the establishments in which these animals are bred. The demand for animals with tumors has become so great that all breeders of white mice and white rats are now on the lookout for tumors, so that the possibility of their having been overlooked is reasonably remote. PARASITICAL RELATIONS OF CANCER. 393 Haaland calls attention to a case in wliich a woman in Paris purcliased two white mice for breeding purposes. In the course of two years she sold about two hundred young offspring, reserving the mature mice for breeding purposes. Among these she observed twenty spontaneous tumors. The last three of these mice, with the cage in which they had developed their tumors, were brought to the Pasteur Institute. The mice were removed from the cage and were placed in a new cage, and into the cage in which they had developed their tumors were placed new mice. None of the mice which had previously been in the cage in which the tumor developed, or the new mice which had been placed in it, devel- oped tumors under subsequent observation. The three mice, however, which had already developed sporadic tumors were placed in a new cage, and in this cage were placed with them a number of mice derived from healthy stock, their ancestors so far as known never having had sporadic tumors. Of the healthy mice thus placed in contact with the mice already infected, four developed spon- taneous tumors. From this it would appear that to a certain extent these mouse tumors are contagious. If this be admitted, what is the significance of the almost exclusive development of primary carcinoma of the mamma in elderly females among these mice? Ehrlich points out that two explanations are possible. First of all, by reason of the great fertility of the animals the older females are almost constantly carrying and nursing young. It is therefore reasonable to assume that the tremendous demands made upon the breast predispose to an unlimited pro- liferation of the epithelium of that gland. On the other hand, it is probable that, through the indiscriminate nursing of the young, first by one mother and then by another, an infection of the breast in one mouse might easily be transferred to that of another mouse. It has been shown that in the early stages of carcinoma the breast still possesses the power of lactation, and it is therefore perfectly pos- sible that, through eversion of the nipple, the virus may be transferred from that structure: in one animal to the corresponding structure of another. Both in Paris and in Ehrlich's laboratory careful experimentation is being carried on for the purpose of ascertaining whether or not this occurrence can be experimentally proven. In the light of Borrel's observation — viz., that healthy mice which are brought in contact with infected mice can acquire these tumors — it would seem that the exclusive appearance of tumors of the breast among animals used solely for breeding purposes presents very suggestive evidence in favor of an infectious factor. Transference of the Infectious Factor in Cancer Cells to Normal Epithelium. The evidence thus far adduced applies only to primary tumors. If there is a contagious factor which can be transferred from one animal to another, bringing about the transformation of normal epithelial cells into cancer cells, then it is not improbable that, in the very beginning of cancer, this contagious factor may be 394 AilERICAX PRACTICE OF SURGERY. transferred for a limited period from one cell to the next. In fact, pathologists generally recognize that, in small, beginning carcinomata, such a transformation can be observed. We have from Orth, in his most recent utterance on this sub- ject, the following: "I am, I confess, of the opinion that there are cancers in which the transformation of preformed epithelial cells into cancer cells takes place continuously in the tissue bordering upon the margin of primary tumors; also that there are multicentric cancers, not only in the sense that the cancer change takes place at the same time in different neighboring spots, but also in such a manner that one spot becomes cancerous later than another." If a pri- mary cancer starts from a given centre and the cancerous transfoimation spreads from cell to cell, it must be that that force or factor which endows normal epi- thelium with the power of limitless proliferation is transferred, at least for a cer- tain period of time, from the iuA^oh^ed cells to the adjoining normal ones. Al- though this appears to be the case in the period of the inception of a cancer, experimentation has shown that the cancer cell, once endowed with this power of proliferation, retains it most persistently, and a transference of this power to other cells never occm-s, unless one or two suggestive observations, which will be referred to later, are evidences of such transference. Success in transplanting these sporadic tumors in the mice has been variable, but the general experience tends toward more successes as the work progresses. In six of the mice in which cancer was transplanted by Bashford, there were only two in which the disease persisted beyond the second generation. Borrel is in possession of an epithelioma and an adenocarcinoma which are transplantable, and Ehrlich has at present ten different sporadic tumors in process of transplan- tation, some as advanced as the sixtieth generation. Bashford has had over three thousand transplanted tumors imder observation. Ehrlich's, Borrel's, and Jensen's observations must likewise run into high figures, and the New York State Laboratory has already had about six hundred. It will thus be seen that the last two years have been very fruitful in experience in the investigation of cancer, and it may be said that, although the work has just begun, manj^ ideas which we have held regarding this process have been shown to be erroneous, and many characteristics have developed which were entirely unexpected. Characteristics of Traxsplantable Mouse Tumors. It must be pointed out that the mere transplantability of cancer throws no light upon the mechanism bj' which spontaneous tumors develop. These trans- plantations are modifications of the process of metastasis. The success with which they haA'^e been accompanied has shown great variability, but on the whole the experiences of all laboratories have been that tumors which have been often transplanted acquire an increased virulence, so that, although the success at- tending the first attempts at transplantation has in manj' cases been as low as PARASITICAL RELATIONS OF CANCER. 395 one or two per cent, in later cases the virulence has risen to such an extent that the average has been as high as from eighty to one hundred per cent. A most interesting example of the tremendous virulence of these transplanted tumors is found in one which is imder observation by Ehrlich. This, known as No. 7 in his series, presents a virulence which is most astonishing. The transplantations with this tumor material have for a considerable period of time given from eighty to one hundred per cent of successes. The transplanted tumor grows with such rapidity that in eight days after inoculation it has been found to weigh 2 gm. ; at the end of two weeks, over 3 gm. ; and at the end of three weeks, usually 5 gm. Tumors as large as the mouse itself not infrequently develop within two months from the time of inoculation. All laboratories which have been working on transplantation have had similar experiences. Some tumors are fomid to grow very slowly, as did that of Morau, which required months for its full devel- opment, whereas others present the characteristics of the tumor described above. In all tumors, however, repeated transplantation, instead of weakening the en- ergy of the tumor, seems to increase its virulence, and it is now recognized that the most distinguishing feature of cancer is the unlimited power of proliferation which the cancer cells possess, this power having already carried some tumors beyond the sixtieth generation of transplantation through healthy mice. All this experimentation has failed to show us how the cancer cells acquire this phenomenal power of proliferation. That the characteristic factor of can- cer is found only in the epithelium is shown by the fact that the stroma in the transplanted tumors is furnished by the host. That this factor, in the course of transplantation of mouse tumors, is occasionally transferred to the connective- tissue elements of the stroma, endowing them with sarcomatous characteristics by which the tumor is transformed into a mixed tumor, is shown by the fasci- nating publications of Ehrlich andApolant {Berl. klin.Wochenschr., 1905, No. 28, and 1906, No. 2). These observers have now encountered this phenomenon in three tumors. In the first case observed, the tumor presented the usual char- acteristics of the adeno-carcinoma of the mouse and had been transplanted without any change to the sixth generation. The tumor consisted of nests of varymg sizes of alveolar arrangement, with a not very well developed connective- tissue stroma. Between the sixth and ninth generations the tumor underwent a change in which the carcinoma suddenly presented the characteristics of a mixed tumor, the thin connective-tissue stroma presenting everj^ evidence of active proliferation; wide avenues of closely packed, deeply staining spindle •cells, with abundant karyokinetic figures, appearing between the nests of epi- thelium. These characteristics persisted from the ninth to the thirteenth gen- eration, the epithelial characteristics graduallj^ diminishing and the nests becom- ing smaller and more widely separated; and in the fourteenth generation the epithelium had entirely disappeared from the tumor, leaving a spindle-celled sarcoma, which is still being transplanted and has reached the fortieth genera- 396 AMEPJCAX PRACTICE OF SIT^GERY. tion. The accompanymg table from Ehrlich will serve more graphically to emphasize this remarkable observation : Familv 16 Carcinoma I 1 Generation Carcinoma 2 Generation Carcmoma I 6 Carcinoma I 9 Mixed tmiior 10b 10a Mixed tumor I 11 . I I ! I 12a 12b 12c mixed 13a Sarcoma 13b ilixed 13c Mixed I 1-4 Sarcoma I 15 Sarcoma The generations marked a, b, c descended from various mice of the preceding series. Recently Apolant and Ehrlich have reported two further similar obser\-a- tions. In one of these the sarcomatous transformation developed in an adeno- carcinoma which was produced by mixing together various adeno-carcinomata which were respective^ in the twentj'- first, the thirtj^-third, the twenty- third, and the nineteenth generations of transplantations. One of the strains derived b}'^ this mixture, between the twelfth and fovuteenth generations, showed a marked increase in the proliferation of the coimective-tissue stroma, which awakened at once the suspicion that the development of sarcoma was taking place. In the sixteenth generation this was so far developed that the tumor presented the characteristics of a mixed tumor. In contrast to the first case reported, the differentiation between the nests of epithelial cells and the prolif- erating stroma was not nearly so marked as in the preceding case. The sarcoma cells likewise were more polymorphous in appearance, typical spindle cells forming only a part of the tumor. They lay in irregular masses that filled the spaces not occupied by the net-like structure of the epithelial portion of the timior. The proliferative cliaracteristics of the sarcomatous portion of the tumor were not nearly so marked as in the first case. The tumor at present is in its tenth generation of txansplantation, and the proliferation of the connec- tive-tissue and epithelial elements appears to be about on the same footing as it was before, the tumor ha\-ing during the last six months shown but PARASITICAL RELATIONS OF CANCER. 397 slight changes in the relative proportion of epithelium and connective tissue. The rapidity of growth of this tumor shows no diminution, the authors having observed tumors of enormous size, in many cases equal to that of the mouse itself. The third observation is the most striking of all. It occurred in the course of transplantation of Ehrlich's tumor No. 7, which is the most virulent of all mouse tumors yet imder observation. This tumor had shown, from the fortieth to the sixty-eighth generation, a marked increase in the connective tissue without the stroma presenting the characteristics of a sarcoma, when suddenly in the sixty-eighth generation it took on a marked sarcomatous appearance, associated with such colossal proliferation that in the next generation many of the tumors were sarcomas without any evidence of epithelioma. Here and there some of the transplanted tumors contained a few nests of epithelium. These remnants of carcinomatous epithelium have been detected as late as the seventy-first generation. The sarcoma cells in this tumor were likewise more polymorphous in character, those of a spindle shape being in a minority. This timior has now been transplanted three generations further without any loss of the colossal proliferative qualities with which it has been endowed from the first. The explanation of this phenomenon given by Ehrlich is that some form of stimulus present in the carcinoma cells is in certain phases of its development transferred from the epithelium to the connective-tissue stroma of the tumor and transforms the connective-tissue cells of this structure into typical sarcoma cells capable of probably indefinite transplantation. It is impossible to draw conclusions from a single observation, but the phe- nomenon described above may possibly be explained by the assumption that the chief characteristic of a cancer — viz., its power to proliferate to an unlimited extent — has, in this particular instance, been transferred from the epithelium to the connective tissue. To assume, on the other hand, a transformation of epi- thelial cells into connective-tissue cells, would be contrary to all our histological loiowledge. It can, of course, be said that the phenomenon under consideration represents merely the sporadic development of a sarcoma on the basis of a car- cinoma. That the ^--factor in cancer may possibly be transferred to other cells is shown by the frecjuent observations referred to by Haaland, and observed in Buffalo, of the development of primary adenomata in the lungs of mice which have been the subject of transplantation of these mammary tumors. Haaland refers to the fact that this primary development of adenomata in the lungs of mice is a not uncommon occurrence, and our own observations corroborate this statement. Natural Immunity to Implantation in Mice. It has been foimd in all laboratories that a certain proportion of mice cannot be inoculated with the tumor. Thus far, a natural immunity against these in- oculation experiments appears to bear no definite relation to heredity, but in all 398 AMERICAN PRACTICE OF SURGERY. laboratories mice have been found which appear to be permanently immune, and these mice have frequently been the offspring of parents both of which were afterward successfully inoculated and died of the tumors. Spontaneous Retrogression in Cancer of the Mouse. Although the disease, once established by implantation, is in a very large per cent of the cases fatal, in all laboratories occasionally spontaneous cures have occurred. These have been observed in Ehrlich's laboratory and also by Bash- ford; and apparently, up to the present time, the greatest number have occurred in the Jensen mice under observation in the State Laboratory in Buffalo. Im- mediately following the transplantation of these tumors — which is done by tak- ing uncontaminated tumor, mixing it in a mortar with three or four parts of normal salt solution, and injecting it beneath the skin of the back through a coarse needle with a syringe or introducing particles through a small trocar — there is frequently a slight reaction, which subsides on the second or third day. It is obvious that in many of these experiments transient infection occurs, as shown by the formation of an abscess. This usually interrupts the experiments but occasionally the swelling subsides and ultimately a tumor develops. In the period from February to June, 1905, not less than twenty per cent of the tumors resulting from successful inoculation underwent spontaneous retrogres- sion. This is a higher percentage of spontaneous recoveries than has yet been reported from any other laboratory. The distribution of the period in which the processes of retrogression were apparent shows that more spontaneous retro- gressions occurred early in the process than late. There are, however, a certain number of retrogressions which occurred in what would normally be the last stages of the disease. One of the most striking examples occurred in a rapidly growing tumor, which reached a weight of over 3 gm. in forty-three days after the inoculation, then began to retrograde and ultimately disappeared. That a spontaneous cure of a genuine carcinoma in the mouse should occur and should be well authenticated would at first seem surprising, but a careful review of the literature has shown that undoubted cases of spontaneous cui'e have also been observed in human beings. It is natural that a greater percentage of these cures should occur under experimental conditions than under the con- ditions in which we encounter cancer at the bedside. Mice used for experimen- tation are taken at random, and it is obvious that some of them have a greater resisting power than others, as shown by the fact that a certain percentage of them possess a natural immunity which protects them from being successfully inoculated. The cases which we meet clinically are those of individuals who ap- parently have no sufficient immunity, and we see therefore only the unfavorable cases. It is not improbable, however, that even in human beings patients be- come infected with cancer, but make early spontaneous recoveries, perhaps with- out attracting even their own attention. PARASITICAL RELATIONS OF CANCER. 399 Evidence of an Acquired Immunity against Cancer in Mice. Researches in the State Laboratory as to the nature of the phenomena asso- ciated with spontaneous cure point very strongly toward the presence, in mice which have recovered spontaneously, of a form of acquired immunity. This is shown by the failure successfully to reinoculate any mouse which has spontane- ously recovered. The immune factor is apparently present in the blood, and in some mice has been sufRciently active, when injected into other mice with grow- ing tumors, to influence the growth of the tumor. In this way small tumors have been made to retrograde and large tumors have been inhibited in their growth. Further proof of the presence of an immune factor in the blood of mice is found in the recent observations of Clowes, which show that when cancer material is treated with a sufficient proportion of the blood of spontaneously recovered mice the number of successful inoculations is markedly reduced. Histological Char.\cteristics of Retrograding Mouse Tumors. Examinations of the histological appearance of tumors undergoing spontane- ous retrogression, and of those retrograding under the influence of injections with immune serum, show identically the same picture. If the action of this Fig. 119. — Microphotograpli. X 260. Epithelium at Margin of Tumor Undergoing Retrogression from x-ray Treatment, serum were cytolytic in its nature, we should expect to find evidences of destruc- tion or direct injury to the cells, but this is not the case. About the margins of retrograding tumors one finds that the cells have undergone simple atrophy, and that where groups of cells remain they frequently coalesce into pseudo-giant 400 AMERICAN PRACTICE OF SURGERY. cells. These are surrouiided by connective tissue, and ultimatelj', through the process of atrophy, disappear. In tumors undergoing retrogression hemorrhage is a frequent occurrence. An examination of the cancer cells immediatel}'^ adja- cent to the hemorrhages in the tumor shows that this process of simple atrophy is most marked where the cells have come in contact with the extravasated blood. Practicalh^, one can see here the direct action of the blood upon the cells. There is no necrosis of the protoplasm, and karyokinetic figures can be found in the epithelial cells until the very last. The picture presented shows that the epithelial cells are subjected to a process which is identical with that which over- takes transplanted or misplaced normal epithelium. Leo Loeb and others have Fig. 120. — Section of Wart Tlurteen Days after First Treatment, Nine Days After Last Treatment witli 2:-ray, Showing Complete Hornifieation of Epithelium of Wart and New Skin Formed from Deeper Layers. (Perthes.) sho\\'n that if fcetal epithelium is asepticalh^ transplanted into the subcutaneous tissues m adult animals, it is able to maintain itself for a period of time during which its d3'namic force suffices for proliferation to the sixth or seventh genera- tion, after which the force is expended, the cells undergoing atrophj' and becom- ing surromided b}' connective tissue, which grows between them. The picture presented here is exactly like that fomid in these retrograding tumors. From this observation it must seem obvious thatinspontaneousl3M'etrograding tumors the immune factor, instead of working directly upon the cells, reduces them to the status of normal epithelium, and thej' are then removed by a process of atrophy and repair which is identical with that which overtakes misplaced normal epithelial elements. Becher, Petersen, and Schwartz have shown that PARASITICAL RELATIONS OF CANCER. 401 similar reparative processes are frequent!)' at ^vorI<; in manj^ human carcinomata. That the connective-tissue activity is secondary is shown by interference with the immune mechanism, which interference can be brought about by bleeding. In the New York State Laboratory it has been found that in the case of tumors which were undergoing retrogression as the result of injections of immmie sera, severely bleeding the mouse would interrupt the process and the tumor would thereupon begin to grow as rapidly as ever. This observation, in connection with the facts which tend to show that the immune factor is in the blood, strongly Fig. 121, — Section of Untreated Wart for Comparison. {Perthes.) indicates that the proliferation of the connective tissue is but a secondary process, which only becomes active when the cancer cells are reduced to the status of normal epithelium. Identity of Histological Characteristics of Spontaneously Retrograd- ing Tumors and Tumors Retrograding through Treatment with Im- mune Sera, the x-Ray, or Radium. The changes which are brought about in carcinoma, either in man or in ani- mals, by exposing them to the activities of the x-ray or of radium, have been shown by Exner, Perthes, and others in man, and by Apolant and Embden and Bashford in mice, to present exactly the same histological picture as that which 402 AMERICAN PRACTICE OF SURGERY. is presented bj^ timiors midergoing spontaneous retrogression. This fact has been under observation for over a year in Buffalo. A section of a tumor retro- grading under the activity of the x-ray or of radium is in no way distinguishable from one taken from a tumor undergoing spontaneous retrogression or retro- gression induced by serum treatment. Examination of the blood of mice which have recovered from timiors through the activity of the x-iay shows that this fluid does not contain any acquired immune factor. If, however, in the course of treatment a mouse is heavily bled, the tumor will frequently begin to grow — a phenomenon which leads to the conclusion that the .x-ray does not act direct!}^ upon the tumor, but through svich immune factors as the mouse still possesses. • !• • *•• '- • ^"*f^,-®'' ..V- .• 5 • ": •• ■^- •* S ' y^ ^^' Fig. 122. — Human Tumor Undergoing Retrogression from Treatment with-r-raj'. (After Perthes.) For this reason it would appear that the .r-ra}^ and radium reduce the virulence of the tumor or so injure the z-factor that the natural immmiity brings about the retrogression of the timior. In this way it is possible to explain those tiuiiors which are not affected by the .r-raj^, and also the fact — which has been fre- quently observed — that tumors which are being favorabh* affected suddenly be- gin to grow in spite of continued treatment. Significance of Perthes' Experiments with the x-Ray on Warts. That the .T-ray, either directly or, as would appear, indirectly, robs the epi- thelial cell of the factor which causes its vmlimited proliferation, and leaves the normal epithelial cells unaffected, is showoi bj' the interesting experiments on warts by Perthes. Perthes has clearly demonstrated that the dose of x-ray re- quired in the treatment of cancer, or for the removal of warts, does not injure directly either the normal epithelivuii or the epithelial cells of the tumor. If the tissues surrounding the tumor are o^^erdosed a so-called x-ray burn may be induced, but this is an injury entirely independent of the ideal therapeutic ac- tivity of the agent. Perthes has shown by sections that a wart which has been properly dosed, frequently with but one treatment, will thereupon undergo a process of retrogression, in which all of the cells forming the wart become horni- PARASITICAL RELATIONS OF CANCER. 403 fied, mth the exception of those of the deeper or germinal layer; and these promptly proliferate and produce, not a new ivart as before, but normal new skin to repair the defect. If the dose is not sufficient the superficial cells will undergo hornification, the wart will be reduced in size, but the cells of the deeper layer will again pro- liferate and produce a new wart. This proves conclusively that the x-ray does not act through any form of injury to the cells themselves. It removes from them the tendency to proliferation which produces the wart, and leaves behind, in the necessary cells of the germinal layer, normcd uninjured cells which are capable of producing Fig. 123. — Microphotograph. X 260. Last Remnant of Epithelium from a Tumor Tjndergoing Spontaneous Retrogr neiu and normal skin. As it is the fate of superficial epithelial cells of the skin, when their period of utility is passed, to undergo hornification, the process of hornification in the cells of the wart is probably secondary. Once their ]3ower of abnormal proliferation has been removed, they succumb to that fate for which they were normally intended, which is hornification; and this involves all of the cells of the wart except those which are destined to resume their normal functions. Characteristics of the UxKxo'n'N Stimulus in Cancer. The observations thus far accumulated on the spontaneous retrogression of tu- mors, the retrogression of tumors through an immune agent, and the direct or indi- rect activity of the .r-ray and radium, tend to show that in these agents we have a means of removing from the cancer cell the x-factor. If, as conceded by Orth, there takes place at the margin of tumors a gradual transformation of normal epithelial cells into cancer cells, and if, by the action of immune sera and the x- ray, we can again reduce these cancer cells to the status of normal cells, it seems 404 AMERICAN PRACTICE OF SURGERY. almost conclusivelj' sho-n-n that there can be added to a normal epithelial cell a factor which is capable of endowmg it with the power of continuous prolifera- tion, and which can again be removed from it, leaving a normal epithelial cell. This normal epithelial cell, it is true, maj- be superfluous, in which case it will undergo processes of atrophy and removal the same as ma}' take place in any other misplaced normal epithelial cell. But if, as in the case of warts, the cell still has a function to perform, it can resmne its natural proliferative activit}' — an activity which does not overstep the bounds set by the physiological laws of normal life. It has been suggested that the miknown factor in cancer is of a chemical nature. No less an authoritj' than Marchand has suggested that it might be some toxin. If the facts in the case are considered, it is obvious, as Clowes has Fig. 124. — Microphotograph. X 260. Alveolus at Margin of Tumor Undergoing Retrogression from Serum Treatment. shown, that this is impossible. An agent which is capable of keeping up contin- uous proliferation in cancer cells — which, theoretically speaking, starts with one cell and passes into its offsprmg through thousands of generations, during which time the number of cancer cells increases indefinitely — must, quantitatively speaking, increase in bulk. That this must be so is evidenced by the fact that this factor can be removed and must be removed from each and every cancer cell before the cell undergoes retrogression. This is shown to be the case in ex- perunental tumors which are undergoing retrogression after treatment by the x- ray or through the acti-\-ity of sera. The changes brought about by either of these agents is foimd to be most marked at the periphery of the tumor, and it has been found that epithelial cells taken from the centres of tvmiors which are PARASITICAL RELATIONS OF CANCER. 405 retrograding at the. margins can be transplanted and will produce tumors, whereas the cells at the margins present changes which show that this would be impossible. Therefore, the agent must be removed from each and every cancer cell ; and as this agent, although present in the beginning in but one or two cells, later comes to occupy a bulk of cells which can scarcely be estimated, and as, furthermore, it must likewise have increased rather than have diminished in activity, it must certainly also have increased in amount. How enormous the proliferative powers of even a small mouse tumor may be is indicated by the astonishing figures which Ehrlich has published in connection with his rapidly growing tumor No. 7. He has estimated that this tumor is now growing at a rate which would permit of its being carried through sixty generations in one year. As the tumor is now giving nearly 100 per cent of increase, he estimates that if from 12 to 15 mice were used for each transplantation, within one week 10 tumors of the size of that used for transplantation would be produced. From each of these in eight days 10 more could be produced, so that in the third gen- eration 1,000 tumors, in the fourth 10,000 tumors, and so on, would result. If this were carried to the sixtieth generation, it would represent 10"° c.cm. of tu- mor if each tumor weighed but 1 gm. In the course of one year this would lead to a bulk of tumor which is scarcely comprehensible. It represents, according to Ehrlich, a cube the edge of which would measure 1,000,000,000,000 kilometres — a distance which it would require light 105 years to traverse. In spherical form it would represent a mass with a diameter 890 times greater than that of the sun, and a volume exceeding that of the sun 7x10"°. If the agent which could keep pace with this tremendous increase in bulk were a toxin, it could only do so by reproducing itself; and the only possible mechanism by which this could be brought about would be by the agent acting upon the protoplasm of the new cell in such a manner as to cause it to produce its like. No chemical agent, however, with which we are acquainted, toxin or otherwise, and which is capable of bringing about a reaction in living protoplasm, causes this protoplasm to pro- duce the same agent. On the contrary, the protoplasm produces, in all cases thus far known, an agent which is antagonistic to the first — in other words, some form of anti-body. For this reason it is impossible to conceive of any chemical agent endowed with the power to fulfil the conditions of the 2;-factor. We are therefore compelled to assmne that the x-factor must be some agent which can reproduce itself, and thus far the only agents with which we are acquainted which can accomplish this are living agents. Hence the most rational explana- tion of the miknown factor in cancer is that it is some living agent. If we so wish we can speak of this agent as a virus, as does Borrel, inasmuch as we do not know its specific natvire. Borrel believes that there is an infectious factor in cancer as yet imdemonstrated, and that it is in all probability an invisible or ultra-microscopic organism. The same contention has been made in the case of syphilis, because the agent was unknown (unless the recent observations of 406 a:\ieric.\x practice of surgery. Schaudinn, and of many others confirming it, should ultimately show that Spirochete pallida represents a phase of the organism of syphilis); and it is likewise held to be true in smallpox, in vaccinia, and in other diseases. SiGXIFICAXCE OF FlLTKATIOX ExPERniEXTS. The belief that the contagious factor is invisible has usually been based upon filtration experiments. The virus of sheep-pox has been show-n by Borrel to pass through the Berkefeld and the coarser grades of the Chamberland filter. This has likewise been sho^Ti to be the case with vaccine viinis. The question arises as to whether filtration experiments are necessarily an evidence of an ultra- microscopic organism. Borrel furnishes light on this point. In his filtration ex- periments vnth sheep-pox he discovered that when he diluted the vh-us with tap water, after four daj's there developed in the filtered and otherwise sterile viinis a small protozoon, to which he gave the name Micromonas Mesnili. The organ- ism when in its largest form in the virus — it is of course impossible to affii-m that the organism mider other conditions does not possess a still larger phase — was three or fom- microns long and as many wide. That the organism in question had nothing to do vrith the virus was shown when distilled or sterilized water was used to dilute the virus. Borrel fomid that his organism followed the same law as the active principle of the virus; that is, it passed through the filters through which the virus passed, and was held back by filters which were proof against the passage of the A'irus. That the organism passed through m some practicallj^ invisible spore form, and then developed on the suitable medimn of the wus, was sho'RTi by its appearance in virus only after four days and the im- possibility of detecting it in filtered water in which the larger forms did not de- velop. Borrel was forced to conclude : " Le passage a travers un filtre n'miplique pas forcement I'idee d'vm microbe invisible." It must be noted that Borrel's ]\licromouas shows as its largest form an or- ganism considerably smaller than the larger inclusions of vaccine, variola, and cancer. However, to assume that because the spore of an organism is sufficiently small to pass thi'ough a certain filter, its largest form would be within a certain Imiit of size, is not justified by biological knowledge. Calkins has described a protozoon, LjTtnphosporidium truttff, the spores of which have a diameter of one and one-half microns and divide into six sporozoites, each less than one-half a micron in diameter. Borrel likewise points out that there is an essential differ- ence between the smaller forms of motile animate parasites and bacteria of rela- tiveh' the same dimensions. The fii'st are more plastic and acconmiodate them- selves to the pores of the filter, passmg through where bacteria are held back. In all probability the sporozoites of Lymphosporidium truttte, less than one-half a micron in diameter, would pass through a bacteria-proof. filter ; and yet the largest form of this organism is a multinuclear amoeba twenty-five microns in diameter. It will be noted that ilicromonas j\lesnili is three to four microns long and as PARASITICAL RELATIONS OF CANCER. 407 many wide. The Spirochgete pallida in its smallest form is one-quarter of a micron in diameter and four to fourteen loiig. Becchi has shown that even large protozoan amoeba?, twenty-five microns in diameter, may pass readily through Berkefeld bougies, and for this reason it is desirable to eliminate filtra- tion experiments in attempting to determine the relative size of organisms. There is a not remote similarity between the subcutaneous lesions of syphilis and some of the infectious granulomata and even sarcomata. Infectious Venereal Granuloma of the Dog. In this connection Bashford has recently described the histological character- istics of an inoculable venereal granuloma found in dogs, which possesses certain characteristics of a malignant tumor, and presents still others which leave no doubt that it is an infectious process, although the virus or organism is as yet undetermined. This tumor seems to be almost a coimecting. link between the infectious granulomata and malignant tumors. It is common in the dog, is transmitted by coitus, and develops in the subcutaneous tissue about the geni- tals. The tumor cells are polygonal, with scanty granular protoplasm and large, spherical nuclei. In the resting stage they possess one large nucleolus and a delicate chromatin reticulum. Mitotic division is common in the nuclei, and, although the type is commonly bipolar, multipolar figures are not vmusual. The tumor is divided up into lobules by delicate connective-tissue septa containing fully developed capillaries. Hemorrhages are frequently found. The general appearance closely resembles that of a round-celled sarcoma with a parenchjona arranged in alveoli. In primary tumors (see Fig. 125) Bashford shows that a transformation of the connective-tissue cells into timior cells can be demon- strated. This is only apparent where the rapid growth of the tumor has not re- sulted in pressure upon the surrounding structiu'es. One striking feature of the tumor is that, although this transformation is going on at the periphery, the greater portion of the bulk of the tumor is brought about by proliferation of the tumor cells, in this way closely resembling the method of growth of a true malig- nant tumor. In the later stages the tumor grows almost entirely from its own resources. The primary lesion in this tumor is therefore in no way different from that of a primary sporadic carcinoma, in which there is likewise a trans- formation, at the margin, of normal cells into cancer cells. When, however, this tumor is transplanted, its true characteristics appear. According to Bash- ford, when the tumor cells are implanted in the subcutaneous tissues of a new host, all of the implanted cells, instead of continuing to proliferate, disintegrate, and a new tumor is formed by the action of the specific factor upon the connec- tive-tissue cells of the host. Evidence of this process is fomid by Bashford at the margin of newly developing nodules after implantation. Inasmuch as Bash- ford believes that the implanted cells all disintegrate, it is obvious that the virus is the only factor which persists. 408 AMERICAN PRACTICE OF SURGERY. All attempts to determine the precise nature of this virus have thus far failed. Filtration experiments do not appear to have been carried out thus far. These tumors frequently grow to great size and sometimes undergo spontaneous retro- gression. In transplantation experiments new tumors can be recognized in from eight to ten days, and subsequently they attain a diameter of several inches. Metastases may likewise develop in the mesentery after intrascrotal inoculation, and the lymph nodes adjacent to large growths are frequently enlarged. The disease cannot be transmitted to the cat, rabbit, guinea-pig, or mouse. Bashford concedes that, in its histological features, local mode of origin, partial growth from its own resources (in the later stages causing pressure on surround- ing tissues and organs), and in the limitation of its transmissibility to one species, ■•> ©I ° ''^ -? > » H'lf r.i/ ' ^-'^-'-T '.tt '\i ^{^^ ^ ® )J •«f.Sai-- Fig. 125. — Infective Venereal Tumor of Vagina of 1 >"g. I'riiuarv growth in vagina. Transfor- mation of connective-tissue corpuscles into tumor cells. X 350. (Basliford.) it closely resembles a malignant growth. He believes that its invariably infec- tive history, the transformation of the surrounding connective-tissue corpuscles into tumor cells even in fully de^^'eloped tumors, its artificial transmission, fol- lowing the laws of such granulomata as tubercle or glanders, and the fact that it occurs naturally in animals before sexual maturity, all serve to distinguish it from true malignant tumors. These objections, in the light of the facts already adduced, are not very con- vincing. On the other hand, we have shown that there is strong evidence of an infection in the primary sporadic tumors of the mouse, and we may add that many authorities concede that in primary tumors there is a transformation of normal epithelial cells into malignant epithelial cells at the margin of the tumor. Furthermore, the fact that the disease occurs naturally in young animals, which PARASITICAL RELATIONS OF CANCER. 409 is likewise true of sarcomata, should speak rather in favor of an analogy to malignant growths, which appear oftener in old age than otherwise. The one respect in which they appear to differ essentially from malignant tumors is that the cells do not appear to possess the power of limitless proliferation. It would seem that in transplantation experiments it would be a matter of great difficulty to determine whether or not all of the implanted cells disintegrate, and the es- sential point in which these tumors appear to differ from malignant tumors seems to be in the transformation of the normal cells of the host, in transplanted tu- mors, into tumor cells. The transplanted tumor in this case appears to repeat processes which are found in the development of sporadic tumors only, and as such it would appear that this tumor should in the future be the source of much fruitful investigation. The points which it has in connnon with true malignant tumors, the fact of its invariable infectivity, and the undoubted presence of an infective factor, should throw much light upon the much more elusive factors in malignant tumors. Sticker, who has carried out extensive transplantation experiments with a tumor similar to the one described by Bashford, and who has carefully com- pared those transplanted by Smith and Washburn, Wehr (1888), and Geissler (1895), arrives at the conclusion that Bashford's interpretation of these tmnors is not correct, and that they are genuine round-celled sarcomas. In this he is supported by Albrecht, Bollinger, Duerck, von Hansemami, Kitt, Luepke, Orth, Ribbert, Schmaus, Schmorl, Schuetz, Arnold, and Weigert, all of whom exam- ined specimens of all five tumors (Smith and Washburn, Sticker, Wehr, Geissler, and Bashford), and diagnosed them to be typical round-celled sarcoma. SUMMARY. The following, then, are the arguments which have been adduced, from the modern research into cancer, in favor of the infectiousness of the process : 1. An analogy exists between certain of the changes in the epithelium in can- cer and those occurring in the epithelium in certain of the acute exanthemata, notably variola and sheep-pox, Icnown infectious diseases. 2. The almost exclusive appearance of cancer of the breast in elderly female mice which have been used extensively for breeding is best explained by the transference of some infective agent, through the medium of indiscriminate nursing, by offspring (Ehrlich). 3. Tumors in mice are almost never found alone. In breeding establishments, where one case appears it is always accompanied by others. Healthy mice, brought in contact with mice with primary tumors, acquire the same (Borrel). 4. The reappearance of sarcoma of the rat in a cage which had contained rats inoculated with sarcoma points to the possibility of cage infection in this form of cancer. 410 .-OIERIC-IX PRACTICE OF SURGERY. 5. A gradual transformation of normal epitjielial cells into cancer cells occm's at the margins of primary cancers (Orth). 6. The continued transplantation of mouse timiors increases rather than reduces then* Airulence. Certain mouse tmaiors imder transplantation have acquued a A-irulence only comparable to that of an acute infectious process. 7. The transformation of an adenocarcinoma into a sarcoma (Elu-lich) is most easily explained by assuming the transference of an infective factor from the epitheliiun into the connective tissue of the stroma. S. A certain nmnber of mice are shown to possess a natural immunity which prevents inoculation with cancer. Spontaneous retrogression of cancer in mice is accompanied by histological appearances which show that the epithelium is not primarity injured, but that the stimulating factor is removed. Spontaneous retrogression is accompanied by a type of acc[uired immunity which prevents the successful reinoculation of the anhnal, and under favorable conditions this factor appears to be present in the blood and behaves not unlike the known antitoxins to infectious processes. 9. The blood of spontaneously recovered mice, when added to cancer mate- rial before transplantation, removes from it the power of continued proliferation. There is no evidence of cytolj'tic action (Clowes). 10. Tumors retrograding under the influence of the .z'-ray and radium present exactly the histological picture of tiunors spontaneously retrograding. The stimulating factor seems to be removed from the epitheliimi through the aid of the immune mechanism. 11. The epithelial cells of the deeper layers of warts, after successful treat- ment with the .T-ray, no longer proliferate to form a new wart, but reproduce nor- mal skin (Perthes), showing that the stimulus to proliferation has been removed and that there remain epithelial cells capable of normal proliferating function. 12. The unknown factor in cancer is apparenth' added to normal epithelium, from which it can be removed, leaving normal epithelimn. Through the prolif- eration of the cells of the cancer, which increase enormously, this factor must of necessity graduall}'' increase in amount. The increase in bulk, through trans- plantation in mouse tmnors, is associated with increased wulence. The onlj' known agent which can fulfil these conditions is a li\'ing organism. The unkno\\"n factor maj- be an ultramicroscopic organism, or one that is simph' midemon- strable. Filtration experiments in infectious diseases of imkno'mi etiology are not competent to throw any light on this phase of the subject. 13. Infectioios venereal granuloma of the dog, an imdoubtedly infectious tumor, presents certain points of similarity to malignant processes. The tu- mor grows largely through karj-okinesis of the tvunor cells which are derived from the connective-tissue cells of the host (Bashford). The cells do not appear to possess the power of limitless proliferation, although perhaps this is not cou- clasively proven. PARASITICAL RELATIONS OF CANCER. 411 Literature.. Apolant: Deut. med. Wochenschr., 1904, No. 31. Apolant and Embden: Zeit. f. Hygiene u. Infektionskranlch., Bd. 42, 1903. Bashford: Scientific Reports on the Investigations of the Imperial Cancer Research Fund, No. 2, part ii., 1905, London. Becher: Virchow's Archiv, voL 1.56, p. 62, 1S99. Borrel: Evolution cellulaire et parasitisme dans I'epithelioma, Montpellier, 1S92. These. An- nales de I'lnstitut Pasteur, 1903, No. 2. Bosc: A Monograph on Cancer, Paris, 1898. Arch, de Medecine Experimentale, vol. xiii., No. 3, 1901. Comptes rendus des seances de la Soc. de Biol., Oct. 24th, 1903, t. Iv. Calkins: Fifth Ann. Rept. of the Cancer Laboratory of the N. Y. State Dept. of Health, 1903-04. Fourth Ann. Rept. of the Commissioners of Fisheries, Game, and Forests of the State of New- York, 1898. Journ. of Med. Research, vol. xi., No. 1, 1904. ■ Cattle: Journ. of Pathology and Bacteriology, vol. ii., 1894, p. 367. J. Jackson Clarke: Centralbl. f. Bakt., vol. xvi., 1894, p. 281. Clowes: Fourth Ann. Rept. of the Cancer Laboratory of the N. Y. State Dept. of Health, 1902- 03. Medical News, Nov. 18, 1905. Councilman: Journ. of Medical Research, vol. xi.. No. 1, 1904. Ehrlich: Berl. klin. Wochenschr., 190.5, No. 28; 1906, No. 2. Exner: Wien. klin. Wochenschr., 1904, No. 7. Feinberg: Deut. med. Wochenschr., vol. xxviii., 1902, p. 185. Foa: Centralbl. f. Bakt., vol. xii., 1892, p. 185. Gaylord: American Journal of the Medical Sciences, May, 1901. Fifth Ann. Rept. of the Cancer Laboratory of the N. Y. State Dept. of Health, 1903-04. Gorini: Centralbl. f. Bakt., Abt. i., vols. 28 and 29. Greenough: Journal of Medical Research, vol. vii., No. 2, 1902. Guarnieri: Centralbl. f. Bakt., vol. xvi., p. 299. Haaland: Aimales de I'lnstitut Pasteur, vol. xix., No. 3, 1905. Hanau: Fortschritte der Medecin, 1889, vol. viii. von Heukelom: Centralbl. f. allg. Path. u. path. Anat., vol. i., p. 204. Howard and Perkins: Journ. of Med. Research, vol. xii., 1904, p. 359. Jensen: Centralbl. f. Bakt., 1903, Bd. 34, H. 1 and 2. Kiirsteiner: Virchow's Archiv, vol. cxxx., p. 463. von Leyden: Zeit. f. klin. Med., 1901. L. Loeb: Arch. f. Entwickelungsmechanik der Organismen, vol. xiii, H. 4. Virchow's Archiv, Bd. 167, H. 2, 1902. Marchand: Deut. med. Wochenschr., Nos. 39 and 40, 1902. Morau: Arch, de Med. Exp., 1894. New York State Cancer Laboratory, Med. News, Jan. 14th, 1905. Bull. Johns Hopkins Hos- pital, vol. xvi.. No. 169, 1905. Nosske: Deut. Zeit. f. Chir., Bd. Ixiv., 1902. Nowinsky: Centralbl. f. d. med. Wissenschaften, Jahrg. 14, 1876. Orth: Annals of Surgery, vol. xl.. No. 6. Petersen: Miinch. med. Wochenschr., vol. xlix.. No. 37. Perthes: Arch. f. klin. Chir., Bd. 71, 1903; Deut. med. Woch., 17 and 18, 1904. L. Pfeiffer: Die Protozoen als Krankheitserreger, Jena, 1891. Pianese: Ziegler's Beitrage, 1896, Supl. i. Podwyssozki and Sawtschenko: Centralbl. f. Bakt., vol. xi., No. 16, 1892, p. 493. Posner; Arch. f. klin. Chir., Bd. lx^^ii., H. 3, 1902. Ruffer and Plimmer: Journ. of Pathology and Bacteriology, 1894, p. 3. Buffer and Walker: Journ. of Pathology and Bacteriology, 1893, p. 198. San Felice: Zeit. f. Hyg. u. Infektionskrankh., Bd. 29, 1898. Schaudinn (and Hoffmann) : Berl. klin. Wochenschr., May 29th, 1904. 412 .-LAIERICIN PRACTICE OF SURGERY. Scheuerlin: Deut. med. Wochenschr., 1SS6, p. 4S. Schill: Sitzung des Vereins f. innere Jled. in Berlin, Xov. 2Sth, 1887. Schwartz: Virchow's Archiv, Bd. 175, 1904, H. 3. Sjobring: Fortechritte der Medicin, 1890, p. 529. Soudake-natsch: Annales de I'Institut Pasteur, 1892, No. 3. Steinhaus: Virchow's Archiv, Bd. 126, 1891. Sticker: Karzinomliteratur, No. 11, 1905. Thoma:,Fortschritte der Medicin, 1889, p. 413. Virchow: Virchow's Archiv, vol. i., 1847. von Wasielewski : Sitzung des Komitees f. Krebsforschung vom Januar, 1904. Wehr: Centralbl. f. Chir., vol. xv., 1888. PART II. COMPLICATIONS AND SEQUELiE. INFECTIONS WHICH SOMETIMES OCCUR IN VARI- OUS SURGICAL DISEASES AND CONDITIONS. By PAUL MONROE PILCHER, M.D., New York. WOUND INFECTIONS. Without exception, surgical infection is due to bacterial activity. Bacteria however, may be present in a wound without giving rise to inflammation. The virulence of the micro-organisms, the environment in which they find themselves, the ability of the tissues to protect themselves — these and many other factors influence the course of the infection. A freshly made wound, presenting crushed and partly devitalized tissue, and a cavity filled with coagulated blood and serum, furnish the ideal conditions for the development of an infective infiammation. It is generally accepted that the Staphylococcus pyogenes aureus and albus and the Streptococcus pyogenes, separately or associated, are in most cases the infective agents. Many other bacteria, however, may be the etiological factors. Among the most important of these are the Bacillus coli communis. Bacillus pyocyaneus, Proteus vulgaris. Micrococcus tetragenus. Bacillus of Friedlander, Bacillus typhosus, the Gonococcus, Streptococcus erysipelatis, and the Pneumo- coccus. Some of these bacteria, imder ordinary conditions, do not produce a suppurative inflammation ; on the contrary, they are more f recjuently associated with some other form of exudation, but under special circumstances they may produce suppuration. The presence of bacterial activity in a wound gives rise to inflammation, clinically recognized by the local redness, swelling, heat, and pain, and the oc- currence of fever. These phenomena must necessarily vary according to the character of the tissue which is the seat of the inflammation. Redness would necessarily be absent in a non- vascular tissue, while heat as a sign of inflamma- tion has not been observed in many of the viscera. The degree of swelling and pain varies with the tissue and the individual attacked. These signs are due to pathological changes in the vessels and tissues. At first there is an active dilatation of all of the vessels and an increase in the rapid- ity of the flow of blood through the tissues; in other words, a hyperamia. This gives rise to the redness and heat. Following this there are a passive dilatation of the capillaries and veins and a gradual slowing of the blood. The relative num- ber of white blood cells is increased, more especially in the veins. Gradually, 415 416 A^IERiaiN PRACTICE OF SURGERY. more or less complete stasis of the blood current takes place, and the white blood corpuscles migrate through the walls of the veins and capillaries, completely surrounding the -avails of the vessels, and pass on out into the contiguous tissue. In the more severe forms there is also a diapedesis of the red blood cells, which is held to be a passive transudation. The swelling is due to the fluid which is exuded from the vessels into the Ijonph spaces and then into the tissue itself. In inflammation of the peritoneum or plem-a the exudate passes dhectly into the peritoneal or pleural caATities. This exudate varies greatly under different con- ditions. It may be a purely serous exudate, but more frequently it is a sero- fibrinous exudate. According to Councilman, the fibrin is formed entirely out- side of the vessels. The fibrinogen contained in the serous exudate is converted into fibrin in the presence of a ferment produced by the degenerated cells. The exudate in the case of a suppurative inflammation is characterized by the pres- ence of a certain number of degenerated leucocytes, an increase in the amount of albumin, and a greater degree of coagulabilitj'' (Hildebrand). It is especially rich in cells. This form of exudate is frequently met with on the surface of wounds, and is known as a fibrinous or croupoiis exudate. It is generalljf associ- ated with superficial necrosis. Again, in suppurative inflammations the produc- tion of pus cells may greatly predominate, and small ca^'ities be formed, contain- ing the pus cells, exudate, and necrotic tissue, and thus an abscess will be formed. In such cases the amount of fibrin found is generally relatively small. According to Councilman, the immediate effect of the presence of growing bacteria in a wound is the production of an area of necrosis around them. Around this ne- crotic area or even within it are seen many leucocytes of the polymorphonuclear variety. They form a definite wall. The chemotactic properties of the necrotic tissue and the bacterial products increase, and the leucocytes invade the necrotic mass. The central mass liquefies, becomes circumscribed by granulation tissue, and an abscess is formed, the liquid contents of which are kno'wn as pus. T^lien the infection is more severe there is often a diapedesis or even a true exudation of red blood cells, and we have the heriiorrhagic exudate, which almost always signifies a necrotic process. Necrosis alwaj^s accompanies a suppurative inflam- mation in the tissues, and consequently there is a loss of tissue. If this is super- ficial it is seen as an idcer; or, if confined within the tissues, it forms an abscess. Always at the periphery of a suppurative mflammation granulation tissue is built up. Suppm'ation may be confined to the surface of the wound, or, beginning in the wound, it may spread rapidly and involve not only the adjacent tissues, but also the general system. As has been already stated, the cause of suppm'ation in a wound is bacterial activitj-. Generallj', the bacteria gain entrance by direct inoculation of the wound. There are, however, other avenues of entrance. It has been conclu- sively demonstrated that imder certain conditions bacteria may pass through INFECTIONS OF OCCASIONAL OCCURRENCE. 417 the epithelium covering the tonsils and gain entrance to the general circulation. This is also true of the mucous membranes lining the intestinal and respiratory tracts. These facts are of special interest in explaining those cases of infection in which there has been no discoverable external wound or those in which an in- jury, such as a simple fracture, becomes infected and gives rise to an extensive suppurative process. It must be remembered that not all bacteria which gain access to the wound bring about suppuration. In the first place, they must find a proper medium for their activities and development. It is true, too, of some bacteria that they cause suppuration in one animal and not in another; also some bacteria acting alone are non-pathogenic, but when associated with other forms of bacteria they become actively pathogenic. Having gained access to the wound, they may ac- tively proliferate and invade the surrounding tissues or pass directly into the lymph or blood streams and bring about a general infection. The next question of importance is. How do the bacteria cause injury to the tissues f As a, result of exliaustive researches, the conclusion has been reached that the phenomenon is fundamentally a chemical process. The bacteria them- selves secrete ferments which act directly upon the tissues, exerting a peculiar digestive action upon them. They further assimilate certain substances from the surrounding tissues and excrete others. These latter assimilation products are chiefly ptomains, such as putrescin, sepsin, and cadaverin, and are poison- ous; so also are the bacterial proteins and toxalbumins (Hildebrand). These poisons act locally upon the tissues, causing necrosis, and the combined resorp- tion into the system of the products of decomposition and the bacterial toxins gives rise to the constitutional intoxication. Of all the pus-producing bacteria, the Staphylococcus pyogenes aureus and albus and the Streptococcus pyogenes are the most frec^uently met with. The staphylococcus is most often the cause of localized suppurative processes, such as furunculosis, carbmicles, localized abscess, acute osteomyelitis and periostitis, pustular skin diseases, empyema, etc. The streptococci are seldom found in these conditions, but are found more frequently in the phlegmonous inflamma- tions. When these cocci — either separately or in combination — are introduced into a wound in sufficient numbers, they give rise to a suppurative inflamma- tion. The local tissue which is infected helps to limit the disease by bviilding up granulation tissue. The vascular system supplies the fibrinogen and the leu- cocytes. The leucocytes invade the inflammatory tissue, and, acting as pha- gocytes, help to limit the growth of the cocci and eventually to destroy them. It is questioned by many whether the leucocytes act as true phagocytes ; be this as it may, they certainly play an active part in inhibiting the spread of the cocci. There are also in the blood a number of other substances, which are di- rectly antagonistic to the bacteria and their products. Two of these, agglutinin and bacteriolysin, are produced in the spleen, bone-marrow, and lymph nodes, VOL. I. — 27 418 a:merican practice of surgery. and seem to act by paralyzing the bacteria and preparing them for the attack of the alexins. Alexin is produced in the blood itself, and is deadly to the cocci. There is also present in the blood serum a much more potent factor, viz., anti- toxin, which is a true bactericide. The protective forces of the body may temporarily limit the advance of a suppurative inflanmiation without enthely stamping it out. An example of this, may be occasionally fovmd in bone abscesses, which subside after a period of considerable activity, remain cjuiescent for years, and then suddenly give rise to severe symptoms. The infectious agents in such cases are almost always staphy- lococci. Another micro-organism of frequent occurrence in suppurative processes is the Bacillus pyocyaneus. Many authors maintain that it exists simply as a saprophyte on the skin, and that, acting alone, it does not cause suppm'ation. Other writers, however, believe that imder certain conditions it must be classed as a pyogenic bacterium. We do know that, when associated with streptococcic or staphylococcic infections, it becomes active and gives rise to a peculiar exudate, called green or blue pus. It shows its blue color only in the presence of oxygen. Wlien pyogenic bacteria become active in the tissues of the body, various types of inflammation may follow. If the process is confined within the tissues an abscess results, which may spread or remain localized. If a general infiltra- tion of the tissues takes place, it is known as a phlegmonous inflammatioji. "\^^ien the abscess is superficial and opens on the skin, it is called thereafter an ulcer. In such a condition there is always a loss of substance, exposing the deeper tissues. Certain localized deep-seated inflammations of the skin are termed furuncles or boils. Cellulitis of the soft parts of the fuigers or toes are called felons, or paronychice. In all of these conditions the ordinary phenomena of inflammation are evi- dent in varying degrees. The constitutional s}nQaptoms are sometimes marked, but thej' rapidly subside upon removal of the local cause. Infection complicating the healing of a wound maj' manifest itself m various ways. It may cause a simple inflammation and active suppuration may not oc- cur, or a most active and virulent suppurative or gangrenous inflammation may result. The process may be limited to the wound and its immediate neighbor- hood, or it may be progressive and inA'oh^e large areas. SIMPLE INFECTION. When a recent womid is infected, it may not show signs of inflammation until the second or third day. If the woimd has been sutured, the constitutional symptoms may be the first evidence of the infection. The patient complains of headache or a feeling of general malaise. There may be anorexia or even nausea. Unless the uifection is extensive, vomiting does not generally occur. The most constant sjmaptom is fever. At first there is little to differentiate this fever from INFECTIONS OF OCCASIONAL OCCURRENCE. 419 the ordinary aseptic wound fever which almost always is noticed in the healing of extensive wounds, especially where there is much loss of blood or destruction of tissue. Such fevers usually subside on the second or third day following the injury to the tissues. The fever accompanying an infection, however, does not subside. At first the body temperature may not be very high, but gradually it increases, until on the third or fourth day it may register 103° F. or higher. The pulse varies. Usu- ally there is a corresponding in- crease, but at first it may not be marked. An examination of the wound, if it be sutured, will show a redness and oedema along the suture line. If the infection be deep-seated there may be no su- perficial signs, but palpation will demonstrate induration and ten- derness. The patient may com- plain of local pain. When the infection is extensive all the symptoms of a suppurative in- flammation are present. If the wound is an open one there will be noted an increase in the amoimt of the secretion which it furnishes. At first, this secretion is sero- sanguineous, but later it becomes purulent. The edges of the wound become swollen and oedematous, and, as the infection spreads into the connective tissue and between the muscular septa, the usual symptoms of a phlegmonous inflammation develop. If the infected area is not incised or opened it may become localized, being circumscribed by granulation tissue — in other words, an abscess may form; or the infection may rapidly spread and give rise to an extensive phlegmonous inflammation. Again, the toxins and the micro- organisms may be rapidly absorbed and give rise to septicaemia or pyeemia. Usually, when the process is discovered early and free drainage is provided, combined with the proper antiseptic treatment of the wound, the signs and symptoms of inflammation gradually subside and the wound heals by granula- tion. If the superficial portions of the woimd heal first, retention of the secre- tions and purulent exudate may occiu-, and then the constitutional sjntnptoms due to the absorption of the toxins will again appear. During the course of healing of such infective processes, if the infection be deep-seated, sinuses and fistulce often result, and these do not heal until all of the necrotic or infected tissue has come away. DISEASE 1 ^ 3 4 5 6 7 8 '■"• P.-. ..„. '■"■ «-"• '■"■ ..„. P.„. .M. P.M. ..„. P.„. .„. P,„. ... P.». 107° 106° 105° c 104° X < t 103 I ''' S 101° s j^ 100 99° 98° 97° e t- ° 15 3 A i 2 i / /^ J \J A I ^ y /" \ /\ / /" s/ V /^ \ / Fig. 126. — Temperature Chart of a Case of Infected Wound Following Operation. 420 MIERICAN PRACTICE OF SURGERY. ACUTE SEPTIC PHLEGMONA. Aside from the simple wound infections and suppm-ative plilegmona which tend to remain more or less localized or are easilj^ controlled by treatment, there are a number of acute infective processes which originate in a woimd and rapidly and progressively spread, often giving rise to most alarming sJ^xlptoms. The mildest form of this tjrpe of infection is the so-called progressive phlegmonous in- filtration, which spreads rapidly from the seat of the original infection, mvolvmg the connective tissue, the intermuscular septa, the fascia, and the tendon sheaths, without leading to localized pus formation. It is most frequently seen in com- pound fractures of the extremities or in extensive crushing injuries. The first symptoms usually appear within three or four daj'S after the injm-y. There is a PULSE TEMPERATURE (FAHR.) s g_ s i g i s 1 i § § ^ \ INJUR ■^ - ■> > <^ < » ■^ " > i CL_ CHILL . '^ •^ ' — ■ ~7 ? ( < MULT PLE ^ ) > INCIS ONS N < ^ - S > >. ^ .;;;^ — " - } ^ < «c . i -5 > ■~ ^> INCIS ON I ^ I < ' < % o \ > • I y ^ k o ^ > k ^ < " £ = / \ ? Fig. 127. — Temperature and Pulse Curves of a Case of Acute Septic Phlegmon foUo-n-ing Extensive Injury of Foot. chill, accompanied by a rapid rise in temperature and a rapid pulse. There is a foul-smelling discharge from the wound and a rapidly extending oedema. The tissues are infiltrated with a foul-smelling sero-purulent exudate, which, if not relieved, results in extensive necrosis and diffuse suppuration. The constitu- tional symptoms are marked. Acute Purulent OiIdeil^. Another form of the same type of infective processes is the acute purulent oedema, first described by Pirogoif . The original wound may have been slight, or INFECTIONS OF OCCASIONAL OCCURRENCE. 421 DAY OF DISEASE 1 2 3 4 5 6 7 A.«. P.«. -■ ..«. ••"■ ..«. A.„. p.„. ..„. P.M. ..M. p.„. A.„. '•"• 107° 106° 105° 2 104° I < 5 103 ^ ioa° < S 101° ^ 100 99° 98° 97° i £ IS \ / ^ / A V N J \ K / \ k/ / '\ r J \l / y / / it may follow or complicate extensive crushing injm-ies. The progress of the infection is rapid and virulent. Within from twelve to twenty-four hoiu-s after the injury the part, usually an extremity, becomes I'apidly swollen and oedema- tous. The sero-sanguineous discharge from the wound becomes sero-puru- lent and is very offensive. Marked constitutional symptoms arise. The body temperature is high and the pulse rate rapid. The swelling rapidly increases. If the tissues are incised they will be found to be everywhere infiltrated with cloudy fluid. Portions of the tissues are already necrotic, despite the short duration of the disease. The odor of the secretions is most foul. The Ijrmphatics are extensively involved. In a few days multiple suppurative foci develop throughout the tissues. The abscess cavities are filled with offensive pus, necrotic tissue, and frequently foul- smelling gas. Often an entire extremity is involved in the process. The disease generally terminates in a fatal septicemia. Gangrene Foudroyante. The gangrene foudroyante, first described by Maisonneuve, is closely allied to the process which has just been described. It most frequently follows a bone injury, and has often been known to follow a crushing injury of the foot or leg. It is characterized by the progressive character of the infection, the rapid course, the gangrenous destruction of the tissues, and the production of gas abscesses and a spreading emphysema (Hildebrand). The cause of the infection is the Bacillus of malignant oedema (Koch). In such cases the extremity swells rapidly and soon gives evidence of a spread- ing emphysema. The secretion from the wotmd is sero-sanguineous and scanty. The extremity shows an advancing dusky oedema. In twenty-four hours the entire limb may be involved. The skin crackles when touched (Spencer). The vems appear as bluish stripes on the brownish-red skin. The constitutional symptoms vary. The body temperature may not be high or we may have a tj^p- ical septic curve. Frequently diarrhoea and involimtary evacuations of the blad- der and rectum occur. The patient is restless. The pulse is rapid. Commencing gangrene is seen. Incisions show multiple abscesses containing pus and foul- FiG. 128. — Temperature Chart of a Case of Acute Purulent OEdema, which Terminated Fatally. 422 AMERICAN PRACTICE OF SURGERY. smelling gas. The gangrene extends rapidly. The body temperature gradually falls, sometimes becoming subnormal, and death follows. The prognosis is bad. Death generally occurs, but cases of recovery have been reported. The treatment consists of multiple incisions and continuous irrigations or early amputation. Lymphangitis. Infections may spread from the original focus and involve the lymph chan- nels, and an endolymphangitis or perilymphangitis be set up. It may further reach the lymph nodes and cause a Ijmiphadenitis. The consideration of this form of infection will be taken up in the article devoted to the Diseases of the Lymphatics. Local Infections of Granulating Wounds. There is a certain form of infection which attacks not only recent wounds, but also wounds which are already covered with healthy granulations. This disease is commonly known as hospital gangrene. The etiology as yet is uncer- tain. Numerous micro-organisms have been found, but no particular one has been isolated which is known to bring about the disease. The first manifesta- tions are a progressive infiltration and a coagulation necrosis of the granulations, the process spreading rapidly at the periphery of the ulcer and at the same time penetrating deeply into the tissues. The disease is further characterized by a gangrenous destruction of the inflamed tissue. The first symptoms are entirely local, and the disease spreads by attacking the contiguous tissues. Three forms have been described: (1) The croupous or diphtheritic; (2) the ulcerating; (3) the pulpous form. The first is characterized by the formation of a pseudo-membrane on the surface of the granulations, underneath which extensive necrosis and gangrene of the tissues rapidly develop. The surround- ing tissues are not much inflamed. The second form is characterized by a rap- idly spreading ulcer, with necrosis of the underlying tissues and a copious, foul- smelling discharge. The third form is the most virulent. There is a rapid puffing up or swelling of the tissues. Hemorrhages take place within the granu- lations, and they undergo a purulent necrosis, followed by gangrene and a separation of the entire mass. The surrounding tissues are markedly oedem- atous and inflamed, and the ulcerated surfaces are exquisitely tender. In all of these forms the process spreads rapidly, attacking and destroying every- thing in its path. The constitutional symptoms are marked, and present all the phenomena of a general systemic intoxication. The prognosis is grave. It naturally varies with the form of the disease, the pulpous form being the most fatal. In the Civil War in this country the mortal- ity was 45.6 per cent. INFECTIONS OF OCCASIONAL OCCURRENCE. 423 SEPTICEMIA. The term septic£emia is no longer accepted in tlie sense of its literal transla- tion, but nevertheless, on account of long usage and general acceptance, it is still so employed. It is not possible to define it pathologically, because its limits are not fixed. We accept it more as a word which is suitable for designating the degree or the severity of certain general intoxications and infections. Clinically we speak of an infection as local when the predominant symptoms are due to the local disturbance, the systemic manifestations appearing as secondary. In the case of an abscess which is confined, the surrounding walls exert a certain amount of pressure upon the contained pus, and resorption of the toxic ma- terials takes place. Frequently bacteria as well are found in the blood, and we practically have a septicaemia. When the abscess is opened and the tension is relieved, the general symptoms subside and the infection is then merely local. If, however, upon evacuation of the pus, the general symptoms continue and we have a systemic intoxication, we speak of it as a septicaemia or a general septic infection. Gussenbauer has defined septicaemia as a "general disease of the body, which results from the introduction into the circulation of the products of decomposi- tion, and which is characterized by definite changes in the blood, a typical suc- cession of inflammatory processes, and a continuous fever, together with peculiar nervous symptoms and critical discharges." The extensive researches of Ogsten, Rosenbach, Doyen, von Eiselsberg, and others have taught us that the general systemic disease known as septicaemia depends upon the introduction of patho- genic, especially pyogenic, micro-organisms into the general circulation. How- ever, there is another general intoxication, known as sapraemia, or septic intoxi- cation. This intoxication, which results from the absorption of the products of putrefaction, is so closely allied clinically to true septicaemia that it must be considered in connection with it. Sapraemia is a septic intoxication or toxjemia, due to the absorption of tox- ins formed by the bacteria of putrefaction. It should not be confounded with the so-called aseptic wound fever, which results from the absorption of the products of aseptic tissue necrosis, and which gives rise to a systemic intoxica- tion. In sapraemia we have a definite pathological lesion; that is, the infection of necrotic tissue with putrefactive bacteria. Among the most important of these micro-organisms may be mentioned the Proteus vulgaris. Locally, as a result of the putrefactive processes, certain ptomains are elaborated, which are absorbed and bring about a general septic intoxication. Symptoms and Diagnosis. — The symptoms which develop are those of a local putrefactive process combined with the constitutional symptoms of a ptomain poisoning which is gradually progressive, which acts as a depressant on the ner- vous system, and which gives rise to considerable fever. The local focus of in- 42i AMERICAN PRACTICE OF SURGERY. fection is generally unmistakable. Frequently the interior of the uterus is the seat of the disease. Following childbirth, there is an infection of the secund- ines retained within the uterus; the foul discharge and the febrile movement direct our attention to the condition, and the diagnosis is then easy. More fre- quently, large masses of gangrenous or sloughing tissue in a wound undergo putrefaction, and the foul odor of the putrefying tissues, as well as the visual picture, establishes the diagnosis. The constitutional symptoms are seldom initiated by an actual chill, but more frequently the patient complains of a head- ache, loss of appetite and general malaise. While there may not be an actual chill there is usually a sensation of chilliness. At first the body temperature rises to 99.5° or 100° F. The following morning it may again be normal. On the afternoon of the second day the temperature becomes higher, and we have a DISEASE 1 2 3 4 5 6 7 8 9 10 11 12 .... P.„. ,.M. P.„. ..„. ..„. ..„, P.„. ..„. P.M. ..„. P.„. ..„. P.„. ..„. P.M. ».M. p... ..M. p.„. ,.„. P.M. .... P.„. 107° 10G° lOo' 'S 104° I 5 103° f 102° £ 101° ^ 100 99° 98° 97° A / 'N s^ A A / / \, / ^ V A ■n /^ S, / V N ^ s/ ^ \/ Fig. 129. — Temperature Curve of a Case of a Mild Grade of Saprajmia. continuous fever with slight remissions, its severity being directly. proportionate to the extent of the local putrefactive process. If the diseased tissue is not re- moved, the headache becomes more intense, the body temperature rises, vomiting and diarrhoea occur. An examination of the blood will show degenerative changes : in the more severe cases poikylocytosis and diminution in the number of red blood cells, and a moderate leucocytosis. The pulse, at first soft and compress- ible, becomes rapid and weak. The tongue is furred and dry. The urine is scanty. Gradually the poison overcomes the nervous system, delirium follows restlessness, and coma develops. Mictm'ition and defecation become involun- tary. The pupils become dilated, the patient is covered with a cold, clammy perspiration, the pulse becomes irregular and feeble, and death occurs. In some INFECTIONS OF OCCASIONAL OCCURRENCE. 425 cases the disease is marked by intense gastro-intestinal symptoms. The vomit- ing and purgmg may be so severe that the case may simulate cholera. In the milder cases, in which the amount of tissue acted upon by the saprophytes is small, the disease soon rmis its course and subsides. Prognosis. — In uncomplicated cases the prognosis is good, because the dis- ease is easily recognized, and prompt treatment is usually followed by a rapid subsidence of the symptoms. The great danger lies in the possibility of second- ary infection, which, when it occurs, generally gives rise to a severe form of sep- tic infection. Treatment. — Prophylactic measures in this condition are of paramoimt im- portance; they comprise the removal, wherever possible, of all necrotic tissue which is liable to undergo putrefaction, or, if this be not possible, the steriliza- tion (through chemical means) of the necrotic tissue and the prevention of in- fection. When the disease is established, prompt measures must be taken to remove all of the infected material and to prevent a reaccumulation. The gen- eral systemic treatment will be discussed under the treatment of septicajmia in general. Septicsemia. — Under this head we will consider that septic infection of the entire body which is brought about by various kinds of bacteria, and which gives rise to the symptoms of a constitutional intoxication without the clinical signs of metastases. This includes the various forms of septiesemia designated as toxaemia, toxintemia, pyotoxinsemia, bacteritemia, and pyosepticsemia. Etiology. — What has been said concerning the relation of bacteria to the sup- purative inflammations is also applicable to septicaemia. There is no specific micro-organism. Unquestionably the staphylococci and the streptococci play the most important role. We may have more than one variety of bacteria pres- ent in the same case, as in double infection, or we may have a secondary infec- tion. It is still doubtful whether the bacteria which gain entrance to the general circulation increase and produce their toxins in the blood. Brunner holds that an acute mycosis never is met with in the human blood, and he believes that there never occurs any marked growth of bacteria in the blood. He further maintains that the micro-organisms are prone to collect in the parenchymatous organs, and that, in the acute cases, they set up metastatic processes, which, however, remain microscopically small, the duration of the disease being too short to develop macroscopic foci or to manifest itself by any clinical evidence. The majority of investigators believe, however, that the bacteria, after gain- ing entrance to the blood, increase and elaborate their poisons in the blood, and then, independently of any other suppiu-ative foci, may cause death. In certain severe local infections it has already been noted that the staphylo- cocci and streptococci produce very poisonous toxoproteins and toxalbumins, and that these poisons may be reabsorbed and give rise to septicaemia. It has also been shown that in such cases numerous micro-organisms reach the circu- 426 AMERICAN PRACTICE OF SLTRGERY. lation, but the action of the reabsorbed toxins is so rapid and severe that they produce the symptoms of the disease before the micro-organisms have had time to increase and become active. This form of sepsis is called toxincemia. In other cases the bacteria themselves rapidly reach the circulation, and there increase and produce toxins, and we have a hactericemia. The question naturally arises. How do the toxins and the bacteria gain en- trance to the blood? In the rapidly fatal cases it seems most probable that they pass directly into the lymph spaces and are in this manner thrown into the gen- eral circulation. In other cases, again, they must first penetrate the granulation tissue, and, passing along the main lymph channels and overcoming the re- sistance of the lymph nodes, enter the blood. Symptoms. — The different forms of septicsemia differ so widely in their clin- ical manifestations that it will be best first to consider the symptoms in general, and then to present some of the more important types of the disease. The symptom to which our attention is first called in septicsemia is fever. In general, it shows itself at first as a moderately high, continuous fever. The morning and evening temperatures, as a rule, vary but little. Sometimes, but not always, the fever is ushered in by a chill or a feeling of chilliness. In a pure septicemia repeated chills seldom occur. In the more severe types of the disease, especially when due to a mixed infection and when there is present a large amount of necrotic and purulent material in the wound, the body temperature is high. In other cases the temperature may be low and even subnormal, and this is always an unfavorable sign, especially when accompanied by a rapid and feeble pulse. When convalescence is established the body temperature gradually sinks to normal. The pulse is a much more important criterion of the patient's condition than the temperature. At first, in the milder forms, the heart's action is not especially accelerated, but as the disease progresses the arterial tension is lowered and the pulse becomes rapid and feeble. In the most virulent forms the heart's action quickly loses in power, and many circulatory disturbances make their appearance. The nervous system is very soon affected by the toxins. At first the patient may complain of headache and a feeling of general discomfort or pain in the wound, but this soon gives way to apathy and lack of interest in his condition and his surroundings. This state may alternate with restlessness, but grad- ually stupor comes on, and in the fatal cases coma and death follow. Delirium does not generally occur. A great change takes place in the patient's general condition. There is pro- found prostration. The surface of the body, at first dry and hot, later is bathed in perspiration, the skin feeling cold and cadaveric. The patient loses weight rap- idly. The expression is listless, the face being drawn and colorless ; the eyes are sunken, and the ale nasi dilated. The tongue at first is thickly coated, and later becomes covered with dry, hard crusts. INFECTIONS OF OCCASIONAL OCCURRENCE. 427 Almost always the patients suffer from severe gastro-intestinal symptoms. At first, there is loss of appetite and the thirst increases. Nausea and vomiting are frequently observed, and diarrhoea is the rule. In the more severe cases there may be active vomiting and purging, as in cholera. di^eaTe 9 10 11 13 13 14 15 16 17 EVACUATIONS 8 3 8 5 1 6 3 8 ? A.„. .... A.„. P.M. ..„. «. ..»..„. A... «. ..„. ..„. A.„. p.„. A.„. P.. ,.„. P.„. ..M. 10T° 100° 105° E 104° I t 103° ^ 103° < 5 101° fi 100 99° 98° 97° - A r- -\ A / /^ / [ \ ^ / / A / ^ V / ' V / \ \ \ H 140 130 130 110 HI ^ 100 90 80 TO 60 / /\ A / A 1 '\ S 1 A s ^ / / ' V / V \ / \l V \ / \ Fig. 130. — Typical Temperature and Pulse Chart of Second Week of Septicaemia. Note rapidity of pulse and frequent evacuations of bowels. The skin often shows a yellowish tinge, and a variety of eruptions may appear. The urine shows albumin and casts. If the disease responds to treatment, a general improvement of the sensorium is first noted; the pulse becomes a little stronger, although still rapid; the body temperature gradually subsides, often showing at first marked morning remissions, until finally the evening rise disappears; the desire for food grad- ually returns ; the heart is the last entirely to recover its normal condition. 428 AMERICAN PRACTICE OF SURGERY. As has been already stated, we recognize clinically several different types of septicemia. Type I. The patient has suffered a compound fracture of one of the long bones. A few days later the signs of infection develop in the wound. Local treatment does not dimin sh the inflammation, and active suppuration takes place. This rapidly spreads and the lymph channels become involved, and all the symptoms of a severe general septic intoxication develop. There is no attempt at healing in the wound. The body temperature has become continuously high and the pulse increasingly rapid. As the disease progresses the patient becomes apathetic. Vomiting occurs. There are four or five loose diarrhoeal movements of the bowels. Examination of the blood may demonstrate the presence of pyogenic bacteria. Prompt and extensive local incisions and antiseptic applica- tions may check the further advance of the disease. The constitutional symp- toms gradually disappear, convalescence is established, and the wound heals. Or the disease may be much longer in its course and not react so quickly to treatment. The following case will serve as an example : A young and healthy adult receives a gunshot wound of the shoulder. He is taken to the hospital and the wound is treated antiseptically. At first there are symptoms of shock, but these rapidly pass away and the temperature and pulse are normal. An examination of the wound shows the presence of dark fluid blood and serum, which are easily expressed from the cleanly cut opening of the bullet wound. Surrounding this opening there is more or less cedema- tous swelling of the parts. Pressure elicits pain. Second day : The general con- dition is satisfactory. The body temperature is 100° F. ; pulse, of good qual- ity and about 100 to the minute. Pain only on muscular motion. Third day: Patient feels ill, is very thirsty, and has no appetite. Evening temperature is 103°; pulse, 110. Some pain in shoulder, increased by motion. Fourth day: The dressings are changed ; they are found to be dry. The womid is covered with a dry, hasmato-fibrinous exudate; no pus; no symptoms of local infection. Evening temperature, 102.5°; pulse, 105. Tongue coated and moist. Fifth day: Sleeps poorly. Great pain in shoulder, increasing thirst. Evening temperature, 103.6°; pulse, 120 and of good quality. Sixth day: Morning temperature, 102° ; pulse, 110. The pain in the shoulder has increased. The tongue is dry and coated. The patient is restless. On inspection the wound shows the entrance point closed by a dry, hard crust. The surrounding tissues, however, are swollen for some distance from the wound, moderately hypertemic, and very painful to pressure. It is possible to express some pus from the wound. Immediately the region is incised and the entire course of the bullet is laid open. Considerable purulent exudate is discovered, and one or two small abscesses are opened. The tissues are discolored, oedematous, and infiltrated. Some bone destruction is found. The purulent exudate is seen to issue from fissures in the surrounding INFECTIONS OF OCCASIONAL OCCURRENCE. 429 tissue. Some bone splinters, possiblj' a piece of clothing, and the bullet are removed. The wound is treated antiseptically and drained. Seventh day: General condition somewhat improved, less pain. Evening temperature, 102°; pulse, 110 and of good quality. During the next five days the purulent exudate in the wound becomes progressively less. Granulations begin to appear. The morning and evening temperatures are lower. On the following day, however, the patient complains again of severe pain in the shoulder. Evening tempera- oiSeAM 10 11 r-i 13 14 15 10 1? 18 19 20 21 33 24 1 A.M. P.M A.M P.M A.M. P.M A.M. P.M A.M. P.M A.M. P.M A.M. P.M A.M. P.M. A.M P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. P.M. P.M. 107° 106° 105° |104° < tl03° ^102° < Sioi° s JiilDO" 99° . 93° 9T° Z Is S „ s 1 13 s > s A \ / K h s / A /\ / \ v_ J \ A 1 \ / V V /^ \ /N \ k A. J V \ 1 A / V '^ V V V \ h V k s/ 1 V V 140 130 120 110 Ul J 100 "■ 90 80 CO /" s/ /\ \. - — . A A s ^ A s/ / /^ K V A \ / /^ \ / / V \ y Fig. 131. -^Temperature and Pulse Curves of a Case of PyosepticEemia. Formation of multiple pus-containing cavities wliich spread rapidly. In some places extensive areas of necrotic, foul-smelling tissue were found ; also gas abscesses. Multiple and repeated incisions. ture jumps up to 103°; pulse, 120. Considerable prostration. Patient listless. Exploration of the wound does not demonstrate any new pus foci ; simply dis- colored, oedematous, infiltrated tissues. Despite wide incisions, the evening temperature reaches 103.5°; pulse, 130 and irregular. Energetic surgical treat- ment fails to produce any change for the better in the patient's condition. The average evening temperature during the next week is about 102.5°, with morn- ing remissions to 99.5° or 100°; the pulse between 90 and 120. At the end of 430 AMERICAN PRACTICE OF SURGERY. the second week staphylococci are found in the blood and urine. At about the same time a retained collection of pus is found in the wound. There is no odor of decomposition or putrefaction. Occasionally the body temperature shoots up to 103° or even 104°, the pulse to 120. At the end of three weeks the temperature remains the same, but the pulse, on the slightest exertion, runs up to 150 and becomes quite irregular. Small necrotic areas are found burrowing outward from the womid. Multiple incisions are made. Still the teinperature remains high, now being almost continuously above 103° and reaching as high as 104.5°. Pulse, 140 to 150, and of very poor quality. Patient sleeping most of the time. Delirious at times. Repeated blood cultures show the presence of the Staphy- lococcus pyogenes in the blood. All of this time the wound has been most energetically treated, and the most advanced therapeutic measures have been used to sustain the strength of the patient and overcome the poisons of the disease. Finally, at the end of the fourth or fifth week, the wound begins to look healthier. The temperature does not rise so high in the evening and the pulse is more regular. Gradually the constitutional symptoms abate, the local con- ditions improve, and at the end of the eighth or ninth week the temperature remains normal. The pulse is still rapid, 110 to 120, but it gradually returns to normal. Into this class of septicaemia fall those cases in which there is no mixed infec- tion and where the symptoms are due more to the toxins and ferments of the bacteria themselves than to the added resorption of the products of decom- position. Of course necrosis always occurs in such cases, but it is not by any means a prominent symptom. In this class of cases the onset often is gradual, but it may be sudden and severe. Many examples of these cases are seen in in- fections of the loiee-joint. The area of local tissue-necrosis is not great, but the bacteria and their toxins are rapidly reabsorbed and give rise to grave constitu- tional symptoms. Another example is seen in the so-called post-mortem infec- tions. Here there is seldom much tissue-necrosis, and often the local infection is so insignificant that it entirely escapes the notice of the surgeon. The develop- ment of the general infection, or bacteritemia, is rapid and severe, and the disease often proves fatal in a remarkably short time. The prognosis in this type of cases depends upon the early recognition of the primary focus of infection and upon the thoroughness and promptness with which the antiseptic treatment is carried out. Even after the bacteria have reached the general circulation, if the local focus of infection can be entirely eradicated, the chances are that the bacterisemia will rapidly disappear Type II. This type comprises those cases which are known as cryptogenetic septiccpmia. In the one set of cases there is a history of injury. A simple fracture, a con- tused wound or hematoma without external wound, or a crushing injury of a INFECTIONS OF OCCASIONAL OCCURRENCE. 431 bone are among the most common examples. Following these injuries are the usual signs of traumatic inflammation. This inflammation does not undergo resolution, but very soon gives rise to a decided febrile movement, which may be initiated by a chill or sensation of chilliness. All the local signs of a suppura- tive inflammation appear. The constitutional symptoms increase and a septi- ca3mia develops. In the other set of cases there is no history of any wound or injury, and with- out known cause the patients gradually or suddenly develop the symptoms of a general septic infection. The course may be acute, subacute, or chronic, but as a rule the s5aiiptoms of multiple pus foci develop, and we have a transition into pyaemia. The etiology of these conditions has already been discussed in the article on Inflammation. Type III. To this type belong the cases of septicsemia due to a mixed infection. Under this division of septicaemia we have to deal with a condition whose manifestations vary according to the local pathological conditions. It is brought about by a number of different micro-organisms working together, a poly-infec- tion, causing extensive local necrosis and decomposition, as well as a general infection of the system. Often streptococci, the Bacillus coli communis, the Proteus vulgaris, and the Bacillus pyocyaneus are associated together in such a process. The symptoms naturally vary, but an example, taken from actual ex- perience, may best be used to illustrate the condition. The patient has received some injury to the spine, and as a result a chronic myelitis has been set up. Despite careful and constant attention, the patient's condition grows worse and a number of bed-sores develop. One or more of them grow larger and become infected. The skin is undermined and a collection of foul-smelling pus is evacuated. The patient has developed a high fever, with all the symptoms of a general septic intoxication. A large fluctuating abscess forms on the thigh and spreads rapidly to the knee. When it is opened, a large quantity of foul, gas-containing pus escapes. Large masses of necrotic tissue are seen everywhere. There is no appearance of healthy granulation tissue. An exam- ination of the urine shows Bacterium coli. The blood shows a pure culture of Proteus vulgaris. The evacuated pus contains cultures of Bacterium coli, Pro- teus vulgaris, and streptococci. These agents working together rapidly over- come the patient, who dies in coma. The symptoms, then, are those of an extensive local necrosis combined with the symptoms of a general septic infection. The body temperature is generally high, but very irregular and remittent in type. The pulse rate is high and the nervous system is markedly involved. The blood changes are not constant, and it is not always possible to demonstrate bacteria in the blood. As a rule, meta- 432 A^IERICAN PRACTICE OF SIT^GERY. static foci do not develop. Tlie s3'mptoms are due more to absorption from the local necrotic focus than to the bacterisemia. The prognosis is almost always bad in these cases. Prophylactic treatment is most important, while extensive incisions and strenuous antiseptic applica- tions are called for when the process is established. During the course of any of the various types of septicemia which have just been described, the symptoms of metastatic pus foci may develop and the symp- toms of pygemia will then be added to those of the existing septictemia. Pathological Anatomy. — In the most acute and severe forms of septicsemia the process is so rapid that few gross pathological lesions maj^ be demonstrated. In such cases there are no special changes in the original wound. In the less severely acute cases, due to the action of pyogenic micro-parasites, the edges of the original wound first show inflammator}^ redness and become puffed up and swollen. If the wound is an open one the granulations look unhealthy and the wounded sm-faces are covered with a fibrmous exudate. In these cases a foul, necrotic odor is usually absent. There are manj- exceptions to this rule, and cases are seen in which, within a few hours of the accident, the wound secretion is most foul. These cases are the most virulent we have to deal with, and generally terminate fatally within a few days. The common pus of a suppurat- ing wound is odorless, and the presence of a necrotic odor generally signifies the presence of bacteria other than the staphylococcus and streptococcus. The local infection may be represented by a fairly large and extending area of putrefying or gangrenous tissue, or by an extensive septic phlegmon. The primary focus may be a carbuncle, an otitis media, an osteomyelitis, a pneimionia, or anj^ sup- purative process. The l}'mphatics are frequently involved, and varj^ing degrees of IjTnphangitis and IjTnphadenitis are observed. In the more severe cases there is a rapid development of a severe angemia . The bacteria and their toxins are present in the blood. The red blood cells are diminished in nmnber and show degenerative changes. Leucoq/tosis is variable. In the severe and rapidlj^ fatal cases there is little if any leucocytosis. In the chronic cases it is moderate, but in the subacute cases the leucocytosis is sometimes marked. The phenomena of thrombosis and embolism are not present. After death decomposition sets in rapidly. The blood is dark, does not coag- ulate well, and cjuickly decomposes. The most constant changes are seen in the gastro-intestinal tract. Small ecchymotic spots may be seen, especially in the mucous membrane of the stomach, duodenum, and rectimi. There is a marked gastro-intestinal inflammation, varying in degree with the severitj^ of the toxin- Eemia. The solitary follicles and Pej^er's patches are swollen, and they some- times break do^Mi and form ulcers. If the intestinal changes are severe the serous covering of the intestines may share in the process and give rise to a cloudy or sero-sanguineous exudate, which collects in the peritoneal cavitJ^ Tlie patholog- ical findings in the heart and limgs are variable. There may be small effusions INFECTIONS OF OCCASIONAL OCCURRENCE. 433 in the pericardial and pleural cavities. In such cases the effusion is apt to be cloudy. Small ecchymotic spots may be noted on the pericardium, endocardium, and pleura. QEdema of the lungs and hypostatic pneumonia frequentlj^ precede death. The spleen is almost constantly enlarged. Few changes are noted in the liver, aside from the so-called cloudy swelling. According to Hildebrand, there occur on the surface of the kidney small areas of hypera^mia, which he attributes to the heaping up of micro-parasites in the afferent vessels and within the capil- laries of the glomeruli. There are present cloudy swelling of the kidney and a ca- tarrhal inflammation of the urinary tract. The nervous system shov.'s few changes. PY.^MIA. P}^a?mia is a general infective disease of the body, characterized by a constitu- tional intoxication in which the signs and symptoms of metastases break in upon the general symptoms. It is not possible to differentiate etiologically between septicEemia and pytemia. As a result of the most extensive experiments by many investigators, it has been discovered that the same micro-organisms ma}' give rise to both conditions; and, further, that at one stage of the disease a patient may present all of the classical symptoms of septictemia, and then suddenly, without any added etiological factor, the clinical signs and symptoms of a metastatic focus develop and a transition to pycemia takes place. The presence of the pus-producing microbes is essential to the development of pya?mia. The old theory, as advanced by Piorry, that the disease is always produced by the entrance of pus into the blood, has been exploded. It is true that when infected pus escapes into the general circulation pyaemia generally results, but in the majority of cases it is not due to such a cause. A primary focus of suppuration is the rule in pyaemia, but, just as is the case in septicajmia, this primary focus is not always demonstrable. From this primary focus the pyogenic microbes gain access to the circulation, and first bring about a general septicaemia. The microbes carried by the circulation may lodge in the paren- chymatous organs and there bring about a secondary inflammatory process ; sup- puration then occurs, and a metastatic abscess develops. Or the condition may be brought about in a different way; that is, through the medium of a thrombus. If the primary suppurative process is in the immediate neighborhood of a large vein, the walls of the vein are apt to become involved. An inflammatory proc- ess develops in tlie perivascular spaces, and a round-celled infiltration of the ad- ventitia and media occurs. The intima becomes swollen, a proliferation of endo- thelium occurs, and fibrin is deposited on it. This becomes the nucleus of a coagulum. Finally, the vein becomes occluded by an extension of this coagulum, and a thrombophlebitis is established. This process extends for a variable dis- tance along the vein. From this thrombus small bits may l^e broken off, and, entering the general circulation as emboli, find lodgment in the various organs, plugging the smaller vessels and in this waj^ producing infarcts. These in VOL. I.— ?8 434 AMERICAN PRACTICE OF SURGERY. turn may tiecome infected by the bacteria in tlie circulating blood, thus givmg rise to metastatic pus foci. Again, in the primary focus the microbes may invade the thrombus and bring about purulent softening of the mass. Portions of the thrombus break down and small particles, emboli, laden with bacteria, mix with the blood stream and pass through the heart into the lungs. The heart it- self does not always escape, and a suppurative pericarditis or ulcerative endo- carditis may be set up. The heart muscle itself is seldom invaded. In this way metastatic abscesses may be set up in almost every part of the body. In the lung a metastatic abscess generally is preceded by the formation of an infarct, due to the plugging of a terminal artery. If the artery— in some other .part of the body, for example — is not a terminal artery, the infected embolus gives rise to an endarteritis and a localized abscess. Many experiments have been tried to ascertain the probability of pus, when injected into the general circulation, giving rise to metastatic abscesses, and as a result of these experiments it has been discovered that only under certain con- ditions do metastatic abscesses develop. Only when large quantities of unfil- tered necrotic stringy pus— i.e., masses which acted virtually as emboli— were repeatedly injected did the metastatic foci develop. It can easily be understood that such conditions as these seldom occur in pyemia in man. It seems much more probable that the bacteria circulating in the blood may become agglutin- ated into clumps, a number of these clumps coalescing and forming a plug, which stops up the small capillaries, and thus gives rise to a metastatic focus. This would explain many of the metastases which are found in the kidney, liver, muscles, etc. There are certain conditions which predispose to the development of pyaemia. The disease seems to be more prevalent in overcrowded hospital wards, and in cities which contain many wounded soldiers, and, in general, in unsanitary lo- calities. The anatomical structure of certain tissues predisposes to the disease, and suppurative inflammation of these tissues has long been looked upon as liable to develop into pyaemia. This is especially true of severe woimds of the bones of the skull and extremities, of wounds of the joints and of tendon sheaths, and of traumatic amputation wounds of the arms and legs; it is also true of wounds which involve the large veins. Sym-ptoms and Diagnosis. — As has been already stated, pyaemia may develop at any time in the course of a septicaemia, but in such cases the number of meta- static foci is generally limited and the appearance of the symptoms of new pus foci is simply incidental and does not in general alter the s3Tiiptoms of the exist- ing septicaemia. It is proposed here to describe a condition which is character- ized by a somewhat different train of symptoms, presenting a distinctly different clinical picture. As a rule, pyaemia develops durmg the period of suppuration in the wound. It may, however, develop before the local suppuration has taken place, owing to INFECTIONS OF OCCASIONAL OCCURRENCE. 435 a direct infection of the blood, or in the course of a chronic inflammation. The latter, however, is exceptional. There may be certain premonitory symptoms in the woimd, such as its general appearance, a change in the character of its secretion, or the development of an extensive thrombo-phlebitis. The general system shows only a slight degree of intoxication at first, with some loss of appe- tite, general malaise, and a moderate fever. The disease itself first makes itself manifest by the occurrence of a severe chill. This is the rule, but there are OA,.f 3 4 5 G 7 8 9 10 11 12 13 14 15 10 17 =vlcu4mKS 4 2 2 3 S 8 7 12 7 10 3 3 6 5 9 107= ^106' <10d = ^104° <103 = ^lor 100 = 99' 98' 9i = A.M.JP.M A.M-IP.M A.M. P.M A.M. P.M A-M.lp.M A.M P.Mi A.M.iP.M.A.M.'P.M A.M.; P.M A.M.: P.M A.M P.M A.M P.M A.M P.M A.M P.M A.M.Ip.M. 5 i 5 i 11 i i 1 1 /] A / \ •^ / \ / \ /■ / / \ / \ / V / / / ' / \ u / / V ; f 1 1 j V 1 V V I 1 1 1 1 1 1/ 1 1 1 : 1 i 1 r'n 1 1 1 1 f ■ lA / 1 ! i i A 160 1 / 140° M1.30= °-130° 110° 100° 90° 80° 70° 60° j ' A l\ / \\ \ A A / / W / \ i J \ A V \ V \ / I / vi A A J V V. _/ / . / \/ V V ! 'i i ! { 1 1 < 1 1 -i ! i '"1 1 ! Fig. 132. — Tj-pical Temperature Chart of a Case of Pytpmia. Primary focus in pelvis; meta- static foci in lung. Stapkylococcus pyogenes demonstrated in the blood. The case was accompanied by marked gastro-intestinal sj'mptoms. many exceptions to it. The most characteristic symptom is the irregular course of the temperature, which rapidly changes from the highest point to the lowest point in a few hom-s. The relation of the chills to the course of the temperature is not always constant. Sometimes the chill is entirely absent, but even in these cases the temperature still shows the marked excursions which are so charac- teristic. As a rule, the initial chill is accompanied by a rapid rise in tempera- 436 AMERICAN PRACTICE OF SURGERY. ture, ]3ut in those cases in Avhich a septic temperature already exists this rise is not so marlced. The chill and rise in temperature maj^ be repeated at irregular intervals during the da}^ or night, or may recur regularly every day or every other day, thus simulating malaria. In the more acute cases the chill is repeated three or four times in a single da3^ Following the initial chill the temperature ma}' gradually drop to normal and so remain for several daj^s, to be again inter- rupted by the occurrence of a chill. The course of the temperature is usually very irregular, and is intermittent or remittent in type. No two cases are alike, and in fact the daily temperature in the same case varies from hour to hour. Some cases will show for a few /lays a regular morning remission, but on the following day there will be a sharp morn- ing rise to 104° F. or higher; or, during the course of the night there may be a chill and a sudden rise of temperature to 105° or over, followed in a few hours by a drop to a subnormal temperature. These wide excursions of temperature are especially characteristic of pyfemia. In exceptional cases there is a regularly remittent type of fever, which is only disturbed by the occurrence of chills. That a chill alwa}'-s means the establishment of a new metastatic focus has not laeen clearly proven, but it is held by the majority of writers to be the most probalale explanation of the phenomenon. The pulse at first is strong and full, and usually varies with the temperature, dropping even to normal. Later in the disease, it becomes rapid and weak, and does not show as great excursions as the temperature. The general condition of the patient varies with the severity and the stage of the disease. The marked apathy and prostration seen in septictemia are alj- sent. The patient is painfully conscious of the severity of his disease, and shows anxiety as to his condition. Gradually he becomes weaker, and the effect of the toxins upon the brain may become more e^'ident. Delirium may develop. Nau- sea and vomiting sometimes accompany the hyperpyrexia, and diarrhoea often occurs late in the disease. The tongue becomes dry and swollen, and the Isreath is foul. An especially characteristic feature of the disease is the yellowish dis- coloration of the skin, which may be due either to a destruction of the "red blood corpuscles and a consequent deposit of pigment in the skin, a hemorrhagic icterus, or to inflammatory changes in the liver itself. The urine shows the usual changes due to an infective disease. Of greatest importance, and a most characteristic feature of the disease, are the clinical symptoms of the development of metastases in the various organs and tissues of the body. In the acute and severe cases the lungs are the organs most frequently the seat of these metastatic abscesses. However, these foci may remain so small that they do not give rise to prominent symptoms, and, as is especially true in the chronic cases, the muscles, joints, and subcutaneous tis- sues often show metastatic foci before the lungs appear to be invoh-ed. It is probably true that in every case of pytemia infarcts occur in one or more of the INFECTIONS OF OCCASIONAL OCCURRENCE. 437 internal organs. These may, however, remam microscopically small and not give rise to symptoms. In the severe forms the number of infarcts is generally large. In the chronic forms the number of secondary foci is generally small. When the lung becomes the seat of a metastatic process, the first symptoms are an increase in the frequency of respiration and some dyspnoea. If the focus is situated in the substance of the lung it gives rise to the symptoms of a lobular pneumonia, which rapidly resolves itself into an abscess. If it is in the neighbor- hood of a bronchus, it may rupture into it and empty itself through the mouth, or it may rupture into the pleural cavity and give rise to the symptoms and se- quelte of a purulent pleuritis, empyema, or pyopneumothorax. More frequently, the metastasis takes place as an infarct immediately beneath the pleura, and a subpleural abscess results. The prognosis in these cases is bad. The diagnosis of liver metastases is much more difficult. The occurrence of icterus does not necessarily point to an involvement of the liver. If the abscesses, which necessarily are small at first, are deeply seated, a diagnosis is often impos- sible. Only when the abscesses are situated near the anterior surface of the liver is it possible to diagnose them wdth certainty. Abscess and infarcts of the spleen and kidney are of less freciuent occurrence, and a metastatic abscess of the brain is only exceptionally seen. The diagnosis of metastatic foci in the muscles, glands, and connective tissue is much easier. But even here the onset is often insidious, and the abscess may not be discovered until it is well advanced. Generally, however, the usual symptoms of a suppurative inflammation are apparent, and the diagnosis is established. Freciuently the joints and bones become involved and give rise to characteristic symptoms. In all of these secondary foci pyogenic microbes are found. The course of the disease may be acute or chronic. In the acute cases the initial chill occurs early in the disease and is frecjuently repeated. The body temperature is very irregular, showing a characteristic curve, dropping at times from above 105° to below 96° F. The patient rapidly loses flesh and strength, and the skin reflects the profound changes in the blood. Grawitz reports a case in which after two days the red blood cells were reduced to 300,000 per cubic millimetre. The pulse becomes rapid and feeble, ranging from 110 to 160 per minute. The tongue is dry. The symptoms of metastases develop, but the abscesses do not reach any considerable size. The stools become frequent and are often blood-stained. Delirimii develops and is followed by coma, and death takes place from heart failure, or suddenly from pulmonary embolism, often with a subnormal temperature. The chronic cases may last for weeks, or even months. This may best be illustrated by an actual case which occurred in the Methodist Episcopal Hos- pital in Brooklyn.* Patient, a few days previously, had suffered from an attack of follicular ton- * Spence: Brooklyn Med. Jour., June, 1904. 438 AMERICAN PRACTICE OF SURGERY. sillitis. ^^'^len first seen she complained of headache, general abdominal pain, and fever. Temperature, 103.6° F. Abdomen someAvhat distended and tender. Leucocj'tes, 9,400. Widal test negative. Second clay, slight epistaxis, vomiting, and chill_v sensations. Fourth clay, slie had a distinct chill and complained of ten- derness of the left forearm. Leucocytes, 9,000. Diazo reaction positive. Tem- perature irregular and ranging from 97.4° to 105.6°. Ever_y day there were chills and profuse, clammy perspiration. General condition steadily growing worse. Slight tenderness on forearm continued, and on the seventeenth day indistinct fluctuation was elicited. An incision was made, and pus was found, dissecting its way between the flexor muscles. The pus showed a pure culture of Strep- tococcus pyogenes. On the nineteenth day a small collection of pus was discov- ered above the right scapula. This was evacuated. Both wounds did well. The chills and fever continued, however, and there was no change in the irregular up- and-down course of the temperature. The patient became greatl}' emaciated, but her mental condition remained fair, and her appetite for the most of the time was excellent. A slight sys- tolic murmur was heard at the base of the heart, but disappeared after a few days. At the end of the fourth week the patient complained of pain in the right shoulder, and there was some tenderness on motion and when pressure was made over the joint. The temperature still continued its irregular course. During the sixth iceek she became restless and delirious at night. The pain in the shoulder continued with varying severity, and at the end of the eighth iceek the shoulder region became slightly swollen. An incision was made into the joint and pus was evacuated. A gradual improvement immediately followed. The temperature became lower, l3ut did not remain normal until the fifteenth week of the disease. At times there were points of tenderness over the upper and lower extremi- ities and on the chest. There was no redness and A'ery little swelling at those places where pus was found. Albumin and casts were present in the urine, but disappeared with the other symptoms. The wound healed slowly and motion of the joint was gradually obtained. This is a very fair example of a class of cases which we occasionally see — cases that run a chronic course with acute exacerbations and terminate in re- covery. The prognosis of pyaemia is almost always bad. In the acute cases all forms of treatment seem to be unavailing, and the patient dies in from one to three weeks. In the chronic cases the prognosis is somewhat better, but even here there are few instances of recovery, and then only after a long, protracted ill- ness. When the metastatic abscesses involve the viscera the disease almost always proves fatal. INFECTIONS OF OCCASIONAL OCCURRENCE. 439 Septico-pycemia. — "\'on Leube has described a special form of septic infec- tion under this title, and although, from a bacteriological standpoint, it is caused by the same micro-organisms which give rise to septiciemia and pysmia, still it should be clinically differentiated from them. The patient generally, without any known suppurative focus, gradually or suddenly develops a general septic infection, which is characterized by an irregular fever, a disproportionately high pulse frequence, great emaciation, marked nervous manifestations, and special symptoms referable to the various organs in which the septic poisons become localized. The fever often resembles that of a fluctuating typhoid, but may be continuously high. Chills are frequent. The heart is early affected, and in cer- tain cases an inflammation of the endocardium is the first symptom of the disease. Von Leube believes that the so-called malignant endocarditis is only one of the manifestations of this disease. Inflammation of the joints and serous membranes is a prominent feature and of frequent occurrence. Symp- toms referable to the nervous sj'stem, such as headache, vertigo, sleeplessness, delirium, convulsions, and temporar}^ paralysis, are quite constant. Icterus is only occasionally seen. The kidne}^ is markedly affected. Changes in the skin are almost constant. Roseola, erythema-like urticaria, purpuric spots, hemor- rhagic pemphigus, blisters, pustules, herpes, etc., develop. Metastatic pus foci may occur anywhere. The disease runs an acute or subacute course, and almost without exception terminates fatall}'. Pathological Anatomy.— The pathological changes which are found in individ- uals who have died from pj^semia are not always constant, but in general they are characteristic of the disease. The primary focus of suppuration may be entirel}^ healed, but usually in the acute cases this is not the case, and we find e\'idences of a gangrenous or necrotic wound in the neighborhood of which the veins are inflamed and thrombosed. In the chronic cases, especially those of cryptoge- netic origin, there are evidences of multiple abscesses. The heart seldom escapes entirel}^ and frequently a purulent pericarditis, an ulcerative endocarditis, or chronic changes in the valves, are found. The most constant changes are found in the lungs. They are, for the most part, due to the lodgment of emboli in the cortex of the lung, most frequently in the lower lobes. These emboli plug the terminal arteries and produce wedge- shaped infarcts. The embolus either contains pyogenic micro-organisms or becomes secondarily infected and a thrombus is formed. A septic endarteritis is set up, which in turn infects the infarct, and a circumscribed abscess results, which lies directly beneath the pleura and maj' give rise to a pleuritis, empyema, pyopneumothorax, etc. However, such is not generally the case, the abscess remaining localized. Other inflammatory foci may also be established in the lung independently of emboli, and lobular pneumonia then results. The liver is frequently the seat of metastatic abscesses. They ^'ary in size from microscopic accumulations of pus cells to an abscess which may destroy an 440 AilERICAN PRACTICE OF SURGERY. entire lobe. Usually they are not due to emboli, but to an accumulation of micro-parasites in the smallest capillaries. The infection may spread to the por- tal vein and cause there a thrombophlebitis. The kidney is occasionally the seat of metastatic abscesses, but more fre- quently there will be found a catarrhal inflammation and cloudy swelling. The spleen is usually enlarged and soft. Brain abscesses are not frequent, but may occur together with a purulent meningitis. In the jonits may be found all forms of suppuration, but generally not of a severe type. The knee, ankle, and shoul- der joints are the ones generally affectetl. The skin also may be the seat of some inflammatory disturbance, the severity of which varies from a mere erythema, which disappears in a few days, to a subcutaneous abscess. All or any of the other tissues and organs may be invaded. In the chronic forms of the disease various degenerative changes are seen. There may be amyloid degeneration of the liver, spleen, and kidney, fatty de- generation of the heart, and chronic changes in the valves. The lung shows the scars of many infarcts and abscesses. There is sometimes a chronic exudative pleuritis. A chronic enteritis is also apt to be present, and various atrophic changes are seen in the kidney. The patient is greatly reduced in weight. treat:\iext of septicemia and pyemia. The treatment of all the various forms of general septic infection resolves itself into an attack upon the pathogenic bacteria which give rise to the disease, in order to destroy them and limit their activity, and to remove from the sys- tem their toxins and the results of their action. There is no other surgical con- dition in which a careful prophylaxis plays so important a part as it does in this disease. Aseptic and antiseptic surgery are two distinctly different things. The for- mer has to do with the prevention of infection by excluding all bacteria from the wound. The latter deals more with the prevention of the growth of bacteria in a wound by the use of certain chemicals which kill or attenuate the micro-organ- isms. The primary prophylaxis of septicaemia and pytemia is included under the consideration of these subjects, and has to do with the preparation of the patient and the surgeon for the operation, the sterilization of the instruments, dressings, etc., and the treatment of wounds in general. The general hygiene of the patient and the sick-room, the prevention of infection in various surgical diseases and conditions, and the treatment of infected wounds will be discussed by other writers, and it is therefore not necessary that I should consider these subjects in detail in the present article. Many surgeons seem to overlook the importance of preventing secondary in- fection or a mixed infection in a wound. It is just as important, for the preven- tion of a general septictemia, to guard against a secondary infection in a wound INFECTIONS OF OCCASIONAL OCCURRENCE. 441 as it is to prevent primary infection in a clean wound. If the presence of infec- tion in a wound is discovered early enough and prompt measures are taken prop- erly to drain the wound and all the foci of suppuration, the chances are that gen- eral sepsis will never occur. In the presence of a surgical injury or any condition in which the vitality of a part is lowered, the most stringent aseptic measures must be adopted to prevent infection. Infections of necrotic or gangrenous areas are especially apt to spread rapidly and cause a general septictemia. In the treatment of compound fractures, extensive lacerated and contused wounds, and burns, asepsis should be carefully carried out. In the treatment of saprtemia the removal of the putrefying material and general stimulation are, in most cases, followed by recovery. When septicaemia has developed, an immediate inspection of the wound must be made ; indeed, it should be thoroughly explored. All pus foci must be evac- uated and liberal incisions made, in order to establish a free drainage of the woimd. The woimd should not be packed Avith antiseptic gauze, as is so often advocated, for this retards the evacuation of the wound secretion. Large drainage tubes should be used and the wound frequently irrigated. Wlierever possible, continuous irrigation is called for. When pyaemia has developed, the secondary foci must be sought for, and when abscesses form they should be opened, if possible, and treated in the same manner as the primary focus. Fochier observed that when active suppuration occurred in pyjemia and septi- caemia the general condition usually improved. He therefore tried experiment- ally the production of artificial supvuration in such cases. This may be done by injecting subcutaneously from 2 c.c. to 5 c.c. of rectified turpentine. There is thus created an abscess in which the pus is sterile. In six of the cases in which he tried this experiment the results were favorable : a general improvement oc- curred, and the temperature was lowered. Trials made by other surgeons have not, however, met with much success. There are a number of surgical conditions which specially call for early inter- ference. Suppurative osteomj'elitis should be treated early and radically. Cer- tain rapidly spreading infections of the extremities call for amputation as the only means of saving life. Klebs first suggested the ligature and removal of veins which contained in- fected thrombi, before the emboli should be broken off and set up metastatic foci. This procedure is especially applicable to thrombophlebitis of the sigmoid and lateral sinuses and jugular vein, arising from suppuration in the middle ear. The first step in the operation is the ligation and excision of a portion of the jugular vein. Then the sinuses may be exposed and the infected material thor- oughly removed. This procedure, as a prophylactic measure, has met with suc- cess in the hands of some surgeons, but it will limit the disease only when it is due to the lodgment of infected emboli. The same principle has been suggested and tried in cases of thrombophlebitis of the portal vein. 442 AMERICAN PRACTICE OF SURGERY. In the cases of septicemia arising from general peritonitis, the first indication is to clean out, as far as possible, the pus and serum accumulated in the peritoneal cavity. The second indication, of no less importance, is to clean out the intestinal tract and establish active peristalsis. The method originated by the writer in such cases is as follows : The first portion of small intestine which presents itself in the wound is taken and a purse-string suture is introduced. This suture should pass through the serous and muscular layers and should include an area the size of a ten-cent piece. An incision is made within this area and a small- sized glass catheter is introduced through it into the lumen, being retained in place by tying the suture. Gas and fecal material are allowed to escape. Then, througli the catheter, the intestine is thoroughly irrigated, as far as is possible, with hot saline solution. After this has laeen done, three ounces of magnesium sulphate is introduced through the catheter into the lower part of the intestine, and the end of the catheter closed. During the first twenty-four hours the intestine is irrigated every three or four hours. Magnesium sulphate is injected daily and the irrigations are continued as long and as frequently as indicated. In this way it is possible to establish active peristalsis and aid very materially in the elimination of the toxic materials from the system. The local treatment in puerperal septicocmia is a broad question and can be only briefly alluded to here. Where the infected process is localized in the uterus, the usual methods of treatment are curettage, hot intra-uterine irrigations, vaginal douches with antiseptic solutions, and the application of an ice bag. These measures, combined with the constitutional treatment to be described below, axe generally followed by a cure. When the process is not confined within the uterus, more drastic measures have been advocated. Tuffier* says "that in a given case of septica?mia, post-partum or post-abortum, when no cause for the fever can be found either in the external genitals or in other organs, when the usual methods of treatment are of no avail, when the peri- toneum and adnexa are intact, and the uterus is large, flabby, and is discharging fetid lochia, and if the patient's general condition warrants it, total extirpation of the uterus should be done, whether there be placental retention, a sloughing myoma, or the so-called metritis dissecans." Many surgeons, however, do not agree with this. The late Dr. Pryor advocated splitting the posterior lip of the cervix, thus providing for a more thorough drainage of the uterus, opening the cul-de-sac of Douglass, and packing it with iodoform gauze. He held that the iodine set free and absorbed by the tissues acted as a powerful local and general antiseptic. The same principle applies in all cases. Wherever possible, limit the local activity of the micro-organisms. General Treatment. — The first indication in the general treatment of the pa- tient is to foster and stimulate in every way the excretory organs of the body. * American GjTiKcologj', January, 1903. INFECTIONS OF OCCASIONAL OCCURRENCE. 443 The bowels should be made to act regularl}', and the rectum should be emptied by daily enemata, if necessary. Diaphoresis and diuresis should be stimulated. The general hygiene and nursing of the patient are of the utmost importance. The patient's body must be frequently bathed, and he should be given every opportunity to obtain fresh air and sunlight. The nourishment of the patient is important. Small quantities of food given at frequent intervals will be best borne by the stomach. If the patient refuses food or cannot retain it, rectal enemata must be given. The rectum should be gently washed out, and then an enema containing peptonized milk, peptonized eggs, and whiskey (not exceeding four or fi.ve ounces in amount), should be given ever}^ four hours. Drugs. — In general, drugs given to affect the course of the disease are not of much avail. Some physicians believe that calx sulphurata, given in ten-grain doses every three hours, will retard pus formation. Alcohol is the one drug which seems to have a beneficial effect in septic conditions. The patients stand it well, and it should be given in small doses frequently repeated. Symptomat- ically, a number of drugs are called for. Heart stimulants, such as tincture of digitalis, caffeine, and strophanthus, are often indicated, as well as drugs to de- crease the gastro-intestinal inflammation. Nerve sedatives may be necessary. Decinormal Salt Solution. — The use of this solution in various ways is unques- tionably of benefit to the patient. Wernitz recommends its use in the form of hot rectal irrigations, to be given through a high rectal tube. The solution is allowed to flow in gently, and the procedure is continued until the patient shows discomfort, or until the return flow is clear, showing that the lower gut is entirely clean. This is repeated frec^uently during the twenty-four hours. Wernitz claims that it is followed by a falling of the temperature, profuse dia- phoresis, increased diuresis, less thirst, and a general improvement in the patient's condition. Repeated submammary or subcutaneous injections of decinormal salt solution may be given. It is rapidly absorbed and acts as an effective cardiac' stinmlant, increasing diaphoresis and diuresis, and often having a distinct sedative effect upon the patient. Intravenous infusions ma}' also be indicated, and may be frequently repeated. Such infusions are almost always followed by beneficial results, and it is probable that they aid materially in the elimination of the toxic material from the tissues and the blood. Serum Therapy. — There are two distinct types of sera used in septictemia. The one acts by virtue of its antitoxic properties, and the other acts as a bacteri- cide. Antidiphtheritic serum is an antitoxin, and has no effect upon the micro- organisms. It has been shown that the diphtheria germs can be made to grow on diphtheria antitoxic serum. The antistreptococcic serum, on the other hand, acts as a bactericide and has little antitoxic action. It has been definitely established that diphtheria antitoxin is of distinct value in the treatment of septica?mia caused by the micro-organisms of diphtheria. It is a specific. This is made possible by the fact that the same organism is always 444 a:merican practice of surgery. the cause of the tlisease. When we study the streptococci, on the other hand, we find that all streptococci are not the same; that is, there seem to be nu- merous varieties of streptococci which cannot be differentiated from one an- other. These chfferent varieties vary also in respect to their virulence, so that when a streptococcic serum is produced it will be found to vary in proportion to the virulence and variety of the streptococcus used in the immunization.* It is not strange, then, that the results of the use of this serum should vary greatly. The use of antistreptococcus serum is indicated in those cases in which we have a pure infection of the streptococcus. When there is a mixed infection, it acts only upon the streptococcic factor of the disease. In 1902 Packard and Wilsonf collected 117 cases in which the serum had been used, and they report recov- ery or marked improvement in 114 of the cases. Bumm, quoted by Young, J concludes that the employment of antistrepto- coccus serum, when a general peritonitis of puerperal origin, a pyaemia, a para- metritic phlegmon, etc., exist, is ineffectual and useless. He believes it is of use in, the early stages where the organism has not extended beyond the endome- trium, or where an extensive bacterisemia does not exist. The serum should be injected early. The dose varies from 10 c.c, repeated twice daily, to 25 c.c. or more, injected every second or third day. Intravascular Antisepsis. — Since the disease is essentially a blood disease, surgeons have long sought for some antiseptic solution which could be injected into the circulation and destroy the organisms without doing injury to the pa- tient. Creole was one of the first to experiment along this line. He did not at first inject substances directly into the circulation, but caused a local hyper- semia of the skin, and then, using a fifteen-per-cent ointment of colloidal silver, rubbed 2 or 3 gm. of the same into the hyperremic area. This is absorbed by the blood and attacks the micro-organisms. Later, he injected from 2 to 10 c.c. of a two-per-cent solution of collargol intravenously. He claims that it is a non- irritating, strongly bactericidal agent, and that by its employment marked im- provement and often recovery follow in even the most severe forms of septic poisoning. , Many surgeons have tried this method, and are divided in their opinions as to its efficacy. Maguire, of London, experimented by injecting a solution of formaldehyde gas directly into the circulation. His conclusions were that 50 c.c. of a 1 in 2,000 solution of formaldehyde — that is, a 1 in 800 solution of formalin — was the max- imum dose that could be safely injected in man. In 1903 a number of cases of advanced septicaemia were treated by injecting this solution intravenously. The results at first were encouraging, but, owing to the dangers and uncer- tainty of the method, it has not come into general use. * Travel: Klinisch-therap. Wochenschrift, 1902. t Amer. Jour, of the Med. Sciences, December, 1902. J Boston Med. and Surg. Journal, Aug., 1905, p. 216. INFECTIONS OF OCCASIONAL OCCURRENCE. 445 In chronic cases most attention must be gi^-en to tlie nourishment and gen- eral stimulation of the patient. Good, nourishing food, fresh air, and hygi- enic surroundings are essential. ERYSIPELAS. Erysipelas is an acute, inflammatory disease of the skin or mucous mem- brane, caused by infection of a wound of the skin or mucous membrane by the streptococcus of Fehleisen. It is characterized by a peculiar, non-suppurative inflammation or dermatitis, which begins in the wound and rapidly spreads over the skin or mucous membrane, and which usually is self-limiting and ends in resolution. It is accompanied by fever. Etiology. — It is generally accepted that erysipelas always arises from an in- fection of a ^Yound with streptococci. The so-called idiopathic cases, most fre- quently seen on the face, are not due to infection from within, but in everj' case there must be some break in the continviity of the epithelium covering the skin or mucous membrane. The original wound may be simply an abrasion or slight pin prick, and may he entirely healed before the symptoms of erysipelas develop ; nevertheless, a wound of some sort must have existed. In surgical practice ery- sipelas is most frequently seen as a complication of infected wounds and in debilitated, alcoholic, or other patients, in whom the resisting powers of the individual are diminished. The existence of a specific micro-organism is still in question. The opinion of many bacteriologists is that it is always caused by the streptococcus of Fehl- eisen. However, there is a diversity of opinion on this subject. Welch* states that " the streptococcus of erysipelas does not differ in morphological or cultural characters from the Streptococcus pyogenes. The same pathogenic effects may be produced by each in animals and man, so that the weight of evidence is in favor of the identity of the Streptococcus erysipelatis with the Streptococcus pyogenes." Clinically, the two manifest themselves in distinctly different ways, and give rise to different pathological processes. In erysipelatous inflammation the streptococci are found chiefly in the lymph capillaries and lymph spaces of the skin and subcutaneous fat. Here they mul- tiply rapidly, and often are seen completely filling the lumen of lymphatic ves- sels. They are generally found most abundantly in the peripheral margins of the inflammation. If the inflammation penetrates more deepl}', which is un- usual, the micro-organisnrs are found in the connective-tissue spaces. The occurrence of suppuration in the course of erj'sipelas is considered by many to be due to a mixed infection. If we accept the theory that the Strepto- coccus erysipelatis and the Streptococcus pyogenes are identical, then the sup- puration is caused by mono-infection. If we believe that the Streptococcus erysipelatis is a non-pyogenic micro-organism, then the ^ occurrence of a phleg- monous inflammation must be due to a mixed infection. * Dennis: "System of Surgery.'' 446 AMERICAN PRACTICE OF SURGERY. The micro-organisms seldom gain entrance to the general circulation, and the constitutional symptoms are due to resorption of the toxins from the seat of infection. Erysipelas is a highly infectious disease, and may be carried by instruments, the hands, clothing, dressings, etc., from one patient to another. One attack does not protect against a second attack. In fact, some people seem to have an especial predisposition to contract the disease, but subsequent attacks are not usually so severe as the primary one. Symptoms. — The period of incubation varies. Generally it is short, from fifteen to sixty hours, or it may last for from three to seven days (Butler). Dur- ing this stage there may be indefinite prodromal symptoms, such as headache, anorexia, or general malaise. Usually the symptoms are ushered in by a severe chill, which may be repeated. This is followed by a rapid rise of temperature (104° or 105° F.), accompanied by anorexia, vomiting, and, in debilitated pa- tients, marked depression. At the same time, or within a few hours, the vicinity of the wound is seen to be swollen and red. At first, there is nothing charac- teristic about this redness and swelling. Frequently, at first, small red streaks may be seen to radiate from the wound, corresponding to the position of the lymphatics. This is best seen when the disease attacks the extremities. Later, these stripes disappear. The redness rapidly extends and involves a considera- ble area. The lymph nodes are more or less swollen. There are subjective symptoms of itching, burning, heat, and pain in the affected area. Usually the erysipelatous patch is sharply circumscribed. It is elevated, irregular in contour, rose-colored or of a bright reddish color, and presents a smooth, glazed appearance. 'Wlien pressure is made with the finger on the hyperEemic area, the redness disappears for a moment and the skin shows a pecul- iar, yellowish discoloration. The swollen tissues do not pit on pressure. The affected part is tender and feels somewhat like leather. In antemic, cachectic individuals the redness is not so marked. The amount of swelling varies with the severity of the infection and the part affected. When there is much loose connective tissue the swelling is more marked. Often on the surface of the skin vesicles appear in large numbers. Several of these may run together and form large bullce. These vesicles and bulla? contain clear or slightly cloudy serum, and may contain pus. As the inflammation advances they dry up and form crusts, or they may open and leave an ulcerated surface. The inflammation is i^rogressive and shows a great tendency to spread. On the face it usually develops on or near the nose, and spreads laterally along the lower border of the orbit. In men it has often been noticed that it stops where the beard begins on the cheek. It may pass up over the forehead and invade the scalp. In the more severe forms the eyelids become greatly swollen and close up the eyes. The disease is most active at the periphery of the inflamed patch, and, while it is thus spreading at the periphery, it may be subsiding in the central INFECTIONS OF OCCASIONAL OCCURRENCE. 447 portion. It may further extend and involve the neck. In facial erysipelas there is always danger of the infection penetrating deeply and causing meningitis. It may spread from the skin and involve the mucous membrane of the nose and mouth, and cases of pulmonary erysipelas have been reported. In severe cases the face and head may become enormously swollen and distorted, and such cases are accompanied by grave constitutional symptoms. The inflammation may not be confined to any one portion of the body. It may start on the arm or leg and, steadily and irregularly advancing at the pe- riphery, creep up over the shoulder or thigh and spread over the body. At the same time at the original site the inflammation may subside and entirely disap- pear, or, after temporary subsidence, it may start up again. Such a condition, called erysipelas migrans or avibulans, may cover a period of weeks. The con- stitutional symptoms are not generally marked. Only exceptionally the erysipelatous inflammation is associated with sup- puration. The pyogenic process may be superficial and result in the formation of pustules, or the infection may involve the deeper structures and set up a phlegmonous inflammation. This does not differ in its essentials from the phleg- monous inflammations already described. The infection may involve any of the deeper structures, and there have been reported cases, not only of periostitis and osteomyelitis, but also of joint involvement. Occasionally, small areas of necrosis and small localized abscesses may form throughout the erysipelatous patch. All grades of inflammation are seen, from the mildest dermatitis to the most severe form of acute purulent oedema or gangrene foudroyante of Maison- neuve. The constitutional symptoms vary, as a rule, in proportion to the intensity of the local disturbance. This, however, is not constant. Sometimes large areas of skin are involved without marked systemic symptoms. The body temperature, as a rule, is characteristic. Following the initial chill there is a sharp rise. The first day the temperature may be only 103° F. The next .morning there is no remission, but the temperatvu'e is higher, reaching 104°. This absence of morning remissions is considered by some to be pathognomonic. The temper- ature continues high for six or seven days, and generally terminates by crisis. Often, however, the drop to normal is more gradual. In exceptional cases, for the first few days the temperature may not be high, even though the typical local symptoms be well developed. At times the temperature is very irregular. Following the initial chill it may reach 106° or more, to be followed the next morning by a drop of three or four degrees. Again, it may follow the type of a severe remittent or intermittent fever, or an irregularly remittent fever. Such irregularities of temperature are not necessarily associated with suppuration. The temperature usually subsides before the local symptoms disappear. The disease is almost without exception ushered in by a chill. It is generally severe and lasts for some time. Or the chill may be less severe and be repeated. 448 AMERICAN PRACTICE OF SURGERY. The chills may be repeated on the following day, or every day. They do not necessarily indicate the involvement of fresh tissue. The pulse is increased in frequencj^ and usually A^aries in proportion to the height of the temperature, seldom becoming A^ery rapid except in the scA'ere cases. The gastric SA'mptoms are often more prominent at the beginning of an attack. The patient's tongue is thickly coated. Loss of appetite, nausea, and repeated DISEASE 1 2 3 4 3 G 7 s ... p.». ..„. P.M, A.M. P.M. A.M. P.M. .... P.M. . .^P.M.,A.».,P.M. A.M. P.M. ..„. P.M. ..... 107° 100° 105° 3 104° I < b 103 u |l02° < S 101° s 99° 98° 07° s / A V ^ l\ .w /\ \n / ' i A ^ \ /^ V . /\ S \ / ^ ! 1 Fig. 133. — Typical Temperature Curx'e of a Mild Case of Facial Erysipelas. vomiting are the rule. Diarrhoea is not a constant symptom. Often severe sjanp- toms referable to the nervous system are obserA'ed. Headache, restlessness, deliri- um, and coma occur. These are more pronounced in the cases of facial erysipelas. In the most severe cases all the constitutional SA'iiiptoms of a general intoxi- cation appear. High ieyer, dry, crusted tongue, alternating delirium and coma, involuntary evacuation of the bladder and rectum precede a fatal termination. In erysipelas of the phlegmonous type, chills often recur and the temperature assumes a more tA'phoid t3-pe. When the disease attacks the mucous meml^rane lining the air passages, marked swelling of the tissues takes place and fatal oedema of the glottis maj' occur. Numerous complications may arise during the course of the disease. Among the most common may be mentioned meningitis, peritonitis, pleuritis, otitis media, nephritis, and pneumonia; also septicaemia and pytemia. Diagnosis. — In a well-deA^eloped case of erysipelas the diagnosis is often easy. The initial chill, with the rapid development of a continuously high temperature, together with the marked swelling and characteristic rose color of the sharply defined er3'sipelatous inflammation, are pathognomonic. "Where the s}anptoms, however, are not so characteristic, the diagnosis is often difficult. Sometimes, INFECTIONS OF OCCASIONAL OCCURRENCE. 449 when the disease develops in tlie presence of other infections, a diagnosis is im- possible. Occasionally we see case.s of chronic dermatitis, with redness and thick- ening of the skin, which simulate erysipelas. In such cases there is no tendency, on the part of the disease, to spread; and, besides, the course is not acute, the area affected is less sharply defined, and there is no fever. There are certain forms of acute dermatitis which are not so easily distinguished from erysipelas. Especially is this true of the dermatitis due to the irritation of antiseptic solu- tions, such as dilute carbolic acid, sublimate solution, etc. The dermatitis in such cases is often most severe in the vicinity of the wound, and at first may simulate an erysipelatous inflammation, especially in the presence of a septic temperature. The inflammation does not spread so rapidly and is not so sharply circumscribed. The characteristic swelling and glased appearance are absent. Erysipelas may be confused with a progressive ^phlegmonous inflammation, but in the latter the inflammation does not usually affect the skin and does not pre- sent the sharply defined, raised edges seen in erysipelas. In simple lym-phangitis the inflammation generally follows the course of the larger lymph vessels, there is no typical inflammation of the skin, and the diagnosis is not difficult. In traumatic erysipelas, if the woimd be large, the erysipelatous inflamma- tion usually is seen to start from one portion of the wound and send out fan-like projections into the normal skin. It has been likened to the flame from a gas jet, which it resembles in contour. The dermatitis does not, as a rule, involve the entire wound symmetrically, although this may take place. There is not much change in the appearance of the wound itself. The secretion may be diminished and a general improvement may be noted. Another point of diagnostic interest is the fact that the dermatitis does not necessarily spread in the direction of the flow of lymph in the lymph vessels. The lymphangitis ma}^ advance against the stream, and the vessels often become entirely plugged with micro-organisms, which multiply rapidly b}^ division. There is no constant relation between the subjective symptoms and the height of the body temperature. Patients are often seen with a well-developed ery- sipelatous dermatitis and with a temperature of 104° or 105° F., without any marked constitutional disturbance. Such a condition, however, is seen only in otherwise strong and healthy persons. Erythema may simulate an erysipelatous dermatitis, but the inflamed area is not continuous, and areas of healthy tissue appear between the erythematous patches. The temperature, course, and constitutional symptoms help to differentiate the two. In former years erysipelas was frequently seen as a complication of hospital gangrene, especially the diphtheritic form, also as a complication of diphtheritic in- flammations of the throat and other mucous membranes. In these cases the in- flammation of the mucous membrane was usually' of a gangrenous type, and it is questionable whether the original infection was due to the streptococcus of ery- sipelas or whether it occurred as a secondarj^ infection. Such involvements of the 450 AMERICAN PRACTICE OF SURGERY. mucous membranes are alwaj's attended with great swelling and difl'use red- ness, which are not especially characteristic and make the diagnosis most difficult. The relation of erysipelas to pyaemia is still a much disputed question. Py- aemia does sometimes occur during the course of the disease, secondary foci be- coming established in the lungs and other tissues, and giving rise to inflammation and suppuration. It is most frequently observed in the phlegmonous and gan- grenous types of erysipelas, also in the cases of erysipelas which develop in large, freshly made wounds which easily develop thrombophlebitis. A thrombus may become secondarily infected by the erysipelas micro-organisms and so occasion pyaemia. The same is true of the relation between erysipelas and septicaemia. A fatal septicaemia, which does not differ from the forms of septicaemia already described, may at any time develop. Pathological Anatomy. — In the milder cases the erysipelatous inflammation is most frequently confined to the skin, but may invade the underlying con- nective tissue. The blood-vessels are markedly dilated and are crowded with cells. There is a varying degree of serous exudation. The superficial layers of the epidermis are raised in places, forming vesicles. The cells of the rete Mal- pighi are at first swollen and enlarged, and become vacuolated, but later they shrink and are partly destroyed. The serous exudate invades the hair folli- cles, and as a result the hair becomes separated from its papilla and drops out. There occurs a rapid and profuse, small-celled infiltration, which is first ob- served in the cutis and subcutaneous cellular tissue (Volkmann). This round- celled infiltration is especially marked around the lymph vessels, and may remain after the bacteria disappear. The lymph vessels become filled with streptococci, which often entirely plug the vessels. According to Tillmanns,* the small-celled infiltration becomes crowded together in the cutis and subcu- taneous tissues, and often forms small, microscopical abscesses. He believes that this takes place more frequently than is generally recognized; further, that the most active stage is found in the outlying regions of the erysipelatous patch, and sometimes, more especially in the cases complicated with pyaemia, during the acme of the disease the connective tissue, the lymph-, and small blood-vessels are filled with streptococcic vegetations. The cocci often extend as a fine network through the tissues. It is not always possible, however, to demonstrate the presence of the bac- teria. They have frequently been found in the circulating blood. In the typical cases the local symptoms subside after three or four days. The round-celled infiltration disappears rapidl}^, while the serous exudate is re- moved more slowly. In the phlegmonous type of the disease the changes arc naturally more extensive and are accompanied by suppuration and loss of tissue. The secondary systemic changes are not characteristic, and resemble those which usually accompany all acute febrile infectious diseases. Degenerative alterations are seen in the blood and the vessels. *" Deutsche Chirurijie, " Lieferuns 5. INFECTIONS OF OCCASIONAL OCCURRENCE. 451 Desquamation usually takes place. Prognosis. — As a rule, the prognosis is favorable, but it varies with the severity of the infection and the general condition of the patient who is attacked. In general, the mild cases run their course in about a week and the disease then subsides. The greatest danger arises from the complications, such as menin- gitis, oedema of the glottis, pysemia, etc., which have already been mentioned. Treatment. — When we consider the etiology and pathology of erysipelas, we find that it is a disease due to the activity of streptococci which do not differ morphologically and physiologically from the ordinary pus-producing strepto- cocci, and that under ordinary conditions they give rise to an inflammatory process which is usually localized and tends to be self-limiting; further, that when the disease invades the general system the symptoms resemble those pro- duced by other streptococci. Finally, we believe that the constitutional symp- toms are due to the resorption of the toxins and other poisonous products elabo- rated by the bacteria, and to the effects produced by the action of the bacterial toxins on the tissues. In other words, the conditions are similar to those which are found in other wound infections, and therefore, aside from the local indica- tions and serum therapy, the general treatment should be the same as is em- ployed in the other forms of wound infections. ProphylcLris is of greatest importance. The disease is highly infectious, and is communicable by means of any object or medium which will convey the bac- teria to a wound. On this account the patient must be isolated, and nothing which touches or is in the vicinity of the patient should escape disinfection. General Treatment. — Good nursing, pure air, and careful attention to hygienic surroundings are important. The bowels should be regulated and the diet should consist chiefly of milk, broths, and eggs. Stimulants are sometimes called for. Alcohol may be given in the form of whiskey or brandy. Alcoholic beverages, such as beer and champagne, may be used in suitable cases. The chloride of iron, in doses of twenty to forty drops every two hours, has been extensively used, but not so much now as in former years. As a general rule, the use of antipyretics is contraindicated. Salinger strongly recommends the hypodermic injection of pilocarpine. The drug is administered until the physiological effects are produced. All drug treatment, however, is unsatisfactory. Local Treatment. — The various methods of local treatment are all based upon the general principles of antisepsis, with the idea of allaying the local inflamma- tion and checking the spread of the disease. Of all the antiseptic solutions used, those of corrosive sublimate, 1 in 1,000, and carbolic acid in varying strengths, have met with the greatest favor. Corrosive sublimate may be employed in the form of compresses kept moist with the solution and applied to the erysipela- tous area, or it may be injected hypodermatically around the edge of the area. Carbolic-acid solutions may be similarly used. Kraske advocated scarification of the skin at the periphery of the inflamed area, and then the application of a warm 452 AMERICAN PRACTICE OF SURGERY. solution of corrosive sublimate. Some writers recommend painting the diseased area and the surrounding skin with tincture of iodine. Others applj' compresses kept moist with alcohol, sodimn hyposulphite, potassium-permanganate solu- tion, etc. Cebrian advocates painting the affected area twice daily with a ten- per-cent solution of ichthyol in collodion. In the experience of the writer the use of a ten- to twenty-per-cent ointment of ichthyol, mixed with an equal quantity of vaseline or lanolin, has been found of advantage. The diseased area is first carefullj' cleaned with soap and warm water, and then the ointment is applied. When suppuration occurs, incision and evacuation of the pus are called for, and the wound should be treated as set forth in the chapter on that subject. Serum Therapy. — Antistreptococcus serum has been employed for over a decade in the treatment of erysipelas, but such are the vicissitudes of the disease that it is impossible to say accurately how much good comes of its use. In 1895 Marmorek reported a series of 306 cases of erysipelas, in 165 of which antistreptococcus serimi was used. Prior to this, the average mortality was as- sumed to be about 5.12 per cent. The dose varied from 10 to 20 c.c. In this series of cases the mortality was 1.63 per cent. When a weaker serum was used, DISEASE 1 3 3 4 5 1 HOU» 4 8 IJ 4 8 u 4 8 13 4 8 U 4|S 12 4 8 U 4 S U\ 4 8 1-2 4 8 12 4 8 12 10T° 106° 105° 5 104° < -103° ^102° Sl01° s JJ^lOO' 99° 98° 97° i s i i i ■i sthesia, but in preventing shock by antesthetizing with a local or general anaesthetic the sensitive tissues. Len- nander's publications on this subject {Mittheilimgen a. d. Grenzgeb. der Chir. vnd Med., 1902, vol. x., and Deutsche Zeitschr. f. Chir., 1904, vol. Ixxiii., p. 297, and Mittheilungen a. d. Grenzgeb. d. Chir. u. Med., 1906, vol. xv.) are the most recent and the best. Connective Tissue. — Crile was unable to find any effect of injury to this tissue, providing nerves were not included. Muscle. — The effect of tearing and crushing of muscles was attended by practically the same phenomena as those observed from similar manipulations of the skin, but to a very much lesser degree. Lennander did not investigate the sensibility of muscles. In my own experience with operations under local auEDsthesia I found that the muscle is not sensitive. However, the nerve near or within the muscle is very sensitive. For this reason, in operations under local anaesthesia, one must be familiar with the position of the various nerves so that they may be rendered ansesthetic by neural or intraneural injections. In cases of amputation on patients suffering from shock I am inclined to the opinion that, if possible, one should avoid division through large muscle bellies; instead, he should select if possible the joint or a position where most of the muscles are tendinous. Bone. — According to Lennander the marrow and the cortical bone are insensitive, while the periosteum is very sensitive. Crile's experimental work confirms this finding. I am of the opinion that the rapid sawing of a bone would be attended with very little, if any, shock. It is very easy, however, to render the periosteum insensible with cocaine infiltration. I have repeat- edly resected one or more ribs painlessly after this method in patients in a very critical condition, with empyema or lung gangrene. Joints. — According to Lennander's most recent communication (Mitthei- lungen a. d. Grenzgebieten d. Med. u. Chir., 1906, vol. xv., p. 465) the joint cap- sule has sensory nerves, but the articular cartilage is insensible. Crile was unable to demonstrate any deleterious effects from various manipulations on large joints. Under local anaesthesia I have been able to open and irrigate without much pain most of the joints. Ai'thritis increases the sensitiveness of the surrounding tissues. Dislocations and compound injuries of the joints are not associated with any considerable degree of shock unless the soft parts and nerves in the neighborhood are injured. Nerve Trunks. — Crile's experimental work demonstrated that the greatest effect upon blood pressure was produced by injuries of nerve trunks. A quick SURGICAL SHOCK. 471 severing with a sharp instrument had much less effect than crushing or tear- ing. The effect on the centres from injuries to nerve trunks can be entirely inhibited by a local infiltration of cocaine centrally to the point of injury. This laboratory experiment is confirmed by quite a number of clinical obser- vations. In amputations, especially if the patient be in a condition of shock, ' the large nerve trunks should be blocked. Operations upon the Head. — In operations upon the brain, incision of the scalp and the making of a bone flap are attended with little effect upon the blood pressure, but exposure and manipulation of the dura and the brain itself have a decided effect. This experimental finding is confirmed by clinical observation. In operations upon the tongue, the floor of the mouth, and the lips, if there is no loss of blood, there is rio effect upon the blood pressure. This experi- mental finding is also confirmed by clinical observation. Injury of the mucous membrane of the nose had no especial effect upon the blood pressure, but in some cases there was a temporary and partial inhi- bition of respiration and the heart. Although the mucous membrane of the nose and the phar3aix is quite sensitive, I have never been able to convince myself that during operations incision or injury of this tissue had any appreciable effect on blood pressure or was adding to shock, but I think that this needs further investigation, and I am inclined to the opinion that, in patients in whom we fear shock during operation, one should anaesthetize this very sensi- tive mucous membrane with cocaine. The effect of injury of the mucous membrane of the pharynx, the soft palate, base of the tong-ue and epiglottis is one of inhibition on the heart and respira- tion to a certain extent. Larynx, Trachea, and Oesophagus. — The chief effect of irritation of the mucous membrane of the larynx, even under anaesthesia, is similar to that of the epi- glottis — a temporary arrest of respiration. If great force is used, there may be a partial or complete inhibition of the heart. The larynx, however, c^uickly becomes tolerant to this manipulation, and the effects are not noted. If the superior laryngeal nerves are divided, these manipulations produce no effect on the respiration and heart action. The effect of the application of cocaine was similar to the division of the superior laryngeal nerve. This experimental finding of Crile of the effect of cocaine used on the mucous membrane of the larynx is an important one to remember. I am inclined to the opinion that in extensive operations on the larynx, base of the tongue and epiglottis, and sensitive mucous membrane of nose and pharynx a preliminary application of cocaine would be beneficial ui that it inhibits the afferent impulses which have an inhibitory effect on heart and respiratory action. Good {American Medicine, August, 1902, p. 293) asked the question "are not some deaths during operation in regions supplied by the trifacial nerve, due to reflex inhibition of respiration and the heart?" 472 AMERICAN PRACTICE OF SURGERY. Tracheotomy. — When this operation is clone under cocaine, no changes are observed in blood pressure. As a rule, when the trachea is first opened, its exposure to the air produces coughing, and there may be for a moment a slight asphyxia. This effect is less if the patient is under general narcosis. Asphyxia. — According to Crile asphyxia produces a rise in blood pressure, to be followed, after the asphyxia has passed, by a fall in the pressure with an increased rapidity of pulse. Experimental investigation on the effect of asphyxia on the vasomotor centres is not complete. In practical surgery when asphyxia takes place during ether narcosis and the patient's general condition is good, the effect upon the patient's general condition as observed by the ordinary methods is not very marked. In weak patients, however, this asphyxia and cyanosis become very dangerous factors, and the ana;sthetist should use every caution to prevent their occurrence. The asphyxia or cyanosis produced by the administration of nitrous oxide has an entirely different effect from that produced by an obstruction to breathing. In the various contri- butions on general ana3sthesia, when this method has been used to introduce narcosis, no bad effects upon the blood pressure have been observed. I have been \mable to find any important contribution with observations on the use of nitrous oxide in cases of shock. Operations on the NecJc. — Lennander has demonstrated that the thjToid gland itself is insensible. This has been observed by all surgeons who have performed thyroidectomies under local anesthesia. Cocaine iirfiltration is only absolutely necessary for the skin incision. Sometimes in the division of muscles the patients complain of pain. Now and then when the thyroid ves- sels are ligated, especially the veins, the patient may complain of some discom- fort, but the remainder of the dissection is carried on practically without pain. The patients complain of great discomfort, however, when traction is made. If the tumor is very adherent to the trachea, pain is experienced during this dissection. It is remarkable how little shock is observed in the extensive operation for the removal of larger goitres, providing no blood is lost. The few blood-pressure records confirm this. Even in patients with exophthalmic goitre who at the tmie of the operation may have a very rapid pulse, one observes no shock. Although the pulse is rapid in this disease, the blood pressure is high, and in the few records has been maintained during the thyroidectomy under cocaine infiltration. The chief danger is acute dilatation of the heart. The insensibility of a thyroidectomy and the absence of shock, if no blood is lost, are one of our best examples illustrating that extensive dissection, when made through insensible tissue, has little or no effect on the vasomotor centres. A contrast to this finding is seen when one attempts to excise a diffuse lipoma of the neck, or a mass of tuberculous or Hodgkin's glands. The dissection may cover a smaller area than a thyroidectomy, but this area contains numer- ous branches of cerebro-spinal nerves, difficult to expose and block with the SURGICAL SHOCK. 473 cocaine infiltration. These patients sviffer more pain ana quickly show symp- toms of shock. E.xtensive dissections of the neck are always attended with a certain amount of shock, even if they are bloodless. The degree of shock is in direct proportion to the condition of the patient. In weak patients, therefore, these extensive dissections become elements of danger. The shock undoubtedly is less if all manipulations are made with the greatest gentleness, when tissues are divided quickly with a sharp knife, and when blunt dissection is avoided. In oper- ations of this character, I believe that the pneumatic rubber suit of Crile should be employed to maintain blood pressure. (See Figs. 140 and 141.) I will discuss this again imder Treatment. Operations on the Thorax. — These may be divided into two groups. In the first the thoracic cavity is not opened, in the second this cavity is opened. The most common operation on the chest belonging to the first group is the extensive dissection for carcinoma of the breast. Crile in his observations on blood pressure in these cases noted only moderate changes. Toward the end of the operation, especially during the dissection of the axilla, when large blood-vessels and nerves are manipulated and divided, a fall in the blood pressure is observed. Crile, however, especially notes that when the dissection is done with a sharp knife and with minimum traction the fall in blood press- ure is insignificant. The change in blood pressure is noted to be marked when the tissues are handled roughly, when the dissection is blunt, when traction is made. These sentences of Crile sound the keynotes to the factors which on the one hand avoid, and on the other increase shock. When our patients are strong, the result of the loss of a certain amount of blood, blunt dissection, rough handling, unnecessar}^ traction and ligation of tissues en masse, although they would cause a change of the blood pressure, if such a record were kept, do not produce sufficient depression to be of much clinical significance. The patients are a little shocked, convalescence is a little prolonged. However, when our patients are very old or very yoimg, or in a weakened condition from any cause, these rough manipulations become serious factors, so serious in some eases that the operation cannot be completed at all, or only in a very hurried and unsatisfactory manner. In the very large experience in the surgical clinic of the Johns Hopkins Hospital with the extensive operation for carcinoma of the breast, I have been struck with two very significant facts — the absence of shock and the apparent low percentage of post-ansesthetic complications. The average anaes- thetic time of this operation has been at least two hours, rarely less than . n hour and a half, frequently two and a half hours, now and then three, and in a few cases four hours. The anesthetist in this group of cases seems to be impressed with the fact that it is to be a long operation. For this reason he is unusually careful with the anaesthetic, which has always been ether. The 474 AMERICAN PRACTICE OF SURGERY. patients are seldom completely narcotized. Although the average age is high, I find that the post-operative pneumonia is distinctly less frequent per hundred than after operations for hernia. We have not many blood-pressure records; but, as far as clinical observations can record, shock is rarely observed, and has never been serious. This apparently has been due to the method of dis- section established by Halsted. From the skin incision, throughout the oper- ation, every bleeding point is clamped; the dissection is made slowly and care- fully; in the axilla especially, vessels and nerves are handled with the greatest gentleness, they are isolated and ligated separately; nerves are cut quickly; blmit dissection is never employed, except for loose fat and cobweb connective tissue devoid of nerves. Crile records that resection of the ribs caused but slight change of the blood pressure, but opening the pleural cavity a marked change. When an empyema is drained the opening of the cavity and the discharge of pus are attended with a rapid fall of blood pressure and an increase in the pulse rate. Here we have another excellent and concrete example of the elements which produce shock and affect blood pressure. According to Lennander the parietal pleura, like the parietal peritoneum, is extremely sensitive. Manipulations of either are almost impossible under local anesthesia. The lung itself is insensitive, and the probabilities are that even extensive manipulations and cutting of the lung would of themselves be devoid of any effect on the vasomotor centres. It is the opening of the pleural cavity that is the chief factor of danger in all intrathoracic operations, chiefly owing to the change of atmospheric pressure with its primary effect upon respiration and secondaiy effect upon the blood-pressure. The observations of Crile on operations upon empyema are important to recollect. In weak patients pleural effusions should be evacuated very slowly. The dangerous effects of opening the pleural cavity due to collapse of the lung and its effect upon respiration and circulation have limited this field of surgery. This is not the place to discuss Sauer- bruch's experimental work or his pneumatic operating chamber designed to equalize atmospheric pressure and eliminate the dangers of intrathoracic operations, nor to consider Brauer's method designed for the same purpose. I have discussed these contributions in the International Clinics for April, 1905, p. 300. Extensive resection of ribs, on account of injur}' to the intercostal nerves, even if the pleural cavity is not opened, and no blood is lost, is an operation attended with some shock. From a limited experience I am inclined to the view that even if general narcosis is employed the intercostal nerves should be blocked by a perineural injection of a weak solution of cocaine. The nerve lies in the groove beneath the rib. In operations on the thorax the sensitive tissues are chiefly the skin, the periosteum of the rib, the intercostal nerves, and the parietal pleura. SURGICAL SHOCK. 475 Diaphragm. — According to Lennander the parietal peritoneum and the pleura on the diaphragm are unusually sensitive. Crile has demonstrated that manipulations of the diaphragm, even though slight, have a distinct effect upon respiration. Undoubtedl}' in all intrathoracic and abdominal operations manipulations of and traction on the diaphragm should be avoided if possible. Abdomen. — Lennander's observations on the sensitiveness of the perito- neum and abdominal viscera are the most exhaustive extant. The parietal peritoneum is extremely sensitive. The visceral peritoneum and the viscera themselves are msensitive, that is, all tissues innervated from the sympathicus and lower vagi are insensitive to touch, pain, and temperature. The reverse is true of all tissues supplied by branches of the cerebro-spinal system. These observations are hnportant not only for the technique of local ansesthesia, but also in operations upon the abdomen, when we wish to lessen or avoid shock by reducing to a minimum sensor}'' impulses in cerebro-spinal nerves. At the present time there are no data, experimental or clinical, to indicate that manipulations of any kind on these insensible viscera or tissues have any dele- terious effects on the centres of circulation and respiration. Handling, tear- ing, and cutting the abdominal viscera are not harmful if done without loss of blood. We must recollect, however, that traction on these viscera irritates the posterior parietal peritoneum and the connective tissues containing nerves. Theoretically, therefore, the elements which produce shock in abdominal operations are irritation of the parietal peritoneum and traction on the abdom- inal viscera. The nearer the viscera are to the diaphragm the greater the degree of this effect. Exposure of the abdominal viscera to air has a bad effect chiefly due to loss of temperature. "WTien viscera are taken out of the abdom- inal cavity traction and loss of heat act together. These theoretical conclu- sions based on our knowledge of the sensibility of the abdominal viscera are borne out by Crile's experimental work and cluneal observations. Manipu- lations in the pelvis, or rather of its viscera, produce very much less effect than on the higher organs. In no field of surgery can its art be better em- ployed in lessening the degree of shock than in the abdomen, and it is very satisfactory to find that the conclusions of clinical observers are confirmed by scientific laboratory experiment. In no other field is the method of anaes- thesia of greater importance. In weak patients the skin incision can be made with local infiltration; the muscle opening, whatever its nature, can be per- formed without pain by the proper intraneural method of Oberst, so well illustrated in Harvey Cushing's procedure for inguinal hernia. General anes- thesia is now given for the division of the parietal peritoneum. Throughout the remaining intra-abdominal operation the anaesthesia deepens when any manipulation is done which would cause, pain if the patient were awake ; for example, traction, separation of adhesions from the parietal peritoneum; 476 AMERICAN PRACTICE OF SURGERY. when abdominal sponges are introduced or removed if they come in contact with the parietal peritoneum. During the operation per se on the viscera themselves, the narcosis can be very light; for example, throughout the entire suture of a gastro-enterostomy practically no anaesthetic need be given. Again, when the abdominal wound is closed, the narcosis must be made deeper. In long abdommal operations and in operations upon weak patients vigilant attention to the most minute details of narcosis and manipulation of the tissues is the chief factor which insures success. In no other operation is shock a more disastrous complication. It may be fatal of itself. If not, it so lowers the resistance of the patient that post-operative comxjlications are more fre- quent. The greater one's experience in intra-abdominal surgery the more is one impressed with these facts. Spleen. — According to Lennander the capsule and the parenchyma of the spleen are insensible. In operations under local anaesthesia this organ can be handled with impunity, providing one does not touch the parietal perito- neum in the neighborhood or make traction upon the spleen. This traction irritates the diaphragm through the ligament, and the posterior peritoneal connective tissue with its nerves through the splenic vessels. Crile in his experimental work on dogs found no change in the blood pressure in operations upon the spleen. Splenectomy, therefore, is of itself an operation in which shock need be feared only if there is hemorrhage or necessary prolonged and vigorous tension. Pancreas. — Crile records no observations on manipulations of this organ. Lennander finds the parenchyma of the pancreas insensible. In practical surgery, however, injuries and operations in the region of the pancreas are fre- quently attended with an unusual degree of shock. This undoubtedly is due to the numerous branches of spinal nerves in the peripancreatic tissue. In rupture of the pancreas from contusion or wound and in the so-called pancreatic apoplexy, in which the pancreas and the peripancreatic tissue are infiltrated with blood from the ruptured artery, the patients exhibit a degree of shock far out of proportion to the loss of blood. This general condition can be explained by the irritating effect of the pancreatic juice escaping into the peritoneal cavity, which excites a chemical peritonitis associated with a hem- orrhagic exudate. Without much doubt, in addition to the depressing effect of this irritant, there is also a toxic element. The same is true of acute hem- orrhagic pancreatitis in which the general symptoms — a combination of shock and intoxication — are far out of proportion to the local infiltration. For example, a similar hemorrhagic and inflammatory exudate about the kidnejr or the rectum is never associated with such a degree of general depres- sion. For this reason, in operations in the region of the pancreas, injury of this organ must be avoided, and if incision or partial excision of the pancreas is necessary the peritoneal cavity must be protected from the pancreatic juice. SURGICAL SHOCK. 477 Lirer. — The peritoneal covering of the liver and its substance, according to Lennander, are insensible. This I have confirmed in local-ana3sthetic oper- ations on the abdomen. An abscess of the liver, after it has been walled ofi" by gauze, can be opened secondarily with knife or Paquelin cautery without pain. Practically, however, in operations in the region of the liver, it is diffi- cult to handle the organ without some traction on the diaphragm. This pro- duces pain if the patient is not under general narcosis, and becomes a factor in producing shock in certain cases. The excision, however, of even large pieces of liver with knife or cautery can be performed without any danger of shock from this manipulation. The only element of danger is hemorrhage. Kidney. — The intimate capsule and parenchyma of the kidney are insens- ible. Crile in his experiments found that in cutting, contusing, or crushing the kidney no effect was observed upon the blood pressure, except when dur- ing these manipulations parietal peritoneum was injured. Nephrectomy of itself had very little effect upon the blood pressure. In practical surgery, however, shock frequently attends operations upon the kidney. The degree of shock is in a fairly direct proportion to the amoimt of manipulation neces- sary to free the kidney. If the diseased kidney, tumor, or inflammation is very adherent to the perinephritic fat and connective tissue or the neighboring parietal peritoneum, the manipulations to free the kidnej^ necessarily involve rough handling of sensitive tissue. Considerable traction is required on the abdominal wound. In these cases, even though there be but slight loss of blood, shock can easily be recognized clinically. Quite frequently in these cases a considerable amount of oozuig cannot be prevented. For these reasons many of the patients are quite shocked. It is in this group of operations that rapidity becomes a very important element in preventing shock. When by performing the operation slowly and carefully the surgeon can lessen the sen- sory impulses which produce shock, time need not be considered. However, when he cannot avoid this rough handling of tissues, as in the enucleation of an adherent diseased kidney, shock is less in direct proportion to the rapidity of the operation. The anuria that may take place as a post-operative compli- cation of kidney surgery apparently cannot be based upon shock as a factor. Testicles. — The testicle, epididymis, and its intimate peritoneal capsule are insensible according to Lennander. The sensory nerves are present in the skin, dartos, and external coverings of testicle and cord. The older views that castration was associated with an unusual degree of shock have proved to be fallacious. According to Crile an effect upon the blood pressure is only observed when rough manipulations are made upon the external coverings or when one dissects a very adherent hernial or hydrocele sac. Therefore, in operations for hernia, hydrocele, and upon the testicle rough manipula- tions should be avoided. In old people with strangulated hernia the operation should be always done under cocaine infiltration. In some cases no attempt 478 AMERICAN PRACTICE OF SURGERY. should be made to excise the sac, because, on account of its size or adhesions, these manipulations become elements of danger in increasing shock. When the sac is not adherent and can be enucleated without difficulty, there is no increased danger in its removal. Spinal Column. — Crile demonstrated that in operations of laminectomy no change was observed in the blood pressure until the membranes of the cord were exposed. Contact, however, with sensory nerve roots showed the most marked change. In my limited experience with laminectomy I have been surprised at the absence of much shock. Undoubtedly the skin, muscles, and deeper tissues, if one confines the incision to the middle line, contain' very few sensory nerves. Crile demonstrated this in laminectomy under cocaine infiltration. Nor did his patient experience pain when the spinous processes and lamina were divided. Extremities. — In amputations the chief factors which produce shock are the divisions of the skin and nerves. This can be prevented by cocaine in- jections. That tearing of the skin and of the nerves are definite factors in pro- ducing shock is confirmed by observations in accident surgery. All patients with lacerated, contused, or crushed wounds of the extremities are shocked in direct proportion to the injury of the skin and larger nerve trunks. The shock may be extreme without the loss of blood. There is no evidence to indicate that the crushing or fracture of the bone is of itself a factor. For example, in exten- sive comminuted fractures without complicating injuries of the soft parts there is no shock. The treatment of patients with extensive injuries of the extrem- ities and shock is one of the important problems of traumatic surgery, and will be discussed later. Duration of the Operation. — From the preceding discussion one can easily understand that the time of the operation becomes a distinct element in shock only when during this time manipulations are made which produce sensory impulses. As stated before, when discussing kidney operations, it is better to prolong the operation, if by this these sensory impulses can be avoided. When, however, the manipulations necessary for the operative procedure are factors which, we know, will produce shock, the time of the operation should be short- ened as much as possible. Irrespective of the manipulations, there are two other factors which produce shock, which must be borne in mind, as they are increased by the duration of the operation: first, the general anassthetic, second the lowering of the temperature by exposure of large areas of fresh tissues to the air. In long operations the quantity of the anaesthetic can be greatly reduced by the so-called method of interrupted narcosis, which I dis- cussed under operations upon the abdomen. The tissues can be protected by moist warm gauze. Within certain limits of time, I do not believe that the general anassthetic or the exposure of tissues to air is as important a factor in producing shock as the rough handling of, tissue. It frequently, then, be- SURGICAL SHOCK. 479 comes a choice of evils, and personally I would prefer a little longer operation for a gentle dissection, bloodlessly, to a shorter operation with more hemorrhage and rough handling. Anaesthesia: The Relation of Anaesthesia to Shock.— Continuous anesthesia alone will kill animals. Chloroform is a more potent factor than ether. Crile in all of his experimental work on animals considered that the general anaes- thetic was always a factor. Blauel (Beitrage zur klin. Chir., 1901, vol. xxx., p. 271) was one of the first to contribute extensive observations on blood press- ure during ether and chloroform narcosis. When other factors are eliminated the arterial tension during ether narcosis is well maintained and usually slightly increased, while in chloroform narcosis there were observed great fluctuations and, as a rule, a lower blood pressure. Chloroform, therefore, should never be given in shock or in any cases in which the lowering of the vasomotor tone would be dangerous to the patient. The most recent communication Hjii this subject is by Mueller (Archiv /. klin. Chir., 1905, vtal. Ixxv., p. 896, and vol. Ixxvii., p. 420). Mueller's observations are concerned chiefly with mixed narcosis. He has demonstrated to his own satisfaction that oxygen is a very important, perhaps essential gas to combine with every anesthetic. In an oxygen-chloroform narcosis the depression and fluctuation of the blood pressure are less marked than with simple chloroform. The oxygen-ether narcosis gives better results as regards blood pressure than the simple ether or oxygen- chloroform. In some cases the best results were obtained with a mixed oxygen- ether-chloroform narcosis given with a special apparatus. I have had no personal experience with these mixed general narcoses, nor with the various apparatus used for their introduction. In my own experience I have so far been satisfied with ether given by the drop method on an ordinary chloroform mask. This has proved the most satisfactory anesthetic in cases of shock or in weak patients for whom a general narcosis was absolutely necessary. A patient in a condition of shock requires very little anesthetic. One seldom, if ever, observes the cyanosis and asphyxia which now and then are a complication in robust individuals. I always combine, if possible, a local cocaine infiltration with the general narcosis in cases of shock or in patients in whom I anticipate shock. Further investigation undoubtedly should be made to demonstrate if Mueller's conclusions are correct. If they are, oxygen and its combination with ether, or ether and chloroform, should be employed. Local Ana'sthesia. — There is no doubt that if the operation can be performed painlessly under local anesthesia there is less shock than if a general narcotic is employed. But, it is very important to remember that the danger of a general anesthetic is less than the prolonged, 'painful attempt under local anesthesia. In the early years of local anesthesia many of its advocates were so enthusiastic that they did not seem to appreciate that some manipu- 480 AMERICAN PRACTICE OF SURGERY. lations were painful. Strong individuals can stand it, and there is no question that for these patients the dangers of pain during the operation are less than the dangers of a general ansesthetic. But this is not true in patients sviffering from shock, or in weak, young, or very old individuals. In these latter cases one should attempt as much as possible with local ansesthesia, but for painful manipulations general narcosis is indicated. For the proper procedure in these cases one will find the observations of Lennander on the sensitiveness of tissues and organs of the greatest value. Spinal Anesthesia. — With this method I have had no personal experience, but since its introduction I have interested myself thoroughly in its literature. There are no observations to indicate that it produces shock. Its dangers are due to the toxic effects of the cocaine introduced subdurally. A patient intoxicated with cocaine undoubtedly has a lower resistance. Blood-pressure records in spinal anaisthesia, if niade, have not been published to any extent, until the communication from Bier's clinic by Mori {Deutsche Zeitschrift /. Chir., 1904, vol. Ixxiv., p. 173). In these observations the spinal ansesthesia was pro- duced by the new method of Bier in which adrenalin is employed with cocaine. No blood pressure observations were made m those cases which were anaesthe- tized with cocaine alone. Mori found very little in the literature on the effect of cocaine injected intraneurally. His observations demonstrate that the blood pressure in spinal anaesthesia produced by adrenalin and cocaine is not as well maintained as that observed after a general ether narcosis, but is very much better than that observed after chloroform narcosis. There is no evi- dence from this observation alone that spinal anaesthesia is a better method than ether narcosis for shock. The experimental work of Schieffer, also from Bier's clinic {Deutsche Zeitschr. f. Chir., 1905, vol. Ixxvi., p. 581), however, is very suggestive. He demonstrated that if animals are shot from a distance of from 30 to 40 metres they fall and do not rise ; that is, the immediate effect of the contact of the shot is out of proportion to the actual injury. When, however, these dogs are first anaesthetized by spinal anaesthesia the immediate shock is either not present at all or is very much reduced. Klapp believes that spinal anaesthesia blocks the afferent sensory impulses in very much the same manner as they are blocked by an injection of a nerve trunk. It will require further investigation to determine whether these findings can be utilized in practical surgery. It is suggestive, however, that for extensive injuries of the lower extremities it might be a good plan immediately to block further sen- sory impulses by an intraneural injection and then proceed with the necessary amputation. Scopolamine-Morphine Ano'sthesia. — At the present time I have been unable to find any blood-pressure records made when this method of anaesthesia has been employed, or to learn whether it has any advantage over cei'ebral or spinal narcoses in shock. SURGICAL SHOCK. 481 Hemorrhage. — According to Crile loss of blood always predisposes to shock, and when it is considerable, even if it cause but little depression in the blood pressure, the animal does not withstand a rather severe or protracted operation. Hemorrhage from venous trunks caused the most profound impression. In practical surgery hemorrhage is a very important element in shock. In my own experience I never feel the same anxiety when patients exliibit symptoms of shock if there has been no loss of blood. If, however, there has been con- siderable loss of blood, the appearance of sj^mptoms of shock should be regarded as an indication to cease further operative manipulations at once, if possible. For example, in cases of osteomyelitis in children, situated in the upper portion of the femur, where an Esmarch cannot be used, the opera- tion in some cases has had to be performed in two or more sittings. The bleeding from the involucrum is always considerable and, without an Esmarch, cannot be checked during the necessary chiselling to explore the infected medullary cavity. I have records of at least five cases in which the condi- tion of the patient was sufficiently threatening to indicate immediate packing of the wound and a postponement of further operation for some days. In these cases the operation has been completed in two or more sittings, with recovery of the patient. Clinical Observations on the Various Factors which Produce Shock.— In the previous discussion on the experimental work it was impossible not to discuss from time to time the confirming clinical observations. Unfortunately, at the present time I cannot obtain a sufficient number of blood-pressure observa- tions taken before, during, and after various operations to compile conclusions of practical value. At the present time, few, if any, surgeons have had suf- ficient experience with blood-pressure records to depend upon them for an estimation of the patient's condition during the operation. In the majority of instances a surgeon of experience can judge pretty accurately the general condition of the patient, and, as a rule, seldom loses a patient from shock. This estimation is not based upon a single factor. His careful study of the case before operation gives him an esthnate of the strength of the patient ; his knowledge of the sensibility of the tissues to be manipulated at the necessary operation gives him a fair idea of the amount of shock he will produce. As the operation proceeds, the character of the respiration and pulse and the color of the skin and lips indicate how the patient is standing the operation. It is not so much the rapidity of the pulse or respiration, as the compara- tive frequency of the pulse and respiration, during the operation, that indi- cates how the patient is withstanding the ordeal. In the majority of cases subjected to operation the general condition of the patient is such that, if the anaesthesia is properly given and the operation carefully performed without the loss of blood, the danger of shock is so insig- nificant that it need not be considered. In these cases we do not need an VOL. I.— 31 482 -\:\1ERICAX PRACTICE OF SURGERY. instrument of precision to record the blood-pressure, although records in these cases should be made for their value in a comparative stud}'. In a smaller group of cases the significance of shock is of the greatest impor- tance. Various factors come into consideration: Anotmia. — Patients with secondarj^ anaemia, especiall}^ if the haemoglobin is low, are not good subjects for operation. AR the factors which produce shock apparently act in these cases with greater severity — the general anaes- thetic, slight loss of blood, all operati^-e manipulations are never borne as well as in individuals with a normal blood comit. This subject I have discussed with the literature in Progressive Medicine for December, 1901, p. 207. It is, therefore, verj^ important for the surgeon to insist upon a complete blood coimt m all those cases in which there is clinical eA'idence of anaemia. Theoretically a blood comit should be made in everj- instance. I believe it is more important than an examination of the ui'me. In practice it is not done. Diabetes. — There is considerable literatm'e on the results of operation in patients suffering with diabetes. I am mclined to thmk that the dangers are somewhat overestimated. Undoubtedly the diabetic patient has a lowered resistance, and it is sometunes difficult to estimate the advent of diabetic coma. Undoubtedh', in cases suffering with diabetes, one would imdertake an opera- tion onlj' when absolutely necessarj-. In my own experience three cases of appendicular abscess suffering with diabetes took the anaesthetic well and exhibited no sjonptoms of shock after the short operation necessary to ilrain the abscess. In a nximber of patients with gangrene of the extremities due to arterio-sclerosis in which there was also glycosuria I obser\'ed that the anaes- thetic was well taken and there was no extreme degi'ee of shock after the neces- sary' amputation. One, however, approaches an operation on a diabetic patient with great caution and uses every means to lessen the quantity of the anaes- thetic administered and shorten the operation. Nephritis. — Operations are seldom performed when the clinical picture of this disease is established. In looking over the records I find a nmnber of cases in which albumin and casts were present in the lu-rne without any other definite SATiiptoms of nephritis. As a rule, local anaesthesia has been em]3loyed in such cases whenever possible. In studjong the histories of these cases and a few with definite nephritis, as well as the literature on decapsulation of the kirlney for different forms of acute and chronic Bright's disease, one is impressed ■nith the fact that these patients take the anaesthetic well and are not more shocked than patients without these kidney lesions. The danger apparently is not from shock, but from the effect of the anaesthetic and operative manipulations on kidnej' function, a subject to be discussed elsewhere in this system. Therefore, in this group of cases the same care should be emploj'ed as that used in patients sufi'eruig from shock or in whom we fear shock, because these preventive measures are important to lessen both dangers. SURGICAL SHOCK. 483 Alcoholism. — My experience in surgery on this class of patients is limited, nor am I familiar with this literature. One is chiefly impressed that this class take the general anajsthetic badly. The dangers of general narcosis are always greater, and therefore, as narcosis is always a factor in shock, it is exaggerated in patients addicted to the excessive use of alcohol. There are sufficient blood- pressure records to demonstrate that alcohol is of no value as a stimulant in shock. In large doses it is a depressant, and for this reason, in accident surgery, if the patient comes to the surgical clinic, as they frequently do, overdosed with whiskey given them as a "first-aid" measure by the ignorant, this intox- icated state must be borne in mind and considered in the treatment. As far as my own experience goes, acute and chronic alcoholism must be regarded pathologic conditions in which the patient is less resistant to all the factors which produce shock. Alcohol is contraindicated in the treatment of shock. General Infection. — It has been my personal experience that patients suf- fering with general infection react more quickly to all the factors that produce shock, and this must be borne in mind in all operations. A high temperature and toxins, whatever their character, apparently after a time affect the centres in very much the same manner as do the sensory impulses which produce shock. Whether these are of an inhibitory or of a depressant character has not been demonstrated. Every one is familiar with the rapidity with which shock manifests itself when patients are operated upon for general peritonitis, and how much more careful one must be in performing the necessary abdominal manipulations. In these cases the patient may sviddenly become almost pulseless when the intestines are removed from the peritoneal cavity. On the other hand, in the normal individual one may keep the intestines out of the abdominal cavity under tension for a relatively long time before symp- toms of shock manifest themselves. Amputations for infected compound fractures or for any infection of the extremities are associated with a rela- tively greater degree of shock than amputations for tumors. It is important, therefore, to bear in mind that operations upon patients suffering with general infection must be conducted on the supposition that shock is a very dangerous factor. Local Infections. — According to Lennander, in all tissues and organs sup- plied by sensory nerves from the cerebro-spinal system the sensibility is increased by an inflammatory lesion. Practically, this knowledge is not of very great importance in relation to shock. It is better, however, to handle these inflamed sensitive tissues more gently. On the other hand, all tissues and organs not supplied by these sensory nerves, but by the sympathicus and lower vagus, are no more sensitive when they are the seat of disease, and for this reason they can be handled with just as much impunity. In local anesthesia it has been demonstrated that inflammation of sensitive tissues increases their sensitiveness to such a degree that, in the majority of 484 AMERICAN PRACTICE OF SURGERY. instances, unless the nerve can be blocked above the area of inflammation, an operation cannot be performed under this method of anesthesia. Starvation. — I use this term to define a condition of loss of weight and strength attributable to defective nutrition, no matter what its cause. We observe the extreme degrees more especially m strictures of the oesophagus, carcinoma of the stomach, pyloric stenosis, and chronic obstruction of the small and large intestines. Undoubtedly, in the cases of pyloric stenosis and chronic obstruction of the intestine lower down there is another factor, that of auto- intoxication. These patients are all bad subjects for operation. They ciuickly react with shock to every factor — anaesthesia, duration of operation, iiem- orrhage, manipulation of sensitive tissues and organs. In this group, perhaps more than any other, the surgeon must use all the means at his command to prevent a fatal condition of shock. Auto-intoxication. — This term is used to define a condition of general infec- tion due to the absorption of toxins from the alimentary tract. Its acute form is observed in all cases of acute intestinal obstruction; the chronic form in all cases of pyloric stenosis and chronic intestinal obstruction. Patients suffering from this toxsemia are bad subjects for operative intervention. Jaundice. — The chief danger of surgical intervention on patients suffering with obstructive jaimdice is that of secondary hemorrhage. In looking over the records of operative intervention upon patients suffering with jatindice due to stone in the common duct I have been unable to fkid any positive evidence that they are bad subjects for anaesthesia and the necessary operative manip- ulation because of the jaundice alone. Those cases in which there are, in addi- tion, marked anaemia and loss of weight, exlribit greater reaction to the operation than those cases m which the jaundice is even more intense, but in which there is no anffimia or loss of weight. It is the duration of the jaundice, and not its intensity, that chiefly affects the general condition of the patient and lowers his resistance. The operative manipulations necessary to expose the common duct, especially if there are adhesions, are of a character that undoubtedly, if prolonged, or performed upon patients with lowered resistance, produce shock. This should be borne in mind. Acute Hemorrhagic Pancreatitis. — In the clinical picture of the early hours of this disease shock is a prominent feature. In the discussion of the operative treatment of this lesion there has been much difference of opinion as to whether intervention is justifiable on account of this condition of depression verging on collapse. In these cases, if an operation is decided upon, every effort should be made to shorten the anicsthotic time and to limit the abdominal manipulations. Shock Associated with Injury. — In accident surgery many patients are admitted to the clinic in a condition of shock the degree of which varies. When an operation is demanded on account of the nature of the injury, the surgeon must not only recognize that shock is present, but must estimate its degree. SURGICAL SHOCK. 485 Shock and Hemorrhage. — In accident surgery the first important factor to be estimated is whether the shock is due to hemorrhage or is simply the result of injury. This differential diagnosis is of chief importance when the injury is subcutaneous, in the chest or abdomen, or about the great blood-vessels in the axilla, groin, or limbs. Hemorrhage must be checked by immediate oper- ation, no matter what the degree of shock. This differential diagnosis, when the possible area of hemorrhage is concealed, is frequently difficult. When the injury is in the region of the axilla, groin, or the limbs the presence of a rapidly increasing swelling is a definite indication of vessel injury and the formation of a hsematoma. A decision in regard to operative intervention in such cases is frequently very difficult. Experience has demonstrated that in a certain number of cases the tension of the surrounding tissues limits after a time the size of the ha3matoma, that thrombosis takes place in the ruptured vessel, and accomplishes a stoppage of the hemorrhage which for the time has threatened life. In these cases the operative manipulation is usually of sufficient magnitude to contraindicate its immediate performance. For this reason it should never be performed unless the indications are that thrombosis is not taking place in time to save the patient from death from loss of blood. The degree of shock in these cases is the best sign of an indication for operation. The differential diagnosis between shock from abdominal contusion with- out hemorrhage, and that with hemorrhage from rupture of the viscera, is a very difficult one. In the former, operation is contraindicated; in the latter, inune- diate laparotomy is imperative. Experience has demonstrated that ruptures of the liver and spleen and large vessels of the abdomen have not the same tendency to spontaneous cessa- tion by thrombosis. Here the blood escapes into the free peritoneal cavity. The conditions favorable to thrombosis which are present in the rupture of the large vessels of the extremities are absent in the abdomen. As a rule, an injury of sufficient force to produce a rupture of the abdominal viscera would of itself cause shock. In my own experience the degree of shock is never as great as m those cases in which there is, in addition, hemorrhage. For this reason an accumulated experience enables one to make the proper diagnosis in the majority of cases. Movable dulness in the flanks is path- ognomonic of hemorrhage; it is not always present. A blood count theoret- ically should be of value, but experience has demonstrated that, as a rule, the blood-changes do not take place quickly enough after the hemorrhage to be of aid in the necessary immediate diagnosis. The leucocytosis of hemorrhage does not appear until some hours after the accident. The aid of a blood-coimt imfortunately cannot be depended upon in these cases. In the literatine the recoveries after immediate laparotomy for rupture of the spleen, liver, and pancreas have been due to an immediate intervention based upon the history of the injury and the clinical pictiire of shock. Now and then an abdomen is 486 AilERICAN PRACTICE OF SURGERY. opened unnecessarily. But if the exploratory exposure of the abdominal cavity is performed under local anaesthesia, there should be no mortality in the cases with negative findings. Unfortunately, I am unable to present any blood- pressure studies in these cases to demonstrate that measurements are of diag- nostic value. I am inclined to think that they would be. In rupture of the kidney the problem is perhaps a more difficult one, be- cause experience has demonstrated that in quite a number of cases the hemor- rhage ceases spontaneously. Yet, in other cases, life has apparently been saved by immediate incision and packing, or, in a few cases, by nephrectomy with ligation of the renal vessels. In this group the indications for operation are based upon the degree of shock, the size and increasing development of the perii'enal hgematoma. In contusions of the chest with hemorrhage from the mtercostal vessels or ruptured lungs the problem of operative intervention is a very difficult one to solve. My own experience has been limited, and the literature is somewhat scanty. The same principles apply as those discussed under rupture of the kidney, or a subcutaneous injury of a large blood-vessel of a limb. In the intrathoracic hemorrhage a certain number of patients recover without operative intervention. In others the hemorrhage must be checked by exposure of the bleeding vessels. Here again the degree of shock is of aid, and the increasing area of thoracic dulness indicates the amount of hemorrhage. The results of intervention in cases of rupture of the intercostal vessels have been good; on the other hand, the results obtained in cases of rupture of the lung are not very encouraging. All of these cases should be watched very carefully, and when the condition of shock gradually grows worse and the physical signs indicate an increase of the ha-matoma there should be no further delay. This group of cases de- monstrates how important it is for surgeons to study very critically shock in all of its clinical manifestations, and how much we are in need of blood-pressure and blood-count records. Amputation During Shock. — This subject has been one of discussion from the beginning of surgery. In all injuries of the limbs associated with an extreme degree of shock, and in which the nature of the injury demands either ampu- tation or some other operative manipulation, the question at once arises whether the best results are obtained by immediate action or whether the patient's chances of recovery are better if the operation is delayed. Experience has demonstrated that there is no fixed rule. In a certain number immediate operation must be performed, in others it is better to delay. The duration of the time of postponement varies. Hemorrhage is always an indication for immediate intervention and must be checked, even though it demand an extensive operation. The danger of further loss of blood is much gi-eater than the danger of an operation m a condition of shock. If hemorrhage has SURGICAL SHOCK. 487 ceased, operation may be indicated, because the pain from the nmtilated hmb is sufficient to be considered as a factor which will increase shock. When these two factors are absent, it is better to delay in order that the patient may have the opportunity to recover as much as possible. The operation, how- ever, must not be postponed too long, because after a time the element of infection becomes an important factor. Wainwright, of Scranton, Pennsylvania, has had a large experience in trau- matic surgery and has contributed to the question under discussion ("Clinical Studies in Blood-Pressure and Shock in Traumatic Surgery," Medical News, New York, March 25, 1905). He writes: "To remove the nerve impulses after trauma, an immediate repair of the injury, if at all feasible, is very important. For this reason our own view is strongly in favor of primary amputations in limbs hopelessly mangled. Leaving a mangled, oozing limb with crushed and exposed nerves, in the hope that delay will give a more favorable opportunity for intervention, will, in many cases, by allowing the cause continually to act, only drive the patient into a condition beyond all hope. A well-covered stimip with oozmg checked, on the other hand, will give a chance to a patient in whom the cause of shock is stopped and to whom the administration of therapeutic measures will not be like pouring water through a sieve." There are cases, however, in which there have been a great deal of injury and much loss of blood, and in which the degree of shock is severe, that appar- ently do better if the operation is delayed, providing the two indications just discussed — hemorrhage and pain — are not present. It has been my observation that in traumatic surgery the patients exhibit- ing a definite clinical picture of shock do, as a rule, better than those in whom the clinical picture of shock is less evident. The former receive appropriate treatment, the latter are apt to be treated on the supposition that shock is absent. In looking over the records of the Johns Hopkins Hospital Surgical Clinic of cases of primary amputation for compound fracture and other crushed injuries of the extremities, I find a few examples of death a few hours after the amputation, from shock. In examining the notes of these cases we are impressed by the fact that, if shock was present before the operation, it was not recognized. They received no preliminary treatment, the operations were not hastened, but a careful, painstaking amputation was performed. On the other hand, the patients in whom the local injury was more severe and the clinical evidence of shock M'as unmistakable have recovered. These patients received preliminary treatment, and the amputation was rapidly performed — in the older cases under primary, short anesthesia; in some recent cases, under anesthesia associated Avith blocking of the nerve trunks. No at- tempt was made to do anything more than rapidly to remove the mutilated limb, cutting through miinjured tissue. 488 AJMERICAN PRACTICE OF SURGERY. The practical deduction from tliis is tliat m all cases of traumatic surgery the possibility of shock must be borne in mind. The clinical picture is often obscm'e: we have no means of estimating accurately the exact quantity of blood lost before admission to the clinic. For this reason it is better to treat these patients on the principle that shock is present to a considerable degree and that a great deal of blood has been lost before the patient came under observation. In my o-uti experience loss of blood is the most dangerous factor in these cases of traumatic shock. Exposure to Cold. — Contributions from military surgeons indicate that ex- posure to cold is a distinct element in increasing the degree of shock. This factor is frequentty present in traimaatic surgery. Exposure to Heat. — That biu-ns may produce an extreme degree of shock has been discussed. I am imable to find any literature giving observations on the relation of shock to high temperatures; that is, whether injured persons in very hot climates exhibit a degree of shock out of proportion to the character of the injury and the loss of blood. In a considerable experience of my own in operations during the severe heat of the summer in Baltimore I have been unable to find that there is any increased mortalit}', but on days on which the temperature has been very high — over 90 or 95 degrees — I have been impressed that a certain number of cases show more evidence of shock at the end of a long operation, and I have quite frequently postponed operations of unusual magnitude on account of the great heat. During this extreme heat it has been my rule to have ice caps placed on the head of the patient during the operation. I have observed a few cases of heat stroke during operation and a few of heat collapse. I have never been called upon to operate upon a patient suffering with heat prostration or heat stroke. In alcoholics I am quite convinced that deliriima tremens is much more frecpent during the hot season of the year, after operations, especially for injuries. ^\Tien secondary operations are necessary, for example, for infected compotmd fracture, these patients are unusually bad subjects. I believe that in critically ill patients extreme degrees of heat in the operating-room should be considered a factor which may mcrease the shock, and precautions should be taken for protection — ice caps to the head, less covering to the body. If possible, the operation should be postponed, or performed at night when it is cooler. Atmospheric Pressure. — Theoretically the blood pressure should be affected to a certain degree by the atmospheric pressm'e. Wliether this is ever a factor in shock in critically ill patients I am not prepared to say, nor have I been able to find anj' in^■estigations on this point. Psychic Factors. — To what extent mental conditions can produce shock, or exaggerate it when present, is very difficult to determine. One fre- quentty observes syncope in strong individuals from the loss of blood. Fear SURGICAL SHOCK. 489 may produce a general condition bordering on shock. This question has not been investigated, from a scientific standpomt, m its relation to practical surgery. In my own experience all these mental conditions, which may be classified mider the term fright, anxiety, nervousness, exaggerate the clinical picture of shock when it is present. But apparently they are not factors of such importance as those already discussed. When these patients are nar- cotized the pulse and respiration immediately improve. The importance of studying this question is chiefly from the standpoint of diagnosis. The surgeon might easily attribute the general condition of the patient to factors other than mental, and thus be led to erroneous deductions as to the presence of shock, or as to its degree. This mental factor must always be borne in mmd, but it is a dangerous mistake to attribute to fear or nervousness the general condition of the patient when in reality it is due to more serious conditions. This mistake is much more to be guarded against than the reverse. I have never been able to convince myself that these mental factors are ever of sufficient significance to influence the results, as far as mortality is con- cerned, of traimiatic or any other form of surgery. Nevertheless, every effort should be made on the part of those m attendance upon the patient to allay fear, and calm all nervous or other anxieties. The ability to restore the patient to a quiet and confident frame of mind may not improve the immediate and permanent results of the sm-gical intervention; nevertheless, it adds so much to the comfort of the patient that every effort in this direction should be made. In operations mider local anesthesia we observe the good effect of this attitude toward the patient. It has been called "moral anesthesia." The surgeon who learns the art of this method can perform imder local ansesthesia many operations for which others have had to employ general anesthetics. This is well illustrated in operations for exophthalmic goitre. If the surgeon gains the confidence of his patient and is able to control the nervous element during the operation, everything goes smoothly. \^'Iien, however, this control is lost, the general condition of the patient immediately gets worse — he be- comes restless, the pulse increases in rapidity, the respiration is labored, and not infrequently it is impossible to finish the operation without a general anes- thetic. By reason of its relation to shock I believe it is safer to use general anesthesia if during the attempt under local anesthesia the sm-geon is unable to calm and control his patient by the so-called "moral anesthesia." Yomiger surgeons especially are apt to miderestimate these mental factors. Their attitude toward patients is frequently one that contributes not at all to the mental comfort of the latter. Tact and cheerfulness compatible with the seriousness of the patient's condition are the two most important attitudes on the part of the surgeon. At the same time he should never allow himself to exhibit any anxiety or give utterance to any expression which could be interpreted as xmcertainty in regard 490 AMERICAN PRACTICE OF SURGERY. to the treatment or its result. As stated before, we have no definite evi- dence that this so-called moral anaesthesia or treatment materiallj' affects the ultimate result. It does, however, affect the comfort of the patient, and, I am ciuite convinced, is one of the most important factors in preventing or lessening a post-operative complication which, for the lack of a better term, has been called " post-opera- tive neurosis." Summary of the Etiological Factors in Shock. — The most important are sen- sory impulses affecting the medullary centres, the next is hemorrhage. General anaesthesia, the duration of the operation, extreme degrees of heat and cold', cer- tain drugs, must be considered additional factors. Although their influence has not been proved, psychical effects should be borne in mind. As general conditions which predispose to shock, or associated with which the important fac- tors of shock act with greater effect, we must bear in mind anaemia, diabetes, nephritis, alcoholism, general infection, local infections, all those conditions which interfere with metabolism and nutrition, collected under the term "star- vation," and auto-intoxication. The sensory impulses which produce shock may be the result of traumatism, or the result of cutting, tearing, or mutilating tissues during an operation. Only those organs and tissues which are supplied by sensory nerves of the cerebro-spinal system need be considered in relation to shock. Their sensibility is increased by inflammatory lesions. Organs and tissues innervated by the sympathetic nerves or the lower vagus are insensible, and at the present time we have no evidence that their manip- ulation or injury need be considered as factors in shock. Tumors, according to Lennander, are insensible. In handling these insensible tissues it is unportant to be familiar with their anatomical relation to or connection with surround- ing sensitive tissues. Drugs and manipulations which in experimental investigations and clinical observations produce a rise in the blood pressure may and do affect the vaso- motor centres in a deleterious sense when these centres are exhausted. Over- stimulation of these centres may be just as dangerous a factor as a primary depressant or inhibitory action. This is important to recollect in interpreting the readings of a blood-pressure chart. The best index to the good condition of a patient durmg an operation is uniform pressure. Fluctuations in the curve should be considered indications of exliaustion. Manipulations which produce a sudden and considerable rise in the blood pressure should be interpreted as overstimulation — factors which have a tendency to produce shock. It is quite true that drugs like chloroform, or any manipulations, or loss of blood, which produce a primary fall in the blood pressure, are more dangerous factors than those which produce a primary rise, but both must be considered factors in producing shock. In the employment of the tonometer, or other blood- SURGICAL SHOCK. 491 pressure-measuring contrivances, the best indication of the good condition of the patient is a unijorm pressure. DIAGNOSIS OF SHOCK. One may classify surgical patients suffering from shock into three groups : those in whom shocls is associated with traumatic injuries, those in whom it is associated with some disease, and, finally, those in whom the shock is de- pendent upon operative intervention. The clinical pictures of shock in all three groups are very much alike. However, the knowledge of the previous history of the patient is of great A^alue in determining the probabilit}'^ of shock and estimating the psychical element and differentiating it from the physical. Extreme degrees of shock are not at all difficult to appreciate. The moderate degrees and the conditions which predispose to shock are frequently very diffi- cult to recognize ; and yet a diagnosis in this stage is of the utmost importance. Crile differentiates between shock and collapse. He writes that the term shock should be used for that condition in which the essential phenomenon is a diminution of the blood pressure and the etiology of which is an exliaustion of this centre of varying degrees due to too frequent and too powerful afferent stimuli. The term collapse should be confined to those cases in which the essential phenomenon is a sudden fall of blood pressure due to hemorrhage, injuries of the vasomotor centre, or cardiac failure. In shock, therefore, we have an exliaustion of the centre; in collapse, a suspension of fmiction. Practi- cally, it is very difficult to differentiate an extreme degree of shock from collapse. In shock in traumatic surgery the knowledge of the amoimt of blood lost and the nature of the injury is of great value. In shock associated with disease a correct diagnosis of the lesion and an accumulated experience with operations upon individuals suffering with a similar disease are the most important aids in estimating the probabilities and degree of shock. In operative interventions the experimental work of Crile on the relation of blood pressure to the different manipulations upon the different tissues and organs, the observations of Lennander upon the sensibility of tissues, and one's experience on the relation of the different operative manipulations to the general condition of the patient, allow the surgeon to estimate, during the operation, with a considerable degree of accuracy, the condition of the patient, how much more the patient can stand without producing a degree of shock dangerous to life. W\\Qn patients are under a general narcosis it is less difficult to estunate the degree of shock. In shock associated with injury and disease — for example, acute pancreatitis, intestinal obstruction, intestinal perforation, general peri- tonitis, etc., etc. — it is frequently difficult to determine how much is mental and how much physical. It has been my personal experience that the greater the degree of shock the fewer the symptoms which may be classified as mental. 492 AMERICAN PRACTICE OF SURGERY. A patient in a condition of shock is quiet, he appears somewhat dazed; although there is no delirium, the action of the mind is slow; there is no nervousness and there are no manifestations which might be called h3'sterical. The pulse, as a rule, is rapid ; the blood pressure, if measured, will be f oimd low. The skin and mucous membranes are pale. The temperature is frequentl}' below nor- mal. All cutaneous and deep reflexes are diminished, thej' maj'' be absent. The skin feels cold and as a rule clammy. The respirations are shallow. A rapid pulse is by no means an indication of shock. It must be mter- preted in its relation to other factors. A blood-pressm'e observation is of the greatest importance to interpret the significance of a rapid pulse. In exoph- thalmic goitre the pulse is rapid, but the pressure high ; and in operations upon patients of this kmd one should always emploj^ a tonometer. In nervous and hj'sterical patients the pulse is rapid, but the blood pressure in the few records at my disposal is nonnal or slightly elevated. Cyanosis should be considered a definite indication of the bad condition of the patient. "\\lien the S5maptoms are chiefl}^ psychical the patient is flushed, restless, anxious, the reflexes are increased, all sj-mptoms are exaggerated. The true mterpretation of these sjmiptoms is, as a rule, not difficult. They disappear the moment the patient is under narcosis. From this discussion it is to be seen that the diagnosis of shock is at the present time not scientific. We have not sufficient observations on blood press- ure m practical surgery to allow one to estmiate the degree of shock by the blood pressure alone. The diagnosis of shock is an art difficult to describe. It is based upon experience and the proper estimation of various factors. Practically, if the surgeon will bear in mind all the points previously dis- cussed, he will be able to estimate the condition of his patient before and during operation with sufficient accuracj' for the purposes of safety. PROGNOSIS. As the result of mjury without hemorrhage, death from shock seldom takes place. If a fatal result is at all to follow an injury without loss of blood, death is almost instantaneous. Recovery from shock due to the primary effect of the uajmy is usually permanent and immediate. Sudden death after an in- jury should, perhaps, be attributed to collapse, as described by Crile. Sudden death from blows upon the lower chest and epigastrium have been observed in so-called solar-plexiLs blows, well loiown in pugilistic encounters. Accord- ing to Crile's experimental research the collapse is due to the effect upon the heart; the solar plexus may be disregarded as a factor. Even in the extreme degrees of shock from injury, if the patient shows any symptoms of reaction, the prognosis for recovery is good, provided no further operative intervention is necessar}^ SURGICAL SHOCK. 493 The prognosis of shock due to operative intervention depends very much upon the condition of the patient. Recovery from an extreme degree of shock usually takes place if the patient was in good condition before the operation and provided that when the symptoms of shock appear the administration of an anffisthetic and operative intervention can immediately be suspended. Wlien hemorrhage is one of the factors in shock, whether it be due to injury or to an operation, the prognosis is not so good. Death may not be immedi- ate, but a patient exsanguinated reacts much less quickly, and the dangers of secondary complications are very much greater than they are in those cases of shock which are not associated with hemorrhage. TREATMENT OF SHOCK. At the present time the consensus of opinion favors a treatment which is simple and, on the whole, passive. In the presence of shock nothing should be done which, with our present knowledge, may increase the condition. The patient should be kept absolutely quiet, flat on the back, in an elevated posi- tion, with the head low. The body temperature should be maintained by artificial heat. Only one drug is indicated hypodermatically — morphine. This is indicated in small doses in all cases. Its quieting effect undoubtedly is beneficial. When the patient is suffering pain, sufficient morphia should be given to relieve this pain. Salt solution given subcutaneously and by enema is indicated in all cases. When there has been hemorrhage the quantity ad- ministered subcutaneously should be greater. If the patient's condition is critical the salt solution should be given intravenously; the quantity should vary from 500 to 1,000 c.c. In very critical cases associated with much loss of blood the intravenous infusion should be given rapidly; in patients less critically ill, more slowly. When the shock is not associated with hemorrhage, according to Crile's experimental work, the administration of the salt solution subcutaneously and intravenously has not given evidence of great value. In practical surgery the clinical evidence favors the employment of salt solution in all cases. But, as a matter of fact, in traumatic and operative surgery the majority of cases of shock are associated with hemorrhage, and for this rea- son salt solution, of course, gives evidence of its great value. In the other cases of shock without hemorrhage, the prognosis is, as a rule, so good that it is difficult to estimate the value of salt infusion. We know, however, both from experimental and from clinical evidence that it is not harmful. For this reason, salt solution should be employed in all cases, intravenously, subcutane- ously, or by enemata, according to the condition of the patient. Crile's experimental work has demonstrated that, in shock, what is required is not a cardiac or a vasomotor stimulant, but some agent which will produce contraction of the peripheral vessels. The chief danger in shock is a dilatation 494 AMERICAN PRACTICE OF SURGERY. of the vessels to such a degree that the patient practically bleeds to death within his own vascular system. This contraction of the peripheral circulation can be accomplished by bandaging the limbs and abdomen, or by the employ- ment of Crile's pneumatic rubber suit which accomplishes the same object by increasing the atmospheric pressure. (Figs. 140 and 141). From the experimental work of Crile and others, adrenalin is the only drug which produces vaso-constriction by its action on the peripheral vessels. Un- fortunately, at the present time the clinical evidence in favor of its employment is lacking. If we were quite certain that this use of adrenalin had no elements of danger, it should be employed in all cases. But at the present time the evidence in favor of its value is not sufficiently positive to warrant us in assuming the risks of its employment, except in desperate cases. Then it should be given intra- venously in salt solution and slowly. In the treatment of patients suffering from traumatic or operative shock I employ position, artificial heat, bandaging of the limbs and abdomen, mor- phine, and salt solution. I agree with Crile and others that strychnine and cardiac stimulants are of no value and may be injurious. A certain number of patients with traumatic and operative shock die in spite of all measures for their relief. In these cases there has usually been hemorrhage. Now and then, during the operation, and less frequently shortly after oper- ation, the patient's condition may suddenly become critical, frequently with- out previous warning, and death may take place in spite of treatment. These may be considered examples of "emergency shock." The sudden change in the pulse and respiration is so rapid and the evidence of impending death is so manifest that it is difficult not only to ascertain the cause of the collapse, but also to know what is to be done for its relief. In some of these cases it may be the anesthetic; in others it may be the cardiac shock described by How- ell. Crile is of the opinion that in some of the cases the condition is due to a sudden dilatation of the heart. At the present time it is difficult to state whether anything can be done for the relief of these patients. Fortunately, the number of such cases is small. The problem needs further investigation. Salt Solution. — The solution used for subcutaneous and intravenous infusion in the surgical clinic of the Johns Hopkins Hospital is as follows: Sodium chloride (NaCl) 0.9 Calcium chloride (CaCl) 0.01 Potassium chloride (KCl) 0.03 Distilled water (H..0) 99.06 This stock solution is prepared by the druggist. The nurse in charge of the operating-room takes 50 c.c. of this stock solution and adds it to 950 c.c. of distilled water. This solution just fills a liter glass flask. The flask is corked SURGICAL SHOCK. 495 with cotton, covered with muslin, which is properly tied to the neck of the flask. These flasks are sterilized by steam under pressure and are ready for use at any time. I do not think that an exact temperature of the solution is necessary. The flask filled with its solution is inunersed in boiling water until it reaches a temperature of 100° to 105° F. It is then poured into a glass infusion appa- ratus or an ordinary rubber douche bag, each provided with a long piece of rubber tubing. Both should be sterilized by boiling. They can be wrapped in towels and sterilized by steam, and in this manner are ready for emergencies. For subcutaneous infusion an ordinary aspirating needle (Fig. 138) is attached to a small piece of rubber tubing in the end of which is a short glass tube. This is boiled with the instruments. When a subcutaneous infusion is indicated the skin along the pectoral border of the breast is cleansed, the flask is filled with salt solution, the needle is attached by telescoping its glass tube end into the long rubber tube, the salt solution is allowed to run out of the needle, the tempera- ture tested on the skin of the arm, the needle is then introduced just below the border of the pectoral muscle, parallel with it in the direction of the axilla. This allows the solution to infiltrate the tissues in the base of the axilla which are very vascular, and absorption takes place rapidly. In ordinary cases 500 c.c. should be allowed to take at least twenty minutes to pass from the flask into the tissues. The same method is suitable for intravenous infusion, except that a differ- ent needle should be employed, one like that shown in the accompanying cut (Fig. 139). As to the locaHty where the injection should be made, I prefer one of the superficial veins at the bend of the elbow. Adrenalin Solution — Brewer of New York advises 15 minims of the 1 : 1,000 commercial solution to 1,000 c.c. of normal salt solution; as a rule, not more than 500 c.c. should be given intravenously; if possible, a blood-pressure apparatus should be employed at the same time. As the blood pressure rises the infusion should be checked. If the blood pressure falls again, the infusion should be resumed. Precordial pain is a contraindication for the further em- ployment of this method. Wainwright employs the adrenalin solution in the proportion of 1 dram of the 1 : 1,000 solution to 2,000 c.c. of salt solution. 496 AMERICAN PRACTICE OF SURGERY. Fig. IJO. — Crile's Pneumatic Suit Adjust edfor an Operation upon the Neck. View taken from one side. Fig. 141. — Front View of Crile's Pneumatic Suit Adjusted. SURGICAL SHOCK. 497 Crile's Pneumatic Suit. — Figs. 140 and 141 illustrate a patient dressed in this suit. It has been placed on the market by the Goodrich Rubber Company of Akron, Ohio, with directions for its employment. In the treatment of traumatic shock the most important question to decide, if operation is indicated, is, when should this be done? This has been dis- cussed. In the treatment of shock during operation the most important factors are: the exact knowledge of the patient's condition before operation; a close watching of his condition during operation, so that the surgeon may at once become cognizant of the first symptoms of shock. When these symptoms arise, it is the art of surgery to be able to estimate how much more the patient can stand, because the most important features of treatment are to withdraw the anaesthesia and cease operative manipulations. The routine treatment of shock has not much value, if anaesthesia and operative manipulations must be continued. If continuation of the operation is absolutely necessary, the patient's head should be lowered and an intravenous or subcutaneous infusion given. But a surgeon runs great risks if he continues to give anaesthesia and proceeds with the operation after symptoms of'shock manifest themselves. Any stimulating treatment in the beginning of an operation is contraindi- cated. It undoubtedly masks and retards the symptoms of shock, so that when the patient does give evidence of shock the condition becomes rapidly more critical. VOL. I.— 33 PART III. GENERAL SURGICAL DIAGNOSIS. GENERAL SURGICAL DIAGNOSIS. By JOSEPH D. BRYANT, M.D., New York City. The principles in surgical diagnosis are certain fixed, essential truths relating to the diagnosis of surgical afflictions, which truths are the legitimate outcome of surgical experience and experiment, and which are employed by the surgeon to determine the presence and measure the comparative significance of sur- gical disorders. The principles in surgical diagnosis are properly divided into the general and the special principles. The general principles in surgical diag- nosis relate to certain diagnostic truths, to which there are no exceptions within the scope of their application; i.e., pain is a general symptom of surgical afflic- tion. The special principles in surgical diagnosis relate to diagnostic truths having a special relation to certain general or local surgical afflictions, but not necessarily having a like connection with other surgical ills; i.e., pain character- izes neuralgia, and not paralysis. The constant advance of the science of surgery develops new principles in diagnosis, and also correspondingly lessens the value of principles of former importance, often indeed rendering them inoperative. The general morbid conditions of the human body, whether of a surgical or of a medical nature, have an expression of their own, called the signs and symptoms. Also each special affliction of either condition has its own distinctive form of expression, by means of which it can be recognized from another of the same class. A variety of affliction of a definite sort, with a form of expression common to itself, may be obscured and its presence lost sight of because of the unexpected intrusion of a dissimilar affliction with manifestations peculiar only to itself, called, if you will, a complication of the primary trouble. Also many of the tissues of the human body have each an expression of affliction peculiar to it- self; i.e., the serous tissues when inflamed develop a sharp, darting pain, the cutaneous a dull, throbbing pain, etc. Briefly stated, medical and surgical afflictions have each a distinctive language which, when properly interpreted, establishes the diagnosis and indicates the treatment, and, toOj often the prog- nosis, and possibly the sequels of the affliction. It is believed that the reader will have noticed that surgery and medicine may be so closely associated with each other by common forms of expression as to be quite inseparable; therefore, a surgeon ought to be in most instances as good an interpreter of symptoms as a demonstrator of surgical technique. The surgeon should be fully equipped with practical knowledge, supplemented 501 502 AMERICAN PRACTICE OF SURGERY. by a well-grounded understanding of anatoni}^, physiolog}', chemistry, pathol- ogy, etc., and a correct estimation of the phenomena relating to the fluids of the body in health and in disease. Mechanical and other practical devices are as much a part of the outfit of a well-equipped surgeon as of the physician. In fact, no means fitted to aid in determining the essential facts in surgical diagnosis should be absent from the surgeon's armamentarium. It is not amiss at this time to observe that the powers of human reasoning in diagnostic attainment are apt to be developed in direct proportion to the paucity of other means of reaching final conclusions in the field of differential endeavor. And, conversely, inductive diagnostic attainment should be care- fully fostered or it will be disabled by the vigorous assaults made on reasoning effort by the use of the novel expedients employed in diagnosis ; not necessarily because of the abundance of these expedients, nor of their presence, but be- cause it is thoroughly human to accomplish a perplexing purpose with as little effort as possible. The scant danger that now attends "explorative incision" is not unlikely in some instances to encourage a degree of mental contentment, inhibiting the reasoning powers, followed, after brief and unconvincing effort, by the expression, "Oh, well! an explorative incision will settle it." Necessarily, the patient is the embodiment of the information on which the diagnostician must depend for his differential conclusions. Here, as in other fields of interrogator}^ endeavor, only carefully considered plans of attaining a comprehensive knowledge of facts relating to a patient, thoughtfully, cour- teously, and consistently employed, will satisfactorily accomplish the purpose. The diagnostic efforts of the surgeon should be exercised in all respects in such a manner as will secure frank and unreserved concurrence on the part of the patient. In the absence of a gracious and sympathetic method of inquiry, comparatively little progress will follow the best-planned endeavors of attain- ing the requisite knowledge. Arbitrary, unsympathetic, and indelicate expres- sion or manner is likely at once to inhibit all concurrent action of the patient related to diagnosis. The patient's and the friends' understanding of the direct and comparative value of testimony in the history of a case is necessarily crude, often misjudged and misleading, and frequent!}^ of little practical sig- nificance. Yet the earnest desire to impart information which these efforts betoken should be given proper respect, duly emphasized by the pleasant and patient bearing of the surgeon. It will not infrequently happen, for good reasons perhaps, that a patient will decline or evade answering queries deroga- tory to his own sense of dignity or self-respect, or to his ideas of propriety, or that may intrude on personal secrets or a sense of duty to himself or to another. These sentiments should be respected by the surgeon, who, without appearing overinsistent, may, notwithstanding these obstacles, be able to ap- proximate the truth sufficiently to meet the aims in view. GENERAL SURGICAL DIAGNOSIS. 503 In all matters of expediency relating to the questioning of patients, due heed should be given to their standards of intelligence and of culture, their sense of refinement, and their familiarity with unsavory and uncanny topics and associations. Some patients, for reasons difficult to explain, will, after being discreetly humored- by the surgeon, freely disclose things of signal impor- tance which were at firkt retained with tenacious reserve. The most delicate form of expression and manner, untainted with any irrelevant references or needless allusions, are requisite in developing the facts of a case in the female sex, especially if they be of a strictly personal nature and in any way encroach on a high standard of proper inherent female propriety. And especially is this plan of action necessary in instances of the yoimg and the unsophisticated of the female sex, and with those whose disinclination to co-operate in an effective manner needs the supporting presence and encouragement of a third person, such as an old friend, a near relative, and sometimes the mother of the patient. Again, sensitively attuned patients of either sex will not infrequently divulge important or perturbing facts more freely and fully in the absence of a third party, especially when the information imparted tends in any way to detract from the dignity, self-respect, or standing of the patient. The needless exposure of the person of a patient of either sex, or unneces- sary dalliance of any sort, as in the use of instruments or in physical examina- tion, or by superfluous and irrelevant talk, especially of a familiar character, should be sedulously avoided. In instances of special examinations of female patients of instrumental or of oral kind, the near-to-hand presence of a third person of responsible station should be had; and, on occasions of the adminis- tration of anaesthetics for diagnostic or other purposes, the third person should be present in the room. It should be remembered that patients differ naturally from one another in many respects, notably in constitutional characteristics, in idiosyncrasies, methods of expression, manner of bearing inflictions of various kinds and of es- timating the severity of pain and other manifestations of injury and disease. In other words, each patient, until a different course is determined upon, should be regarded as a more or less independent factor in diagnostic endeavor, and be estimated accordingly in all essential particulars. The use, on the part of the surgeon, of ambiguous and technical expressions should be avoided, and only such terms should be employed in diagnostic effort as are of easy comprehension by patients already more or less perturbed by the situation and by the fear of the announcement, by the surgeon, of unfavorable findings. The unlettered often mistake the application of common words or may be ignorant of their existence. Hence, if great care be not exercised under these circumstances by the surgeon in taking the history of the case, he will be so misled as to negative an important proposition in diagnosis. "Have you ever been injured before?" is often promptly answered by the patient in 504 AMERICAN PRACTICE OF SURGERY. the negative; and, if the answer be as promptly accepted, it will, in many in- stances, destroy the preA'ious history of the case in this important respect. The incorrectness of the answer is due to the forgetfulness of the patient, or to a failure to appreciate the import of the inquiry or possibly the meaning of the word injury itself. In the taking of the history of a case, it is usually a better plan to permit the patient to make a preliminary statement of his case, guided somewhat b}' the surgeon, if need be, in order to bring out the logical sequence of events. This plan of action lends courage and gives importance to the patient, and, when advantageously used by him, hastens a correct understanding of the truth, especially when the landmarks thus established by the narrative are utilized by the surgeon in securing a more detailed expression of the facts. Only rarely, indeed, does one meet with a patient who is unable to give an intelligent account of his o\\m case, even when aided by the inquiring surgeon. In such exceptional cases the surgeon can hope to secure sufficient data for the formation of an enlightened opinion only by paying the closest attention to the patient's statements and by exercising much patience and forbearance. Also it should be remembered that the correctness of a diagnosis and the promptness with which it is secured depend, not only on the complete and accurate history of the case in all respects, but also on the experience, the knowledge, and the sagacity of the surgeon. It is not sufficient merely to give the proper name to the disease, but the extent and location of the tissue changes, the causes, the present and prospective complications, the treatment, the prognosis, and the sequels should each be given due weight in the judgment of the surgeon, based on intelligent appreciation of the information gained from the testimony of the afflicted witness. Surgeons of large experience are very cautious about utilizing the elements of probability when they come to frame a diagnosis, but the beginners, the impatient, and those whose resources are still undeveloped and who have yet to feel the sting of frequent and mortifying failure are very apt to make an un- safe use of these elements and to draw hasty conclusions. The overconfidence and inattention born of extended experience, of youthful enthusiasm, and of pretentious ignorance are certain to lead with distressing frequency to igno- minious failure in diagnosis. It is only those who have properly trained minds and who are willing to gain experience by honest and painstaking labor who can expect to attain eminence as diagnosticians. Finally, a word of caution should be added regarding the temptation to make long or distressing examinations of patients who are severely afflicted with weakness or pain, with no other object in view than that of making a prompt diagnosis. Nor should the mistaken zeal of the physician or surgeon lead him to sacrifice m the slightest degree a patient's chance of recovery for the purpose of forestalling the autopsy findings. As before remarked, "The patient is the embodiment of the information on GENERAL SURGICAL DIAGNOSIS. 505 which the diagnostician must depend for his differential conclusions." The oral testimony of the patient and that obtained by careful systematic scrutiny of his person and of the fluids of his body, together with the knowledge gained by the surgeon through a proper interpretation of the circumstances relating to the case, should, in the great majority of instances, provide sufficient evidence for the determining of a diagnosis. THE EXAMINATION OF THE PATIENT. In examining a patient for diagnostic purposes certain well-established com- mon facts, such as the name, age, occupation, habits, family history, etc., of the patient should be given precedence for apparent reasons. Afterward, the line of inquiry may begin with an analysis of the first onset of the disease sus- tained by the patient, or with that of the present attack. If the former course be adopted, it will be desirable also to investigate the facts relating to all subse- quent attacks. This plan may be denominated the direct or the analytic method of procedure. The reverse of this practice may be employed by commencing the examination with the present phenomena, and following them back to the beginning of the affliction. This latter method is denominated the synthetic method of procedure. We have no hesitation in expressing a strong preference in favor of the former method, since our long experience with it has amply justified this conclusion. And more especially are its advantages apparent in complicated cases and those with long and varied histories of disease or in- jury. In instances only of recent injury or disease, the briefer plan of analytic examination may be utilized at first, but with the idea of later estimating the effect of remoter troubles on the patient's welfare. The direct or analytic method of examination places before the surgeon in a consecutive and logical manner a complete general history of a patient, and any omissions in this re- spect will be due to the lack of experience of the examiner or the failure of the patient properly to comprehend the meaning of the questions submitted for reply. In the indirect or synthetic method of examination there is much lia- bility of overlooking important contributive facts, and, too, the method is apt to be more embarrassing to the patient and perplexing to the surgeon than is the analytic plan. However, in instances of local injury and in other afflictions with brief histories, as well as in those requiring prompt therapeutic action, the synthetic plan is usually preferable. As before stated, by means of the analytic plan the facts of a case are gradually revealed in a logical systematic manner, disclosing in a direct way their mutual, consecutive relationship with each other up to the last moment. A record of events of any kind, made from the beginning to the finish, is much more likely to be complete and effectively connected than when the synthetic method is employed. In either instance, however, only great care, fortified by a thoughtful and painstaking method 506 a:mericax practice of surgery. of making such inquiries, will enable the surgeon to secure a complete and reliable history of a case. Too often the finding of an unusual or striking feature in the history of a case will cause the examiner to lose sight of the main purpose in view, and follow enticing developments, of little or no coutributive importance, to obscure and irrelevant endings. When, in the course of the taking of a histor}^, especially of a complex nature, an imexpected or unusual feature appears, the fact should be specially noted and reserved for later analysis, and not permitted to divert the course of the examination from the regular line of procedure. The Maimer of Questioning Patients.— Already much has been said re- garding the general manner of the examiner toward the patient, but it still remains to speak definitely of the arts of phrasing and so systematizing the questions as to make the best use of opportunity. The query commonly addressed by us to a patient is, " Up to what time (year) of your life were you perfectly well?" or, "Were j'ou ever ill or injured? If so, what was the date of your first injmy or illiress?" After ascertaining by careful analysis the causes, nature, severity, results, and other important features of the first of the afflictions, the remaining ones should be given a similar consideration. The asking of a patient, "What is the matter with you?" or, "What is your com- plaint?" often amuses the patient and sometimes misleads the sm-geon, causing the former to reply, with comical or sententious mien, "I came to you to find out," or to express gravel}' a diagnosis that has not a good fomidation. By the former reply one may be annoyed; by the latter, one is often deceived. Therefore, we have long since ceased seriously to propound these questions, limiting ourselves in this respect to those admitting of no cavil or misunder- standing, such as "Of what do you complain?" "How long have you been ill?" or, "How long ago were you injured?" etc. These are entirely proper queries, calling for prompt and intelligent replies, leading to direct and logical con- clusions. In instances of traumatic violence, especially in those depending on a fall or a blow, the facts relating to the cause and the distance of the fall, the manner of striking, and the physical characteristics of the object struck, together with the immediate effect on the ability of the patient to care for himself and the causes of the hinderance to do so, are matters of great impor- tance that should be ascertained at the outset in a systematic, logical man- ner. So far as it is possible to do this, an estimate should be made of the results likely to follow a blow of a given force. The Circumstances of a Case.— It is plain that it is of great importance, as regards both the diagnosis and the prognosis, that all the circumstances of a case should be ascertained in the most complete manner; and, in addition to what can be learned hj questioning, there should be a most careful exam- ination of the organs and the fluids of the patient, with the idea of disclosing any subtle or obscure threatenings of life. The securing and the proper grouping GENERAL SURGICAL DLA.GNOSIS. 507 of the evidence gained by all examinations, up to the time when the surgeon is called in, constitute the history of the case; and it is proper to say in this connection that a well-taken and wisely comprehended history constitutes the true route to correct diagnosis and rational treatment. Two methods of examination of a patient are commonly practised — the general and the special method. The former method relates to information regarding the influence of age, sex, habits, occupation, family history, etc., on the afflicted patient. This knowledge is gained by questioning the patient and the friends and relatives. The special method relates to information gained by the personal examination of the patient by the surgeon; it is also often called the special examination. It is manifest that both general and special exam- inations are absolutely essential to the securing of reliable conclusions. The General Examination of a Patient. The Age. — The age of a patient exercises a striking influence on the nature, the effect, the results, and correspondingh^ on the outcome of treatment, of disease or injury. AVhile youth is decidedly sensitive to shock and pain and loss of blood, yet it is largely exempt from the weakening influences of the responsibilities, acts, and duties incident to advancing age. The subtle effects of physical and mental strain, of deteriorating practices, and the natural changes of advancing years lessen the resisting power of the human organism in almost a direct proportion to their degree and extent. For these reasons children who escape the effects of shock, loss of blood, severe pain, and restlessness recover in an astonishing manner from injury and disease that often promptly terminate existence in adult life. Adult patients differ in endurance from one another more than do the young. Aged patients with good muscular and mental vigor, well nourished but not adipose, having good digestion, sound organs, and pliable vessels, can withstand well the trials of physical infliction and may be classed as enduring patients. Patients, however, with conditions the reverse of these, especially when complicated with alcoholic influences, should be treated with conservative deference, as they often promptly succumb to the effects of even comparatively moderate physical punishment or to the delirium of previous alcoholic excess. The common manifestations of disease in different parts of the body have different meanings at different ages. A pain in the knee of a child suggests disease of the hip ; in the adult, disease of the knee itself. A pain in the bladder of a child may point to stone in the organ, but never to enlarged prostate. Tumors having similar characteristics and locations in the young and the old have different natures and meanings; in the former they are, as a rule, innocent growths; in the latter malignant. Enlargements of lymph nodes in the young are common, often indicating simple irritation or tuberculous infection; in the adult such enlargements are infre- 508 AMERICAN PRACTICE OF SURGERY. quent and often dependent on malignant changes. Injury near a joint in the young may cause diastasis, but never in the adult, for manifest reasons. Injuries of equal force are more liable to cause fracture in the adult than in a young person, since the bones break the easier in the latter class. Cutaneous diseases in children are strongly suggestive of one of the exanthemata; in adult life they more commonly indicate other forms of infliction. The Sex. — Women withstand operations and injuries rather better than do men, a difference due in part to the greater patience and fortitude of the former, increased by the benefit of greater temperance and discretion in things that so often unfit the opposite sex for the patient support of physical hardship. And, too, con- finement in bed and general inactivity are less irksonie to the female than to the male sex. The physical and psychical natures of the sexes are radically dif- ferent in health, and correspondingly diverse in disease. The emotional ele- ment dominates the female; the physical and the unemotional dominate the male. We find, therefore in the female not infrequently general hysterical manifestations, and also local ones referable to a joint, a limb, the bladder, a special organ, the special senses, etc. — in fact, to almost any part of the body, and, too, presenting rational, or unreasonable, and even grotesque character- istics. Later, these hysterical patients often suffer from an almost omnipresent and depressing fear of cancer of the uterus or breast, even to the end of life. It rarely happens, however, that one of the male sex exhibits hysterical mani- festations of a general or local nature. Commonly, local evidence of disease in the male sex justifies the belief that such disease actually exists. The male sex, like the female, has its fears of impending dangers, but of a different nature. In youth and during advancing manhood, fear of heart disease is apt to be the uppermost thought in the patient's mind, followed by a long period of comparative mental rest in this respect. In advanced years, however, he is likely again to be disturbed by apprehensions of enlarging prostate and of cerebral apoplexy. In either sex in these circumstances the motto of the surgeon should be, "Carefully examine, promptly diagnosticate, and quickly remedy a real or imaginary infliction." It is proper to say at this time that the inflictions of the male sex are largely the heritage of occupation, of exposure, of mental and physical hyper-activity, and of bad habits; those of the female, on the other hand, grow out of the complications and sequels of menstruation and child-bearing, combined with those begotten of inactivity, introspection, and emotional domination. The Occupation. — The occupation of a patient has, indeed, very much to do with the nature, the severity, and the outcome of disease or injury. The occupation itself may directly cause infliction or contribute the influences that favor its occurrence or development. Necrosis of the jaw, lead colic, soot- cancer of the scrotum, patella bursitis, olecranon bursitis, malignant pustule, glanders, etc., are each striking examples of the direct influence of occupation GENERAL SURGICAL DIAGNOSIS. 509 on physical ills of the watchmaker, the painter and the plumber, the chimney- sweep, the scrub-woman, the miner, the tanner or the wool-sorter, and the stableman, respectively. The modern chauffeur contributes by his calling, as do his patrons by their presence, a fair share, illustrative of the relation- ship between injury, on the one hand, and occupation and pastime on the other. The "glass arm," the rounded shoulders, the curved spine, etc., testify re- spectively that the baseball pitcher, the tailor, the shoemaker, and the farmer bear, each one, the indelible stamp of his calling. Those whose avocations expose them to the allurements of overeating and drinking and of late hours, to say nothing of the besetments of vice that often attend such forms of busi- ness, are, in many instances, illy equipped to withstand even minor degrees of injury or disease, and they can scarcely hope to recover from injury or disease that in a decided degree imperils the lives of those who have in the past given due heed to personal welfare. The Habits. — Whether or not the patient has been temperate, virtuous, and law-abiding is of great significance in estimating the probable results in instances of grave injury or disease. The liability on the part of those who in- dulge in excessive eating or drinking, of contracting a disease, or of directly or indirectly fostering its development by such habits, is of vicious import in lessening human vitality. The manner of dress, the habits of labor, the periods and methods of recreation, the amount and the character of the food and the regularity of eating, along with the use of narcotics, are matters that exercise an influence for good or for evil on the patient, usually in direct proportion to the excess of indulgence. Often, however, for reasons difficult clearly to define, what are apparently indulgences for one person will promptly bring to grief another less immune than he to their effects. It is important to remember that the virtuous may bear innocently and unsuspectedly the evidence of impure asso- ciations and their sequels. In such cases as these the surgeon should exercise great discretion; otherwise irremediable sorrow and perhaps unmerited dis- grace will be unwisely added to distressing affliction. The Antecedent History.— The antecedent history of a case should in- clude, not only the past record of the patient in all matters relating to disease or to injury, but also, when the question of disease is involved, that of his an- cestors. Either a special or a general invulnerability to disease on the part of a forebear may be transmitted, and when this happens it may manifest itself primarily in the first generation, sometimes in the second, and perhaps even in a later generation. According to Colles, syphilis of the child means syphilis of the mother, whether or not the mother shows other symptoms of the disease. The child, however, will infect the nurse. It not infrequently occurs that a young patient with pronounced or scanty manifestations of glandular, nervous, ocular, auditory, or other symptons of disease is allied remotely or immediately •with unsound ancestry bearing a history strongly suggestive of syphilitic or 510 AMERICAN PRACTICE OF SURGERY. tuberculous infection. In such cases as these, especially those suspected of a S3'philitic taint, wise discretion should prompt the surgeon to employ the requi- site treatment without arousing incriminating suspicion on the part of those who maj' regard with justifiable pride the praiseworthy records of an honored ancestry. The recognition of certain family characteristics compels the belief that rheumatism, gout, hsemophilia, color-blindness, tumors of a simple or of a malignant nature, are apt to be transmitted from parents to their offspring. Tliat this should be so is emphasized by the well-knowm facts of the transmission of personal distinguishing traits from parents to children. In view of the fact that there are numberless instances in which the transmission of such diseases has not taken place, we should be admonished not to give too great heed to coincident marked disease in those who bear a blood relationship to the patient. The antecedent history of a patient with reference to disease and injury falls better for consideration under the personal history of the patient. The Personal History. — The personal history of a patient should include a record of his personal characteristics as well as of the diseases and injuries which he has sustained, and of their outcome. Incidentally, his habits, more especially the objectionable ones, are subject to review, since thej^ may have a very important bearing on the prognosis and treatment of the patient. The temperament of a patient has not a little to do with the outcome of sur- gical injury and of disease, as well as -with the results of operative interference. The patient with a full pulse, vigorous heart, high arterial tension, warm surface, and excitable nature, is more liable to unfavorable reaction from injury and surgical effort than is one with the reverse characteristics. A patient with sluggishness of thought and action, and comparatively iirdifterent to suffering and confinement, usually bears well the inflictions of physical injury. As a general proposition, those of good physical vigor bear operations better than those of a feeble state. However, the athlete who prides himself on his strength of frame and fleetness of limb, whose entire system is fitted only for active effort, is unsuited for the confinement of the sick-room. The semi-invalid and the one to whom confinement and inactivity bring no special regret are, other things being equal, better fitted for the ordeals of an operation than is a trained athlete. When expedient, therefore, the former class should serve a brief pre- paratory period in confinement, attended with free tmloading of the system by the emunctories, before an operation is commenced. Tlie obese patient is ill fitted for an operation, especially when the obesity is the result of indolence, luxm-y, or intemperance. Hereditary obesity is of less moment than is the acquired, especially when it occiu-s in a person who has not been able to exercise control over his appetite. Physiologic plethora, when present in a person who is otherwise phj^sically and functionally vigorous, offers no obstacle to recovery from injury or disease, or to the securing of suc- cessful results from operative effort; but the acquired plethora of the tippler GENERAL SUEGICAL DIAGNOSIS. 511 and the gourniand should be as a beacon warning against operative practices not supported by the logic of expediency and not protected by the strictest modern technique. In the presence of an obscure or incomprehensible injury of a patient, apparently due to assault, it is a relief to know that it may be de- pendent on the effects of alcohol or epilepsy. On the other hand, a knowledge of the fact that a person is a victim of epilepsy may spare him the ignominy of being regarded as the slave of intoxicants. In making these estimates, however, it must be remembered that a liquor-laden breath does not surely indicate the habitual use of alcoholic drinks; some solicitous friend or some good Samari- tan may have given liquor as a remedial measure to a patient who had never before experienced its taste. The deformities incident to a previous injury of a patient, especially of the skull or a joint, are of significant import in estimating the gravity of a recent injury located at the seat of, or involving the functions of, the part previously injured. The history of a previous fracture of the hip or thigh, with or without shortening, in the presence of a recent severe injury of these parts, is of im- mense importance, and such knowledge may be absolutely necessary for deter- mining the degree and the extent of the present injury. The great lesson taught by the preceding facts Is: Carefully take the his- tory of the case if you expect to make a correct diagnosis. Whether or not a patient be single or married, happy or unhappy, active or idle, whether sexual indulgence be occasional or frequent, lawful or illicit, are each a matter worthy of careful scrutiny in either sex. The history of the effects of menstruation, child-bearing, miscarriages, and the complications and sequels of parturition on a patient ought to be carefully weighed. The environment of a patient is a matter of great importance, siiice those who are favored with healthy surroundings are much the better fitted to meet the contingencies of injury and operative practice. Patients who are exposed to the deteriorating influences of special miasms, bad ventilation, damp and sun- less surroundings, are poorly qualified to meet physical emergencies, especially when the quantity, quality, and amount of food partaken fall short of the natural demand. Mental emotions of a depressing nature, such as apprehension, fear, remorse, disappointment, etc., from whatever cause, particularly when of a direct personal bearing, as fear of the outcome, whether real or imaginary, exercise discouraging effects on many patients. Steadfast hope, sure and abid- ing faith in the medical attendant, aided by a genial and philosophical nature and encouraging associations, contribute more to a successful issue in many cases than the faithful utilization of the therapeutic agents of a near-by phar- macist. The therapy of hope wields a mighty influence in recovery, and ought always to be administered with a free hand when circmnstances justify such a course. The nature of a morbid growth may be estimated, with considerable proba- 512 AMERICAN PRACTICE OF SURGERY. bility that the estimate will prove to be correct, by the length of time that it has existed, for if of long standing, with no special evidence of malignancy, it may be regarded for the time as an innocent growth. On the other hand, a rapidly increasing local growth, attended with local discomforting symptoms, should not be regarded as a harmless development, but should be promptly suspected to be of a malignant or destructive nature until otherwise determined. It appears proper at this time to assert that the nature of a growing tumor should be investigated at once, and that it should be promptly removed when the least suspicion of malignanc)' is found. Enough has been said already to emphasize the great importance of a care- ful general examination of a patient for diagnostic purposes. Hardly less than this would suffice, and not more can be said here because of the limited room allotted to this article. The Special Examination. The special examination includes the physical, both being of a general charac- ter. The examination of a patient may be conducted to a final conclusion by the combined diagnostic products of the following fields of inquiry: 1. Inquiry by the unaided senses of sight, touch, and hearing, and some- times of smell. 2. Inquiry addressed to the digestive, respiratory, circulatory, nervous, locomotor, and genito-urinary systems. 3. Inquiry directed to examination of the secretions, the excretions, the discharges, and other fluids of the body not already considered. (See the article next in regular order.) 4. Inquiry facilitated by the use of anesthetics and by drugs of narcotic effect; also inquiry supplemented by the findings of explorative and operative aid. Simple Inspection. — An experienced and observing surgeon can quickly determine the nature of certain diseases and injuries by noting the posture of the patient or of the injured part. The striking signs of coxitis, of dislo- cation of the head of tlie femur, and of fracture of the femur are such as to make a diagnosis of one from the other, by means of inspection, not at all diffi- cult under ordinary circumstances. The dorsal posture of a patient with flexed limbs, the distended abdomen, the thoracic breathing, and the anxious facies suggest so decidedly the presence of peritonitis as to require strong opposing evidence to effect a change of opinion. A patient carrying flexed an injured arm, supported by the opposite hand, with the head inclined to the injured side, will quite likely have sustained a fracture of the clavicle. A young patient, who in walking carries the body straight and stiff, with the shoulders elevated; who moves with a shuffling gait, stepping down with deliberation and care; and GENERAL SURGICAL DL\GNOSIS. 513 who, on standing, leans for support in an involuntary manner on friendly ob- jects, presents a familiar picture of spinal caries, which is completed beyond gainsay when the patient squats instead of bending forward to pick an object off the ground or floor. A patient with severe injury of the neck, who, with anxious facies, on moving grasps firmly the head between the hands, rigidly holding it thus while turning the body to either side for any purpose, may have fracture or dislocation of the cervical spine. The sitting posture betokens oppressive breathing, more especially when the shoulders are fixed by contact of the upper extremities with an unyielding support. Involuntary sliding down in beds points to extreme exhaustion. A patient with acute pleurisy from traumatism or disease, or one with pneumonia from the same cause, will lie upon the afflicted side so as to limit painful motion. In pleuritic effusion, and sometimes in thoracic aneurism and in movable abdominal tumors, the patient will lie on the diseased side to gain the increased comfort afforded by unhindered expansion of the unaffected side. In severe colic from whatever cause patients usually lie in the lateral position, with the limbs and body flexed on each other; then again, in severe abdominal colic, in gastric ulcer, in aneurism, and in verte- bral caries patients lie on the abdomen to secure the relief afforded by direct pressure, as well as that which comes from a change in the position of the spine and of the abdominal contents. The color of the skin, the state of nutrition of the body, the degree of muscular development, etc., are each important, as indicating whether or Hot the patient be temperate or ansemic, or be suffer- ing from disease of the heart, the liver, or some other organ. The superficial or pictorial anatomical appearances of definite parts of the smiace of the body, as related to injury and disease, present diagnostic factors often of great value. In order properly to estimate the diagnostic value of abnormalities in appearance, one should be familiar with the normal surface outlines. Owing to the differences which naturally exist in certain regions of the body in health, a proper estimate of the changes following injury or dis- ease of a part is often made with difficulty. The Surface of the Body. — In examining the surface of the body, it is es- pecially essential that the patient be placed in a good light which shall fall with equal intensity upon corresponding portions of the surface, i.e., the abnormal and the normal. The patient should lie straight, or sit erect if practicable, with the limbs placed symmetrically. The influence of respiration on the sym- metry and movements of the thorax and abdomen should receive close attention. Due allowance should be made for the effects of an uneciual shedding of light on a part and for any abnormal coloring of the skin dependent on disease or upon some artifically colored rays of light. The flattening of the shoulders due to fracture of the acromion process, to dislocation of the head of the humerus, or to atrophy of the deltoid, is very liable to cause — even in the mind of an experienced surgeon — perplexing doubt 514 AMERICAN PRACTICE OF SURGERY. as to the true state of affairs. The outhne of the spines of the vertebral column and the prominence of special ones are matters of prime importance, as undue deviations of the former and increased prominence of the latter bespeak a marked degree of lateral curvature and of antero-posterior curvature (Pott's disease), respectively. If we wish to render more evident the degree of lateral deviation of one or more of the vertebral spines, it is only necessary to rub the skin with the fingers several times, with some degree of force, over these bon}^ promi- nences. The skin at these points will thus be rendered red. Inspection of the Thorax. — Inspection of the thorax enables one to note whether or not the intercostal spaces and the respective sides of the chest respond normally to the respiratory acts, thus determining the presence or absence, in the chest, of fluid and its location. Such an inspection will, at the same time, reveal to us whether or not the heart be much enlarged or unduly active, and whether the thorax be symmetrical. The presence of collapsed lung or of fractured ribs causes restrained respiratory movements. Inspection of the Neck. — The two sides of the anterior aspect of the neck should be carefully compared, so that one may be able to note, later, the slightest abnormality of outline or of action. The fact that malignant disease, aneurism, glandular tumors, bronchocele, etc., are not infrequently located in this intricately constructed and important region sufficiently emphasizes the need for a most careful examination of the parts. In gunshot or stab wounds of this region emphysema of the subcutaneous tissue of the neck should lead to prompt investigation of the integrity of the trachea, the oesophagus, and the lung. The circumscribed areas lying directly beneath the lobes of the ear are specially worthy of stud}', since here is often seen the earliest evidence of enlargement of the parotid gland and of the overlying lymph nodes. Inspection of the Face. — The distressing tetanic grin, the pinched features, and the gasping inspiration of approaching dissolution, the involuntary frown of peritonitis, and the facies which expresses apprehension of the torturuig spasms so frequent in acute disease of joints and in severe neuralgias, notably of the trifacial type, are of common occurrence. A knowledge of the relation- ship of the eyes to their bony environment and to each other enables the sur- geon to discover, comparatively early, the presence, in the antrum, of a rapidly increasing growth, encroaching on the cavity of the orbit and its contents, and consequently to adopt the necessary surgical measures before the disease has advanced too far. The Abdomen. — The surface of the abdomen should be inspected with care, so that abnormal deviations referable to the outline, color, markings, move- ments, and the circulation may be quickly noticed and their significance readily estimated. For example, it is important, in making the distinction between a hernia, on the one hand, and a hydrocele or a scrotal tumor, on the other, to note whether or not an inguinal tumor first appears from above or from below. GENERAL SURGICAL DIAGNOSIS. 515 or remains in situ wfien the patient in standing or when he is lying down; and whether it does or does not convey an impulse on coughing. Even more impor- tant in many respects is a similar scrutiny of the femoral areas, for here hernia, abscess, glandular growths of simple, specific, and malignant natures find an open door, and, unfortunately, their presence and nature are in many instances ascertained too late to permit of the administering of satisfactory relief. The lymph nodes of this situation freely communicate with near-by clusters of sim- ilar nodes, offering early opportunity for extensive infection. Inspection, es- pecially of individuals with thin abdominal walls, reveals the presence of intra- abdominal tumors of considerable size, and also, in some cases, the increased peristalsis characteristic of intestinal obstruction. The Color.— In the diagnosis of disease and injury color plays a part of con- siderable importance. The scarlet blush of acute infiammation, the dusky red of subacute inflammation of a complicated or of a specific character, the mottled hues of venous obstruction and the livid one of asphyxia, the varying shades of color observed in traumatism, the inky aspect of dying tissue, the uncanny pallor of anasarca, and the sallow and waxy hues of advanced ma- lignancy — all of these testify in some measure to the important information which color may convey. Translucency of a diseased part can be quite well considered in connection with color. A translucent tumor is largely made up of a thin, colorless fluid, as in hydrocele of the scrotum and of the spermatic, cord; also in spina bifida. The normal tissues of the hand, the ear, and the cheeks are, in thin persons, when subjected to a powerful light, fitted to the purpose. Palpation. — On the abdomen, more particularly than elsewhere, palpation should be practised with gentleness and care, especially when the part thus examined is tender or inflamed or liable to be bruised or ruptured by the act. Incautious palpation of a diseased appendix, or of an abcess or cyst, may cause prompt rupture, with fatal extravasation of the contents. In palpating, the hand should be warm, be laid flat on the surface, and be allowed to remain quiet until the patient and the part are reconciled to its presence. Circular or to-and-fro movements, made in opposite directions and gradually increased in force and area, are employed to determine the depth, the sensitiveness, and the mobility of the deeper parts and of the overlying tissues. If the move- ments are too vigorous or the ends of the fingers are carelessly used for the pur- pose at first, the aims of the measure will be defeated by the muscular contrac- tions due to pain, to acute expectancy of the patient, and perhaps to irrational objections as well. The cautious and deliberate use of the ends of the fingers in palpation enables one to judge of the size, the depth, the mobility, and the physical characteristics (hard, soft, elastic, irregular, etc.) of a growth, to say nothing of the degree of sensitiveness of the parts. By palpation we determine the presence of fluctuation due to the existence of fluid in the tissues. Muscular 516 AMERICAN PRACTICE OF SURGERY. fluctuation may be mistaken for that caused by the presence of fluid, unless the muscles be palpated in the long axis instead of the transverse, when the fal- lacy will disappear. The crackling of emphysema, the crepitus of fractures, the thrill of an an- eurism, the friction of roughened synovial and serous membranes, and the creaking of joints, etc., are easily determined by means of palpation. The weight of a morbid growth springing from a pendulous part of the body, like the mammary glands, or the testis, or that of a pendulous growth elsewhere lo- cated, is determined by a sense related to that of touch; and since malignant and fibrous growths are denser than those of a fatty or cystic nature, this ele- ment of dissimilarity may be of use in differentiating them. An estimate of the temperature of a part, like the estimate of its weight, can, in many instances, be made by touch sufficiently well for all practical purposes. The fallacies, how- ever, that maj' arise in this practice are numerous. Thermometers are so uni- versally available, and their importance as an aid to diagnosis is so thoroughly established, that one is not justified in placing more than a passing reliance on a mere maimal estimate of the temperature of a patient. The Examination of the Principal Systems of the Body. The principal systems of the body, as arranged for the purposes of our pres- ent study, are five in number, viz., the digestive, the respiratory, the circulatory, the nervous, and the genito-urinary systems. But with the limited amount of space at our disposal, we can scarcely hope to do more than touch very lightly upon the questions of diagnosis as they are related to each of these systems. The Digestive System. — The digestive system comes first in the natural order of distribution, and it also deserves that position on account of its com- manding importance. The Lips. — The smooth lips of the young, the pallid lips of the feeble, and the cyanosed lips of those with deficient aeration of the blood are pictures with a significant meaning. The unclosed lips of dyspnoea, when parched and purple, indicate acute or chronic interference with the proper oxygenation of the blood. A downward and outward deviation of one angle of the mouth may be due to loss of power on the opposite side, or to undue contraction on the same side, as in facial paralysis and in cicatricial contraction respectively. The swelling of a lip may suggest traumatic violence, deep-seated inflammation, great local irritation, the urticaria of idiosyncrasy, the bite of an insect, or the effect of an injury inflicted during epileptic convulsions. A fissure, an ulcer, or a mucous patch of the lip are lesions which suggest a specific nature. An ulcer of the lip with induration of the related lymph nodes may be of either a malignant or a specific nature, and the microscope should be employed to determine the ques- tion. GENERAL SURGICAL DIAGNOSIS. 517 The Gums.— The swollen and spongy gums of scurvy, the blue line of lead poisoning, the red line of tuberculous and of cancerous cachexia and of diabetes, and the pallor of anaemia are among the many indications of disease related to the gums. The Teeth. — The early dentition of precocity and of syphilitic endowment, the delayed dentition of rickets and cretinism, the peg-shaped, notched teeth of syphilitic belonging, the teeth with dentated edges and furrowed surfaces of bad nutrition, the loosened and decayed teeth of scurvy, of purpura, and of phosphorus poisoning, are manifestations of great diagnostic value. The Tongue. — The tremulous tongue of the alcoholic, the halting protrusion dependent partly upon loss of muscular power and partly upon mental obtuse- ness, the genuine deviations caused by organic paralysis, the apparent devia- tions due to facial paralysis, are of diagnostic importance. The smoker's patch, the syphilitic mucous patch, the chancrous, the tuberculous, and the malignant ulcers should each be promptly recognized and their meaning esti- mated. The dry tongue of mouth-breathing, of continuous high temperature, of dehydration of the body, of asthma, of prostration, and of mental emotions is in each instance significant. The Palate, Tonsils, and Pharynx. — The offensive odor of follicular tonsil- litis, of gangrene, of cancerous and syphilitic ulcerations should be noted. The discoloration of the palate or pharynx due to venous obstruction, and the presence in these situations of circumscribed hemorrhagic points, with or without the escape of blood, require investigation. Perforations or ulcera- tions of the hard or the soft palate and adhesions of the latter to the posterior pharyngeal wall point to syphilis. Bilateral paralysis of the soft palate sug- gests diphtheria, possibly vertebral caries; unilateral denotes deep-seated in- terference, as in intervertebral pressure and fracture of the base of the skull. An aneurism in close proximity to the faucial tonsil may cause the latter to pulsate. Deep-seated ulceration of the tonsil suggests cancerous or syphilitic invasion that may involve the internal carotid artery and cause prompt death from hemorrhage. Acute tonsillitis attended by deep or superficial suppura- tion, especially the former, displaces the tonsil toward the median line, and calls for an incision to afford prompt relief. In exceptional cases the tonsil and contiguous tissues may be the seat of an extensive invasion of malignant disease which nevertheless causes so little local disturbance as to fail to arouse a suspicion of serious trouble. The mucous membrane of the pharynx is liable to various phases of disease of simple, specific, or malignant nature; it is also subject to acute and chronic expressions of the various forms of pharyngitis. The pharynx may be encroached upon by a post^pharyngeal abscess, causing slow or rapid interference with deglutition and respiration; such an abscess is due to vertebral caries or to some deep-seated infection close at hand or more distantly located. Difficulty 518 AMERICAN PRACTICE OF SURGERY. in swallowing may also result from rheumatic lameness, from spasm, from paralysis of the muscles of the larynx, or from hydrophobia, tetanus, or strj'ch- nine poisoning. The (EsoTphagus. — Stiffness of the neck due to acute inflammation of the oesophagus or to pre-ocsophageal suppuration simulates that which is depend- ent upon traumatism or upon rheumatic invasion. Diseases invading the mcuous membrane of the oesophagus are characterized by the production of a glairy and sometimes frothy or viscid mucous secretion, which is dislodged by hawking, and is especially abundant in acute inflammation and cancer of the gullet. Hemorrhage of the oesophagus usually comes from the lowor end of that tube, being due to varicose veins or to obstructive disease of the liver or heart, especially in old people; it also may come from intra-mediastinal pressure, from cancer and other forms of ulcer, and also from the presence of a foreign body or from a severy injury. The amount of blood discharged is usually small, alkaline, of bright color, and not mixed with the contents of the stomach unless vomiting has happened. Emphysema in the connective tissues of the neck suggests perforation of a lung or of the trachea or of the oesophagus. In the latter case there must exist a communication between the oesophagus and the trachea or one of the deeper bronchi, such a condition being due in all probability to ulceration or to a wound of these passages. When obstruction exists in the course of the oesophagus, auscultation to the left of the ninth or tenth dorsal vertebra may reveal delayed or absent second sound of normal deglutition. Any pathological change causing local or gen- eral enlargement of the oesophagus in the neck can be felt behind the trachea, usually better to the left side. Percussion may disclose conditions correspond- ing to those which have just been mentioned; and further confirmation may be obtained by the employment of the a:-ray, which reveals the presence of a bright area (emptiness) immediately next to 'a dark one caused by the presence, in the unequal lumen, of a mixture of bismuth or some other metallic salt introduced for the purposes of the test. The technique and the danger of introducing an oesophageal bougie should be well understood. In this connection I may sa}^ that the examiner will do well to refresh his memory regarding the size, direction, length, and other anatomical characteristics of the oesophagus, and also to studj^ well the diseases to which this organ is liable, in order that he may not, by his explorative procedures, expose the patient to any imusual danger. The Stomach. — The general anatomical relations and characteristics of the stomach cannot properly be stated here. The amoiait of information that may be gained by an examination from the outside is largely regulated by the degree of adiposity of the abdominal ^A'all and the size of the stomach. Usually, when the patienl; is lying on his back, it is possible to outline a dis- tended stomach by the surface shadow of the lower border, which moves with GENERAL SURGICAL DL\GNOSIS. 519 the respiratory act. Visible gastric peristalsis, in which the movement pro- gresses from the left costal arch downward to the right, is an indication of pyloric obstruction; so also is displacement or distention of the organ, con- ditions which can quite readily be ascertained b}^ the modifications of the normal percussion and succussion areas, etc. By transillumination with appro- priate apparatus one may determine, with a fair degi'ee of accuracy, the size, shape, and location of the stomach; also the presence of tumors and such other morbid changes of the viscera and contiguous structures as may modify the transmission of light. This plan of investigation, however, along with that of the x-ray and bismuth test, should supplement rather than supplant the findings of palpation. Palpation and percussion are fertile methods of ascer- taining the truth in regard to conditions of the stomach, and M^hen combined they are the most conclusive of all. The method of palpation already noted should be practised here, and its efficiency will be decidedly in- creased by placing the patient in the knee-elbow position, thus causing the stomach to fall forward upon the abdominal wall. These measures are decidedly enhanced in value by co-operative action on the part of the patient, and the measure of success obtained will depend largely upon the degree to which the abdominal muscles are relaxed, the thinness of the abdominal wall, and the size, mobility, and degree of involvement of the stomach. "\^Tien all these conditions are unfavorable, and notably when they are associated with pathological changes in neighboring organs, it becomes wellnigh- impossible to make a diagnosis. When the palpating fingers meet with increased resistance, especially of an unyielding, hard, and irregular nature, there is substantial ground for suspecting the presence of a cancer, and par- ticularly so when the mass occupies the usual site of a carcinoma of the stomach. Although cancer of the pylorus is commonly felt, as one might expect, above the navel and to the right of the median line, it sometimes occupies a lower posi- tion. When the tumor is confined strictly to the pylorus, it is not likely, even though it may be freely movable from side to side, to move up and down to any extent in harmony with the respiratory moA^ements of the diaphragm: but, when it is adherent to some freely movable organ like the liver or the diaphragm, then its movements will correspond to those of the part to which it is adherent. Cancer of the stomach is usually a small, hard mass with an irregular surface, while cancer of the neighboring retroperitoneal lymph nodes presents a broad surface, also hard and nodular, but influenced little or not at all by the respira- tory movements. When palpation in the region of the stomach reveals the existence of an area of diffuse tenderness, varying in severity at different points, one is warranted in concluding that a diffuse gastritis, or perhaps simply a dyspepsia, is present. When the ingestion of hot or stimulating substances, or of certain articles of food, causes pain, and when, further, this pain is aggravated by palpation, it is 520 AMERICAN PRACTICE OF SURGERY. permissible to suspect the existence of a gastric ulcer. If such an ulcer really exists, it ■u"ill be found that cool, demulcent, and soothing drinks lessen the pain. Diffuse pain in the region of the stomach, and pain also in the back, are symptoms of which patients affected with cancer of the stomach sometimes complain. Such spontaneous pains are less common in cases of ulcer of the stomach. Finallj^, there is a certain number of cases of both forms of disease in which the patient makes no complaint whatever of pain. Lactic acid is usually, but not alwaj^s, present in the gastric contents of patients affected with cancer of the stomach. There are many difficulties in the way of determining, by means of percus- sion, the boundary lines between the stomach and adjacent organs. When the stomach contains a watery fluid and the colon gas, or vice versa, there is no special difficulty in determining the topographical relations of these organs to each other. In the case of a distended stomach the relative positions of the greater curvature and the navel furnish a simple and fairly trustworthy indica- tion of the size of the organ. There is one condition, however, in which this guide cannot be safely followed; I refer to the descent of the stomach without any associated enlargement. Adhesions of the stomach to adjacent structures are very likely to diminish the area which the organ normally occupies, as deter- mined by percussion. On the other hand, when the stomach loses some of its motor power and, as a result, is distended, the dimensions of this area will be increased. Auscultatory percussion intensifies the sounds and enables the diagnostician to determine with greater precision the outlines of distended organs. The changing of the position of the patient, or the introducing into the stomach of a soft bougie, often adds to the value of a previous estimate. Auscultation enables us to determine the presence of the deglutition sound of oesophageal obstruction, as already stated above, and of the splashing sounds of fluid in the stomach and even in the transverse colon. The latter may be heard upon simple palpation, with or without the aid of a stethoscope. In some instances distinct splashing can be heard at a distance from the patient, without the aid of any instrument. AMien, long after eating or drinking, a splashing sound is caused by vigorous palpation, dilatation or atony or displacement of the stomach may be inferred. The Stomach Contents. — A knowledge of the various test meals employed and of the technique of lavage is essential to a suitable understanding of the diagnosis and treatment of diseases of the stomach. These are matters, however, w^hich belong more strictly in the domain of medicine than in that of surgery, and we will therefore say but very little here on the subject. Free hydrochloric acid with no lactic acid characterizes the products of normal digestion. Con- versel}^, the absence of hydrochloric acid suggests the possible presence of a cancer of the stomach, while the presence of alkaline or offensive vomiting GENERAL SURGICAL DIAGNOSIS. 521 indicates hemorrhage from the stomach and fecal invasion of the organ. The presence of bile and of various medicines mixed with the contents of the stomach materially changes the appearance of the stomach contents in health and in disease. It is therefore important to weigh this fact carefully before final con- clusions are drawn. The presence of a splashing sound in the stomach may be present for two or three hours after the taking of food, especially when a liberal amount of fluid is ingested at the same time. When the splashing is heard at a later period than this, the noise suggests obstructive changes in the stomach, loss of tone, or of delayed absorptive powers. The presence of undigested food in the stomach six or seven hours after ingestion indicates conclusively an ab- normal delay in the gastric digestive process, and calls for a careful survey of the case. In this connection it should be noted that vomited and regurgitated ingesta present distinctive differences. In the former, disintegrated muscular fibres are mingled with the characteristic stomach contents ; in the latter, the fibres are intact and not associated with gastric matters. The "stagnation test" — i.e., the determining, by the stomach tube, that the digestive functions of the organ are performed more slowly than they should be — is of great practical utility. Mucus is freely expelled from the stomach by vomiting in cases of severe gastric irritation and in other gastric disorders, and often, too, it is mingled with the fluids of the oesophagus and the mouth. The employment of the rec- ognized tests for saliva and for mucus is essential under these conditions. Blood expelled from the mouth by vomiting may have come from the stomach, the oesophagus, or the lungs, or from the mouth or its accessory cavities. The source from which it originates is clearly a matter of great importance. Blood coming from the stomach is expelled by vomiting, and is mixed at first with the gastric contents; later, if the stomach has been emptied and if nothing has been introduced into it since the vomiting occurred, the blood will be found unmixed with food. If the blood be abundant and if it be promptly expelled, it is florid; but if it be meagre in amount or long retained in the organ, or swallowed, the redness is not marked, and the matter vomited may be of "coffee-ground" appearance. When bile becomes mixed, in the stomach, with ingesta of various kinds and with Epsom salts (administered for the purpose of inducing catharsis), there is produced a mass which, when brought to view by the act of vomiting, resembles so closely partly digested blood as to require special means to make a clear distinction between the two. In cancer of the stomach hemorrhage is comparatively frequent, but rarely profuse. In ulcer of the organ the reverse of these manifestations is more often the case. The destructive blood changes of acute or chronic disease, the traumatism produced by external violence or by vomiting, and the engorgement of the blood-vessels due to portal obstruction may each cause hsematemesis of a trivial or severe character. Blood from the oesophagus is usually of small amount, unless it be due to 522 AMERICAN PRACTICE OF SURGERY. rupture of an aneurism, it is expelled by regurgitation, and is not mixed with the stomach contents except in those cases in which it may have been swallowed and afterward expelled by vomiting. The fluids of the mouth and the cesopha- gus, and perhaps the secretions of the bronchial tubes, may be mixed together, provided that much irritation of the first two regions has been present or that coughing has attended the escape of blood. This history of bleeding from the oesophagus should contraindicate the use of an oesophageal tube, until a thorough examination has established the fact that the patient's need is greater than the danger attending the emplo3auent of the instrument. The presence of an aneurism in immediate contact with the oesophagus should be especially thought of in this connection. Blood from the lungs is expelled by coughing, as a rule, and is not mixed with the contents of the stomach, unless vomiting has been provoked by severe coughing or from some other reason. The amount and color of the blood vary according to the cause of the hemorrhage and the condition of the patient. Bronchial bleeding may be noted in the form of streaks in the mucus expelled by coughing, or it may be quite profuse. In both cases the blood will have a florid color. When the blood comes from pulmonary tissues the amomit may be small or profuse, florid or dark, according to the extent to which the disease has invaded the arterial or the venous supply. The rupture of an aneurism into the bronchus suggests the escape of a large amount of blood, although at first it may be only of small amount. In the case of repeated hemor- rhages the amount increases rapidly. Blood from the mouth may originate from either of the sources already described, and be detected by the same char- acteristics as before stated. Blood from the pharynx, the posterior nares, and other parts of the region may be swallowed in considerable amounts, especially while the patient is in the recumbent posture; and, if it be expelled by vomiting, it may be mistaken for gastric hemorrhage — an important fact in fracture of the base of the skull, in which condition it is quite liable to occur because of the semi-conscious state of the patient. At this time it is wise to remind the reader of the general constitutional effects of great loss of blood (shock), and also of the influences, on the blood, of profuse and repeated hemorrhages. (Consult the articles on these subjects in the present volume.) The Liver. — The relation of the liver to the chest wall, the diaphragm, the peritoneum, the pleura, the intestines, and the gall Ijladder, together with the modification of those relations incident to the mobility of the organ, furnishes a series of anatomical facts of comprehensive importance in relation to diagnosis. Briefly expressed, the upper limit of liver dulness, in the normal state, corre- sponds, in the mammillary, midaxillary, and scapular Ihies, to the sixth, eighth, and tenth ribs respectively. The normal width of liver dulness, in the mid- sternal, the mammillary, the midaxillary, and the scapular lines, is three and three-fourths, four, six, and three inches respectively. These and associated topographical facts afford an opportunity of estimating the degrees of change GENERAL SURGICAL DIAGNOSIS. 523 in the general and circumscribed modifications of the area of fiver dulness, as caused by disease either of that organ or of contiguous organs. Passive conges- tion, amyloid disease, leuksemia, hypertrophic cirrhosis, cancerous infiltration, etc., furnish illustrations of the diseases which may cause a general increase in the size of the liver; atrophic cirrhosis and acute yellow atrophy affording the best examples of diseases which may cause a diminution of the size of the organ. Circumscribed modifications of liver dulness are due to the presence of ab- scess or cancer or cyst, and to such deformities as floating lobes, Riedel's lobe, and tight-lacing liver, so located as to interrupt the normal outline of liver dul- ness. Other factors which may alter the area of liver dulness are an enlarged gall bladder, a diaphragmatic hernia, a rickety thorax, and Pott's disease of the spine. Pulmonary emphysema, pleuritic effusion, an intrathoracic tumor, and subphrenic abscess (between liver and diaphragm) are among the diseases that change the superior outlines of liver dulness and at the same time displace that organ downward. On the other hand, the liver may be displaced upward, and the outline of the area of dulness be correspondingly altered, by any of the follow- ing pathological conditions: an abdominal tumor, such as a pancreatic cyst or a cyst of some other organ; abdominal distention from the presence of gas in the intestines or of pus or other fluid in the peritoneal cavity; collapse or con- traction of the lungs; and paralysis of the diaphragm. Then, again, other areas of dulness — due, for example, to the presence of an accumulation of fteces in the colon or to cancerous or tuberculous disease of the omentum or of the posterior aspect of the kidney — may become blended with that of the liver, and thus greatly enhance the difficulty of making a diagnosis. Finally, it must not be forgotten that, under normal conditions, the liver is moved appreciably downward by the diaphragm with each full inspiratory act. In penetrating wounds of the thorax, it is important to know that the dome of the diaphragm corresponds to the fourth rib on the right and to the fourth interspace on the left side of the chest, and that ordinary respiration alters this curve but slightly, -while a full inspiration makes a decided change, as the influence on the line of liver dulness will disclose. In instances of perihepatitis from traumatisms of various kinds, from abscess, and from inflammation of the liver, friction sounds, tenderness, and even enlargement of the organ may be found on physical ex- amination. The location of the pleural (costo-phrenic) sinus and the relation of the pleura to the diaphragm, and of the liver to this muscle and to contiguous vis- cera, are each of much significance. Before operating, for the purpose of evac- uating an abscess of the posterior portion of the liver, it may be found necessary to obliterate the pleural sinus; the purpose of this preliminary step being to prevent infection of the pleural cavity. On the other hand, it is sometimes found that this obliteration has already taken place through the action of an inflammation of recent or of old date. The obliteration of this sinus cripples 524 AMERICAN PRACTICE OF SLHIGERY. the action of the diaphragm. The diaphragmatic pleura and the opposing puhnonary plem-a may miite to protect the lung for a time against the invasion of sub-diaphragmatic or hepatic abscess. The liver may be safely approached from above through the diaphragm by reflecting upward from it the diaphrag- matic pleura. Finally, it must not be forgotten that the relation of the gall bladder to the costal end of the ninth (freely movable) rib, and the presence there of the lower border of the liver in health, are anatomical facts which have an important bearing upon diagnosis. The Intestines. — At the outset one ought to be entirely familiar with the topography of the abdomen and its contents in health: otherwise, ■ even marked abnormal deviations will not be noted and, as a result, their significance will not be appreciated. A reasonable knowledge of the anatomy of this region enables one to understand why it is that, in a distended colon, the distention is well marked except at the splenic and hepatic flexures; why it is that abdom- inal distention, beginning at the upper or the lower part of the abdomen, in- dicates, in the former case, distention of the stomach and jejmium, and, in the latter, of the ileum alone; and, finally, why it is that a special tympanitic en- largement at the right iliac fossa tells of a distended csecum. The latter fact is often of great importance, indicating, as it does, at which side (colonic or enteric) an obstruction exists, and often causing the csecum to be regarded as the "key" to the seat of intestinal obstraction. The relations of palpation and percussion to the presence of fluid in the abdominal cavity, and the change in the positions of percussion sounds in their relations to one another, due to changes in the position of the patient, ought to be kept clearly in mind, as being important diagnostic facts. '\^^ien a loop of small intestine is in a distended state, due to a distal obstruction in the immediate vicinity, it is possible, in the case of a person with thin abdominal walls, to excite easily visible peristaltic mo^•ements by the application of cold to the abdomen. A knowledge of the anatomical topography of the abdomen makes it pos- sible for the diagnostician to determine, with a fair degi'ee of accuracy, what pathological changes are taking place in the different parts of the imderl3^mg abdominal cavity; and a further knowledge of the relations in health and dis- ease between the gall bladder (distended) and the kidney, and the modifications which respiratory action may cause in these relations, furnishes a safe basis upon which a differential diagnosis may be constructed. In estimatuig the size, location, and degree of mobility of the kidneys, it will be found that inspec- tion, percussion, and palpation (mainly bimanual), in combination with a care- ful consideration of all the symptoms and an examination of the urine, furnish us with the only means of arriving at the truth. Investigations in this field are very difficult to carry out, and require, if successful results are to be attamed, considerable skill and experience. The same remarks apply with nearly equal force to the spleen and to other organs GENERAL SURGICAL DIAGNOSIS. 525 of the abdominal cavity. The consideration of all the details connected with the diagnosis of the different diseases of the abdominal organs does not form a part of the writer's purpose in preparing the present article. These subjects will all be fully discussed in the special articles which are to appear in the later volumes, and the reader is therefore referred to them for any further informa- tion which he may desire. The method of ascertaining the condition of the contents of the pelvis by means of the finger introduced into the rectum or the vagina is one of the most valuable methods of diagnosis that we possess. By it we are enabled to learn the presence of an obstruction in the intestinal canal and to form a fairly good idea of its nature — whether a new growth or a lesion of an ulcera- tive nature. It is also possible, by the same procedure, to ascertain the exist- ence of intestinal prolapse, or the presence, at or near the brim of the pelvis, of an offending appendix or ovary, of an abscess, or of a malignant tumor springing from bone. Finally, this method of exploration enables us to learn the condition of the bladder, prostate, etc., in the male, and that of the uterus and its appendages in the female. Far too many instances of irremedial cancer of the rectum, vagina, and uterus come to light in consultation practice to warrant the belief that commendable forethought is always practised by the medical attendant first in the field. We have no hesitation in asserting that the loss of life and the great misery caused by these afflictions will be lessened decidedly when an uiflexible rule is adopted of examining the rectum, the va- gina, and the uterus, when practicable, in all instances in which advice is sought for the relief of ailments of these or of contiguous parts. Fffical incontinence owes its origin to localized loss of power of the sphincter muscle, and this in turn may be due to a variety of causes, e.g., overdistention, relaxation, incision, rupture of the perineum, etc. Pauiful defecation, with or without rectal tenesmus, comes from various causes. Among them may be enumerated: an anal fissure, a facal mass, an inflamed prostate, a rectal cancer, and an inflamed or retroflexed uterus. Rectal tenesmus often causes great suffering, and it is especially frequent in those who would unwisely en- deavor to gain relief by persistent straining at stool. Impacted faeces, foreign bodies in the rectum, prolapsed hemorrhoids or prolapsed mucous membrane, cancer of the rectum, rectal polypus, dysentery and inflammation of the bowel, and intussusception will cause more or less tenesmus. Rectal tenesmus is not infrequently associated with painful defecation, often adding much suffer- ing and prostration to an already painful infliction. Voluntary resistance to the desire, the adoption of the recumbent posture, and prompt exploration of the bowel to ascertain the presence therein of an exciting cause are the measm-es which should be taken for the relief of the suffering. The Stools. — The frequency, shape, color, consistence, odor, and constit- uents of the stools should always be noted, especially in cases of intra-ab- 526 AMERICAN PRACTICE OF SURGERY. dominal injury and disease. The frequency of defecation in disease and in injury should be compared with the habit of the patient m health, due allow- ance being made for the kind and quantity of food which he eats and for any medicaments which he may have taken. The size and shape of a stool are regulated by the amoimt and the con- sistence of the faeces, the shape and size of the canal, and the degree of the force of expulsion. A small round stool suggests anal prolapse or an annular stricture of the rectum, and it may attend intussusception; the ribbon-shaped stool indicates the presence of large hemorrhoids, an enlarged prostate, or spasm of the anus, and it sometimes attends stricture of the rectum. The color of the stools is modified by the kind of food ingested, by anything that interferes with bile formation and discharge, by medication, etc. Milk and starchy foods predispose to light yellow stools: dark-colored fruits and fluids darken the stools, changing them often to correspond with the substances ingested: interference with the proper discharge or with the formation of bile causes light or clay-colored stools, according to the degree of the interference, and suggests the presence of cholelithiasis, cancer, etc., or structural change in the liver, pancreas, or duodenum. The green stools of infancy and the dark ones of any age indicate, respectively, bacteriologic coloring and the effects of iron, bismuth, etc., medicinally emploj^ed. Red and tar-colored stools indicate the presence of blood, the former coming, as a rule, from the lower bowel, especially the rectum. If the stools are red and if they originate from some point much higher up than this, the amount of the blood must, at the time of the hemorrhage, have been large and the expulsion rapid. The tarry stool indicates the occurrence of hemorrhage high up in the digestive tract, or in the upper part of the lower bowel, or in the small intestine, or, perhaps, even in the stomach; or it may indicate slow expulsion of the intestinal contents, and also the influence of the digestive process on the blood that has escaped into the intestinal canal. Microscopical or chemical and spectrum examina- tions may be needed clearly to establish the presence of blood in a stool. The consistence or density of a stool is often a matter of much surgical significance, as related to the presence of impacted faeces causing diarrhoea, as indicating the degree of intestinal constriction consistent with the passage of a stool of a given diameter, as denotmg in a degree the amount of the discharge attend- ing an ulcerative process m the intestine or the escape, into the gut, of the contents of a contiguous abscess or cyst. Scybalous masses passed with or without the aid of enemata are often of important significance as related to intestinal obstruction and to medication. The naturally offensive odor of a stool is increased to near the line of putridity by the diminution or absence of bile in the intestine, as in obstructive disease of the gall ducts, in specific or malignant ulceration of the intestine, and in the gangrenous processes of dysentery. Long-retained, unabsorbed nutritive enemata not infrequently GENERAL SURGICAL DIAGNOSIS. 527 lead to highly offensive stools. In suspected intestinal obstruction the escape of unusually offensive flatus is often happily followed by a reassuringly copious stool. A stool in the normal state is composed almost entirely of the products of the digestive tract and the associated organs, and of those portions of the food which cannot be digested. Morbid processes, however, may increase the amount of mucus and even stain it with blood, as in inflammations of the mucous membrane of the intestine and in intussusception. Sloughing mucous membrane may add to the stool membranous shreds; disease of the pancreas due to injury or to a calculous obstruction may add fat; gall stones, too, are sometimes found in it, and they may be of such a size as to cause com- plete intestinal obstruction. Pus, foreign bodies, and various kinds of para- sites also invite attention in special instances. The Respiratory System.— The careful study of the topography of the thorax, when it is in an active as well as when it is in a quiescent state, a thor- ough knowledge of the means of making a physical examination of the chest and of the signs elicited by such an examination, along with an understanding of the normal and abnormal rhythm of respiration, constitute the minimum of knowledge requisite for an intelligent appreciation of the common respiratory phenomena of injury and disease. It is important for the surgeon to note, not only the limits of the pleural cavities in health and in disease, but also the relation of the lungs to the pleura and to the chest walls; otherwise he may imperil the patient's chances by a needless invasion of a pleural cavity or of the lungs. Since these relations are much changed by the deep respiratory act, the importance of making an incision into the pleural cavity midway during an inspiration or an expiration ought to be apparent. That the pleura in health extends in the mammil- lary, the midaxillary, and scapular lines about two, three and one-third, and one and one-half inches, respectively, lower than the corresponding borders of the lungs is a matter of much practical significance in thoracic operations and in abdominal operations related to the lower border of the ribs (see remarks on p. 523 with regard to the area of liver dulness). The important points in chest topography, so far as it relates to diagnosis, are the following: the clavicle corresponds to the first rib; the projection at the junction of the first and second pieces of the sternum corresponds to the second rib; the nipple, in the male, corresponds to the fourth intercostal space; a line passed over the nipple around the chest crosses the sixth interspace at the axillary line (important in tapping the chest); the cartilage of the seventh rib and the ensiform process form an epigastric angle; the cartUage of the ninth rib corre- sponds to the gall bladder; and the eleventh and twelfth ribs can be located outside the erector spinas in stout persons. Inspection. — The inspection of the chest in health and in disease, if intelligently 528 AMERICAN PRACTICE OF SURGERY. conducted, is of great significance. Ordinary inspection may be supplemented with advantage by the use of the x-ray. One should note the frequency, the type, the character, and the rhythm of the respiratory acts. It is also impor- tant to observe whether or not the normal costal breathing is modified by the presence of disease or injury of the pleura, the lungs, or the diaphragm, or by disease of the abdomen from any cause; whether or not the diaphragmatic type is changed from the normal by pleurisy, pleurodynia, intercostal neu- ralgia, peritonitis, paral3'sis or spasm of the abdominal muscles, fracture of a rib, etc. Nearly all forms of disease increase the frequency of the respiratory act. Narcotic poisoning and disease or traumatism of the respiratory centre lessen the frequency of respiration. Cerebral compression changes the character of respiration, which becomes stertorous. Significance of the Changes in the Character and Rhythm of the Respiratory Acts. — Increased inspiratory effort points to an obstruction to the entrance of air, dependent on an impediment in the larynx or trachea; a^lema of the glottis and pressure from an aneurism upon the trachea are the two patho- logical conditions which ought to be thought of in this connection. This kind of obstructed inspiration is attended by increased expansion of the subcla- vicular regions and by retraction of the supraclavicular and intercostal spaces, and of the epigastric area. Labored expiratory effort is attended with bulg- ing of the intercostal spaces; emphysema and asthma being the common causes. In the former disease bulging of the soft parts above the clavicle may be observed during inspiration. The modifications in rhythm include the Cheyne-Stokes respiration and the sensory and pupillary phenomena so often associated therewith. This form of respiration is noted especially in grave cardiac, renal, and cerebral disease and as a result of certain injuries; and it is sometimes observed in the typhoid and septic states associated with pneumonia and the eruptive fevers. The jerking respiration of acute pain in the chest, as in fracture of a rib, the snoring breathing of the coma of disease and of narcotic poisoning, and the noisy respiration of faucial obstruction or paralysis are familiar phenomena and aptly illustrate modifications in re- spiratory rhythm. The uniformity of expansion of the chest attendant on normal respiration is modified in a striking degree by disease and by excitement. Dyspnoea de- pendent upon some cause or other may be associated with a chest which remains of the same degree of expansion during both inspiration and expiration. Men- tal excitement and physical effort are each capable of producing the same effect. Usually, however, such a condition of things suggests the existence of actual disease, as, for example: some lesion that interferes with the proper entrance of air into the lungs; a loss of respiratory power; a traumatism of such a nature that the patient voluntarily fixes his chest in order thereby to escape pain; acute disease involving both sides of the chest. Deviations confined to one GENERAL SURGICAL DIAGNOSIS. 529 side of the chest usually imply disease or injury of its bony framework, and the lack of mobility of the affected side is commonly emphasized by the greater mobility of the sound one, which is performing compensatory work. Defor- mity of the thorax may be partial or general in extent, of transient or permanent tenure, of trivial or serious aspect, and easy or impossible of correction. Various instruments are employed for determining the dimensions, the respiratory capacity, the mobility, and the surface outlines of the chest. In- formation with regard to these, however, cannot properly be given here; the reader must seek for it in the special articles. In a general survey of a patient's chest it is desirable to note carefully the condition of the surface circulation. In a normal state the superficial veins are not especially noticeable, but they may become so enlarged, through the influence of some disease which interferes with the circulation within the thorax, that their tortuous outlines are plainly visible. In a case of long standing, which recently came under my observation, the patient's face, ears, eyes, tongue, and throat were so engorged as to give him, for a time, until the obstructed circulation had regained its equilibrium, a distorted mien. It was found that the obstruction existed in the interior vena cava at a point located just above the heart. As a result of this obstruction the capillaries and veins corresponding to the attachment of the diaphragm to the thorax were much enlarged, and became rapidly and enormously distended because of a temporary increase in the obstruction; and as a further result there was venous engorgement of the structures of the body which empty their blood into the channels of return circulation above the diaphragm. It will not be amiss at this time to direct attention to the following anatom- ical facts which have an important bearing upon the question of -diagnosis : Litten's Diaphragm Phenomenon. — This manifestation of diaphragm action occurs in thin persons, and is best seen by placing the patient on the back in a good light and inspecting the chest at an angle of fortj^-five degrees. It consists of a shadowy line which lies at an acute angle to the ribs and travels downward a distance not exceeding two and one-half inches (in forced inspira- tion) in harmony with the downward movement of the diaphragm. The mani- festation is seen to begin at the sixth interspace on both sides with inspiration, and to move downward to the free borders of the ribs as the inspiratory act is completed. In expiration the reverse of the movement is noted. The vital capacity of the lungs is thought to be proportionate to the width of the shadow. Eliot has called attention to the increased depth and the fixity of the costal arch in the presence of disease of the contiguous viscera. Normally, the arch is mobile and quite easily encroached upon by pressure against the lower ribs. In disease, however, it is wide and faxed. Harrison has described a groove that appears on the chest of rickety subjects and is associated with impeded inspira- tion due to obstruction of the nose, fauces, and bronchial tubes, from various 530 AMERICAN PRACTICE OF SURGERY. causes. This grooved line begins at the xiphoid cartilage, and extends along the arched surface of the thorax to the axilla on either side. The Circulatory System.— T/ze Heart. — The established position of the heart in the chest in health and the ordinary phenomena attending its activities are matters of such common knowledge as fortunately to recjuire no special mention here. The apex in health in the adult is noted in the fifth intercostal space, just inside the mammillary line. Prior to the tenth or twelfth year the apex beat is in the fourth intercostal space, at or just outside the mammillary line. In making these observations it is essential to note if the nipple is dis- placed from the normal site; also to remember that changes of position in health are attended with change in the site of the apex beat. If the body be inclined to the left, the apex beat approximates the midaxillary Ime; with a full inspiration it is moved downward and to the right. In old age the apex beat is depressed, and in transposed viscera the change in the site of the beat is correspondingly modified. Deformities of the chest incident to spinal disease or to some other cause change the relations of the heart-beat to the chest wall. Diseases of neighboring viscera, characterized by the pushmg in- fluence of fluids, gases, solid and aneurismal tiunors, etc., and by the pulling effects of contracting organs and adhesions, aided or not by abdominal disten- tion, often change the position of the entire organ to a degree comparable with the extent and activity of the morbid process. Hydrothorax, pneumothorax, tumors and phthisis of the pulmonary tissue, aneurism of the aorta or of the contiguous vessels, and abdominal distention, encroaching on the diaphragm, are some of the pathological conditions which may produce a displacement of the heart.- Hypertrophy, dilatation, and aneurism of this organ, and peri- cardial- effusion increase and change the area of cardiac dulness in accordance with the degree and direction of the modifying process. In children with rickets or with marked hypertrophy or dilatation of the heart, or with peri- cardial effusion or aneurism of the heart, the precordial region may be bulging. Thrills and friction sounds are appreciated by the hand, the tremors corre- sponding to the sites of the valves of the heart and the direction of the blood flow. ; Aneurism of this organ also gives to the hand of the examiner the char- acteristic thrill. The friction sound of pericarditis, traumatic or otherwise, is often readily distinguished by means of palpation; auscultation announces the absence or feebleness of heart sounds, their location, rhythm, the seat of greatest intensity, also the presence of abnormal action, enabling one to judge of the need of treatment and of the value of the remedial measures employed, especially on urgent occasions. The heart sounds are intensified by a variety of causes, e.g.: approximation of the organ to the ear, as may be effected by pressure from the outside; thin- ness of the thoracic wall; hypertrophy and increased action of the heart; up- ward pressure upon it by tumors; pericardial adhesions, etc. The heart sounds GENERAL SURGICAL DIAGNOSIS. 531 are diminished by conditions diverse from those just preceding, such as, e.g., a thick chest wall, distention of the lung or of the pericardium with blood, pus, or air, and weakened heart action from any cause. The splashing sound heard on auscultation indicates the presence of air and fluid in the pericardium. All of the foregoing are of importance in cases of traumatism of the heart. The significance of the various murmurs, etc., may best be considered in books and articles devoted to the purpose. The duskiness of the surface of the skin attending general obstruction of the circulation, and the paleness from feeble or depleted blood supply, need only be mentioned to establish their significance. The Vessels. — The pulsation and enlargement of the large arteries of the extremities and neck are a part of the history of old age, cardiac hypertrophy, excessive physical exercise, excitement, etc. These phenomena, when observed in the neck, signify aneurism of the aorta, atheroma. Graves' disease, etc. Undue enlargement of the carotids and of the innominate, in such cases, is sometimes mistaken for aneurism. Pulsation of the abdominal aorta in thin, nervous, or apprehensive subjects is frequently the cause of much distress, and may be mistaken for aneurism, especially when associated with pain, enlarged pancreas, or a tumor of the stomach, omnetum, or colon. The epigastric pulsation which is often observed in these cases, or which may be transmitted from above by a hypertrophied heart directly,' or by contact with the liver, is also often a source of needless solicitude to the patient and possibly to the medical attendant. However, in all these cases a careful differentiation of the phenomena observed from those which attend a case of genuine aneurism ought soon to clear up all doubts. And in this connection it is well to examine the smaller arteries, with the idea of noting their shape, size, and pulsation as related to arterio-sclerosis. Of much significance are the pathological changes to which the veins are liable. A sudden pain in the calf of the leg or in the instep, the tenderness and hardness in the course of the femoral or iliac vein, followed by swelling of the leg and foot, are so commonly an important part of the history of crural phlebitis as to require no more than mention at this time, unless it be to warn agamst the possibility of mistaking it for rheumatism, as is frequently done. In ligaturing a distended vein, in a case of varicose veins of the lower extremity, it has sometimes happened that the ligature has included a contiguous impor- tant nerve, thus greatly aggravating the original pain due to the distention of the vessels. The surgeon, therefore, needs to be on his guard against this accident. Wlien the veins of the arm or the leg become gorged with blood and the skin of the affected limb takes on a dusky hue ; and when, furthermore, these changes are soon followed by the development of oedema and pain in the parts involved, we may unhesitatingly assume either that a thrombosis has occurred in the chief vein or that it is being pressed upon by some patholog- ical product at a point in or not far distant from the axilla (in the case of the 532 AilERICAX PRACTICE OF SURGERY. arm) or the groin (in the case of the leg). For example, a cancerous growth in the axilla or in the pelvis is a common cause of such a sequence of events. In this connection it should be said that the pressure of a tumor of the medias- tinum or lung, or of an aneurism of the arch of the aorta, or of the subclavian, the axillary, or the innominate artery (right side), or pressure from enlarged axillary lymph nodes, may each be followed by discoloration and cEdema of the corresponding extremity. It must not be forgotten, however, that the free clearing out of the contents of the axilla for cancer may be followed by painful and excessive oedema, because of the resulting destruction of lymphatics — changes which may be confused with oedema from pressure of lymph-node involvement attendant on a relapse of a maligiiant growth. Enlargements of h-mph nodes and morbid growths pressing on the iliac veins of either side cause cedema and pain of a lower extremity. Finally, there remains the pos- sibility that the oedema may be due to other and general causes. The enlargement of the superficial abdominal veins, taken in connection with the fact that the l^lood in them courses in the reverse direction, indicates the existence of some obstruction to the portal circulation. (See also the instance of obstructed circulation in the superior vena cava referred to on p. 529.) The veins of the mucous surfaces are not infrequenth' dilated, because of portal obstruction and of the hindrance of the circulation incident to arterio- sclerosis. The hemorrhoidal and the spermatic veins and those of the broad ligament, etc., sustain special inflictions of a varicose nature, which may be mistaken for disease or other morbid processes of these regions. The ^'eins of the neck are large and cjuite superficial, and the varying conditions serve as an important index of many conditions. For example, a collapsed jugular indicates thrombosis of the lateral sinus, especially when pressure on the vein above the clavicle is not followed bj' distention of the vein. Distention of the jugulai's attends coughing and straining efforts in health. Obstructed pulmonar}- circulation and obstruction to A-enous return from pressure on the innominate and other deep veins of the neck and chest, as from tumors and aneurism, cause free engorgement of the veins of the neck. The indistinct influence of an inspirator}- effort on the jugulars m health is rendered more distinct when these vessels are engorged from any morbid cause. Pulsation of the jugulars may be transmitted from the contiguous carotids, or it may be due to obstruction of the return flow, as in the case of an intrathoracic tumor or aneurism, in mitral regurgitation, in interference with the pulmonary cir- culation from anj' decided cause, and in increased intrarenal pressure. The valve at the bulb (junction of subclavian vein with the jugular) conmionly arrests the upward flow, but m long-standing or decided obstruction dilatation of the ^•ein follows, and this impairs or destroj's the usefulness of the valve in preventing a return flow. Murmurs are sometimes heard in veins; they are usuallv of anaemic origin. GENERAL SURGICAL DIAGNOSIS. 533 The pulse is interrogated to determine the force, frequency, and rhythm of the action of the heart and the degree of tension of the arteries. The pulse should, in every instance, be taken under conditions which are, as nearly as possible, alike; and, when it is practicable to do so, the test should be made at established inter^'als. A change in position of the patient, excitement of any kmd, active digestion, the time of day, etc., are each of important moment in estimating the proper significance of the heart's action and the state of the pulse. A full minute of estimate of the pulse is better than a fractional esti- mate nmltiplied to equal the count of a minute." The latter practice is apt to increase the numerical record in proportion to the smallness of the fraction of the minute, especially when a full measure of the fractional count is the multiplicand. In taking the pulse it is well to test the radial arteries of both sides, espe- cially when the patient shows signs of prostration ; for an unusually small vessel of one side may mislead the surgeon in properly estimating the patient's con- dition. The temporal, femoral, or carotid vessels may be selected for estimat- ing the pulse when for any reason the radial at the wrist is not available, but at the same time it must be remembered that the nearer to the heart and the larger the vessel the more pronounced is the action. The slow and feeble pulse of cerebral compression, the rapid and feeble one of cerebral and other kinds of shock, and the diminished frequency (bradycardia) of pulsation in increased arterial resistance, in arterial sclerosis of the medulla, in Bright's disease, in bile poisoning, in aneurism of the heart, in convalescence from acute disease and depressing injury, etc., are not infrequent exhibits of the heart's action under these varying conditions. The increased rate (tachycardia) of pulsa- tion in Graves' disease, in the abuse of the use of narcotics, in excessive sexual indulgence, in neurotic states, in loss of blood, etc., is of significant import. The pulse beat in children is naturally and markedly of greater frequency than in adults. Blood pressure is a matter of importance and can be sufficiently well esti- mated by one who is experienced in the taking of the pulse. The information gained in this way can be promptly utilized in estimating the degree of shock or the amount of loss of blood in a particular instance. Ordinary experience determines the presence of the hard, wiry pulse of acute peritonitis. However, the employment of special instruments for the purpose of scientifically record- ing the blood pressure is much the better and more reliable plan. The various examples of sphygmographs and sphygmomanometers are to be found in the article on Blood Pressure in Surgical Conditions. The Temperature. — The technique of taking the temperature is of such common knowledge as to call for no mention here. A well-tested and reliable thermometer should be employed at all times. Whether or not the mouth, the axilla, the rectum, or the vagina be selected as the proper site will depend 534 AMERICAN PRACTICE OF SURGERY. on the circumstances of the case. A sense of dehcacy may render it inadvisable to use for this purpose the vagina or the rectum; a sense of expediency may make us hesitate about using the mouth, especially in the imaginative, the young, and those not in proper control; but the demands of accuracy will approve of the selection of whichever place will furnish us with the most trust- worthy results. In any event it will readily be admitted that it is always wise to cause the instrument to be cleansed in the presence of the patient before using. Care should be exercised in all instances in taking the temperature and in recording the results. When efforts at deception are suspected, only vigi- lant and protracted observation, amounting to keen surveillance, will defeat the purpose of those who are interested in the endeavor to deceive. In esti- mating the importance of the temperature record in disease it is well to recall that the normal temperature of the rectum and vagina is higher than that of the mouth, and is less liable to accidental variations; on the other hand, the temperature of the axilla is almost a degree lower than that of either of the mucous channels already mentioned, and only with comparatively great care can a correct record be made in this locality. Normally, the temperature of the body is highest during the daj'time, and is lowest at from two to four in the morning — facts which are to be considered in estimating the fluctuation of the temperature in disease at the time mentioned. The frequency of taking the temperature is a matter both of custom and of demand. The intervals of custom are a matter of choice — once in three or four hours, when practicable. When the circumstances of a case demand the adoption of a certain interval we must conform to the needs of the case. In any instance neither over-anxiety nor exceeding diligence should be permitted to measure the interval. Physio- logically, youth, exercise, digestion, excitement, and heated environment increase the temperature. Old age, cold, and depressing influences lower it. The normal temperature is 98.6° F. ; but shock, loss of blood, starvation, wast- ing disease, cerebral abscess (often), myxcedema, and great prostration are attended with a subnormal temperature (97° F.). Sometimes a sudden drop to 94° F. or less attends the intermittent manifestations of pyaemia, with abscess complications, and of the liver infections. High temperatures of such romantic altitudes as 150° F., more or less, need not be considered seriously in connec- tion with the morbid processes of physical disease. One of 122° F. appears to be entitled to respectful consideration. Personallj^, I have not yet observed a temperature above 110° F. — once in a case of hysteria (probably deceptive); several times in cervical injury involving the spinal cord, soon followed by death of the patients; and once in insolation, also followed by death. The giving of the coal-tar products in advance of a diagnosis of the cause of the fever, for the purpose of reducing the temperature, is an error often com- mitted, and always invests the case with an element of needless uncertainty that should be avoided. GENERAL SURGICAL DIAGNOSIS. 535 The relation of a patient's body temperature to the time of operation is a matter of decided significance. A fever (100° to 103° F.) developing within the first twenty-four hours after an operation, attended with no obvious symptoms, and disappearing within three or four days, is characterized as an "aseptic fever" or as "post-operative fever," and is due to the presence in the blood of irritating products (nucleins, etc.) resulting from the injury. Wlien, however, the body temperature remains elevated for three or four days, and other symp- toms appear, or if, after becoming normal, the temperature again rises, the woimd should be examined at once, as infection is quite certain to be present. Wlien, two or three days after an operation, chilly sensations and discomfort, followed by a rapidly rising temperature (102° to 104° F.), occur, with thirst, headache, pain in the wound, and tenderness and swelling of the adjacent soft parts, genuine surgical fever, due to the absorption of the toxic products of fer- mentation bacteria, is at hand. T\'hien the temperature rises to a considerable degree (103° to 104° F.), with morning remissions and evening exacerbations and a well-defined chill; and when, at the same time, the wound appears dusky and cedematous and is quite tender, suppuration fever, due to the absorption of the toxins of poygenic organisms, is present. The temperatures of saprsemia, of septic infections, and of pysemia are quite characteristic in their curves. (See the article on this subject in the present volume.) A high temperature with or without a chill in the presence of an operation wound of quite normal appear- ance, suggests the onset of erysipelas; and, if the suggestion prpve true, there will soon be seen unmistakable local evidences of the disease. The existence of a temperature suggestive of the presence of pus, with no evidence at the seat of the injury corroborating such suspicion, often demands a scrutiny of the most searching character to reveal the seat of the trouble. The Nervous System. — For the purpose of this article it will be sufficient if we devote our attention to sensation, motion, reflex action, the modifica- ;tions of special senses, and the changes in nutrition of various parts. The senses of touch, of pain, of heat, of locality, of pressure, etc., are of varied im- portance in their relation to diagnosis. The sense of touch may be exaggerated (hyperesthesia) in neuralgia, neuritis, and disease of the spinal cord, and it forms a part of the history of hysteria and spinal irritation. It may also be exaggerated by the effect of local irritants. The sense of touch is diminished (hypffisthesia) in disease and injury of the posterior columns of the cord, of the posterior part of the internal capsule, of the parietal lobe, and of the pons. The insane, the defective, and nervous subjects may suffer in this manner. A total loss of the sense of touch (anajsthesia) follows destructive lesions of a special nerve, of the spinal cord, or of the brain, when the lesion destroys the -related functional continuity in either of these structures. If a nerve be destroyed the effect is local; if the cord be at fault, sectional anesthesia of the body is present when the damage involves both sides, and anaesthesia is noted 536 AMERICAN PRACTICE OF SERGERY. on the opposite side of the boch- when only one side of the cord is injured. In a lesion of the brain ansesthesia is commonly associated with hemiplegia when the latter is present. In a circumscribed lesion of the cortex only an extremity may suffer ansesthesia. In functional anaesthesia of one-half of the body, areas of irregular or of synmietrical outline are present. The sense of pain (algesia) differs in different races and in various persons. The Teutonic and Slavonic peoples suffer less, it is thought, than do others. It should be appreciated by all concerned that persons of dull perce]3tions and phlegmatic natures are less sensitive to pain than are those of an opposite char- acter. Habitual hardship, religious and other kinds of excitement blunt the sense of pani; but refined restraint and associations and long suffering unfit the sensibilities to bear pain. The surgeon should be able after a little time to differentiate between those who bear severe pain uncomplainingly and those who for different reasons magnify their sufferings. In any instance indiffer- ence, heedlessness, or superficial examination on the part of the surgeon may be followed by discomfiture, criticism, and loss of professional station. The kinds of pain are numerous, and to each kind can often be attached a special degree of significance, particularly as indicating the seat of disease and the variety of tissue iuA-olved. Acute pain of a distressing, lancinating character is a sure accompaniment of an acute inflammation of a serous (especialljO or synovial membrane. The pains of neuritis, and of neuralgia, and those caused by a tumor and by aneurismal pressure are often severe and radiating. Dull pain occurs in acute inflammation of viscera, in chronic inflammations gener- ally, and in connective tissue, in which latter case a throbbing sensation is fre- quently present when this tissue is acutely inflamed. Itching of often torment- ing nature characterizes acute inflammation of mucous surfaces, especially in conjunctivitis, pharyngitis, and urethritis. Burning pain marks inflammation of the skin, as in erysipelas, sunburn, and in other local irritating reactions. Boring or grinding pain is indicative of disease of bone or of periosteum, of the pressure of an aneurism on bone, and of gastric ulcers. Sickening pain char- acterizes acute disease of, and especially traumatic pressure on, the testis. Throbbing pain happens especially with boils, carbuncles, plantar and palmar abscess, and in whitlow, and is dependent on the confinement of the morbid process by unyielding overlying tissues. Paroxysmal pain and shifting pain are characteristic of such diseases as neuralgia, colic, rheumatism, and locomo- tor ataxia. Ordinarily, the location of the pain corresponds to the seat of the morbid process causing it. Sometimes an injur}- done to the main trunk of a nerve, or to one of its branches, will give rise to pain, not at the seat of injury, but at the area supplied by such nerve. This is known as transferred pain. Such a trans- ferred pain occurs in cases in which the trunk of a nerve or one of its branches is pressed upon by a tumor or is subjected to some other form of irritation. GENERAL SURGICAL DL\GNOSIS. 537 Then, again, in amputation for an irritable stump or for disease or traumatic destruction of a foot or leg, it often happens that the distress continues after the operation and is assigned by the patient to the amputated part. The pathologic change which takes place in the end of the nerve, in a stump, or in a nerve which has been included in a ligature, produces a sensation like that caused by the orig- inal infliction. Pain at the inner side of the knee in disease of the hip, in the testis in renal disease, in the nipple in uterine disease, in the dorsal region in dis- ease of the stomach, in the sacral region in disease of the uterus, in the abdominal wall in Pott's disease of the spine and in some cases of pneumonia or pleurisy, especiall}' in children — these are, all of them, examples of transferred pain, sometimes called reflex. The determination of the differences in the pain sense (algesia) in different persons, in the different parts of the body, and in different diseases, is effected by various devices and by the hand of the diagnostician. The manual method is a good one when the temperature of the parts and the pressure exer- cised are practically adjusted. In the use of any measure for this purpose care should be exercised not to confuse the records of the results. A more extended statement of these matters can be found in books devoted to special diagnosis. Hypersensitiveness to pain (hyperalgesia) of the keenest nature sometimes appears in inflammation, and in nearly all instances tenderness is a part of the local history of inflammation and of many other disease processes. The opposite of these conditions (hypalgesia) betokens a lesion of the nerve, of the spinal centres, or of the focal area of the brain. The integuments of idiots and epileptics, and also of parts of the body continuously exposed to irritating contact, present this manifestation. A loss of the sense of pain (analgesia) is a specially important manifestation, indicating destruction of nerve tissue from injury, transverse spinal myelitis, a tumor, or an injury of the cord, disease of the posterior part of the internal capsule, or disease or injury of the parietal lobe. Insanity, hysteria, and hypnotic suggestion may take a part in the causative his- tory of this change, and in the last two instances the exhibit is often of irregular, singular outline. Syphilis may cause analgesia. The Heat Sense (thermo-sesthesia). — The heat sense enables one to recognize the differences in the temperature of various things and of different surfaces. The sense of heat may be in abeyance in a part, independently of that of cold, or the reverse may happen ; also these senses are sometimes confused with each other. A complete loss of the sense of heat (thermo-ansesthesia) occurs in in- stances of destructive nerve lesions similar to those found in analgesia, and con- sequently is a symptom of great importance. In pressure myelitis and in involvement of the gray matter of the cord exclusively, tactile sense is retained, but the temperature and pain senses are lost (Musser) . A loss of tactile sense, with the loss of pain sense, happens in injury of the trunk of a peripheral nerve. The sense of locality varies in different parts of the body, being most evident 538 --LAIERIC-IX PRACTICE OF SL'EGERY. on the lips and least e^^dent on the body between the scapulse. This sensation is lessened m the various forms of hyperesthesia, especialh' of central origin, in tabes dorsalis, and in injui'ies of the parietal lobe. Tlie full significance of the pressure sense has not j^et been decided, but that it is of importance in indicating the structm-al changes incident to ataxia and paralysis is evident. Impairment of the muscular, articular, and tendinous senses occui's m cere- bral ataxia, cortical lesions, and those of the crura and pons; also in transverse injmy or disease of the spinal cord. Motion. — The manner of standing and that of moving are fruitful sources of inquiry in the affected and in the well. In the latter, they are important as indicating the tj^e of the individual: in the former, the apparent de^aation from the normal indicates disease or injur}-. A normal person, standing with the feet close together and with the eyes open, will .sway forward and back and from side to side about an inch in each du-ection. The loss of the muscular, articular, and tendinous sensations, as in locomotor ataxia, greatly increases the swajing, and the patient is likely to fall if the eyes are closed. Disease of the middle cerebellar lobe and am-al vertigo likewise cause this ataxic state. In other respects the manner of standing is suggestive of the infirmity of disease or of old age. The bending forward, as in paralj-sis agitans, in spinal disease, in old age, and in some instances of intoxication: and the bending backward, as in pregnancy or in increased abdominal weight from anj- cause, and also in instances of intoxication, are manifestations of significance, ^liether or not the Imibs be alike or be specially distorted are circumstances which should be noted. As in standing, so in walking, the body is bent backward with increased weight in front, and the feet are more ■nidely placed to insure a fij-mer support. That limping and halting gaits distinguish the impau'ments of rheumatism, dis- ease of joints, etc., are facts which require no special mention here. Tlie ataxic gait of locomotor ataxia, the gait of alcoholic intoxication, of cerebellar tinnors and of cerebellar ataxia, the "prancing" gait of paralyzed flexors of the foot, the spastic gait (rigid and stiff-moATng limbs and shuffling step) of lateral spinal sclerosis, the involuntary hastening gait of paralysis agitans, the waddling gait of lordosis, of congenital dislocation of the hip, and of pseudo-liypertrophic muscular atrophj-, are each not infrequently seen. Reflex Action. — Three kinds of reflexes will be mentioned — the cutaneous or superficial, the- tendinous or deep, and certain organic special reflexes. Re- flex action invoh^es the passing of the peripheral stimulus along an afferent (sen- sor}-) ner\-e to the motor cells of a nerve centre in the spinal cord or medulla, and the changing of the stimulus by these motor cells into a motor impulse, which is reflected along an efferent nen-e (motor) to a muscle which conse- quently involuntarily contracts. It therefore follows that these three nerA-e factors and the muscular factor necessars- in a reflex action should each be GENERAL SURGICAL DIAGNOSIS. 539 healthy if a proper response is to be obtained, and that when either factor is out of order the reflex result is correspondingly affected. The irritation of the skin at the selected site by stroking, picking, pinching, etc., by heat or cold, or by chemical irritants, and perhaps by a breath or a breeze, will in the nor- mal state cause the desired result. Generally, conditions increasing muscular tone increase the reflexes, and opposite conditions lessen them. Reflexes are lessened when the attention of the patient is engrossed in the procedure, and increased if the patient be required to make a severe muscular effort, such as the clenching together of the fingers of each hand. In the coma of uraemia and of saccharine diabetes, attended with lessened muscle tone, exaggerated reflexes sometimes appear, especially when the muscles are much relaxed (Musser). The common superficial reflexes are the scapular, the epigastric, the abdom- inal, the cremasteric, the gluteal, and the plantar, belonging to the spinal cord; and the conjunctival, the pupillary, and the palatal, which are connected with the medulla. The palatal reflex is lost in bulbar paralysis and in hysteria. The remainder of these reflexes are interesting, and each in turn signifies the state of the nerve centre presiding over it. The Deep Reflexes. — The deep reflexes are more particularly those of the knee and ankle, to which may be added special ones of the foot. The reflexes of the jaw, the elbow, and the wrist, although not as constant as are the pre- ceding, are frequently sought for, and when present they are given the proper diagnostic significance. The knee-jerk, or patellar reflex, is invariably present in health. The absence of this reflex, therefore, signifies disease or injury of one or more of the factors of the reflex arc. Hence the loss of the jerk in neuritis, in disease of the posterior roots and columns (locomator ataxia), in disease of the anterior horns (poliomyelitis), and in transverse myelitis of the second and third lumbar segments. The shock of cerebral hemorrhage, traumatic compression of the brain, and traumatism of the spinal cord may cause abeyance of the jerk; and it may be wanting in diphtheria and in other diseases of decided toxic nature. Exaggeration of the movement indicates the presence of a competent reflex arc minus the inhibiting influence of cerebral cells or of their transmitting fibres in the lateral pyramidal columns. Increased irritability of the spinal cord exercises a similar influence. In apoplectic hemiplegia (shortly after), in cere- bellar ataxia, in sclerosis of a lateral column, in transverse myelitis and injury, in the pressure exerted by a tumor, and in unilateral lesions of the cord above the reflex lumbar centres exaggerated movement takes place. In a unilateral lesion the increase of movement is on the affected side. In tetanus, strychnia poisoning, and hysteria, and in spinal irritation, this manifestation is present. Ankle clonus has the same significance as the knee-jerk phenomenon. Tap- ping of the hamstring tendons or the inner condyle of the tibia causes adductor 540 a:\ieric-\^' practice of surgery. reflexes, which, however, are not of independent chnical significance. Ankle clonus or tendo-Achillis reflex is present in nearly all health}^ persons. Ankle clonus is present in organic disease and may be noted in functional trouble, and even then organic change should be suspected until disproved. The presence of exaggerated ankle clonus or ankle-jerk in a case is sjonptomatically equivalent to the presence of exaggerated knee-jerk. Lesions of the motor regions of the brain, transA'erse myelitis, lateral sclerosis are causative of ankle clonus. If the gi-eat toe be flexed on the sole, the foot on the leg, the leg on the thigh, and the thigh on the body, and if at the same time the great toe be tapped on the tendon, Sinkler's reflex -nill appear. If, with the lower limb extended, the inner surface of the sole of the foot be stroked with the hand from the heel upward, the toes ^ill flex in health; but if, instead, the great toe be extended, either alone or wdth the others, Babinski's reflex is produced, indicating in both instances transverse injury of the spinal cord, as may happen in fractiu-e of the spine, as well as in transverse myelitis, or in p}Tamidal injm-y or disease. The Special Senses. — The special sense of touch has been already con- sidered. The senses of sight, smell, taste, and hearing will be verj- briefly mentioned. The Sense of Sight. — Tlie palpebral fissm'e and the pupil are the openings through which light reaches the eye. The imopposed raising of the lid in miconsciousness and the twitching opposition attended with upturning of the eyeball in hysteria are significant features. The swelling of the lids and protrusion of the ej'eball incident to cerebral thrombosis, and the prompt pro- trusion of the ball and extraA-asation of blood beneath the upper conjunctival fold in fracture through the anterior fossa of the skull, are important mani- festations. Contusion of the supraorbital ridge or of the contiguous area, attended with ruptm-e of vessels, may cause an extravasation of blood to develop gradually in the upper lid. Orbital emphysema often is present in fracture of the nasal bones, especially when shortly after the accident the patient makes an effort to expel the nasal contents. The deviation of the eyeball from its normal position should be observed, and its relation to injury at the base of the brain, to tumor development, to intracranial disease, and to functional change should be carefully noted, and estimated by consulting special sources of information. The Pupil. — Before examining the pupil, the surgeon should pay careful heed to the precautionarj- requirements commonly stated in books and so essential to the securing of intelligent findings. A changed outline of the pupil- lary margin suggests the activity of SA'philis, of rheumatism or gout, and per- haps of tuberculosis. Irritative dilatation of the pupil arises from congestion of the cervical portion of the cord or from meningeal inflammation or new growths in this GENERAL SURGICAL DL4.GN0SIS. 541 region; from high intracranial pressure dependent upon surgical traumatism, cerebral tumors, or other pathologic changes; also from spinal and intestinal irritation and from mental disorders. Paralytic dilatation of the pupil is present in disease or injury situated at the base of the brain and affecting the nucleus of the third nerve; in sinus thrombosis (late); in cerebral softening; in fracture or dislocation of the cer- vical vertebrge, with injury of the cord fcilio-spinal centre). Involvement of the cervical sympathetic by a tumor or an aneurism in the neck may cause the myosis indicative of a paralyzed sjanpathetic or the mydriasis of an irri- tated one. Fractures of the cervical spine involving the cord will for similar reasons produce a like effect on the pupil of one or both sides. Irritative contraction of the pupil happens in meningitis, in tramnatism, in intracranial pressure on the third nerve or its nucleus, in hemorrhage, in tumor, in abscess, and also in disorders due to other causes. This form of contraction follows excess Ln the use of tobacco and overstrain of the eyes. Traumatism or pressure involving the cervical sympathetic may cause con- traction or dilatation of the pupil, depending on the severity of the injury. Paralytic myosis arises from involvement of the cervical sjmipathetic in fractures or dislocations of the cervical spine, and also from the pressure exerted by a tumor or an aneurism. Degeneration of the posterior colunms of the spinal cord and limrbar paralysis, etc., cause it. The influence of various drugs on the changes in the pupil should not be overlooked in this connection. It may be useful to remark that the pupil may be contracted in the rapid breathing of Cheyne-Stokes respiration, and dilated Ln the interval of arrest in the acts. A pupil irresponsive to light and darkness, but responsive to accommodation (Argyll-Robertson pupil), is highly mdicative of locomotor ataxia. The pupil dilates in health if the skin of the neck is pinched, unless the sympathetic be destroyed or the patient have paresis or structural change of the eye itself. The alteration in the area and outline of the visual field is exceedingly important in determining the presence of disease and its local- ization in the brain, and of disease of the visual fields themselves. The wide scope, the great importance, and the special technique of the examination of these cases render it necessary that this work should be done by an expert. Injury or disease of the base of the brain, so located as to involve either the optic nerves or the optic tracts, the chiasm, the posterior part of the optic thalamus, the external geniculate body, the anterior quadrate body, or the visual centre of the occipital lobe, distvu"bs or destroys sight, according to the degree and extent of the disease or injury. The Sense of Smell. — The sense of smell plays an important part in surgical diagnosis, giving warning of impending disasters and of the presence of unsavory things. It warns us of approaching gangrene of exposed and pulmonary tissues. 542 A-MERICAX PRACTICE OF SURGERY. determines the first evidence of feculent vomiting, detects the ammoniacal odors of urinarj' incontinence, notes the sweet breath of estabhshed pj^jemia, and otherwise enables one to detect hidden offensive processes, and in a general way indicates cleanliness of the patient, of the fabrics surrounding him, and of the room of his confinement. A modification or loss of the sense of smell may depend on modifying changes m the mucous membrane concerned, on an injury of the olfactory bulb or tract or the vmcinate gjTus. A modification in degree or character, or the loss of the sense of smell, may follow a severe blow on the head or fracture of the base, or attend hysteria or result from structural changes in the olfactory centres of the bram. The Sense of Taste. — This sense, like that of smell, is modified by the state of the mucous membrane related to the fmiction; therefore the condition of the surface of the tongue and of the soft palate is of great importance; also disease affecting the glosso-pharjiigeal, the trifacial, and facial ner\-es is of much significance in this relation. The sense of taste may be lost or modified by basilar meningitis, by a tumor or an abscess at the base of the brain, and by a fracture of the base of the skull involving the facial nerve. Abnormal taste impression occiu-s from taking bromides and other medicinal agents. Hysteria modifies the sense of taste. The practically intimate association between the senses of taste and smell should be considered, in order that we may avoid the error of supposing that there is a genuine loss of taste, when as a matter of fact this seeming loss of taste is due to some cause which is interfering with the appreciation of odors by the sense of smell. The Sense of Hearing. — To hear and not to imderstand the meaning of words is no more embarrassing and not nearly so distressing at times as it is to be unable to interpret correctly the utterances of disease. Therefore an educated ear is of superlative importance in promptly detecting and correctly interpreting the significance of morbid sounds in a patient. The surgeon should be cjuite as able as the phj^sician to discover by auscultation and percus- sion cA-idences of disease of the pleura, the lungs, and the heart; othen\'ise he is ill prepared to judge of their influence on patients subjected to surgical interference or on those suffermg from tramnatic injury, and to estunate rightly the effect of anajsthesia in these circumstances. This sense, the same as the preceding senses, is impaired by the state of the external ear, i.e., by the presence of wax, blood, pus, or of foreign bodies in the external auditory canal and by its occlusion through swellmg of its walls. Lesions of the auditory nerves, of the posterior part of the quadrate, of the internal geniculate bodies, and of the cortex of the fu'st and second convolutions of the temporal lobe, compromise or destroy the sense of hearing. Extensive disease of the middle and internal divisions of the internal ear, fracture of the base of the skull, con- tusion and laceration of the base of the brain, tumors, hemorrhage, and inflam- mation located in this vicinity effect the same result. Syphilis is a fertile GENERAL SURGICAL DIAGNOSIS. 543 source of deafness. Tinnitus of differing kinds, from established and from indefinable causes, is frequently present. The variety synchronous with the action of the heart and arrested by compression of the carotid is often depend- ent on vasomotor paralysis, aneurism in the temporal bone or at the base of the brain, etc., and on inflammation of the middle ear. Finally, the impor- tance of morbid auditory sounds can be properly estimated only by the history of the case and by their relations with morbid processes of the brain. The Reaction of Degeneration. — A comparison between the normal respon- ses of nervous and muscular energy to galvanic and faradic currents and those obtained in disease, is of great importance, indicating, as it often does, the location of disease in the respective factors of the reflex arc, the nature of the process, and the probable outcome of the affliction. Generally speaking, absence of response to the faradic stimulus, and equal or greater response at the positive than at the negative pole, characterize tlegenerative reaction. For the means and the methods employed in the securing of these results and in interpreting their importance, the reader is referred to the special sources of information. Injury to the Spinal Cord. — Complete Transverse Injury. — In injury of the spinal cord, followed by complete ana-sthesia, complete paraplegia, flaccid paralysis, and loss of tendon reflex, with vasomotor paralysis and absence of voluntary control of the bladder and the rectmn, the inference is warranted that complete transverse destruction of the cord has taken place. The occasional presence, in these cases, of cutaneous reflexes or of twitching of paralyzed muscles from pyramidal-tract irritation, and the absence of the reaction of degeneration, need not cause a faltering in diagnosis. Complete Unilateral Injunj. — In complete unilateral injury of the cord, complete paralysis and loss of muscular sense occur on the same side as the injury, and all sensation except muscular sensation is abolished on the opposite side. The muscles energized by the injured segment of the cord undergo atrophy, and below this area spastic paralysis and increase in reflexes occur, and a zone of anaesthesia is located above the paralyzed area. Partial Lesions of the Cord. — The manifestations of partial lesions of the spinal cord depend on the situation and the extent of the injury. An injury of the pyramidal tract may mterfere with the voluntary control of the cere- brum over the ganglion cells below the seat of the lesion, and if the inhibition continue spastic paralysis will follow. Disturbances invohdng the anterior horn interfere with the transmission of impulses from the cerebrum to the periphery, destroying the reflex arc and causing flaccid paralysis. W^ien in- dividual ganglion cells or groups of cells are destroyed, the resulting secondary changes will correspond to the nerves and muscles directlj^ associated with them. In a partial lesion of the pj'ramidal tract above the cervical enlarge- ment the lower limbs are more paralyzed than the upper. Division of the 544 AMERICAN PRACTICE OF SIT^GERY. anterior roots Avill produce the same result as the destruction of the correspond- ing ganglion cells. A lesion of the posterior tract will cause ataxia and dis- turbances of muscular, tendinous, and joint senses of the same side as the injury, and the sense of touch may be abolished. In destruction of the posterior roots sensory and reflex phenomena are lost. A lesion of the posterior horn near to its base will cause disturbance of the pain and temperature senses. Destruc- tion of the roots of certain cervical nerves will affect the arms only, the legs remaining normal. Individual muscles and sensory areas are fortified, as a rule, by a chief nervous supply, supplemented by a minor one at either side of this; therefore, paralysis may not be evident until after the three associated roots are destroj^ed. Injury involving the phrenic nerve may cause paralysis of the correspondmg part of the diaphragm. Injury of the eighth cervical nerve or the first dorsal, or fracture of the corresponding vertebra", or injury to the spinal cord relating to fracture of any of the dorsal vertebra? from the third to the sixth, and even higher than the sixth, may injure the cilio- spinal centre of the cervical sympathetic, causing stimulation of the nerve with dilatation of the pupil, or paralysis of it with contraction of the pupil. Vasomotor Paralysis. — In severe injury of the spine, vasomotor paralysis occurs, causing an increase of the amount of blood in the corresponding parts of the organism. The parts thus affected become warmer, the veins are dis- tended, and priapism is likely to be present, especially in young males. The internal organs suffer, perhaps because of resulting aiitemia; and the organs which suffer chiefly are the kidneys and bladder. The Cerebrum, Etc. — The contents of the cranium are not considered in this article, except in the general isolated manner already stated. The ex- tended scope and the special importance belonging to this topic render it mad- visable to consider the subject in this place. Effects of Traumatic Lesions of the Spinal Cord from Disease or Injury (from Weichmann). — In this list the effects of traumatic section of the spinal cord through certain speciallj^ selected parts are illustrated onh- b}' a few of the more practical examples: Fourth Sacral. — Paresis of the levator-ani, sphincter-ani, and the detrusor- urinse muscles. Third Sacral. — Paralysis of the preceding muscles, paresis of the rectum and bladder, loss of ejaculatory power, and weakened erection. Second Sacral. — Loss of erection, plus the precedmg results. First Sacred. — Paralysis of anus, bladder, and genitals, etc. Fifth Lumhar. — Paralysis of rectum, bladder, and genitals, etc. Fourth Lumhar. — Paral3'Sis of rectum, bladder, and genitals, etc. Third Lumhar. — Paralysis of rectum, bladder, and genitals, etc. Loss of patellar reflex: ankle clonus may be present. GENERAL SURGICAL DLIGXOSLS. 545 Second Linnbar. —FateWar, tendo-Achillis, and cremasteric reflexes lost; sensation of testicle lost, etc. First Lumbar. — Patellar and cremasteric reflexes lost, tendo-Achillis reflex increased or lost, etc. Twelfth to Third Dorsal. — Complete anaesthesia dov^Tiward from a little below the seat of injury; complete paralysis; reflexes of lower extremity lost (exaggerated if lesion be incomplete); paralysis of respiratory muscles causes diaphragmatic breathing. Second Dorsal. — Aneesthesia in a line with the second interspace; also at inner surface of the upper third of arm, plus the preceding. First Dorsal. — Pupil disturbed; modifications in power and sensation of upper extremity and of the pectoralis muscles. Pronator cjuadratus weakened. Eighth Cervical. — Upward increase of anesthesia and increased involvement of the corresponding muscles; loss of digital abduction and flexion of little finger (difficult); pupil distended. Seventh Cervical. — Pronation of forearm impaired or lost ; supination pos- sible; hypersesthesia on radial side of arm, forearm, and hand: arm reflexes lost. Sixth Cervical. — Increased upward paralysis and loss of sensation; diffi- culty in turning the head; reflexes of arm lost. The impairment of the respi- ratory function may soon cause death. Fifth Cervical. — Complete paralysis of upper extremities; scapula can be raised; rotation and bending of head difficult; dyspnoea from involvement of phrenic nerve causing paresis of the diaphragm. Anaesthesia up to the lower part of the neck; death not long deferred. Fourth to First Cervical. — Complete transverse lesion causes immediate death from loss of power of the diaphragm, due to destruction of the phrenic. In focal and imilateral lesions of this part of the cord life will be prolonged and recovery may take place. The Genito-urinary System.— The attention of the reader is directed to the following subdiA'ision of this topic : 1. The modifications of the normal excretory power of the kidney. 2. The modifications in the manner of passing the urine. 3. The modifications in the composition and character of the urine. 4. The examination of the urethra, prostate, bladder, ureters, and kidney. Rarely is there anything of an interrogative nature in medicine or surgery of more importance than that of a careful scrutiny of the urine in all surgical cases, especiafly those in which an operation is required. Not one only, but repeated examinations should be made of the urme, of a thorough, searching character, and by one whose well-known competency in this respect admits of no doubt. The finding, in a single instance, of casts or albumin or of other objectionable factors ought not to be regarded of much greater significance 546 AilERICAN PRACTICE OF SURGERY. than that it necessitates a closer scrutiny, when possible, before the inaugura- tion of operative action. However, when operative delay will not bide longer scrutiny, then action based on the full significance of the findings should be employed at once. The amount of the urine passed in a given time, and its chemical composi- tion as modified by the amount of fluid taken, are matters of supreme importance. It is in these circumstances that it is especially important to investigate the presence or not of cedema, high arterial tension, distinct atheroma, cardiac enlargement, etc. And if it happen that the patient have nausea, headache, respiratory distress, with contracted pupils and other well-kno'mi and dreaded evidences of renal disease, the question of what to do and when to do it is of no small moment. In these circumstances even a cautious administration of a general anaesthetic, an insignificant operative effort, or any act that produces some depression of the patient's strength may be promptly followed by suppres- sion of urine and death. The easy, painless passing of a sound has been known to precipitate the final act. Heedless attention and incomplete preparations in operations in these cases have cost many lives and cast many shadows on otherwise justifiable operative endeavor. The modifications in the manner and frequency of passing urine are the out- come of changes in the channel, in the size and shape of the stream, and in the urgency of the act. The free flow and the full oval stream of health are hindared, thinned, or made dribbling by constriction or obstruction of the channel, by narrowing of the orifice, or by loss of the expulsive force. There- fore stricture of the canal or the presence of gravel in it, or narrowing of the meatus from inflammation, ulceration, or some congenital defect, and loss of the effect of expulsive power of the bladder from paralysis or obstruction, are among the causes of a deformed stream. Frequent micturition, from intolerance of the bladder to the presence of urine, or from the presence in it of a stone, a foreign body, or a morbid growth, is quite common. Diseases of the spinal cord and tumors of the medulla so modify the reflex centre of the organ as to hasten the frequency of micturition. AH varieties of cystic inflammation, prostatic enlargement, changes in the specific gravity and constituency of the urine dependent on diabetes, oxaluria, etc., and cantharidal medication, hasten the act. Renal and ureteral calculi and diseases of the rectum, anus, and spinal cord add urgency to the in- tent. Diminished frequency of micturition is less common than the former act. An abeyance or loss of the normal sensation of the mucous membrane that signals the presence of urine in the bladder, by reason of the local numbing effect due to a fever, to cerebral disease, to alcohol, opium, etc., to say nothing of indifference to the desire, diminishes the frequency of urination. Free perspiration, the ingestion of a small amount of fluid, spinal concussion, delayed GENERAL SURGICAL DIAGNOSIS. 547 metabolism, and diminished excretion from kidney disease accomplish the same result. Retention of Urine. — Retention of urine may be either incomplete or com- plete. Retention is dependent either on obstruction of the channel or on diminished expelling force, or on both combined. Retention of urine in severe injury of the spine is the result of reflex contraction of the vesical sphincters, dependent on the influence exercised by the nerve plexus in the wall of the bladder, when the spinal centres are at fault. Prostatic disease, pedunculated tumors of the neck of the bladder, or foreign bodies or blood-clots in that cav- ity cause retention by obstructing the inner orifice of the urinary channel. Inhibition of the lumbar centre from shock, operations on the urinary organs, rectum, and contiguous parts, often cause retention, requiring the use of a cath- eter to relieve the distress. Overdistention, voluntary or otherwise, causes retention of urine; and it should be said at this time that in this condition the bladder should not be emptied at once, but partially emptied instead, thus avoiding the collapse and paralysis of the bladder, with the con- gestion and possible inflammation of the organ that often follow a prompt emptying. A too great emphasis cannot be laid upon these facts. Complete retention is infrequent, as a few drops escape from time to time in nearly all instances. Complete retention of urine may be mistaken for rupture of the bladder and for suppression of urine. Partial retention is often mistaken for involuntary and frequent micturition, as it is denoted by frequent urinary acts, 'feeble stream, and perhaps by dribbling of urine. The introduction of a finger into the rectum or of a catheter into the bladder will determine a difference between complete I'etention and rupture in the former, and partial retention and invol- untary, frequent micturition in the latter instance. Overfloiv of Urine. — This expression signifies that there is retention as well as overflow of urine. The bladder becomes much distended and the urine escapes periodically, attended often by painful vesical contractions. Later, however, paralysis of the bladder ensues from the effect of long-continued distention or overdistention, and dribbling of urine is the result. These cases have been mistaken for frequent micturition. A means of differentiating the two conditions has already been mentioned. Irrepressible Micturition. — In this form the bladder, the nervous suppl}-, and possibly the urine itself are concerned. The diseases that — in co-opera- tion, perhaps, with an ultra-irritating urine — increase the sensibility of the mucous membrane of the bladder and its nervous supply, exalt the urination sensation to such a degree as to render proper control of tlie act impossible. In acute cystitis this form of urination is of common occurrence. Urgent Micturition. — In urgent micturition the desire to urinate is strong, yet controllable. This form is more frequent than irrepressible micturition. 548 a:\iericax practice of surgery. Preoccupation, suggestive sounds, as of falling water, mental emotions, as ap- prehension and fright, may each prompt the desire. Retarded micturition is characterized by the unusual length of time occupied in completing the act. The retardation may be due to delay in "starting the stream," or to slowness in emptying the bladder, or to a combination of both of these causes. This kind of m'ination does not call for active interference on the part of the surgeon. As a matter of fact, the presence of this condition is appreciated only when the time available for a special completion of the act of urination fails to accomplish the purpose. Delay in "starting the stream" comes from slight obstruction to the passage of the water or from slowness of action on the part of the expulsive forces. Atony of the bladder, special nerve lesions, mental emotions, and blunted sensibility, etc., contribute each something toward the production of this condition. hiternipted Micturition. — The normal act of urination is free and continuous until near the completion, when spasmodic acts cause the escape of the urine in jets, with or without interruption of the flow. The causes of the interrupted variety of urination are to be sought for in the bladder and urethra, and its mechanism is largely of a valvular type, the force of the stream effecting the closure. Stone, blood-clots, pus, stringy mucus, pedimculated growths, for- eign bodies, etc., are common examples of the obstructing agents. Congestion of the prostate or of a urethral constriction often causes matutinal interference with the stream. The causes of interrupted micturition often lead promptly to difficult micturition. Difficult Micturition. — Difficult micturition is often associated with and follows the interrupted kind. Anything which weakens the powers of expul- sion, especially the bladder, or obstructs the flow of urine, is likely to cause difficult micturition. When the difficulty always occurs at the beginning of the act, urethro-vesical obstruction is indicated; when it occurs at the close of the act, stone, blood-clots, and foreign bodies in the bladder are causes of the difficulty. The loss in the contractile power in the bladder from any cause occasions this kind of trouble. Obstructed Micturition. — Obstructed micturition follows an advanced state of the disorders which cause difficult micturition. In practice it is not wise to make a special distinction between the obstructed and the difficult kinds of urination, since the earlier the treatment of the cause the safer it is for the patients and the better are the results. Incontinence of Urine. — Incontmence of urme signifies the inability of the bladder to restrain the escape of its normal contents, the urine rimning away as soon as it reaches the bladder, unless defamed by the force of gravity or the friction incident to the curves of the urethra. The above statement defines "true" incontinence. The expression "false" incontinence is misleading and nosologically inaccurate, since it corresponds only to the invokmtary and GENERAL SURGICAL DLIGNOSIS. 549 unconscious acts, better and correctly expressed as ''overflow" of urine. Incon- tinence depends on any modification of the bladder which permits early, con- tinuous, and uninterrupted flow of urine from it, rendering the bladder a passive part of the urinary canal. Prostatic hypertrophy, interfering with the vesical sphincters; malformation of the bladder; paralj^sis of the neck of the bladder and of the sphincter muscles of the urethra, are causes of this affliction. Involuntary Micturition. — Involimtary micturition in adults is an outcome of both hypertesthesia and anaesthesia of the bladder. In children various reasons are assigned for this infirmity, among which may be mentioned irri- tation of the anal and urethral openings and insufficiency of the vesical sphincter, allowing urine to enter the urethra, from which it is promptly expelled. In adults hypersesthesia is encountered in those who suffer great hardships and deprivation, and are afflicted with those pathological conditions which commonly produce an irritable bladder. In those afflicted with typhoid and t3'phu3 fevers, and in profound asthenic states from other causes, the anesthetic variety is the one conmionlj^ observed. Also fright and shock often cause involuntary micturition. Painful Micturition. — Discomfort and pain of the urinarj' tract occur before micturition, on account of the effects of causes that increase the sensibility of the mucous membrane of the bladder and the prostate and the irritating power of the urine. Therefore the causes of these two factors of the trouble are indeed numerous. Pain during micturition depends on diseased action within the bladder or withm the urinary canal. Cystitis and urethritis from various causes, increased irritating changes in the urine, are the fertile sources of this form of infliction. Pain after micturition may be of two kinds; it may either increase or diminish in severity after the completion of the act. The diminution of pain after micturition indicates that contact of urine with the bladder and m'ethra, or distention of the bladder, was the probable cause of the pam. An increase of the pain toivard the end of micturition and after the act warrants the diagnosis of stone in the bladder or of enlarged and hyper- sensitive prostate from various causes. In this variety of the disorder the emptying of the bladder of urine permits the organ to contract on the stone or foreign body, or on the enlarged and sensitive prostate, causing severe pain in the bladder and at the end of the penis, or possibly in the latter only. In micturition, pains referred to the thigh, testicle, or loin originate not infre- quently from the pelvis of the kidney and from the ureter; those in the sole of the foot, calf of the leg, and thigh frequently depend on urethral stricture. Referred prostatic pains appear in the perinseum and lower part of the rectum. Hence, the local and referred pains of micturition should be given a careful study. Force of the Stream. — The force of the stream may be increased or dimin- ished. The causes of urgent and of irrepressible urination increase the force 550 AMERICAN PRACTICE OF SURGERY. of the stream. The fcirce is diminished b}' the various causes of weakened vesical contraction and by the presence of obstructive mfluences in tlie urinary- canal. The Consideration of the Genito-Urinary Organs. — This is not the proper place in which to consider the various diseases of the ui'ethra, but we may be permitted to say a few words with regard to the relation of the urinary canal to the perinteum and the rectum, as bearing on the important subject of urinar}' extravasation. The perinseum should be examined, both deeply and superficially, in order properly to interpret the changes that arLse from urinary extravasation at this situation. The deep early induration incident to rupture of the membranous portion of the urethra — an induration which is felt in front of and from within the anus — contrasts strongly with the more extended and superficial induration which follows an escape of urine either from a deep-seated rupture or from a rupture of the anterior portion of the urethra. It is a matter of great practical importance that the surgeon should be thoroughly familiar with the anatomical relations of the different structures in this region: the bulb of the urethra, the median line of the perinieum, the rami of the pubes and ischium, and the tuberosities of the latter. The Prostate. — The condition of the prostate in health and in disease can be estimated by the finger introduced into the rectum. The size, shape, and sensibility of the organ may thus easily be ascertained. The sensibility of the structure and the deviations of the prostatic sinus can also be learned by means of suitable instruments introduced into the urethra. Consequently it is an easy matter to determine the presence of prostatic enlargement and to ascertain with reasonable certainty the nature of obstructive changes in the prostatic urethra. The relations between pain and urination in various kinds of prostatic interference with the act have been given already as full consideration as our space will permit. It is necessary to remember, however, that a sensitive prostate and the presence of a stone in a sensitive bladder cause similar pains after urination, and for similar reasons; also that a mov- able stone in the bladder arrests the urinary flow promptly, and that a change in the position of the. patient may as promptly relieve the pain; and, finally, that an enlarged prostate slowly diminishes the flow, which is not influenced by change in position. With the fimger in the rectum the seminal vesicles can be felt high up, on either side of the prostate. At the same time the soft area of a prostatic abscess, the hard area of a prostatic calculus, the hard and irregular nodular outlines of malignant and tuberculous disease, may also be determined. The Bladder. — The relative situation of the bladder in the pelvis of the different sexes, different ages, and at different periods following micturition is exceedingly important in cystotomy and puncture of the bladder above the pubis; also in the instances of external violence directed from above into the GENERAL SURGICAL DIAGNOSIS. 551 pelvis (wagon wheel, kick, etc.) or in fracture of the pelvis. In these circum- stances the greater the amount of urine in the bladder the greater is the danger of rupture, and conversely. The outline of an overdistended bladder and the outline of an enlarged uterus are each of prime importance, and often of embar- rassing and disastrous significance when mistaken for each other. The history of a long interval in urination, attended by the development of an oval, supra- pubic, abdominal tumor, disappearing coincidently with violence of any kind or without apparent cause, should arouse serious apprehension and corre- sponding activity regarding rupture of the bladder. If, however, the bladder has become contracted, because of disease or obstruction of the urinary channel, less distention and correspondingly less danger will attend the case in these circumstances. The bladder can be examined by means of the finger introduced into the rectum; and it can be examined from the inside by the aid of various devices constructed for that purpose (consult the article on Surgery of the Bladder, in a later volume). A certain amount of information can also be obtained by percussion, by palpation through the overlying abdominal wall, and by com- bined palpation and the use of the x-ray. By means of the finger introduced into the rectum one can determine the presence of a collapsed or distended bladder (useful in detecting rupture of the bladder), of a sensitive or insensi- tive organ, of the presence in it of a foreign body, the extremity of an instru- ment, or a solid growth; and especially are these features emphasized by com- bined manipulation. A knowledge of the points of reflection of the peritoneum from the bladder should be known, so that a proper estimate may be made of the question whether or not extraperitoneal or intraperitoneal rupture of the organ has taken place. Combined manipulation, with the hand on the abdo- men and an instrument in the bladder, may be practised, but always with exceeding caution. As I am convinced, from personal knowledge, that errors with regard to this matter are of frequent occurrence, I will again caution against the mistaking of the involuntary act and the overflow that attends an overdistended bladder, for unobstructed, frequent micturition. The x-ray may reveal the presence of a stone or a foreign body in the bladder, or the existence of a fracture or a dislocation of the pelvis. The Ureters. — The condition of the ureters can be ascertained by nieans of external manipulation, by cystoscopy, by direct catheterization of these chan- nels, and by explorative incision. In thin subjects and in those with much thickening or distention of the ureter from inflammation, from an accumulation of urine, from the presence of a stone, or from any other cause, external palpation may serve to locate the tube, especially the lower part, provided vaginal or rectal palpation be added to the abdominal effort. In stout subjects, on the other hand, external palpation can offer no encouragement; at the most, it may enable one to ascer- 552 AMERICAN PRACTICE OF SURGERY. tain the presence of a tumoi' or of tenderness at or near the site of the ureter. However, by the aid of cystoscopy, supplemented with catheterization of the ureters, it is possible to determine whether or not the canal be permeable or be obstructed Avith stone or inflammatory products, and whether it be dis- charging healthy or abnormal urine. The latter fact can be made out by the cystoscope alone, and thus the state of each of the kidneys may be decided. Segregation of urines may be practised for a similar purpose. Increased fre- quency of urination attends pain in the ureter, especially when it is due to a passing calculus. The kidney also may suffer from referred pain in these cases. The Kidney. — A kidney is said to be movable when the entire lengtii can be examined, and to be -floating when it can be freely moved in any direction. Misplacement of the kidney happens about once in one thousand cases. The misplacements may be slight or excessive, or of little degree, and the misplaced organ may occupy the iliac fossa or may lie against the promontory of the sacrum or between the rectum and bladder, etc. Sometimes both kidneys are misplaced. A single kidney happens once in twenty-fovu- hundred autop- sies (Morris).' In the absence of a kidney the opposite one is much increased in size. In a physiologically enlarged kidney the normal outlines of the organ are maintained. In enlargement from morbid causes, as from distention or from a tumor, the outline will be changed, but the modification will vary accord- ing to the location, the extent, and the nature of the disease. Overdistention and acute malignant changes obliterate the normal outlines of the organ, often fusing them with those of the contiguous soft structures. As a rule, the inner outline maintains the longest a distinguishing feature — the notch indicating the hilum. The right kidney may be mistaken for a distended gall bladder, the left for the spleen. The presence of the colon in front and on either side of the kidney, with tympanitic resonance when the intestine is distended; the greater freedom of movement of the gall bladder on manipulation or when the position of the patient's body is changed, unless the gall bladder be adherent — in which case, however, it still will be more movable than the kidney; the superficial location of the gall bladder as contrasted with the deep position of the kidney, with often a marked interval between them, discoverable when pressure is made upon the gall bladder — these are the important diagnostic features which should be borne in mind when an examination of the kidney of the right side is made. On the left side the shape and the location of the spleen, its movements on respiration, the sharpness of its border, and the fact that it is in front of and the kidney behind the colon, are the diagnostic features of importance. So far as the kidney is concerned, the following favorable facts should be remembered by the surgeon : the relation of the organ to the peritoneum; its accessibility from the loin for operative purposes; and its possession of a fatty capsule. Finally, there remain to be mentioned the following common manifesta- GENERAL SURGICAL DIAGNOSIS. 553 tions of morbid action on the part of the geni to-urinary organs : the connection of priapism with injury of the spinal cord, the retraction of the testis in renal colic, the elongation of the prepuce in stone of the bladder, urinary inconti- nence, and local itching. The Employment of a General Anesthetic for Diagnostic Purposes. The surgeon ma}- often be very greatly aided in his efforts to make a diag- nosis by administering to the patient a general anesthetic. This procedure not only renders the manipulations painless, but also causes complete relaxa- tion of all the muscles, and thus renders it possible for the surgeon, in an obscure case — e.g., an abdominal tumor or an injured hip or elbow — to determine the outlines and nature of the tumor, and to ascertain the character and full extent of the injury. The fright of children and the serious apprehension of adults in regard to pain, as well as their sensitiveness about ha^dng their private parts exposed, may be thus entirely relieved. It should be remembered, how- ever, that relief from pain by this means does not give the surgeon licence to exercise unnecessary or unduly prolonged or needlessly severe efforts in attaining the purpose. On the contrary, great discretion should be exercised in these circumstances, and often actual restraint is needed on the part of the surgeon to prevent the adding of increased hurt to previous injury, more especially in the case of contentious persons. Only sufRcient force, and that under intel- ligent guidance, should be used to achieve the aim in view. The giving of an anaesthetic only for the purpose of eliciting crepitus in a fracture that should be determined by other means, is a use of opportunity that can be seldom justified. The rupture of an abscess by the employment of a degree of force which it is difficult to estimate under these circumstances is a result deeply to be regretted. Local ancesihesia of rectal and other passages is sometimes employed to lessen the infliction of pain during an examination. The employment of atropia in the eye, of tuberculin for tuberculous invasion, of specific treatment as a test of syphilis, of pilocarpine to test the response of the cervical sympathetic, of cathartics to evacuate the bowels, are illustrations of the use of drugs in diagnosis. The fact- that opium masks symptoms, and may for this reason mislead the surgeon, should be kept in mind. Operative procedures of a simple or severe nature are emploj^ed for diagnos- tic intent, and always the strictest aseptic technique should mark the per- formance. The use of the trocar and cannula, the aspirator, the aspiratory needle, and the hypodermic syringe to determine the presence, the situation, and the nature of a morbid process related to various parts of the body, is already Avell understood. The danger of infection from the escape of fluid, especially in to the peritoneal cavity in the absence of adhesions; the danger of 554 AMERICAN PRACTICE OF SURGERY. infecting the healthy skin from puncturing an underlying malignant growth, and of the involvement of important overlying tissues in instances of opera- tive approach, are illustrations of danger demanding thoughtful care. The puncturing of the thorax, the abdomen, and the bladder are usually innocent procedures, but of sufficient import to exact exceeding care in their use. The incision of a tumor for diagnostic purposes, followed by its removal at once if the conditions found demand it, or by closure of the wound if further operative interference be found unnecessary, is sometimes practised in tumor of the breast and elsewhere. Malignant infection of the healthy parts is regarded as possible in this measure. Abdominal explorations should not be done solely for the purpose of making a diagnosis, but with the further idea of gaining additional knowledge regarding the prognosis and treatment of a case. There- fore, before making an explorative incision, one should stop to consider the advantages to the patient that may follow the act. The pi'actice of making an explorative incision to determine only a question in prognosis is unjusti- fiable, except when requested by a patient having a full appreciation of the important facts in the case. The cutting into an inoperable malignant tumor can rarely be justified, as no physical gain can follow and decided loss is almost sure to result. The idea that an explorative incision is devoid of danger has cost many lives, saddened many hearts and homes, and impaired many pro- fessional reputations. Editors' Note. — The article on Blood Pressure, etc., referred to on p. 533, was to have been published in the present volume, immediatel}^ after that on Surgical Shock, but the sudden illness of the author has compelled us to trans- fer it to the Appendix, at the end of vol. viii. THE BODY FLUIDS IN GENERAL SURGICAL DISEASE, WITH SPECIAL REFERENCE TO THEIR DIAGNOSTIC VALUE. By HARLOW BROOKS, M.D., New York City. Although the study of the body fluids has been largely developed in connec- tion with surgical science, the discussion of this subject is now more extensively treated in works relating to internal medicine. This is not as it should be, for the well-equipped surgeon must have at his command all the facts and methods of medical study, since in so many instances surgery, both in diagnosis and in treat- ment, is now called upon to assist or supersede the methods of internal medicine. Since the space at our command is so limited, it has seemed best to me to consider the subject entirely from the practical rather than the theoretical stand- point, and for this reason I shall devote myself chiefly to matters of diagnostic importance, for it is in this direction that study of the body fluids has proven of greatest utility to us. References to technique and methods of examination have been omitted, for the reason that space does not permit of their full statement, and incomplete discussions of technical matters are more misleading than they can possibly be useful. Full elaboration of this subject is furnished in such special arid general text-books as those of Ewing, Wood, Simon, and Mallory and Wright. But very little reference will be made to the characteristics of the normal fluids of the body, as it is assumed that the reader is already familiar with them. Although the data secured from the study of the body fluids often appear to be of the most conclusive nature possible, in diagnosis particularly they should never be considered absolutely final, but must be accorded the value of symp- toms only. There is now perhaps a tendency in modern medicine to overvalue, as in the past the inclination has been to undervalue, the evidence of the test tube and the microscope; but the broad-minded clinician must first secure all the evidence at hand, and then with careful judgment eliminate the unimportant, until final diagnosis rests not on any one sign or symptom, but on all. THE BLOOD. The examination of no one tissue yields more valuable data in general sur- gical diagnosis and prognosis than does that of the blood. This examination may be special, brief, and very limited in its extent; or in other cases, where a broad and comprehensive view of not only the special condition but also of the 555 556 .^ilERICAN PRACTICE OF SLTIGERY. general nutritive functions of tlie bodj' is desirable, a detailed study may be necessary, and will richly repay the time spent on it. A great deal of important evidence can be elicited even by the most simple and primitive examination. Thus, the puncture of the finger-tip or lobe of the ear, with close observation of the exuding drop, judged from the rapidity of the flow, may give the required data as to the relative abundance of blood fluids. In other instances, where it is desirable to ascertain perhaps the coagulability of the blood as a preliminarj- to operation, tolerably definite information may be thus obtained by timing the clotting of the drop as it flows from the minute wound, though this can be determined with absolute accuracy and almost as easily by the use of the extremely simple and ingenious coagulometer of Biffi. In cases suspected of hsemophilic tendencies, this same simple observation dis- closes a condition the knowledge of which may save the operator serious diffi- culties. In this disease it is well for us to recall that, in at least some cases, the blood, when removed from the body, clots in very nearly the normal time, as in a case recently reported by me ; the primary essential lesion in haemophilia being not in the blood, but in the blood-vessels. Clot formation is notably delayed in many, but not all, cases of jaundice, particularly when the haemoglobin percent- age is low; and this should be taken into consideration when operation on javm- diced and anaemic patients is contemplated. Recent hemorrhage is suggested by increased fibrin formation, and, when this factor has been watched through- out the course of the disease and a rapid increase is discovered, it is strongly indicative of hemorrhage, perhaps from obscure and unsuspected foci. Even the presence or absence of anaemia of marked degree may be roughly suspected by this method, although in all cases of this nature a thorough examination of the blood should be made. The percentage of haemoglobin is often a measure of the gravity or of the duration of the disease process, and it is therefore specially important to ascer- tain this when the question of operation arises ; for it is much better in many cases, in which immediate operative relief is not demanded, to wait until a higher percentage can be secured, not onh^ because both chloroform and ether greatly depress the haemoglobin content, but also because in cases of this nature convalescence is prolonged and even the chances of ultimate recovery may be jeopardized. This seems particularly true in cases of chlorotic anaemia, in which, as a rule, preparatory treatment of the anaemia, for even the brief period of a few days, greatly improves the general condition of the patient. A knowledge of the haemoglobin percentage is often of assistance in the dif- ferential diagnosis of malignant and innocent neoplasms, for, as a rule, it will be found that the percentage either diminishes rapidly or remains stationary at a low figure in the malignant tumors, while severe or progressive anaemia is rare in innocent growths, except when it is due to loss of blood or to some other more or less independent pathological condition. EXPLANATION OF PLATE II. (Preparations Stained by Goldliorn's "One Solution.") Fig. 1. — Myelogenous Leukaemia. The patient was a man 42 years of age. He presented himself on account of an abdominal tumor, which was found to be a greatly enlarged spleen. Lymph nodes but slightly enlarged. The case presented but slight anaemia, and its real nature was not suspected until the blood was examined. The cut shows the presence of frequent very large mononuclear white corpuscles (myelocytes), the cytoplasm of which is studded with neutrophilic granules. The presence of these myelocytes typifies leukaemia of tliis special variety. Fig. 2. — Severe Secondary Anaemia, Clinically Simulating Pernicious Anaemia, but Found to be Due to Chronic Atrophic Gastritis. Htemoglobin, 53%; red corpuscles, 2,004,000; leucocytes, 6,150. The illustration shows marked variation in size and deformation (poikilocytosis) of the red cor- puscles. The amount of haemoglobin contained in the cells is very irregular; some of the cells are deficient in haemoglobin, while others contain more than the normal quantity. Polychromatophilic or granular degeneration is shown in two large red cells (macrocytes). Complete recovery, in so far as the blood condition was concerned, followed appropriate treatment. Fig. 3. — Ljinphatic Leuka?mia. Male, aged 47 years. Enormous enlargement of superficial and deep lymph nodes, hver, and spleen. Slowly progressive enlargement of lynii:)h nodes extending over the past seven years, first noted in superficial cervical nodes. The figure shows a tj^^ical microscopic field illustrating the marked relative and absolute increase in the lymphocytes. The preponderance of these cells characterizes this leukaemia and distinguishes it from the myeloid form shown in Fig. 1. Two myelocytes are present in the field. The ease presented profound aniEmia (Haemoglobin 42%), as indicated by the very pale red corpuscles, a few of which, however, show an abnormally liigh hajmoglobin index. Fig. 4. — Severe Secondary Anaemia, Following Long-continued Haemorrhage (Epistaxis and Menorrhagia). Hemoglobin, 30%; red cells, 3,112,000; leucocytes, 9,500. Note the deformity (poikilocytosis) and the low h:Emoglobin index of the red corpuscles. Some of the corpuscles show beginning endoglobular degeneration. Fig. 5. — Anemia Five Days After Severe Hemorrhage. Traumatic rupture of the spleen with splenectomy. Complete recovery. The blood shows variation in haemoglobin index, a few macrocytes, slight endoglobular degenera- tion and occasional polychromatophilic degeneration of the red corpuscles. A slight polynuclear leucocytosis was present in this case. Fig. 6. — Fatal Ana;mia Terminating Mixed Intestinal Infection with the Hook Worm (Uncinaria americana), and a Tape Worm (Ta?nia saginata). The case was originally diagnosed as one of duodenal ulcer. The figure shows the marked degeneration and deformation of the red corpuscles; endoglobular changes are very marked in the average red cell. One nucleated red corpuscle (normoblast) is present. The eosinophilia, usually marked in cases of this kind, was but slightly developed in this instance (3% to 5%), probably on account of the lack of reaction on the part of the greath' depressed body tissues. AMERICAN PRACTICE OF SURGERi". PLATE n. mw-i Fig.l 1?% %lE»\-^ii;j -Sj' .e MgA. ^ liu Qurv Fig.2. c^^'\ ifT^ ,,fSi^. e ") HarloM' Brooks Del, 0. J •* ri^.5. I-ith. Anst. T, E. A. Funke, Leipzig. Plate Illustrating Various Blood Lesions THE BODY FLUIDS IN SURGICAL DISEASE. 557 Whenever ansemia occurs in any surgical disease, its nature, whether primary or secondary, and its cause should always be sought for. In most instances this necessitates a count of the red blood corpuscles, which adds more than enough valuable data to repay the small expenditure of lime necessary for carrying out this reasonably simple procedure. It is in this way, and also by the deter- mination of the hfemoglobin percentage, that the differentiation between pri- mary (Plate IV., Fig. 2) and secondary anjemia is made. Furthermore, in those cases in which disease of the internal viscera is suspected, it often directs the queries of the surgeon in the right direction. Even more important than the count of the red cells is, in many cases, the examination of these bodies when properly prepared and stained by one of the modern polychrome methylene -blue methods. For example, cachectic antemia (Plate II., Fig. 2, and Plate III., Fig. Fig. 142. — Ova and Embryos of Filaria immitis ; from the Blood of an Infected Sea Lion. 1), in which one sees marked poikilocytosis, polychromatophilic and other de- generative alterations in the red corpuscles, may be distinguished from the an- aemia of a person who is convalescmg from an acute hemorrhage by the charac- teristic picture of pale red cells and numerous normoblasts which the latter condition presents (Plate II., Fig. 5). Malignant growths may also be thus in part differentiated from those of an innocent nature. In my opinion, careful study of the red blood cells, of their size and shape, of the presence or absence of nu- clei, and of the changes in their cytoplasm, is, in the majority of cases, more instructive than the simple red-cell count with which so many clinicians are con- tent. Malarial, trypanosomatous, or relapsing-fever infections discovered in this direct and absolute way may fully account for an otherwise confusing pyrexia or a splenic tumor (Plate III., Figs. 2 and 3); in the same way the demon- stration of filaria (Fig. 142) may account for chyluria or elephantiasis. If 558 -\3IERIC.\X PRACTICE OF SURGERY. we find the picture of leukfemic blood, so patent to the merest glance, we maj^ often be warranted m excludbig the possible diagnosis of lympho-sarcoma or of tuberculous or sj'philitic Ij-mphadenitis (Plate II., Figs. 1 and 3). The presence of megaloblasts and normoblasts, in combination with an appreciable diminution in the number of red cells and a relatively high haemoglobin index, maj', in a case in which the other aspects seem to point rather to a gastric or an intestinal neoplasm, indicate a primary pernicious ansemia (Plate IV., Fig. 2). Probably, however, the information afforded by a determination of the htemoglo- bin percentage, b}' a count of the red blood cells, and by an examination of the condition of these cells, is, from the standpoint of general surgerj% the most im- portant of all. It throws light upon the general nutritive conditions of the body as a whole, and indicates accurately the extent and the din-ation of the disease. Tlie surgeon should not content himself with a smgle examination of the blood or even with a few such examinations: he should — if he desires to throw light upon the diagnosis or to watch intelligently the progress of the disease — have the examinations made regularly and the results charted in the same man- ner as are the pulse and body temperatm'e. Of especial value to the surgeon is that part of the examination of the blood which relates to the counting of the leucocytes. By this means it is generall}'^ possible definitel}' to recognize the existence of a deep-seated inflammatory proc- ess which might othei-wise escape detection. Sepsis and general as well as local infections are also manifested by the same procediu-e, at times with surprising accm'ac}' (Plate IV., Fig. 3). The absence of leucocytosis is also of verj^ great importance, since it either indicates that inflammatory lesions are lacking alto- gether or demonstrates the overwhelming \ii-ulence of some infectious process on the organism; furthermore, it maj^ signify some special type of inflammatory disease, as tuberculosis, mfluenza, or tj-phoid, in which conditions the leuco- cytes are sometimes subnormal in nmnber. Much is also to be learned from a study of the types of leucocytes present in each case, and in either hj'per- or hj^o-leucocytosis differential leucocyte coimts should be made. Thus, the diagnosis of honphatic leuktemia maj' be made in large part from a relative and absolute increase in the lymphocytes. Trichino- sis, hook-worm (Plate IV., Fig. 1, and Plate II., Fig. 6), and some other vari- eties of parasitic disease may be strongly suggested bj' proportionate increase m the eosinophilic white cells, which, it should be remembered, are also increased in certain forms of bone disease, notably in involvement of the marrow by some form of new growth. Relative increase of the polynuclear neutrophiles with leucocj-tosis Is indicative of inflammatory disease, ordinarily of bacterial origin, and no leucocytosis .should be taken as confirmatory of inflammation vmless it be of this variety (Plate IV., Fig. 3). Tlie clinician must always bear in mind the frequent exceptions which are encountered in connection with leucocytosis. Thus, even large pus accumiila- EXPLANATION OF PLATE HI. (Preparations Stained by Goldliorn's Polychrome Methylene Blue.) Fig. 1. — Cachectic Ansemia, from a Case of Uterine Carcinoma. The severity of the ansemia is shown hy the decrease in number of the red corpuscles, their diminution in size (microcytosis), and poiIdloc>^osis. Most of the cells show a high color index, causing the condition somewhat to resemble that seen in pernicious anaemia. A single myelocyte is present in this field, as is frequently the case in anaemia from malignant neoplasms. Hiemoglobin, 50%; red corpuscles, 1,430,000; leucocytes, 7,300. Fig. 2. — Severe Secondary Ansemia due to jEstivo-autumnal Malarial Infection. The infection was contracted in Porto Rico during 1S98, and resulted in death shortly after the patient's return to this country-. The severity of the infection is indicated hy the number of invaded corpuscles seen in the single field. Five cells show smaU "ring-form" jjarasites; in one, two plasmodia are present. A single extra- cellular organism, a "crescent," is shown. The marked endoglobular degeneration of even the unin- fected red cells is weU indicated in the figure. Fig. 3. — Double Tertian Malarial Infection. The double character of the infection is shown by the presence of two parasites nearing segmentation, and two relatively young forms. Paroxysms were quotidian in character. The blood also shows a moderate degree of secondary anemia, indicated by poikilocytosis and low color index. AMERICATC PRACTICE OF SURGERY. PLATE III 'm$- Fig.l. Q o o & i^'- o Kg. 2. i^^i ^ \ rig.3. HarloM- Broo'ks Dp] .ith. Anst. v. E. A. Panke, Leipzig. Plate Illustrating Various Blood Lesiorus THE BODY FLUIDS IN SURGICAL DISEASE. 55& tions, if of long standing or well encapsulated, may cause slight or no increase in the leucocytes, while occasionally very slight infections, as small boils, may, in particularly susceptible patients, cause a pronounced leucocytosis. In no important case should the surgeon be content with a single count, but sev- eral should be made and at different periods, so that technical errors and physio- logical conditions may not confuse the symptom. Perhaps it is also well to point out the possibility of over-valuing leucocytosis as a sign in diagnosis. The surgeon may easily be led to draw wrong inferences if he fails to remember that leucocytosis, even of considerable degree, may exist as a physiological phenomenon, and that it may also follow the use of certain drugs, as phloridzin. When there are found, in the blood, leucocytes the cytoplasm of which con- tains glycogenic granules that assume a dark-brown color when brought in con- tact with a solution of iodine (a condition to which the term "iodophilia" is often applied), we may interpret this circumstance as indicating quite accu- rately that pus has formed somewhere in the body. On the other hand, it is not safe to infer that the absence of leucocytes of the variety we have just described may be taken as an evidence that pus has not formed in any part of the body. It must also be remembered that diffuse amyloid degeneration, such as is observed particularly in syphilis and in tuberculous or chronic inflammatory disease of bone, is likely to be characterized by the presence, in the blood, of these same leucocytes. When the iodophilia is found to be progressive w-e are warranted, I believe, in drawing the inference that the suppuration is also on the increase. The relation of the blood plates to surgical diseases I believe to be very in- definite and uncertain. An increase in the number of the platelets is taken by some as indicative of a tendency to rapid clot formation. A few authors think that these bodies are actively concerned in the thrombosis so frequent in certain diseases, particularly in pneumonia and typhoid. A close study of a large series of cases in regard to this point durmg the past two years has fully convinced me that there is no relationship betw^een the number of blood plates and the tend- ency to thrombosis or rapid clot formation. Bacterial examination of the blood is resorted to more and more frequently in cases in which there is question as to general hsemic infection, and its great utility cannot be overestimated. It sometimes affords the only means at our disposal for demonstrating what particular bacterial agents are concerned in any general and in certain local infectious processes. It should be generally under- stood that the amount of blood required for a satisfactory examination should be relatively large, that the amount of the media into which the blood is to be inoculated should be abundant, and, finally, that several kinds of pabulum should be used, particularly such as most closely approximate the human serum. Negative results in these examinations are not to be given too much considera- tion in diagnosis, on account of the great possibility of technical errors. Posi- 560 AMERICAN PRACTICE OF Sl^RGERY. tive findings are of the most definite character possible, and in a good many in- stances this demonstration of tlie etiological factor of the disease shapes not only the diagnosis, but also the treatment and the prognosis. Kryoscopy of the blood is as yet ordinarily but little employed in general surgical diagnosis or study, though its findings are occasionally of great worth in special surgery, particularly in diseases of the kidnej^ or in cases in which transudates are formed. Kryoscopy of the urine or of the transudates or exu- dates is of little utility unless compared with the basis furnished by the same method applied to the blood. When this method is employed for the blood alone it does not appear to furnish as trustworthy results as are supplied by other and better-established methods. The determination of the alkalinity of the blood, though often of interest and value to the internist, particularly in such conditions as diabetes or in the severe anajmias, has thus far, in my hands, proven of little value as an assistance in surgical diagnosis. The more unusual methods of examining the blood — such, for example, as those for determining the total percentage of iron and the specific gravity — have thus far proved of little use. This is doubtless largely due to the facts that the technical details are somewhat complicated and consume considerable time, and that we do not yet possess sufficient physiological data on which to base our clinical studies. There can be no question that, as the normal chemistry of the blood becomes more thoroughly elucidated, the pathological chemistry will keep pace and will finally yield results probably more valuable even than are supplied by our now largely morphological studies. The very suggestive work on the psonins, toxins, and antitoxins promises much for future research along these lines. The serum reactions which are based on the formation of specific anti-bodies in the blood under the influence of specific infections or toxEemias, while they are more commonly employed in medical conditions, also lend themselves to surgical diagnosis with equally beneficial results. The most important, to the surgeon, of these agglutinative or serum reactions are those which are observed in typhoid fever and tropical dysentery, both of which, when the technical de- tails are carried out with proper care, and when positive results are secured, are definitely instructive signs of great utility. On the other hand, they are nearly worthless when only negative results are obtained. THE CEREBRO-SPINAL FLUID. The technique of lumbar puncture is so simple, and the evidence furnished by analysis of the cerebro-spinal fluid often so valuable, that it should be con- stantly employed in the differential diagnosis of surgical diseases of the brain and cord. By the relief of intracranial and spinal pressure it also becomes oc- casionally a measure of considerable therapeutic value. Differential diagnosis between ursemia and meningitis, frequently so diflScult, is occasionally rendered EXPLANATION OF PLATE IV. (Preparations Stained by Goldhorn's Polychrome Methylene Blue.) Fig. 1. — Blood Smear from a Case of Trichinosis. The eosinophilic leucocytes arc markedly in- creased in number, both relatively (14%) and absolutely. The red corpuscles show some diminution ill hsemoglobin staining and a few microcytes are present, but the ancemia at this stage of the infection was not a marked feature of the case. The condition was accidentally discovered in the course of routine examinations of the blood in a surgical ward. Fig. 2.— Pernicious Anaemia. The case was originally supposed to be one of gastric carcinoma. The red corpuscles are few in number, but their hcemoglobin index is high above normal, a condi- tion quite characteristic of pernicious anaemia. Marked poikilocytosis is present and microcytes and macrocytes exceed normal-sized red corpuscles in number. Polychromatopliilic degeneration is marked in some of the cells, and both normoblasts and megaloblasts are present in considerable numbers. One of the latter cells shows karyokinetic changes in its nucleus. Megaloblasts arc more or less diagnostic of pernicious anjemia, though also occasionally fotmd in cachectic ana-mias. Fig. 3. — Polynuclear neutrophilic leucocytosis (32,000 Leucocytes per c.mm.), Occurring in an Acute Attack of Appendicitis in a Chlorotic girl. The relatively high number of polj'-nuclcar leucocytes is well shown in this typical field. The chlorosis is indicated by the low haemoglobin index, low red-cell count, and poikilocytosis. AMERICAN PRACTICE OF SURGERT. PLATE IV IB O ng.2. i P k • '^"- •'Mi 4''?'' Pig. 3. f-^'! Harlow Brooks Del Lith. Ani:t. V. E. A. Funke, Leipzig. Plate Illustratinf Various Blood Lesions THE BODY FLUIDS IN SURGICAL DISEASE. 561 easy by this pieans. Ventricular hemorrhage may, in a certain number of cases, be differentiated from subdural hemorrhage by the fact that the fluid withdrawn is diffusely blood-stained, whereas in the latter condition the cerebro-spinal fluid is generally clear. Inflammatory conditions of the meninges are indicated by a turbid, purulent fluid which clots readily, while the formed elements present are chiefly desqua- mated endothelial cells and polynuclear leucocytes or pus cells. In tuberculous disease, however, clot formation is usually but slightly marked, the fluid is more clear, and lymphocytes commonly predominate in its sediments. The cerebro- spinal fluid may also furnish most important aid in establishing the differential diagnosis between localized cerebral abscess or thrombosis and diffuse menin- gitis. In certain specific inflammatory diseases of the meninges, as in epidemic cerebro-spinal meningitis or, more rarely, in tuberculous meningitis, it is pos- sible to demonstrate, either by means of smear cultures or by animal inocula- tion, the specific cause of the disease, — frequently a matter of the greatest importance. Although lumbar puncture is stated by most authors to be absolutely with- out danger, too rapid or too complete removal of the fluid may occasionally cause immediate collapse and death. Although surgeons need no warning as to the danger of infection of the cerebro-spinal space by careless methods, this possibility should always be held in mind. THE SECRETIONS. In our discussion of the different secretions we shall consider only those alterations which throw light upon certain diseased conditions of the body, or which modify these several fluids. The Saliva. An increase m the amount of the saliva may indicate mercurial, iodide, or other mineral poisoning, the specific kind of which can be easily determined by chemical methods. Decrease in the amount may also signify poisoning, as from atropine, or it may indicate that one or more of the salivary ducts is occluded, as by a calculus. Chemical examination of the saliva is frequently resorted to for the determination of the rate of gastric or intestinal absorption. One of the iodides or some one of tlie drugs which are excreted by the saliva is administered, and the time which elapses before it appears in this secretion measures quite ac- curately the rapidity of absorption. The determination of the digestive action is rarely necessary in surgery, but may be utilized in appropriate cases. Tubercle bacilli, actinomyces, gonococci, diphtheria bacilli, and other spe- cific micro-organisms may be found in the saliva, either as contaminations from diseased foci in the buccal cavity or as an evidence of a diseased state of the 562 AMERICAN PRACTICE OF SURGERY. salivary glands. Pus cells, blood, and desquamated epithelium may be dis- charged from the duct of an infected gland, and the finding of these products may furnish the first indication that any such disease exists. The Gastric Juice. An examination of the contents of the stomach is often of the greatest pos- sible assistance in surgical diagnosis, and therefore it should never be omitted in cases in which some organic disease of that viscus is suspected. Where vomitus is not available, a test meal should be ordered, and after a definite time the con- tents of the stomach should be removed through the tube and submitted to both morphological and chemical analysis. In surgery and medicine alike probably the most important single investigation in connection with the gastric secretion is the determination of free hydrochloric acid. The diminution in quantity or the absence of this acid, when the condition is found to persist, is strongly sug- gestive of gastric carcinoma, particularly when deficiency in free hydrochloric acid is associated with the presence of lactic acid. The presence of free hydro- chloric acid by no means excludes the diagnosis of carcinoma of the stomach, since it is often found present, even in normal amounts, particularly when the cardiac extremity of the stomach is largely intact. It is a noteworthy fact that free hydrochloric acid is rather more commonly found in sarcoma than in cancer of the stomach. The diagnosis of carcinoma of the stomach is further corrobo- rated by the presence of broken-down blood in the fluid contents of this organ. Occasionally particles of new growth may be found in the fluid, and, on being submitted to microscopic examination, they may definitely establish the diag- nosis. On the other hand, when blood is found associated with abundant free hydrochloric acid, this circumstance is considered indicative rather of ulceration than of a cancer. As a rule, lactic acid is absent in cases of simple ulceration; when it is present it is generally found in cases of pyloric ulcer, in which affec- tion there is apt to be gastric dilatation with more or less fermentation of the food. An interesting and often highly instructive test is that which consists in administering to the patient a measured amount of food or drink, and then, after a definite period of time has elapsed, withdrawing it for examination. In this way the peptic capabilities of the stomach and the degree of pyloric perme- ability may be ascertained. It is also an easy matter, in cases of dilatation, to determine, by actual measurement of the fluid contents of the stomach, just how far the distention of the organ has progressed. The finding of certain forms of bacteria in the stomach may be of diagnostic import; nevertheless, too much reliance should not be placed upon such evi- dence, since the presence of bacteria is largely determined by the food. In my experience the occurrence of the Boaz-Oppler bacillus is of no value in the diag- nosis of cancer of the stomach. THE BODY FLUIDS IN SURGICAL DISEASE. 563 The discovery of pus in any considerable amount is much more suggestive of some extraneous suppuration draining into the stomach than of a suppurative gastritis. In these cases the pus should always be carefully studied, in the hope that it may contain cells or organisms which by their character indicate the origin and location of the primary suppuration. Indol, skatol, bile, or even simple fecal odor may assist materially in the diag- nosis of ileus, while parasites and their ova are by no means uncommonly found in the gastric contents, either indicating infection from the gut or parasitic dis- ease of the stomach itself. The Nasal Secretion. Study of the nasal secretion is often of considerable value, particularly in in- fectious diseases, such as diphtheria, tuberculosis, or cerebro-spinal meningitis. The clinician must, however, remember that pathogenic bacteria, notably meningococci, diphtheria bacilli, and pneumococci, may exist in the nasal pas- sages without disease necessarily taking place, although in these cases even slight traumatisms to the nasal mucosa may be followed by serious infection, such as probably takes place in the development of epidemic cerebro-spinal meningitis. When pus is found in any considerable amoimt, its point of origin should be determined. A good deal of pus may originate from inflammation of the mucosa only, in which case the exudate is very apt to be chara,cterized by the presence of a good many eosinophile cells; but large amounts of pus are much more likely to be due to suppuration of the antrum. Where nasal growths exist the number of epithelial cells in the secretion may be considerably increased, but.no more so than in some simple catarrhal proc- esses. Investigation of the nasal secretion is necessary in traumatic injuries of the head ; for example, in fracture of the base of the skull, when cerebro-spinal fluid may be found escaping from the nose. This fluid may be recognized by its non- albuminous character and by the presence of a substance which reduces Feh- ling's solution. In a case of recent fracture, the specimen of fluid collected is commonly more or less stained with blood, but in certain instances of cerebral tumor, and also in some cases of hydrocephalus, cerebro-spinal fluid may be found escaping from the nose, often in such quantities as to cause great annoy- ance to the patient. In cases of this nature the fluid is, of course, ordinarily free from blood, except such as may enter from the nasal mucosa, which is also likely to contribute the mucus, leucocytes, and desquamated epithelium normal to the nasal secretion. The Sputum. The sputum, which normally consists chiefly of the secretions of the tracheal and bronchial glands, often well repays study, though to a much less degree in surgery than in internal medicine. 564 AMERICAN PRACTICE OF SURGERY. Tubercle bacilli, pneumococci, actinomyccs, and other specific organisms in the sputum are of great significance, while cells and j^articles of tissue from pul- monary tumors may be discharged in the same manner, thus materially assist- ing diagnosis. In nearly all cases of inflannnatory disease of the respiratory tract, blood cells, fibrin, leucocytes, and pus are present to a greater or less de- gree, and are often indicative of the character, extent, and standing of the focus Fig. 143. — Echinococcus. Embryos and liooklets discharged in the spiitu cyst of tlie hmg. I from a case of hydatid from which they arise. Pus, sometimes mixed with hepatic cells, may be dis- charged through the sputiun from a liver abscess, which not uncommonly bursts into the lung; in the same manner echinococcus booklets, nodules of actinomy- cotic material, etc., may be discharged (Fig. 143). In gangrene of the lung or in extensive tuberculosis considerable masses of pulmonary tissue may be expectorated, and may be of such character as to de- mand microscopic examination for their definite recognition. The Mammary Secretion. In most surgical diseases affecting the mammary gland when functionally in- active, examination of the secretion, as a rule, shows little of direct value. On account of the superficial location of the gland, which renders its physical ex- amination relativelj^ easy, studies of the secretion are not generally necessary. Nevertheless, at times they become highly valuable. Sufficient secretion may, in certain conditions, be expressed from the nipple or gland to give on examina- tion a fairly certain knowledge of the changes which are taking place. Blood or pus may indicate the formation of an abscess, and the bacteria found in the se- cretion may show its cause. In the by no means rare cases of mammary tuber- culosis, tubercle bacilli are not, as a rule, demonstrable in the secretion. In THE BODY FLUIDS IN SURGICAL DISEASE. 565 certain tumors of tlie breast, particularly adenomata, cells and secretions more or less characteristic of the growth may be discharged. Examination of the secretion during lactation is rarely necessary in surgery; at most, it may be thought desirable in a case in which suppuration or a neo- plasm is suspected. The variation in the quantity or quality of the milk in sur- gical disease may, however, become of importance, since in so many conditions;, such as shock, the amount becomes diminished or the character changed. Secretions of the Female Genital Tract. In many conditions affecting the female genital tract, and particularly in the infectious diseases which so commonly affect these parts, systematic study of the secretions becomes a matter of necessity. Not only should all abnormal discharges receive attention, but the apparently normal secretion of each glan- dular distribution should be investigated. Thus, gonorrhoeal affection of the vulvo-vaginal glands may exist without vaginal infection and vaginal infection without cervical involvement. The results attending these examinations may be somewhat confusing, unless one bears thoroughly in mind the character and great variation of the secretions normal to these parts. Thus, the vaginal secre- tion, in addition to leucocytes and desquamated epithelium normally derived from its own wall, is almost invariably more or less composed of materials from the endometrium of the uterus and cervix. Just before, during, and for a con- siderable time after menstruation, blood, broken-down epithelium, leucocytes, and frequently more or less pus are present in the discharge ; but such material found unassociated with menstruation would be strongly suggestive of endo- metritis or even of a new-growth of the uterus. Similarly, the desquamated epithelium naturally present in the vaginal se- cretion may be confused with products due to the erosion of a tumor. In every case of purulent discharge from the genital tract the material should be espe- cially examined for the bacteria present. Gonococci, tubercle bacilli, and mem- bers of the proteus group of bacteria can, as a general rule, be satisfactorily rec- ognized — at least so far as it is necessary to do so for clinical purposes — by the examination of smears alone. Wherever it is deemed of great import that the precise character of any inflammatory process be decided, bacterial cultures should be made; this is often of great value, particularly in post-partum infec- tions. Before a final negative conclusion is reached in any case of infection, several examinations should be made. Occasionally there are found, in the matter discharged from the uterus, por- tions of tissue, the examination of which may definitely decide the important question between some form of tumor of the endometrium and the products of inflammation or conception. I have found it in all cases much the safest pro- cedure not to rely on gross or direct microscopic examination only of this fresh material, but to prepare and examine it after the usual histological methods. 566 AJIERICAN PRACTICE OF SURGERY. Unless this course be adopted as a rule, serious diagnostic mistakes will inevi- tably occur. An examination of the vaginal secretion sometimes reveals the presence of parasites or their ova, of which the thread-worm and the Trichomonas vaginalis are probably the ones most frequently met with. It is needless to say that an absolute diagnosis of disease of the genital tract of the female should never be made on the examination of the secretions alone; this should be but supple- mentary to as complete a physical examination as is practicable in any particu- lar case. "WTiere growths or swellings suggestive of sj^philitic infection are present, the secretions from them, or, if necessary, expressed blood or serum, should be searched for the Spirocha?ta pallida, since it now appears that this organism is quite constantly associated with recent syphilitic lesions. Secretions of the Male Genital Tract. In diseases of the genito-urinary tract of the male the urethral secretions should be investigated; early examination frequently establishes the diagnosis, for example, of a gonorrhoeal urethritis, before the clinical symptoms have de- veloped. Streptococcus, pneumococcus, and other infections may be detected in the same manner, as may also tuberculous disease. As regards the tubercle bacillus the differentiation from the other acid-fast bacilli should be made cer- tain, if necessary, by animal inoculation. Where prostatic disease is in question, the secretion from the prostate maj^ be readily obtained by first causing the patient to urinate or by othernase wash- ing out the urethra, after which massage of the prostate and seminal vesicles drives the secretions from these glands into the urethra, from which locality they may be secured for examination. Gonorrhoeal, tuberculous, and other in- fectious processes are readily detected in this manner. In cases ui which syph- ilitic infection is suspected, a search for Spirochsetse pallidae should be made. When lesions of the testis or epididymis ai'e present, much may be learned by an examination of the seminal secretion. Pus and blood in more than minute amounts may indicate inflammatory disease; or blood alone, a new-growth. The demonstration of bacteria in the secretion may absolutely decide the na- ture of the process, and the presence or absence, character, and motility of the spermatozoa may throw m.uch light on the true character of the lesion. The permeability of the epididymis and of the vas deferens may also be determined by such an examination of the secretion in the urethra, and the siu'geon is now and then surprised at the considerable number of cases in which few or no spermatozoa reach the urethra. A discovery of this nature serves, in not a few cases, to determine the proper course of surgical treatment. Surgeons are too apt to neglect this very simple and often decisive method of examination, even in those cases in which it is perfectly practicable to secure the secretion for investigation. THE BODY FLUIDS IN SURGICAL DISEASE. 567 Other Secretions. In the various bacterial diseases of the eye the lachr^inal secretion may fur- nish evidence of the specific type of infection of the conjunctiva or of its adja- cent glands and mucous tracts. In exploratory procedures it is occasionally possible to secure the secretions from the internal viscera, as that of the pan- creas or liver, and thus the surgeon may obtain direct evidence of changes tak- ing place in these organs. In short, all of the secretions may, under diseased conditions, contribute facts which have an important bearing upon surgical diagnosis, not only in cases of local disease, but also in those of a more general nature. THE EXCRETIONS. The Urine. Examination of the urine plays a large part in the diagnosis and study of nearly all disorders of the body. Its importance, however, is greater in the do- main of internal medicine than in that of surgery. Its chief value, in the latter domain, is to be found in the special surgery of the urinary organs. One point of great importance in connection with the exammation of the urine — a point which has but recently received adequate attention — is that the amount and character of the food, drink, and medication have a most direct and important bearing on the urinary picture. An examination of the urine should, therefore, be prefaced by a close inquiry into this important question, so that the urinary findings may not be incorrectly interpreted. Thus, for ex- ample, the amount of water taken as food or drink, and the quantity excreted by the skin, respiration, and bowel determine to a large extent the color, reac- tion, and specific gravity of the urine. Articles of food, such as rhubarb and asparagus, and even excessive amounts of albumin or sugars, or drugs, such as phloridzin, may cause marked and apparently serious alterations in the color, odor, and chemical nature of the urine. Another frequent source of error lies in the manner in which the specimen is collected, and it should always be borne m mind that the urine may be con- taminated by substances derived from the bladder, prostate, and urethra; or by materials entering the urine from the external genitals, the rectum, or the va- gina in women; from the air, or from the vessel into which the specimen is voided. Substances foimd in the urine, particularly when of imusual nature, should never be considered as of clinical significance until all these possibilities of contamination, which may even be wilfully effected, have been considered and excluded. Ureteral catheterization has furnished us with the means of determining ac- curately the condition of each one of the kidneys separately, and, since it has been shown that under normal conditions both, organs excrete alike, we can now 568 AMERICAN PRACTICE OF SURGERY. definitely decide whether one or both are involved in any disease process, and to a certain extent we may also conclude as to the relative extent of the disease. This precaution is of particular bearing on cases in which operative measures on one or both kidneys are contemplated. As already intimated, the amount, color, reaction, and specific gravity of the urine are to be considered in connection with the amount of fluid ingested as well as with that excreted elsewhere. When these do not appear to be normally balanced, there is reason to suspect the existence of disease. The precise nature of the disorder must be determined by further investigation, which demands examination of the urinary excretion for the entire twenty-four hours, after the patient has been placed upon a simple, though normal and easily determined diet, as of measured amounts of bread, milk, and lean meat. Much more valuable data for the estimation of these points is to be derived from kryoscopy of the urine, by means of which the molecular concentration may be determined from its freezing-point. For the proper understanding of this, the same method must also be applied to the blood and to any transudates which may be present in the case. Any discrepancy between the normal bal- ance — as, for example, increased concentration of the blood with decrease in the molecular concentration of the urine — indicates deficient renal activity. A procedure presenting fewer technical difficulties to the surgeon, and at the same time giving an accurate test of the permeability of the kidney, is afforded by the administration of phloridzin or methylene-blue and the determination of the time required for its easily recognized appearance in the urine. Where ure- teral catheterization is also practised, the relative activity of the two kidneys may thus be ascertained. The amount of urea excreted in the urine is rarely of much importance to the surgeon when the rate of permeability of the kidney has already been demon- strated; but when the amount remains high in the presence of a light nitro- genous diet, it is strongly suggestive of tissue destruction, as in diabetes. De- creasing excretion of urea is shown in such conditions as Weil's disease, acute yellow atrophy of the liver, and in some cases of diffuse carcinosis. The respec- tive amounts of urea and uric acid excreted in surgical conditions are of rela- tively great importance in surgery, on account of the diminished solubility of uric acid and the consequent tendency to precipitation and calculus formation, either when it is thrown out of solution in the kidney on account of increased excretion, or when the chemical characteristics of the urine are such as favor its precipitation. Albuminuria is of considerably less significance in surgery than in medicine, except for that which takes place in hsematuria or in post-operative cases. Al- buminuria may occur in surgical shock, after operations, particularly where ex- tensive manipulation of the tissues has been necessary, after injuries to the head, in carcinomatous peritonitis, in abscess of the liver, and in nearly all the diseases THE BODY FLUIDS IN SURGICAL DISEASE. 569 of an infectious nature. It may follow the administration of many drugs, no- tably those of an irritant nature, or may occur after the observance of a certain diet — for example, the ingestion of egg albumin. In certain cases it may also appear apparently as an individual peculiarity without demonstrable disease or other cause. The occurrence of albumin in the urine in surgical disease is of great importance only when its causation is of a serious surgical nature, and albuminuria per se is no longer of the grave significance which the text-books of a few years ago led us to believe. It may occur apparently without any connec- tion with renal lesions, and, conversely, kidney disease, often of the most grave nature, may exist without albuminuria. The simple presence of albumin in the urine, where renal permeability is within the range of normal, is now no longer considered as contraindicating operation or the administration of a general an- aesthetic, though its cause be distinct renal disease. Extra percautions in the selection and use of the anjesthetic may, however, be necessary.* When albuminuria occurs as a manifestation of the escape of blood into the urine its surgical importance is great, and the probable point of entrance of the blood must be ascertained, as well as the cause. Such an escape of blood may occur from a renal or cystic neoplasm, from a stone located in the kidney itself, in the ureter, or in the urinary bladder; from some inflammatory condition or from a simple congestion of the kidney; or, finally, from some traumatism of the bladder or urethra. Glycosuria is also of less interest in surgery than in general medicine, though its occurrence in surgical diseases is often of the most grave significance, both from the standpoint of diagnosis and from that of surgical therapeutics. The wide difference between simple glycosuria and glycosuria as a symptom of dia- betes mellitus must be fully appreciated, since the former condition may be but a temporary one and due perhaps to individual peculiarities, dietetic conditions, or the use of certain drugs, as phloridzin ; while the latter is a disease in which glycosuria is a single manifestation and in which gangrene, delayed healing, and fatal coma are notoriously prone to occur. Temporary glycosuria may take place in injury to the head or in certain cases of mental or physical shock. Indican is a product of albuminous decomposition which occurs in the urine in the case of excessive putrefaction, particularly in the stomach and small in- testine. Simon asserts that its presence and amount are of diagnostic impor- tance, since it is found particularly in cases of derangement of the gastric secre- tion or of the motor powers of the small intestine. Its appearance, in my opinion, is too inconstant and indefinite to render it of any great diagnostic value. The occurrence of bile pigment in the urine takes place when there is any obstruction to prevent the normal flow of the bile into the intestine, as may oc- *The special chemical nature of the albumin excreted is often more or less diagnostic as to its cause; thus Bence-Jones albumin, which is easily recognized by its special reactions, occurs \n most if not all cases of multiple myeloma. 570 AMERICAN PRACTICE OF SURGERY. cur from an impacted gall stone, from catarrhal swelling of the mucosa of the duct, or from the pressure of a neighboring tumor or an inflammatory deposit. It also takes place whenever from any cause the liver is unable to convert the waste blood pigment normally, as in acute yellow atrophy or in Weil's disease, or when an excessive destruction of the corpuscular elements of the blood throws an overabundant supply of pigment on the liver, as in malaria, pernicious anae- mia, and like maladies. Bile in the urine is almost always associated with more or less jaundice, so that its diagnostic value is ordinarily only corroborative and necessitates a much wider investigation for the determination of its cause. The estimation of the chlorides of the urine is not of much value in surgery, except as a means of showing the degree of absorption from the gastro-intestinal canal. They are decreased, sometimes very markedly, in many acute infectious diseases, notably in acute inflammation of the lung. The phosphates of the urine are also of relatively little importance, except as they may be deposited in the renal pelvis or bladder, and so tend to the forma- tion of stone. They are much augmented in extensive tissue destruction. Unquestionably the most valuable facts derived from the examination of urine in surgery are those secured by microscopical study. In this relation care must always be taken not to interpret incorrectly certain bodies which normally occur in the urine ; thus, epithelial cells in greater or less numbers are naturally eroded from the mucosa of the kidney pelvis, from the bladder and urethra, and from the skin and mucous membrane of the external genitals. Further, when epithelial cells in small numbers only are found, absolutely nothing definite can be told from their morphology as to their point of origin — a fact of simple ele- mental knowledge of normal histology which is too often forgotten by over- hopeful and inexperienced microscopists. When large flakes of epithelium are thrown off, a certain amount of probability may be given to statements as to the point of origin, but nothing of sufficiently definite character to warrant the adoption, on this basis alone, of operative measures. Occasionally considerable bits of tissue may be thrown out into the urine, particularly in necrotic forms of inflammation or in papillomatous neoplasms. Too much reliance must not be placed on the presence or absence of casts. Hyaline casts, even in considerable numbers, may be present in the urine from apparently normal kidneys, particularly after diuresis, and even granular casts in small numbers may be found with a relatively normal excretion ; conversely, extensive and even fatal nephritis or uremia may exist without the presence of casts. Blood, epithelial and pus casts are, of course, indicative of disease ; and, as a rule, granular casts in any considerable number are of similar import. Blood in the urine, if certainly derived from the urinary tract, is a most im- portant surgical sign. When hajmoglobin, with perhaps blood serum only, is found, as in the heemoglobinuria of profound malaria or in toxemias associated with extensive destruction of blood corpuscles, or in such states as Raynaud's THE BODY FLUIDS IN SURGICAL DISEASE. 571 disease, no lesion of the kidney itself is indicated. When red corpuscles are found in the urme, it is permissible to assume that in some part of the urinary- tract there exists profound congestion or even inflammation, or that there is a new-growth or a granuloma. The quantity of the blood and the time when it appears in the urine, taken with the other clinical symptoms and signs, usually indicates sufficiently where the lesion is located. Pus in the urine is, of course, confirmatory of inflammatory disease m the urinary tract. When it is continuously well mixed with the urine, suppuration of the renal tissue or pelvis is indicated; when it is associated with blood and crystals, stone is to be considered; or when, in addition to the pus, there are fragments of tissue and blood, a neoplasm or tuberculosis is suggested. Wher- ever pus is found in the urine, specimens secured under aseptic conditions should be examined bacteriologically. Occasionally mere examination of prop- erly prepared smears is sufficient, as in gonorrheal infection ; but often bacterial cultures, with isolation of all the organisms present, are necessary. Where tu- berculosis is suspected it is well not to rely exclusively on a smear examination in any case, both on account of the great rarity of the organisms in some in- stances, and on account of the difficulty often presented in the distinction of the tubercle bacillus from other acid-fast bacteria frequently present in the urine. In these cases animal inoculation is the only safe procedure. Crystalline and amorphous deposits in the urinary sediment are of great sur- gical significance, particularly when renal or cystic calculus is suspected. The most important of these deposits are uric acid or urates, calcium oxalate, and triple phosphate. Amorphous phosphates, when out of solution while the urine is still in the body, are also frequently involved in the formation of stone, partic- ularly when associated with various gums and colloidal bodies which are actively concerned in the precipitation of urinary salts and in the formation of stone. Rare crystals of xanthin, leucin, or tyrosin, and infecting protozoa, as the trichomonas or Balantidium coli, are infrequently of much surgical interest. The F^ces. Examination of the fseces furnishes a most direct means of ascertaining not 'Only the condition of the digestion and the absorptive powers of the gastro- intestinal tract, but also, in many cases, the state of outlying viscera and the presence or absence of general as well as local disease. As with the examination of the urine, account must be taken of the food and drink before inferences are drawn from the appearance or from an analysis of the stools. Thus, a largely vegetable diet gives rise to greater and softer movements than one mostly of meat; foods rich in chlorophyl give a green color; milk gives rise to abimdant light yellow movements; while drugs, as iron, bismuth, manganese, as well as ■certain berries, give a dark, almost black color. Certain inferences are to be drawn from the shape of the fseces. Narrow, 572 AMERICAN PRACTICE OF SURGERY. ribbon-like excreta are formed in rectal stricture or in nervous spasm of the anus; small, roimd, scybalous masses occur in constipation or sometimes as a result of a highly nitrogenous diet. Gross inspection often suffices for the detection of such bodies as the larger parasites (Fig. 144), roimd worms, segments of taenia, and seeds or pits of fruit, bits of undigested vegetable matter, gall stones, and the like. Ordinarily stea- torrhoea can also be diagnosed by gross examination; the light clay color of the movement, with contained fiakes or globules of white fat, indicating deficient bile flow, disease of the pancreas, or perhaps a diet over-rich in fat. Blood in the stools may be readily discovered in many cases by the unaided eye. When it is found fresh and bright red in color, particularly streaking the Fig. 144. — Uncinaria americana, Male and Female. From a case of severe antemia occurring in a soldier returned from Porto Rico. surface, hemorrhage from the anus or rectum, as from hemorrhoids, is suggested. Large amounts of fluid or clotted blood, but slightly altered, indicate hemor- rhage, perhaps from ulceration in the lower portion of the small intestine or from the colon. When the blood is well mixed with the stool and more or less di- gested, the color of the movement becomes black or dark green and carmot be definitely diagnosed without the use of the microscope or by chemical means. Such findings are observed in intestinal or gastric hemorrhage, where the amount of blood lost is not large, and they may signify small ulcers, or cancer of the stomach or small intestine, or perhaps simple congestion, as might take place in cardiac incompensation or portal thrombosis. Intestinal hemorrhage, which, if known, would be of the greatest diagnostic value, may take place without produaing in the stool alterations sufficient to attract the naked eye or to be discoverable upon microscopic examination. Thus, in the early stages of cancer of the stomachj in hook-worm infection, in cirrhosis of the liver, and in many THE BODY FLUIDS IN SURGICAL DISEASE. 573 other conditions in which only minute quantities of blood escape into the bowel, chemical examination of the stool may be necessary, and the detection of blood by the guaiac or other chemical tests becomes in such instances of great value. Mucus in excessive amounts ordinarily indicates catarrhal colitis, and, when it is streaked or flecked with blood, ulceration is to be considereel, in which case bits of eroded tissue, globules of pus cells, and small masses of fibrin are ordinar- ily present. When considerable masses of tissue are passed the surgeon is jus- tified in suspecting the presence of a new-growth, and, in some cases, portions sufficiently large to warrant histological examination may be secured and may render an absolute diagnosis of cancer or papilloma possible. It must not be forgotten, however, that animal tissue from the food occasionally passes through the entire intestinal tract with but little change, and it is therefore wise to con- FiG. 145. — Amcebip coli. From the fa-ces oi a case of tropical abscess of the Uver occurring in a soldier recenth^ returned from tlie Philippine Islands. sider animal tissues as always derived from the food until it can be shown that they emanated from another source. Epithelial cells desquamated from new- growths are rarely in sufficient number to excite suspicion, and this is due to the simple fact that the cells which are eroded from the intestinal mucosa, under natural circumstances or as the result of a simple inflammation, are very nu- merous. In all the departments of medical science study of the faeces for the detection of animal parasites is demanded, and in no branch more so than in surgery. The discovery of ova of the anchylostoma, for example, satisfactorily explains the type of often actively progressive cachectic anaemia which is more than occa- sionally mistaken for that of a malignant tumor. Demonstration of amoeba coli (Fig. 145) in the fecal discharges frequently clears the diagnosis of abscess of the liver, while the occurrence of ova or segments from the various ttenife or round- 574 AMERICAN PRACTICE OF SURGERY. worms often explains otherwise confusing symptoms. Bacterial examination of the faeces yields in some cases valuable surgical data. The mere demon- stration of typhoid or dysentery bacilli, now no longer a matter of great technical difficulty, renders the diagnosis of these diseases at once final and conclusive. Perhaps, however, no more valuable facts are ascertained for the surgeon by the examination of the faeces than are given him by careful daily study in con- valescent cases, particularly after laparotomy — cases in which, by the aid of such regular examinations, the diet may be regulated according to the digestive and absorptive peculiarities of each individual patient. THE TRANSUDATES. The importance of the examination of the transudates lies in the fact that we are thereby enabled to differentiate them from the exudates. The transudates are of passive origin, occurring in hydraemia, in circulatory disorders, and in affections in which the liquids are insufficiently excreted, owing to defective action on the part of the kidneys, skin, or bowel. Any of these conditions, therefore, may be suggested by the presence of transudates. The character of transudates differs somewhat, both chemically and morpho- logically, according to their location. Thus, those from the pleural cavities are ordinarily of somewhat higher specific gravity than those occurring elsewhere. Sedimentation and microscopic examination generally disclose a few epithe- lial cells, macerated and desquamated from the walls of the involved space, or blood cells, usually very much distorted or swollen. Absence of clot, low percentage of hjemoglobin, and lower specific gravity distinguish the transudates from the exudates, which may be further differen- tiated when necessary by kryoscopy. THE EXUDATES. Since the origin and nature of the inflammatory exudates are fully discussed in an earlier chapter, we shall consider them here briefly and only in their im- mediate bearing on surgical diagnosis. For the purposes of surgical diagnosis systematic examination must be prac- tised wherever exudates are found. An examination of both the gross and the microscopic appearances, and also a bacteriological investigation, are of much more importance than chemical methods, although these must also be occasion- ally employed. The exudates may be serous, hemorrhagic, chylous, chyloid, putrid, or puru- lent. Their coagulability and general character can, as a rule, be determined with the unaided eye at the operating table, but the microscope is usually nec- essary to furnish the more important data as to probable origin or precise type. THE BODY FLUIDS IN SURGICAL DISEASE. 575 From the character of the cells contained in the exudate its etiology can often be accurately determined. Serous exudates closely resemble transudates. After they have stood for a short time, however, a moderate amount of clot usually separates out and sedi- mentation shows the presence of formed elements having more or less marked characteristics. Cells dislodged from the wall of the cavity into which exudation has taken place are usually demonstrable, and leucocytes, commonly poly- nuclear neutrophiles, are present in greater or less number; Where the exu- date has been of long standing the cells usually show hydropic degeneration, and may eventually be represented only by amorphous detritus. Hemorrhagic exudates are characterized by the presence of blood in consid- erable amount, for nearly all serous exudates and even the transudates contain a few red blood cells. They may occur after traumatism, in pernicious angemia, purpura, haemophilia, and in similar hsemic diseases, but are most commonly seen associated with tuberculosis or malignant neoplasms. Where the transudate is tuberculous in character, it is usually difficult to demonstrate the tubercle bacillus except by animal inoculation. In the case of cells derived from a new growth, it will often be found that they exhibit karyo- kinesis. Furthermore, such cells are sometimes present in such numbers as to give the fluid a milky turbidity. When small pieces of the new-growth are found in the fluid, then it is sometimes possible to make an absolute diagnosis from an examination of the exudate alone. Chylous exudates are met with in cases in which lymjoh channels of consid- erable size have broken into the body cavities. They are rare, but are readily recognized by the presence of fat and oil globules, which are suspended in the fluid in such a manner as to give it the appearance of milk, both macroscopically and microscopically. Chyloid exudates occur when extensive destruction of epithelial cells takes place, as a result of which destruction minute fat globules and much cell detritus are set free. Such exudates are mostly found in cavities the walls of which are either cancerous or tuberculous. Putrid exudates are recognized by their foul odor; they are usually dark in color, and their sediment is made up of necrotic detritus only. The purulent exudates contain pus, and their chief characteristics are those of pus. In certain conditions the gross appearance alone of the pus suffices to reveal its etiology or character. Thus, in suppuration caused by the bacillus pyocyaneus the exudate is green in color, and infection with the yellow staphy- lococcus is often productive of a pus having a deep golden hue. "\Anien mixed with blood, the fluid acquires a characteristic bloody tinge; when it emanates from a tuberculous focus, it is very apt to contain curds and coagula of whitish- gray necrotic material. The characteristics of pus in the various processes are in the main determined by the etiological factors concerned in its production. 576 AMERICAN PRACTICE OF SURGERY. For this reason particular attention should be paid, in the examination of pus, to the discovery of its etiology. In many cases this may be possible from the simple examination of smear preparations, as in tuberculous, gonorrhoeal, and diphtheritic exudates. In all cases special staining methods should be em- ployed, viz., such as are calculated to bring out the factors supposed to be pres- ent in each case ; or, when necessary, several methods should be used, as are, for example, sometimes required for the absolute identification of the gonococcus. Where many bacteria of different sorts are present, it is usually impossible, except in the case of such specific inflammations as tuberculosis or gonorrhoea, to decide, from this brief examination, which is the more important. In these cases, as well as in those in which no bacteria or protozoa can be demonstrated in smear preparations, cultures on appropriate media, and often tinder both aerobic and anaerobic conditions, must be made, and the various organisms iso- lated, and their respective virulence tested, if necessary, by animal experiment. In some cases direct animal inoculation is to be preferred, particularly when the question of tuberculous infection arises and when the bacilli are not sufficiently abundant to admit of easy detection by the ordinary staining methods. Certain specimens of pus are best examined fresh, as, for example, the pus of liver abscess, for the reason that the demonstration of the amoeba coli is more easily accomplished in this manner than when it has been stained; but, as a rule, stained preparations are to be preferred. Pus should always be carefully searched for cells or bits of tissue that may have been dislodged from the primary seat of the disease, which may be thus disclosed. This is often of value, particularly in malignant tumors, where active growth is closely associated with necrosis. Certain points as regards the age of pus may be determined by submitting it to a microscopic examination. Thus, when it is of rather recent formation, the leucocytes and other cells contained in the fluid are as a rule well preserved, and the pus cells retain to a large extent their typical neutrophilic granule-staining reaction. On the other hand, when the pus is old these bodies are largely or entirely broken down, the serum may have become absorbed, and the pus may be represented only by a sterile, cheesy material, sometimes more or less calcified. CYST CONTENTS. Diagnosis as to the origin of most cysts is possible from the examination of their contents. In many cases such an examination is of the utmost importance to the diagnostician, particularly when differentiation between true cysts and neoplasms which have undergone cystic degeneration is necessary. Encapsu- lated accumulations of inflammatory exudates, resembling cysts, may also be recognized in this manner. In some cases microscopic study of the material aspirated from the cavity suffices for the diagnosis, as in the ordinary ovarian cysts, but in a certain number of cases chemical investigation is also necessary. THE BODY FLUIDS IN SURGICAL DISEASE. 577 C}'sts of the kidney or simple hydronephrosis may be recognized by the de- tection of urea or uric acid in the cystic fluid. Hydatid cysts are manifested by the presence of the hydatid hooklets or scolices (Fig. 143), cysts of the hver by tlie presence in the fluid of bile-coloring matter, and pancreatic cysts may sometimes be identified bj^ tryptic reactions obtainable with the fluid aspirated from them. In the case of dermoids and the more solid cysts, as of the thyroid gland, diagnosis is commonly possible by the gross or microscopic inspection of the ma- terial removed, although aspiration of these cysts is often impossible, especially where hair or teeth-like structures are present. In nearly all instances removal of a portion of the contents through small incisions and the use of the micro- scope render diagnosis easy. THE EPIPHYSES AND THEIR RADIOGRAPHIC INTERPRETATION. By PRESTON M. HICKEY, M.D., Detroit, Michigan. The introduction of the Roentgen ray as a diagnostic aid in surgery lias led to the establishment of a special field of study which may be termed radio- graphic anatomy. The intelligent use of the radiograph presupposes on the part of the observer some knowledge of the radiographic art, as well as some ac- quaintance with the normal and pathologic appearances. The successful use of the microscope as an aid in clinical medicine demands a preliminary laboratory training the results of which are valuable in proportion as the technique is exact and the observer experienced. To realize the value of radiography the proper construction must be placed upon the findings of the photographic plate. The lights and shadows coaxed forth from the creamy surface of the sensitive film by the chemical developer must be interpreted in the light of a previous training in this special field, and not judged through preconceived ideas based on inadequate data. The radiographic study of the human bony framework during its process of development presents varying pictures which often prove deceptive to the inexperienced. Before taking up in a series the various plates which are ob- tained at different ages, it would be well to remember that all radiographs are produced according to the laws of projection and should be interpreted with a full understanding of these laws. The Roentgen ra3^s given off from a Crookes tube properly energized proceed principally from a central point on the target of the tube. These rays diverge in a definite ratio. Fig. 146 illustrates this point. The further removed the oJDJects are from the photographic plate and the nearer they are to the target from which the rays emanate the greater will be their apparent magnification. Rays which come off at somewhat of a tangent to the target will produce more distortion than the more direct rays. The practical lesson to be drawn from these observa- tions is that the target of the tube should be placed as exactly as possible over the part which is to be radiographed, and the part which we most desire to be clearly sho^vn should be approximated to the photographic plate. Bodies between an x-ray tube and the photographic plate cast shadows upon the plate proportionately to their atomic weights. In the human body, tissues containing lime cut off the ray more than does muscle or cartilage ; hence. RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 579 the unossified ends of the bone cast such feeble shadows that they are practi- cally invisible in the ordinary radiograph. In Fig. 147 is presented a radiograph of a new-born child delivered at seven months; it shows at a glance the condition of the long bones and the wide spaces between them occupied as yet by only soft tissues. The striking flexibility of the joints and their natural protection against fractures at this early age are well illustrated. The epiphyses of the long bones, being still cartilaginous, are photographically invisible. The carpal and tarsal bones, with the exception of the OS calcis, are absent. The development of the carpus, from a radiographic standpoint, shows that the OS magnum and the unciform are first noted in the order of appearance of Fig. 146, — The Rays from the Target of the x-ray Tube, AK, diverge from one point so tliat the object O, met first by the rays, would appear larger on the photographic plate, SP, than it would on a similar plate (5' P') situated fartlier awa}' from the tube. the various osseous centres. These bones usually ossify during the first few months of life. In an infant at the age of fifteen months we are accustomed to find the lower epiphysis of the radius manifesting itself first as a small point. During the second j-ear of life these two bones, the os magnum and the imciform, and the lower epiphysis of the radius increase in size, Avhile as their growth advances we find that the proximal epiphyses of the first row of the phalanges begin to make their appearance. The next carpal bone that can be distinguished is the cuneiform. Fig. 148, which represents the hand and WTist of a child at fi'^'e }'ears of age, shows four of the carpal bones present, namely, the os magnum, the unciform, the cunei- form, and the semikmar. Tlie lower epiphy>sis of the radius is well formed. Tlie lower epiphysis of the ulna has not yet appeared. The epiphyses of the phalanged bones are ail more or less distinctly visible, while tlie metacarpals show their distal epiphyses. 580 AMERICAN PRACTICE OF SURGERY. /n\ % Fig. 147. — Radiograph of a Xen-born Child Delivered at Seven Months. The epiphyses of the meta- carpals and phalangeal bones have not yet appeared. The carpus is still cartilaginous and lience pro- duces no shadows on the photographic plate. The humerus, radius, and ulna present no bony ep- iphyses. The lateral centres for the sacrum are distinct. The ilia are distinct from theos pubis to the ischia, which are united at their superior ends. The head of the femur produces no shadow, while in the knee joint the distance between the femur and the bones of the leg is quite striking. (Original.) RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 581 In Fig. 149, which represents the hand and wrist at eight years, we note the lower epiphysis of the uhia. The scaphoid, trapezium, and trapezoid also are distinct. The space between the ossified portions of these carpal bones is still considerable. The lower epiphysis of the radius appears at a much later time than has been assigned by the older anatomists, usually at the age of about seven year.s. In the wrist at eleven years (see Fig. 150) we find a proximal epiphysis — the epiphysis of a second metacarpal. The appearance of the epiphyseal line might easily be mistaken for a fracture line. The second metacarpal is peculiar in the fact that it usually develops from three centres. Fig. 14S. — Radiograph ot Hand at Five Years. 1, Sliaft of fifth phalangeal; 2, epiphysis of same; 3, epiphysis of fifth metacarpal; 4, os magnum; 5, unciform; 6, cuneiform; 7, semilunar; S, ulna; 9, epiphysis of radius; 10, radius. (Original.) In Fig. 151, which illustrates the wrist at twelve years of age, we note the peculiar notch at the proximal end of the second metacarpal, which marks the incomplete union of this bone with its proximal epiphysis: In Fig. 152 we note the superimposed .shadow of the pisiform as_ covered by the greater shadow of the cimeiform. In considering the development of the carpus, from a radiographic stand- point, we must remember that there are considerable variations in the times at which the different wrist bones make their appearance. While the above statements will be true of the great majority of cases, there will, howe^-er, be some to which these statements do not apply. The irregularity may be present symmetrically in both the left and the right joints, although not infrequently 582 AMERICAN PRACTICE OF SURGERY. children are encoimtered in M-hom the osseous development of one carpus is strikingly different from that of its fellow on the opposite side. Local condi- tions — such, for example, as a pre-existing tuberculosis — may sometimes be the cause of this irregularity. None of these peculiarities, however, will give rise to an}^ considerable difficulty in their interpretation. Of all joints in the body, the elbow is the most interesting from a radio- graphic standpoint. This is due to the fact that there are so manj- different Fig. 149. — Hand at Eight Years. 1. Ungual phalanx of thumb: 2, epiphysis of same; 3, proximal phalanx of thumb; 4, epiphysis of same; 5, first metacaqDal; 6, epiphysis of same; 7, trapezoid: S, trapezimn; 9, os magnum; 10, scaphoid; 11, lower epiphysis of radius; 12, radius; 13, fifth ungual phalanx; 14, epiphysis of same; 15, second phalanx of little finger; 16, epiphj'sis of same; 17, third phalanx of little finger: IS, epiphysis of same; 19, cpipliysis of fifth metacarpal; 20. fifth metacarpal: 21, unciform; 22, cuneiform; 23, semilunar: 24, lower epiphysis of uhia; 25, ulna. (Original.) centres of development in the elbow, in consec[uence of which the appearance of the elbow joint varies radiographically year by year from birth to the age of sixteen. "\Mien radiography was first cmploj^ed in the study of injuries of the elbow joint, many mistakes were made in diagnosis, through lack of knowledge of the normal appearance of the joint at successive ages. Injuries about the elbow in children naturally present difficulties in diagnosis owing to the com- plexity of the structures involved. The bony structures contiguous to the RADIOGEAPHIC INTERPRETATION OF THE EPIPHYSES. 583 Fig. 150. — WrhSt at Eleven Years. 1, Epiphy.«is of fifth metacarpal; 2, shaft of fifth metacarpal; 3, miciform: 4, os magnum; 5, cuneiform; 6, semilunar; 7, lower epiphysis of ulna; 8, ulna; 9, sec- ond metacarpal: 10, epiphj'sis of same; 11, epiphysis of first metacarpal; 12, trapezoid; 13, trape- zium; 14, scaphoid; 15, lower epiphysis of radius; 16, radius. (Original.) Fig. 151. — Wrist at Twelve Years. 1, Proximal phalanx of thumb; 2, epiphysis of same; 3, first metacarpal; 4, notch marking nearly completed union of second metacarpal and its epiphysis; 5, epiphysis of first metacarpal; 6, trapezoid; 7, trapezium; S, scaphoid; 9, lower epiphysis of radius; 10, radius; 11. proximal phalanx of little finger; 12, epiphysis of same; 13, epiphysis of fifth meta- carpal; 14, fifth metacarpal; 15, os magnum; 16, unciform; 17, cuneiform; 18, semilunar; 19, lower epiphysis of ulna ; 20, ulna. (Original.) 584 AMEEICAN PRACTICE OF SURGERY, joint develop usually from nine centres, which, however, are not ahva3's radio- graphicallj' distinct. Cases have been recorded in which a fracture was supposed to have been present in an injured elbow, and the attending ph}'sician was misled by the radiograph, thinking that the epiphyseal lines were solutions of Fig. 152. — Hand at Thirteen Years. 1, Epiphysis of fourth metacarpal ; 2, fourth metacarpal: 3, unciform; 4, os magnum; .5, cuneiform; 6, pisiform; 7, lower epiphysis of radius; S, lower epiphysis of uLna; 9, ulna; 10, radius; 11, shaft of first metacarpal; 12, epiphysis of same; 13, trapezium with coalescing shadow of trapezoid; 14, scaphoid; 15, semilunar. (Original.) Fig. 153. — Radiograph Showing Lateral ^'iew of Elbow at Six Years. 3, upper epiphysis of radius; 4, radius; 5, ulna. (Original.) 1, Humerus; 2, capitellu continuity caused by violence. In the interpretation of radiographs of the elbow, greater care is necessary to secure proper reading of the appearances presented than in any other part of the body. The first manifestation of an epiphyseal nucleus in the elbow is that of the RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 585 capitellum, which appears in the form of a httle rounded knob usually during the second or third }'-ear of life. In Fig. 153, which is a lateral view of the elbow at six years of age, the capi- tellum has attained considerable size, so that it projects somewhat into the Fig. 154.— Radiograph Showing Lateral View of Elbow at Seven Years. 1 , Humerus ; 2, capitellum ; upper epiphysis of radius. (Original.) 3, upper rounded space formed by the greater sigmoid cavity. In this figure we note the appearance, as yet barely distinguishable, of the upper epiphysis of the radius, which shows itself first as a little button-like body. Fig. 155.— Radiograph Showing Lateral \'icw of Elbow at Ten Years. 1, Humerus; 2, capitellum; 3, upper epiphysis of radius; 4, radius; 5, epipliysis of olecranon; 6, ulna. (Original.) In Fig. 154 the capitellum occupies more of the sigmoid cavity while the upper epiphysis of the radius is much more distinctly visible. 586 AMERICAN PRACTICE OF SURGERY. In Fig. 155 we see at ten years of age the primar}' centre for the olecranon. The capitelhim at this age has, superimposed upon it, the shadow of the trochlea, which, however, in lateral views of the joint, cannot usuall}' be made out. The upper epiphysis of the radius has increased in size so that its diameter is about eriual to the diameter of the shaft of the radius. Fig. 156. — Radiograph Showing Lateral View of Elbow at Eleven Years. (Variation.) 1, Humerus; 2, capitellum; 3, upper epiphysis of radius; 4, radius; .5, ulna. (Original.) Fic. 157. — Lateral View of Elbow at Fourteen Years. 1, Humerus; 2, capitellum; 3, upper ep- iphysis of radius; 4, radius; 5, secondary centre for olecranon ; 6, primarj' centre for olecranon ; 7, ulna. (Original.) Fig. 156 shows the elbow joint at eleven j^ears of age. In this plate no trace of the olecranon is j^et discernible. This must be considered simply as an irregularity of dcA-elopment in a particular indi^'idual. The other epiphyses show the degree of development normal for that age. RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 587 In Fig. 157, which is a lateral view of the elbow at fourteen, we find that the primar}^ centre for the olecranon has greatly increased in size and that a second- arj' centre has appeared. These usually coalesce during the next six months, giving rise oftentimes to a peculiar elongated body. Here also the shadow of the trochlea is superimposed upon the shadow of the capitellum. The shadow of the trochlea is posterior to the shadow of the capitellum, while the shadow of the internal condyle cannot usually be differentiated in a lateral view. Their superimposed lines often make their recognition a matter of some difficulty. In Fig. 158 we have a lateral view of the elbow at age fifteen, which shows the partial union of the olecranon to its shaft. The serrated line which marks the partial epiphyseal separation has been oftentimes mistaken for a fracture line. In two cases of injury which came under the writer's observation, the patients were compelled to wear splints for several weeks owing to the misinterpreta- FiG. 158- — Radiograph Showing Lateral Meu' of Elbow at Fifteen Years. I, Plumerus; 2, capitel- lum; 3, upper epiphysis of radius; 4, radius; 5, comi^act tissue of the lower end of humerus; 6, ep- il^hj'sis of olecranon j^artial joint; 7, ulna. (Original.) tioninthisrespectof the radiogram of the injured joint. At age sixteen the separa- tion between the epiphysis belonging to the radius and its diaphysis is so slight as often to escape notice. The vertical view of the developing elbow is perhaps more deceptive than the lateral views and requires study for its comprehension. In Fig. 159 is seen the elbow joint of a six-year-old boy. The capitellum is well formed while the small disc of the epiphysis of the radius is sharply shown. In Fig. 160, which is a vertical view of the elbow at age ten, the centre for the 5SS .\.MERICAX PRACTICE OF SURGERY. iuternal condyle is well formed. The capitellum is -n-ell sho-nii; the superim- position of the trochlea over the shadow of the sigmoid cavity pre^'ents its recognition. In Fig. 161. which is a vertical view of the elbow at age eleven, we find the upper epiphj'sis of the radius remarkaljly well defined. The capitellum shows a Fig. 159. — Xeitical View of Elbow at Six Years. 1, Humerus; 2, ulna; 3, capitellum; 4, upper epiphysis of radius; 5, radius. (Original.') Fig. 160. — Vertical View of Elbow at Ten Years. 1, Humerus; 2, trochlea; 3, capitellum; 4, ep- iphysis of radius; 5, radius (Original.) partial attachment to the shaft, although the internal edge is distinctlj' sepa- rated. The olecranon fossa manifests itself as a rounded space of less density than the adjacent thicker an(_l more compact bone tissue. At this age the centre for the internal condjde is also quite distinct from the diaphysis. RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 589 In Fif. 162 — a vertical view of tlie elbow at age twelve — the internal condyle is partly attached to its shaft. Oftentimes in carefully prepared plates the epi- physis of the olecranon can be made out in the light shading of the olecranon fossa. On the external surface the capitellum has increased in size, and the Fig. 161. — Radiograph PUowing Vertical View of Elbow at Eleven Years. 1, Hi. fossa; 3, capitellum; 4, upper epiphy.si.s of radius; 5, radius; 6, trochlea; 7, ulna. (Original.) Fig. 162. — Radiograph Showing Vertical View of Elbow at Twelve Years. 1, Capitellum; 2, upper epiphysis of radius; 3, radius; 4, humerus; 5, trochlea; 6, ulna. (Original.) trochlea can often be made out with its shadow superimposed on that of the sigmoid cavity. The upper epiphysis of the radius is still ununited. 590 AMERICAN PRACTICE OF SURGERY. In Fig. 163, which is a vertical view of tlie elbow at age thirteen, we find the centre for the olecranon manifesting itself more distinctly through the shadow of the olecranon fossa. The peculiar appearance of the capitellum should be Fig. 16: 3, liurnerus . — Radiograph Showing '\'ertical Mew of Elbow at Tliirteen Years. 1, Trochlea; 2, ulna; 4, capitellum; 5, upper epiphysis of radius; 6, radius. (Original.) Fig. 164. — Shoulder Joint at Eleven Years. 1, Coracoid process; 2, distal extremit.v of cla-vicle ; 3, acromion process; 4, head of humerus; 5, epiphj-seal line; 6, shaft of humerus. (Original.) noticed, since on its upper and outer border we find an irregular projection which marks the extension of the bonj^ structure m its endeavor to bridge across the intervening space. On the internal side the internal condyle is partly RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 591 Fig. 165. — Radiograph Sliowing Hip Joint at Seven Years. 1, Ischium ; 2, head of femur; 3, centre of greater trochanter; 4, femur. (Original.) Fig. 166. — Hip Joint at Eleven Years. 1, Ilium; 2, liead of femur; 3, great trochanter. (Original.) 592 AMERICAN PRACTICE OF SURGERY. attached to its shaft. At this age the trochlea can usually be made out quite distinctly. The radiographic appearance of the shoulder joint during the development of the child does not usually vary, and presents no particular difficulties of interpretation. In Fig. 164, which was made from an eleven-year-old boy, the epiphyseal line separating the head of the humerus from the shaft is distinctly seen. This ordinarily persists until about the nineteenth or twentieth year. In Fig. 165, which represents the hip joint of a child of seven, we find the head of the femur quite distinct. In the interpretation of radiographs of congenital dislocation of the hip it is important to remember that the first bony appearance of the head of the femur ordinarily occurs at the end of the first year of life. In the same figure we see the separate centre for the great trochanter, which makes Fig. 167. — Radiograph Showing Lateral View of Knee Joint at Seven Years. 1, Patella; 2, upper epiphysis of tibia; 3, tibia; 4, femur; 5, lower epiphysis of femur; 6, upper epiphysis of fibula. (Original.) its appearance at widely varying periods, sometimes as early as the fourth year, and again, in some cases, not until the eighth year. The lesser trochanter generally makes its first appearance at a much later date, usually about the eleventh or twelfth year. In Fig. 166 the greater trochanter (at age eleven) is most distinctly shown. It usually unites with the shaft at about the same time as when the epiphyseal line between the head of the femur and the shaft disappears; namely, about the eighteenth year. The lower epiphysis of the femur is shown in Fig. 167, which is a lateral view RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 593 of the knee joint at seven years of age. The patella is a bone which radiograph- ically appears at different ages — usually after the third or fourth year; it pre- sents the form of a rounded shadow without the well-defined angles which later distinguish it. The upper epiphysis of the tibia, as well as the upper epiphysis of the fibula, usually appears during the second year of life. The development of these epiph- yses and the change in shape of the patella are illustrated in Fig. 168, which is a lateral view of the knee at age eleven. During the next year the upper epiphysis of the tibia throws out, from its lower part, a projection which is fashioned Fig. 16S. — Lateral View of Knee Joint at Eleven Years. 1, Patella; 2, inner condyle; 3, epiphys- eal line at upper end of tibia; 4, epiphyseal line between the femur and the outer condyle; S, outer condyle; 6, spine of tibia; 7, upper epiphysis of fibula. (Original.) somewhat like a tongue — a projection which afterward becomes the tubercle of the tibia. The antero-posterior view of the knee joint is shown in Fig. 169, which was made with the posterior surface of the joint next to the photographic plate. The distance of the patella from the plate increases its apparent size, so that its shadow is less distinct and can scarcely be differentiated from the lower end of the tibia. The spinous process of the tibia is shown as it projects into the joint space. The epiphyseal lines are so distinct and regular that their appear- ance is not likely to lead to a misinterpretation. VOL. I.— 38 594 AMERICAN PRACTICE OF SURGERY. Fig. 169. — Radiograph Showing Vertical View of Knee at Eleven Years. 1, Femur; 2, patella; 3, lower epiphysis of femur; 4, spine of tibia; 5, upper epiphysis of tibia; 6, tibia; 7, upper epiphysis of fibula; S. fibula. (Original.) Fig. 170. — Vertical View of Ankle Joint at Eleven Years. 1, Tibia; 2, fibula; 3, epiphyseal line of fibula; 4, lower epiphj-sis of fibula; 5, epiphyseal line of tibia; 6, lower epiphysis of tibia. (Original.) RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 595 Fig. 171. — Radiograph Showing Lateral View of Ankle at Seven Years. 1, Superimposed shadow of fibula; 2, lower epiphysis of tibia; 3, astragalus; 4, os calcis; 5, tibia; 6, scaphoid; 7, cuboid. (Original.) Fig. 172. — Lateral View of Ankle at Eleven Years. 1, Tibia; 2, lower epiphysis of tibia; 3, astrag alus; 4, scaphoid; 5, os calcis; 6, epiphysis of os calcis; 7, cuboid. (Original.) 596 AMERICAN PRACTICE OF SURGERY. Fig. 170 is a vertical view of the ankle at age eleven; the lower epiphysis of the fibula, as it forms the external malleolus, is a well-known object. On the in- ternal side the broad epiphysis of the tibia is shown above the talo-crural joint. In Fig. 171, which is a lateral view of the ankle joint at seven years of age, the distance between the tarsal bones is strikingly obvious. At birth the tarsus usually shows a small centre for the os calcis and one for the astragalus. The cuboid appears during the fifth month, while the scaplioid is first seen about the fourth year. The considerable space which is present between the bony Fig. 173. — Radiograph Showing Lateral View of Ankle at Tweh-e Years. 1, Scaphoid; 2, internal cuneiform; 3, cuboid; 4, tibia; 5, lower epiphysis of tibia; 6, fibula; 7, astragalus; S, os calcis; 9, ep- iphysis of os calcis, (Original.) centres of the tarsal bones before the age of five explains at a glance why moulding operations upon the foot at this age are possible. The epiphysis of the os calcis appears ordinarily at the eighth or ninth year. In Fig. 172, which is a lateral view of the ankle at age eleven, this epiphysis is shown in an already ■\^'ell-advanced state of development, with fine osseous deposits between its main bodj^ and the os calcis. Further development of this epij^hysis occurs during the following year, as is shown in Fig. 173. In Fig. 174, which gives a lateral view of the anlde at age thirteen, we have the partial union of the epiphysis with the os calcis. This union may take place a RADIOGRAPHIC INTERPRETATION OF THE EPIPHYSES. 597 Fig. 174. — Radiograph Showing Lateral View of Ankle at Thirteen Years. 1, Tibia; 2, fibula; 3, lower epiphysis of tibia; 4, astragalus; 5, scaphoid; 6, internal cuneiform; 7, cuboid; S, lower ep- iphysis of fibula; 9, os cal-cis; 10, epiphj^sis of os calcis. (Original.) Fig. 175.— Radiograph Showing Lateral View of a Cretin's Foot at Twelve Ye cuboid; 3, tibia; 4, fibula; 5, astragalus; 6, cs calcis. (Original.) 1. Scaphoid: 598 AMERICAN PRACTICE OF SURGERY. year or so later. In this radiogram tlie distance between the tarsal bones approaches that of the adult foot. The general development of the child may oftentimes be inferred with a fair degree of accuracy from the degree of development of the osseous frame- work. In Fig. 175, which is a lateral view of the ankle of a cretin — twelve years of age, — we find the bones showing the degree of development which we should ordinarily find at four years. The mental development of the patient corresponded to the intelligence which we should expect to find in a child of five years. In interpreting radiographs of injured joints of children, as the writer has insisted above, some experience is necessary. We should be familiar with the appearances ordinarily presented at different ages, and we should be able promptly and correctly to interpret the exceptions which may occur. Ordi- narily, it is a safe rule, in cases of obscure injury, particularly about the elbow joint, to make a second radiograph, at the same time, of the uninjured joint, for the purpose of comparing it with the radiograph of the injured joint, both of the pictures to be taken under the same conditions. It has been the experience of radiographers that epiphyseal separations are rarely met with. The clinical diagnosis of a traumatic separation of the epiphysis will often be found to be inaccurate, as the radiograph usually shows a solution of continuity through the bony structures adjacent to the epiphyseal line. The sudden violence at the time of injury seems to snap the bone in preference to pulling apart the more yielding soft tissues. This is perhaps fortunate, as the readjustment of the bony fragment can be better effected than the replacement of the unossified structures nearer the joint. THE TECHNIQUE OF RADIOGRAPHIC WORK AS APPLIED TO SURGERY, AND THE INTER- PRETATION OF RADIOGRAPHS. By Mr. WALTER J. DODD and ROBERT B. OSGOOD, M.D., Boston, Mass. I. RADIOGRAPHIC TECHNIQUE The development of x-ray work since Roentgen's discovery has been rapid and the broadening of its field of usefulness has been great. A short decade has seen the interesting plaything of surgery absorb the attention of earnest sci- entific workers until many men have sacrificed the general practice of medicine to become specialists in radiology, or even to devote themselves exclusively to certain branches of the art. It is not the purpose of this article to consider in great detail the technique and apparatus necessary for these special x-ray investigations, but rather to outline with sufficient clearness apparatus and methods which, if obtained and followed, will allow a busy practitioner to install and operate an x-ray plant with satisfaction and accuracy. In large centres it is now possible to obtain x-ray work which is up to the best modern standards. Its field of usefulness, however, is by no means confined to these large centres, and in many instances the advantages of office plants and personal operation far outweigh the value of these larger x-ray laboratories. We wish it distinctly understood that the apparatus here suggested and the methods advised are simply those which, from practical experience, we know to be accurate and with which Avork of high quality can be done. Where sev- eral forms of apparatus, of nearly equal value, have been devised, the simplest have invariably been chosen for description. The methods advised should be considered for the most part as working bases from which the practitioner begin- ning x-ray work may start, later elaborating and adapting them to his indi- vidual needs. To the interpretation of x-ray plates far less space has been given than the importance of the subject justifies. The writers believe that here again the aim of the work should be to suggest broad diagnostic points, feeling sure that the power of finer discrimination can come satisfactorily only through large expe- rience and patient comparison with the normal. In the description of the characteristics of the various conditions which will .599 600 AMERICAN PRACTICE OF SURGERY. be considered later, we presuppose good and even lighting of the plates, such as is shown in Fig. 176. This illuminator will be subsequently described. We wish to acknowledge our indebtedness to a valuable and exlraustive un- published paper by Dr. E. A. Codman, of Boston, and to the work of Schuchardt, "Die Krankheiten der Knochen und Gelenke" (" Deut. Chir.," Bd. xxviii.). We shall consider the evidence of the various diseases in the skiagraph alone without discussing the histologic and pathologic changes or the detailed etio- logic factors. The therapeutic uses of the 2:-ray have been exhaustive!}^ treated in avail- able books. We do not feel qualified to speak authoritatively on the technique of these measures, nor of their value. Pure surgery concerns itself little with most of the diseases commonly so treated. While recognizing differences of opinion among careful observers, we personally feel that a;-ray therapy, except Fig. 176. — Illuminator. Light, evenlj' diffused, reflected from white back of box. in the superficial forms of epithelioma, should ne^'er take the place of surgery in operable cases of cancer. Although differences of opinion also exist as to the value of x-ray treatment following operations for carcinoma, the evidence in our minds seems to warrant its use as a post-operative safeguard against recur- rence. In the keratoses and superficial epitheliomata the results of x-ray treatment are certainly comparable with the surgical procedures. In the treat- ment of lupus and the superficial forms of tuberculosis, it undoubtedly offers us the best method at our disposal and sho-s^-s results little short of marvellous in the light of our old conceptions. Measurers of the intensity and the quality of the rays are to be obtained in varied forms of greater or less accuracy. Some of these meters should be used in therapeutic work, and the treatment standardized as much as possible. A knowledge of electricity can never be other than a help in radiology. We do not deem, however, an intimate acquaintance with the subject essential to THE TECHNIQUE OF RADIOGRAPHIC WORK. 601 practical x-ray work. The basic principles must be known; to be an electrical engineer is unnecessary. It will be taken for granted that the principles of con- duction and induction are in a general way understood, and the component parts of plants adapted to different forms of current, or to an entire absence of avail- able current, will be described. The following list comprises what we consider the essentials of an x-ray plant: Coil; Interrupter ; Several good x-ray tubes; Rheostat ; Switchboard with ammeter for primary circuit, fuse of lower reading than main fuse, and knife switches; Compression cylinder ; Adjustable table or support for patients; Illuminating lantern ; Solid and well-constructed tube holder. Coil. The plant about to be described has been submitted to the severe test of hospital as well as large office practice. No originality of method or apparatus is claimed, the purpose of the writers being to describe apparatus and technicjue that have proved to be practical, simple, and satisfactory. In order to do quick radiographic work the coil should give a discharge of at least 4 to 8 inches. It is not simply length of spark that is needed, but Fig. 177. — Illustrates spark spoken of as thin spark. Impossible to get higher reading than 3 mil- liamperes witli this coil; from IJ to 2 milliamperes being the average reading with 16 amperes on pri- mary circuit. Length of spark 8 inches. Exposure for hip, in the case of an adult weighing 160 lbs., from 2 to 3 minutes. (Original.) volume. A coil that will give a long, thin 12-inch spark is not to be com- pared with one that will give a flaming 8-inch spark. The flaming discharge indicates quantity, and quantity is essential to speed, and speed is essential to good work. By speed we do not mean snap-shots. We must keep in mind the fact that we are not dealing with light from one source, but that the x-ray light gives rise to other radiations, all of which have more or less influence on a pho- 602 AMERICAN PRACTICE OF SURGERY. tograpliic plate. For this reason we must striA-e to get, in as short a time as is consistent with good work, the greatest quantity of .r-ray light, thereby eliminat- ing secondary radiations as much as possible The coils used by the writers are capable of giving a 6- to 10-inch flaming discharge (Figs. 177 and 178) when used with a Wehnelt interrupter; the ammeter in the primary reading 10 amperes, and service being derived from a direct current of either 220 or 110 volts. The primaries of these coils are so wound that self-induction has been greatly increased over that of the primaries used when the electrolytic interrupter was first intro- duced. It is to Dr. Walters, of Hamburg, that the credit of variable primary Fig. 178. — Illustrates flaming discharge, 8 inches in length. Meter will read 10 milliamperes with 10 amperes on primary circuit. Exposure for hip, in an adult weigliing 160 lbs., 20 to 40 seconds. (Original.) inductance should be given. Such winding is absolutelj' essential to good results with the Wehnelt interrupter. All large coils of first-class make are now equijjped with primaries of this type and are most highly recommended. Coils of first-class manufacture will always give the spark at M'hich they are rated, but the operator is advised not to submit the coil to such strain. Never spark the coil to its full capacity. You can test a 12-inch coil without forcing the discharge through the air gap of 12 inches. To test a coil of 12-inch rating the writers place the discharge rods about 8 inches apart and slowly turn on the current. If the coil is in good work- ing order, sparking will begin with a thin, continuous, snappy spark which is thicker and broader at one end. This is the cathode or negative terminal of the coil and should be marked with the negative sign. As more current is allowed to flow in, the discharge increases until finally we get the yellow con- THE TECHNIQUE OF RADIOGRAPHIC WORK. 603 tinuous spark. Never test the coil by sparking unless it is absolutely nec- essary, as the coil is likely to become overheated and affect the insulation of the secondary circuit. Interrupter. The purpose of the interrupter is to break the primary current rapidly and completely, while at the same time the period of make is long enough to saturate the primary coil. Mechanical interrupters of modern pattern have reached a high stage of perfection and are heartily endorsed by many, but the current- carrying capacity of all mechanical interrupters is low and the time of expos- ure must be long when compared with an mterrupter of high-current-carrying capacity, such as the liquid electrolytic, mercury, and Wehnelt. As the writers believe from their own experience that the Wehnelt is by all means the most satisfactory for good radiographic work that type alone will be described. The action of the electrolytic interrupter is brought about by electrolysis of acidulated water, gas forming at the anode or positive plate, which gas for an instant envelops that plate and momentarily breaks the current; a very high rate of interruption may thus be obtained. The electrolytic or Wehnelt interrupter consists of a lead plate or tube, which must always be connected to the negative termuial of the main current, and a platinimi point which must ahvays be made positive. These are then placed in a vessel of glass or earthen- ware containing sulphuric acid, specific gravity 1.20; the platinum point is usually passed through a glass or porcelain tube, the strength of current being dependent upon the amount of platinum surface projecting through the tube into the liciuid. As the amount of current depends on the amount of platinimi surface thus exposed, we can readily see that we have at hand an interrupter the current-carrying capacity of which is almost imlimited and far beyond what it is possible to use with our present knowledge of tubes and coils. The Wehnelt interrupter was made practicable for radiographic work by Dr. Walters' improvement m induction-coil construction whereby the self-induction of the primary could be raised by using two or more layers of wire according to the vacuum and spark resistance of the tube. It is now possible to use the Weh- nelt interrupter when employing tubes for therapeutic purposes. By raising the self-induction we are enabled to use tubes of much lower vacuum; and the writers have used such tubes for over twenty minutes' continuous operation with three amperes on the primary circuit, the spark length of the coil being a heavy 10-inch flaming discharge when used with one layer of primary, where- as with two layers of primary on this particular coil it is impossible to get a flam- ing discharge of more than three and one-half inches in length even with fif- teen amperes on the primary circuit. It is interesting to note that the character of the spark is almost completely changed when the self-induction is raised. It is much shorter, but at the same time much thicker (Fig. 177). This 604 AMERICAN PRACTICE OF SURGERY. fact may be taken advantage of to operate tubes of very low resistance, and at the same time get good radiograpliic results, although the exposure is inva- riably longer. This discovery, made by Dr. Walters, is one of the greatest steps in advance, it being now possible to take advantage of that most efficient and admirable interrupter, the Wehnelt electrolytic. It is now possible by means of this interrupter and coils of modern construction to get good radiographs of the deeper parts of the body in a few seconds — a very brief time when com- pared with the period of several minutes reciuired by the older apparatus. The interrupter used by the writers consists of a piece of lead pipe one and three-fourths inches inside diameter, three-sixteenths inch thick, and aljout twelve inches long. This is fastened to a board by cutting two ears or lugs, bending them back and screwing the same to the board. A hole is now cut Fig. 179. — Interrupter Board with Lead and Glass Tube attached. Tlic .spiral wire, 1, is attached to the lead pipe. The loop, 2, is attached to the platinum wire. A slot is cut in the lead pipe close to the board for the outlet of the glass tube, which is inside the lead pipe. The latter is 12 inclies long, with an inside diameter of 1^- inches. Liquid in stone crock comes to within one inch of outlet of glass tube. (Original.) through the board corresponding to the centre of this lead tube (Fig. 179). Into this hole a glass tube ten inches long and one-half inch inside diameter is placed. To the lower end of this tube a capillary tube one and one-half inch long is sealed, this capillary l^eing for the platinum wire to pass through. This tube has a side outlet, two inches from the top, to allow the liquid, which always rises in the tube when the interrupter is running, to pass out, otherwise it would overflow on to the cover. A copper wire, sixteen inches long, is now taken, and to one end of it a piece of iridized platinum four inches long is fastened. By flattening the end of the copper wire slightly, a small hole may be bored in it and the platinum wire passed through, bent over, and then soldered securely in place. The copper wire is passed through a cork, which is fitted tightly into THE TECHNIQUE OF RADIOGRAPHIC WORK. 605 the glass tube. Special care should be taken to prevent the platinum from coming in contact with the lead pipe. The board with the tube attached is now put in a stone crock large enough to hold from one to six gallons. Six-gallon stone crocks are used with the interrupter illustrated in Figs. 179 and 180; and the fluid to be used is either sul- phuric acid, specific gravity 1.20, or a half -saturat- ed solution of magnesium sulphate acidified with sulphuric acid. This magnesium-sulphate solution was suggested by E. Hauser, of Madrid, and has been used at the Massachusetts General Hospital for eight months without being renewed. The objection to the Wehnelt interrupter, on the ground that the solu- tion gets overheated (that is, above 90° F.), seems to be obviated to a great extent by means of this solu- tion ; for we have employed it day after day, and on testing have found it to be 115° F., which high tem- perature does not interfere with its efficient action. The acid or the magnesium-sulphate solution used in the interrupter should be covered with some heavy oil, such as dynamo oil, to the extent of about one- eighth of an inch deep. This prevents evaporation of the liquid and also the spraying which always oc- curs to some extent when heavy currents are used. As before stated, the amount of current passing into the primary circuit is dependent upon the amount of platinum or anodal surface that comes in contact, through the glass tube, with the liquid. On the coil used at the Massachusetts General Hos- pital, where a direct current of two hundred and twenty volts is used, one-quarter of an inch of plat- inum of the size one forty thousandth gives three and one-half amperes; three-quarters of an inch will give eleven amperes; and one inch fifteen amperes. These figures cannot be taken as a guide, however, because so much depends on the resistance in the primary as well as in the secondary circuit. To connect up the Wehnelt interrupter it is necessary to determine the positive terminal of the mains. To do this, we advise taking a dilute solution of potassium iodide, moistening a piece of filter paper with it, then bringing both wires into contact with the filter paper, great care being taken not to allow the wires to touch each other. If a dilute solution is used the iodine will be liberated Fig. ISO. — Interrupter tube. Length, lOJ inches ; inside di- ameter, i inch. To the larger tube is sealed a capillary tube, IJ inch long, through which a platinum wire slides. This capillary tube is large enough to carry the platinum wire without friction. (Original.) 606 AMERICAN PRACTICE OF SURGERY. and a blue color will become evident at the positive pole. If, however, a strong solution is used a brown color will appear at the positi-\-e pole and sometimes this may be confused with the charring of the paper which oc- curs quite frequentty at the negative pole. For this reason a dilute solution is advised. After it has been determined which is the positive pole it should be connected directlj^ to the platinum terminal of the interrupter. The other, or negati^'e, terminal is connected to the primarj^ of the coil, the other end of the primary being connected to the lead of the interrupter (see Fig. 179). The interrupter having now been connected at all points, it is necessary to find out the amount of amperage that ^^■ilI be needed for operating each Fig. ISl. — -Y-ray Room of [Massachusetts General Hospital, showing closet containing interrupters; on top of closet is the switchboard with knife switches, ammeter, and fuses. Fuses are of lower resist- ance than main fuses, so that when fuse blows out it maj' be replaced without the annoyance of going to main board, which may be in the cellar or at some distance. The operator works behind a screen, which, in this picture, has been pushed to one side. (Original) particular apparatus. From experiments on se\Tral coils ^^"e have ascertained that from twelve to fifteen amperes, with t^A'o huntlred and t\A-ent3- or one hundred and ten volts of a direct current, will be found sufficient for all radiographic work, a rheostat being used to control the amount of current fiowing into the primary circuit. A lower voltage, if available, is recommended, from si.xty to ninety volts being considered the best. The crude interrupter described abo^■c is by no means meant to take the place of the more elaborate and easily adjusted apparatus now on the market, but its simplicity of construction and the fact that we have had several inter- THE TECHNIQUE OF RADIOGRAPHIC WORK. 607 rupters of this tj'pe in use for over a year justify us, we think, in furnishing dimensions (Figs. 179 and 180). We have spoken of the rheostat controlhng the amount of current that goes into the primary circuit, and we feel that we are justified in saying tliat without it we cannot get the Ijest results obtainable from an efficient and always Fig. 182. — Coil showing mechanical interrupter, also switchboard with switches, rheostat, and meters. Wehnelt interrupter can be placed in closet below. Tlie writer believes that a better arrangement is to have the .switchboard at a distance from the coil and tube stand. 3y this plan the operator may always have the protective screen interposed between him and the active tube. (See also Fig. ISl.) satisfactory apparatus. To have sufficient platinum exposed in the liquid to give fifteen amperes in the primary circuit, ^^■ithout a rheostat to control it, is, to say the least, a somewhat dangerous proceeding; for, although the spark from a large induction coil may not cause harmful effects if received by the patient, it is certainly sufficient to make him hesitate as to the advisability of again submitting himself to such an examination. The rheostat gives the 608 AMERICAN PRACTICE OF SURGERY. operator complete control of the current passing into the coil. By this means he can use more or less according to the vacuum of the tube; moreover, if he uses the rheostat instead of the switch when shutting off the coil, all danger of the patient getting a shock is ob^'iated. In our work we are accustomed to use a twenty-ampere rheostat with one-half or one-ampere steps. With this fine gradation the operator has great control over the amount of current going into the primarj^ circuit. (Figs. 181 and 182.) If the alternating current is the source of supply, a coil may be operated to good advantage by using the Wehnelt interrupter, or better by using in series with this interrupter the aluminum rectifier, tlms converting the alternating into the direct current. It is not cpite so easily managed as a coil operated on the direct current, but, if care be taken to keep the twenty-per-cent aqueous solu- tion of ammonium phosphate alkaline, good results may be readily obtained from this rectifier. If expense is not to be considered, a motor converter is to be by all means recommended. Storage batteries may be used provided they be large enough to give sixtv volts or over. For this purpose the storage bat- . tery of an automobile may be utilized, and the aluminum rectifier may be used for charging the storage batter}'. Many operators prefer the static machine, and there is certainly much to be said in its favor. In order to get good results from static machines a large one capable of being driven at a high rate of speed is necessary. This type of apparatus has been greatly developed since the advent of Roentgen's discovery, and the objection to the influence of atmos- pheric conditions has been in large measure eliminated. The static machine will give beautiful radiographs, is by no means as hard on the tubes, and is much simpler to operate. The objection to it is the liability, in damp weather, or when operated in certain climates, of failure to start even after much manipu- lation. Another objection is the time of exposure required. Much longer exposures are necessary than with the coil. Still, many operators prefer it to the coil and get beautiful results. Tube. The type of tube should be adapted to the machine. It is advisable to use small tubes on coils of short spark length, and large tubes on coils giving long, heavy discharge. The tubes used by the writers are of the Gundelach, Voltholm, and Friedlander tj-pe. To accurately describe the appearance of an .T-ray tube as the process of seasoning or ageing progresses seems almost impossible. The illustrations used by the writers (Plate V.) are intended to emphasize the more important visi- ble changes that the tube undergoes during the time of ageing, which ageing we believe to be essential to good results. A^^ien an x-ray tube is used for the first time it usually is of high resistance. EXPLANATION OF PLATE V. Fig. 1. — Illustrates an Unseasoned High-Vacuum Tube. With 12 amperes on primary circuit only 0.5 to 1 miliiammeter can be forced through the tube. Radiographs taken under such conditions give thin plates showing practically no contrast between bone and flesh. Lowering the vacuum of this tube will increase the radiographic value, but only temporarily, as the tube is unseasoned, and will soon, even with short exposures, present an appearance such as is illustrated in Fig. 2. A seasoned tube may present an appearance similar to this. Fig. 2. — Illustrates a Low-Vacuum Tube. The tube, under such conditions, is of very little value for radiographic work. It is very important to note that when the tube is in this state, showing cathode stream, we get a very high reading on miliiammeter with comparatively little energy flowing into the pri- mary circuit. This may be due not so much to the degree of vacuum as to what gases the vacuum is composed of. In unseasoned tubes we have gases driven off from terminals, whereas in seasoned tubes the vacuum is reduced by means of the regulator. Fig. 3.— Illustrates the Appearance of the Tube when Working to the Best Advantage. Notice the illuminated spot on the anode, which, although not essential, does seem to indicate increased radiographic value. In order to get high reading on the miliiammeter with this tube, when used on coil giving spark as illustrated in Fig. 178, it is necessary to use at least 12 amperes on the primary; parallel spark gap resistance being 6 to 7 inches, and miliiammeter reading between 6 and 8 milliamperes. The average exposure for adult hip, under such conditions, is from 20 to 40 seconds. Fig. 4. — Illustrates a Tube that Shows an Inverse Discharge. Under such a condition the fluo- roscope will be briUiantly illuminated, but the radiograph will be flat; that is, it will lack contrast be- tween bone and tissue, and the definition will also be vc*ry poor. It is very important to note here that the miliiammeter, wl.en the tube is in this condition, will read zero; yet we may have exactly the same condition in the primary circuit as exists wiien the tube presents an appearance such as is illustrated in Fig. 3 of the present plate. The inverse discharge is so great that direct a:-ray reading is completely wiped out. This inverse discharge may be overcome to quite an extent by using a series spark gap or ventral valve tube, by lowering the vacuum by means of the regulator and then raising self-induc- tion of the primary. It is advisable not to operate the tube when it presents this condition, as the tube then becomes blackened and overheated. Overcome the tendency of the coil to produce this con- dition by the means suggested, viz.. by the series spark gap or ventral valve tube. Some coils will operate much better if the spark gap is kept constantly in series with the tube. American Practice of Surgery. F. AILKER DEL Stages in "Ripening" or "Seasoning" X-Ray Tubes THE TECHNIQUE OF RADIOGRAPHIC WORK. 609 and the discharge will jump across an air gap of 5 to 7 inches as estimated by means of parallel spark rods, with which nearty-all coils are equipped. Under such conditions the tube should be lowered by means of the regulator, that is, by allowing the discharge to pass through the chemical or by heating the pala- dium regulator if of the osmosis variety. This allows gas to pass into the tube, and in this manner lowers the resistance. If the current is now turned on in suf- ficient quantity the tube will glow with an apple-green fluorescence. Bright flu- orescent spots oftentimes appear on different parts of the tube; this appearance may last for several minutes if only a small amount of energy is allowed to pass through the coil. If, however, heavy discharges are sent through the coil, this condition soon changes in a new imseasoned tube with the Wehnelt interrupter, and a warning note is invariably heard just previous to this change, and the expert knows that the resistance of the tube is about to fall very rapidly unless the current is diminished or shut off completely. If the current is shut off just previous to this fall in resistance or lowering of vacuum, and the tube allowed to cool completely, this process may be repeated many times; but if the current is not shut off and the tube is allowed to run, the anode becomes hot, blue vapor ap- pears in the bulb, the color changes to a more yellow-green, and then there is seen a stream of bluish vapor between the cathode and anode. At first, this stream impinges on the anode, but as the vacuum gets lower it will be seen that the cone- shaped stream changes and apparently two cones are formed having the apices midway between the anode and the cathode (Fig. 2, Plate V.). This blue stream is known as the cathode stream. Just previous to this double-cone appearance the anode becomes very hot. The radiographic value is greatly increased, then there is a sudden and greatly diminished radiographic value. The anode appears less hot, and finally the tube becomes completety filled with blue vapor. Dur- ing the latter part of this condition a stream of blue vapor may oftentimes be seen starting from the anode and apparently striking the glass either in a line perpendicular to the face of the anode or at right angles to the cathode stream. Where this blue stream strikes, the anode is said to be the source of x-ray light. Such a tube is of very little value for radiographic work, but if properly treated the process of seasoning will go on and eventually the tube will present an appear- ance very much like that sho'mi in Fig. .3, Plate V. A beautiful rich yellow with a sharp line of demarcation divides the tube into two distinct parts; a brightly illuminated spot showing on the anode if the current is powerful enough. This bright spot is caused by the cathode stream striking the anode, and in a perfectly focussed tube covers an area of about one-sixteenth of an inch. If it is much larger than one-sixteenth of an inch in diameter, except under conditions described under low-vacuum tube (Fig. 2, Plate V.), it shows that the tube has not been accurately focussed, and radiographs taken with such tubes lack the fine definition so necessary to good plates. If the spot is smaller than about one-six- teenth of an inch the bombardment of the cathode stream has so much force that VOL. I.— 39 610 AMERICAN PRACTICE OF SURGERY. the anode -u-ill be punctured if of light weight; if the anode is of a heavy type, as is the case in the tubes used by the writers, the face of the anode will be fused at this point, eA'^en with short exposure. Wien the tube reaches this stage (Fig. 3, Plate Y.) it is of great value for radiographic work, although by no means fully seasoned. The process of seasoning, if properly managed, goes on from this point until we get a tube the color of which changes to that of a more yel- lowish-green resembling that of Fig. 1, Plate V., except that the color is richer and the fluorescent spots are not so persistent if at all present. Wlien the tube reaches this last stage, which may take several weeks of daily use, it should be carefully tested and labelled, as it is now the tube needed for radiographs of the deeper parts. During this process of seasoning many interesting and remarkable phenomena may be observed. One of the most striking, after that demonstrated in Fig. 2, Plate V., is the condition of very high resistance which all tubes seem to pass through if kept in use long enough. The tube glows with this character- istically beautiful color when started up for a few seconds, then suddenly it seems as though a deep inspiration had occurred, for usually, without any warn- ing whatsoever, the glow disappears and there is a loud roar in the interrupter; and even if more current is sent through the tube it cannot be started up again without lowering the vacuum. This is probably caused by the complete exhaus- tion of the terminal of occluded gases as well as by the using up of the original vacuum. ^Vlren the tube reaches this condition it is necessary to lower the vacuum more frequently than before, by means of the chemical regulator. The tube seems to be able to take care of large quantities of liberated gases. It has been noticed by the writers oftentimes that the whole tube will be filled with a bluish ^'apor which will instantly disappear, and the beautiful richgreen- ish-j'ellow take its place. When the tube reaches this condition we consider it of the greatest radiographic value, it being capable, when properly operated, of giving good radiographs with very short exposure ; also definition is greatly increased and there is very little diminution in the contrast so noticeable when using a yellow tube, as illustrated in Fig. 3, Plate Y. To accomplish this process of seasoning and ripening an x-ray tube, weeks of careful manipulation during the daily routine work will be recjuired, and it is possible to ruin all chances of ever bringing this condition about unless the operator appreciates certain basic principles in the proper manipulation of .r-ray tubes. The temptation to beat all records for x-ray exposure is probably the cause of so many failures. To illus- trate how necessary a sufRcient length of exposure is, let us take the ordinary photographic process. Is it possible to get the best results of interiors or of subjects in which there is a variety of values as to light and shade by a short exposure? A short exposure of such a subject will usually produce a negative which shows under-exposure of the deeper shadows. We think the same holds true in taking radiographs of the deeper, thicker parts of the body and even of the extremities. We should remember that it takes time for the x-ray light to THE TECHNIQUE OF RADIOGRAPHIC WORK. 611 pass through the part exposed to the phiotographic plate, and that the different parts of the body have different degrees of power to absorb light. If we can appreciate this important fact, our failures in this line of work will be fewer in number and our successes greater and more valuable. Another condition, one of the most annoying and very common, is the ten- dency which some x-ray tubes have to be greatly influenced by the inverse dis- charge — an influence which is manifested by the appearance of several rings back of the anode, also throughout the entire tube. In addition to this the whole tube takes on the yellow fluorescence, and the line of demarcation so characteristic of tubes when operated to the best advantage is very faint. This condition may be overcome to a great extent by the use of the series spark gap so universally adopted. The spark gap used by the writers is the multiple spark gap introduced by Dr. Francis Williams, of Boston. Some coils are so constructed that this in- verse di^rcharge is great enough to jump several inches, as indicated by the fact that when this condition does occur in a tube it may be overcome by pulling the series spark gap out until the sharp anode line appears again. This condition of tube is illustrated in Fig. 4, Plate V. During this stage the fluoroscope is bril- liantly illuminated, and it is possible to get radiographs of even the deeper parts with tubes in this concUtion, but they lack contrast and detail. The soft parts cannot be differentiated, and, except for the almost entire lack of detail, plates taken under such conditions, resemble those which are taken with the high vacuum tube. This condition usually occurs just before the vacuum drops, when the steady hum of the Wehnelt interrupter changes to the irregu- lar roar. It may be overcome to a great extent by lengthening the series spark gap and turning off some of the current. If you are fortunate enough to have a coil with variable primary inductance, the difficulty may be almost completely eliminated by using a higher self-induction in the primary, two or more layers according to the degree of vacuum. Following is a brief account of the important steps in the process of season- ing tubes as used by the writers. Before giving this account, however, we shall take the liberty of telling what we think to be some of the causes of so many tubes being ruined long before they have passed through the successive stages described above. The desire to get short exposure, and the lack of the appreciation of the fact that an x-ray tube is an exceedingly delicate piece of apparatus, are responsible for many fadures. To connect up an x-ray tube, close the circuit, turn on the rheostat, and use the full capacity of the coil, par- ticularly on a new tube in an endeavor to get a short exposure, is a serious mis- take. You may succeed in getting a few good radiographs, but invariably the tube will go to pieces, blue vapor and the blue cone will appear, as illustrated in Fig. 2, Plate V., and, for the time being at least, the tube is useless. When a new tube is received it is tested by the following method: After being connected to the coil the current is turned on and the resistance of the 612 AMERICAN PRACTICE OF SURGERY. tube noted by means of the parallel spark gap or millianmieter. If the tube lights up with yellow color, as in Fig 3, Plate V., the current is turned off at once and the tube tested radiographically or by means of the milliammeter in series with the tube as described later. If the tube gives an appearance like that shown in Fig. 1, Plate V., more current is turned on ; if fluorescent spots still persist and the color is green, the tube is lowered by means of a chemical or a palladium regula- tor. If a palladium regulator is used we employ an alcohol lamp with very small flame, the lamp being attached to a wooden stick four or five feet long, as advised by Dr. Rollins, of Boston. Palladimn takes hydrogen from the flame, and this hydrogen passes into the tube and lowers the resistance. We consider this a most delicate and satisfactory regulator. After the resistance is lowered to such a degree that the tube has the appearance of that illustrated in Fig. 3, Plate v., it is tested radiographically or by means of the meter in secondary circuit. We have spoken of a stage in which the tube presents the appearance shown in Fig. 3, Plate V., but we should at the same time call attention to the fact that many tubes will resemble this in color, and yet be far from sea- soned. We must say, however, that the tendency of the manufacturers to-day is to at least partially season tubes before shipping: this is done by run- ning them on a coil during the process of exhaustion, and the practice is much to be commended. If the tube is of low resistance (see Fig. 2, Plate V.) the following method is adopted : The vacuum being low it is necessary to increase or raise it. If the coil has variable primary inductance, raise the self-induction of the primary. In many instances a tube may be made useful for ratliographic work by this means. The series spark or ventral tube may be tried, but we believe it is better to begin the process of seasoning and proceed as follows: the tube is allowed to run with a small amount of cm'rent, only sufficient to bring the tube to a dull glow ; this is to be continued for about twenty minutes, then more current is to be turned on until blue vapor just appears; the tube is noAV allowed to cool and the process repeated several times. If the operator is doing therapeutic work, this type of tube may be used to advantage on certain cases and the process of seasoning hastened in this way. After the tube has reached such a stage, re- sembling that of Fig. 3, Plate V., it is tested for radiographic value. We do not consider it full}^ seasoned when it presents the appearance shown in this figure, for this condition may be only temporary and the terminals and the other parts of the tube may still contain the gases that cause the vacuum to drop when overloaded or heated. Radiographic Tests. We have said that the tube should be tested radiographically, or by means of the milliammeter, in secondary circuit, with the tube. It will be noticed that fluoroscopic means of measuring x-ray light have not been referred to. For several years the fluoroscope has been completely dis- THE TECHNIQUE OF RADIOGRAPHIC WORK. 613 carded by the writers except for the location of foreign bodies and in chest examinations. Many times during tlie earlier days of .r-ray worlv it was observed that, wliile the fluoroscopic picture was exceedingly beautiful, the plates were of almost no value. After we had learned to judge the value of the tube by its appjarance our results steadily improved. Having studied the fluoroscopic picture under all its varying changes, and having taken hundreds of plates during these changes, we feel compelled to say that this instru- ment is most umeliable. Even the ingenious devices, such as the skiameter, must be included in this sweeping statement. To say, when one is taking a radiograph of a suspected renal calculus in a patient weighing one hundred and fifty pounds, that the skiameter furnishes a certain reading, does not, as we believe, convey A B Fig. 183. — Two Fluoroscope.s Used bj^ the Writers for Different Purposes. (Original.) .4 illustrates fluoroscope employed in making examinations of the cliest or in searching for foreign bodies. B represents an instrument formerly used when testing tubes. A skeleton hand is fastened on the bottom of the screen which is covered with black cloth. This instrument was discarded several years ago. 1 is a sheet of lead J in. thick, painted with several coats of white lead paint ; 2 is a sheet of aluminum \ in. thick and is large enough to protect the face of the operator; this is painted with several coats of white lead. Inside the top of the fiuoroscope is set a piece of lead glass, \ in. thick, to protect the eyes. information of value to anybody except the person who is conducting the oper- ation, and even he will be in error sometimes. The fluorescent screen is dete- riorating slowly but surely; the operator can at certain times make a better observation than at others, and what is to one observer a briUiant screen with black or gray bones or clear areas in the skiameter, may not be so to others. Then the all-important factor of the distance of the screen from the tube is often- times forgotten or neglected. We must remember that the value, both fluoro- scopically and radiographically, increases inversely as the square of the distance. One of the very important objections to the use of the fluoroscope for such pur- poses is the danger to the operator. Fig. 183, A, illustrates an instrument that has been in use for several years by the writers; it is described as a protective 614 AMERICAN PRACTICE OF SURGERY. fluoroscope, and we still continue to use it when we have need of making such examuaations. Tlie method used for testing tubes is the following ; After trj'ing a tube in the mamier described above, apply the radiographic test. This consists in taking a radiograph of some subject that resembles, at least in its chemical structure, the hmnan bod}-. For this purpose the hind quarter of a good-sized sheep is often emplo}'ed; this may be so cut that only enough to cover a 6J by Fig. 1S4. — Illustrates specimen used when testing tubes. Exposure 10 seconds, distance 20 inches. MiUiammeter reading 4 milhamperes ; ammeter in primary circuit reading 12 amperes; spark resist- ance 6 inches. Under such conditions an adult liip ■n'oxild be given an exposure of from 20 to 40 sec- onds, according to size of patient; the tube being at the same distance from the plate. (Original.) Si-inch plate is used. (Fig. 184.) This is then placed m ten-per-cent formalm for about ten days. It may be used fresh, and it is possibly better when it is in this state ; but for the operator who has to test tubes quite frequently, the formalized specimen is more practical. After it has been removed from the formalin solution it should be washed and then placed in normal salt solution to which chlorinated soda in the proportion of 1 : 50 has been added. This is to over- come to some extent the objection that a dry specimen does not present the same conditions as the li-\'ing. The writers are in the habit of using a dr}' speci- THE TECHNIQUE OF RADIOGRAPHIC WORK. 615 men, one that was placed fresh in a formahn solution and allowed to remain there for thirty days; it is well preserved and in no way offensive. "\Mien this specimen is employed as a test, a piece of parchment paper is placed over the plate holder and an exposure is made. If the tube will take a thoroughly satis- factory radiograph of this specimen m from five to ten seconds it may be counted upon to take a good radiograph of an adult hip (160-pound patient) in two or three times that length of time; that is, in from ten to thirty seconds. We realize that this test is of a rather crude character, for in the living subject the Fig. 185. — Radiograph Showing Renal Calculi; specimen consists of a block of beef six indies thick, three inches wide, and six inches long; kept under conditions described on page 614. (Original.) physical conditions — the movements caused by the circulating blood, the amomrt of fat or muscular tissue clothing the part, etc. — -^-ary enormously. Neverthe- less, experience has taught us that we maj- rely upon it with some degree of confidence. For abdominal work — as, for example, in the search for calculi — the \\Titers use a piece of beef about six inches square ; on the top of this are placed capsules of gelatin which have been treated with formaldehyde, thus rendering them insoluble; these capsules, which var}' in size from a weight of 1 grain to one of 15 grains, contain mixtures of calcic phosphate, calcic oxalate, sodium urate, and calcic carbonate. (Fig. 185.) The test can be made still more perfect by introducing, along with the capsules, a thin rubber sac con- taining partly air and partly water; the object of this step being to reproduce in some degree the conditions which actually exist in the living subject. The time of exposure required for securing a satisfactor}^ radiograph imder the conditions of this test is just about one-half that which will be required in the case of a living human being. The employment of such a test will generally save the operator from the necessity of making a second appointment with the patient. 616 AMERICAN PRACTICE OF SURGERY. MlLLIAMMETER. Recently there has been perfected an instrument kno-rni as the ammeter for x-ray tubes; we refer, not to the hot-wire meter, but to the one invented by Dr. Snooks, of Philadelphia. The •n-riters have done much work with this instrmnent and offer here their results. We believe it possible to utilize this instrmnent in estimating the radiographic value of x-ray tubes. This meter measures the amount of current passmg into the tube, indicates a rise or fall m A'acurmi A'ery accurately, and warns the operator at once of the presence of that harmful and annoving condition Icnowii as the "mverse discharge." To Fig. 1S6. — Shows Increased Radiographic Value when MilUanuneter reads Higher. Meter reading was 6 milliaraperes, the other conditions being exactly the same as in Fig. 187. Increased radio- graphic value indicated by almost complete absence of soft parts. This effect could not be accom- plished in the process of printing, and is due solely to increased value of x-ray light, as indicated by higher reading on miUianuneter. (Original.) illustrate this test we will take an apparatus giving a 10-inch very heavy flammg spark with ammeter on the primary circuit reading 12 amperes, tube 20 inches from the plate. A new tube is used; it is found to be of high resist- ance, the meter will not register oA'er 1 miUiampere, it has a parallel spark resist- ance of 6 inches or more. Tlie vacuum is now lowered. (A Gundelach tube is preferred for this test, as the regulation of its vacumn is much more delicate and the vacuum obtained more permanent.) Tlie ammeter will give a higher reading at once. If, however, the current is allowed to run through the tube for a minute or two it will be noticed that the indicator begins to .swing back THE TECHNIQUE OF RADIOGRAPHIC WORK. 617 and forth, sometimes going to zero; the tube during this stage presents the appearance of Fig. 4, Plate V. This swinging of the indicator is caused by the "inverse discharge," and on many coils it may be overcome completely by the use of the series spark gap, by the ventral tube, or by means of the varia- ble primary inductance. If the current, however, is allowed to run on, in a few seconds the picture will change; the tube seems to quiet dowii, and the note in the interrupter is no longer mtermittent and unsteady, but gives a loud roar. The tube is faULng in vacuum; it becomes blue, and the cathode stream is seen. At this point it is interesting to note that the milliammeter will show Fig. 187. — This radiograph was made with the milliammeter reading 2 milliamperes, the anode 24 inches from plate, and the time of exposure 10 seconds; developed 12 minutes. Compare with Fig. 186, which was taken under the same conditions exactly, except as regards the reading of the mil- liammeter, which was 6 milliamperes. (Original.) its highest rating. We wish to emphasize the fact that the tube has the same appearance as that presented in Fig. 2, Plate V.— a very low tube, mifit for radiographic work, and yet the reading of the ammeter indicates its highest value. It is at this point that the amperage on the iprimary circuit and the parallel spark gap should be observed; it will be found that the meter in the secondary circuit reads high, while that in the primary circuit has a low reading; also that the parallel spark resistance has been reduced several inches, i.e., from 6 or 7 to ^ or 5. This condition will always take place in a tube that is un- seasoned or in one that has been overloaded. This high reading of the milli- ammeter does not indicate high radiographic value; that is, if we mean by 618 AMERICAN PRACTICE OF SURGERY. this expression (a:-ray value) the property of affecting photographic plates. Eig. 2, Plate V., illustrates this condition of low vacuum tube, giving high read- ing on milliammeter. When a seasoned tube is used, and the spark resistance mid amperage on the primary are carefully observed, the milliammeter icill be found to be of great value. Fig. 188. Fig. 189. Figs. ISS and 189 represent radiographs taken on two different coils under exactly the same con- flitions of distance and time, with miUiammeter reading the same in both exposures. Notice that racUographic values are equal. The same subject is used in Figs. 1S8, 189, 190, and 191. (Original.) Observe that these plates were taken on different coils, but with same meter reading. Other conditions •were e.xactlv the same. Fig. 190. Fig. 191. Fig. 190 illustrates high radiographic value when milliammeter shows high reading — 5 seconds; I milliamperes. (Original.) Fig. 191 illustrates low radiographic value wlien milhammeter shows correspondingly low reading —5 seconds; 1 milliampere. (Original.) THE TECHNIQUE OF RADIOGRAPHIC WORK. 619 The operator is invariably warned of this condition by the swinging of the indicator and the sound of the interrupter just previous to lowering of the vacuum. At this point it may be well to state that by having sufficient self- induction in the primar}^, a properly balanced coil, and service derived from a direct current of from 60 to 110 volts, this "inverse discharge" may be al- most completely overcome. As before stated, this unseasoned tube must be worked up in resistance. Label the tube and treat it as suggested. To avoid this low vacuum it is neces- sary that we do not overload the tube by crowding on the current or running it for a long time. "\^lren heating the palladium we should stop the heating process when the milliammeter reads two milliamperes. We may have used thus far only a part of the full capacity of the coil; if now more current is turned on, the meter may read a little higher or remain at two. Good radiographs of even the deeper structures may be taken with this apparently lo^^' reading if a seasoned tube is used. The process of seasoning is greatly lengthened by the use of tubes such as those of the Gundelach, Voltholm, and Friedlander type, owing to the large amount of metal in the anticathode or anode. Our observations have led us to firmly believe that the milliammeter may be used as an indicator of the radiographic value if , let us again emphasize the 'phrase, "a seasoned tube" is used. If the tube starts up with the appearance of Fig. 1 or 2, Plate V., it is of little value. With Fig. 1, Plate V., the reading will be low, J to 1 milliam- pere : the radiographic value will be fair, the penetration high, the definition good, but the degree of contrast low. If the tube gives the appearance which is seen in Fig. 3, Plate V., the reading will be higher, the penetration good, the defini- tion excellent, and the contrast very high. We have demonstrated this many times and have adopted this means of estimation, confirming it always by taking a radiograph of the specimen. (See Figs. 184 and 185.) The tube is then labelled with primary and secondary anmieter reading and length of spark resistance, which resistance we do not consider absolute, as so many conditions affect it. Figs. 188-191 illustrate the value of this method for estimatmg the radio- graphic value of x-ray tubes. Development of Plates. One of the reasons for poor results is failure properly to develop the plates. It is not necessary? that the operator should be an expert photographer in order to get good radiographs, and the practice of sending .r-ray plates to the pro- fessional photographer to be developed is to be condemned. The WTiters' experience has led them to adopt certain routine methods of development with standard formuko and usually standard time, so that a man of little expe- rience in this line of work can be sent into the dark-room with a strong likeli- hood that he will invariably get good results. The professional photographer usually underdevelops .r-ray plates, and hence underdevelopment is one of the 620 AMERICAN PRACTICE OF SURGERY. -To illustrate undeveloped plate (only 6 minutes). Compare with Fig. 193, wliich ' developed 6 minutes longer. (Original.) Fig. 193. — Taken under exactly same conditions as Fig. 192. but development was carried much further. Developed 12 minutes. (Origmal.) THE TECHNIQUE OF RADIOGRAPHIC WORK. 621 the great causes, of poor plates (Figs. 185-192). It is of advantage to know the principles of photography, to know that the-plate is coated with gelatin, that the agent acted upon by the light or .r-ray is principally silver bromide, and that the richer the plate is in this silver salt the better the plate will be, other things being equal. For this reason, although ordinary photographic plates may be good enough for fractures and gross lesions, for the finer work they are not to be compared with the special .r-ray plates (see illustrations Figs. 194 and 195). Description of Dark-room. A well -ventilated room from which all white light can be excluded is neces- sary. A single ray of white light may be responsible for poor results by acting on the photographic plate during the process of development. After a room Fig. 194. — Ordinary Photographic Plate. Observe difference between this and Fig. 195. (Original.) Fig. 19.5. — Same subject as Fig. 194, taken and developed under exactly same conditions, but on a special x-ray plate. (Original.) which can be darkened completely has been obtained, the next thing of impor- tance is to secure a suitable light by which to develop (Fig. 196). The light advised by the makers of x-ray plates is a ruby lantern or box through which the light is transmitted by means of two layers of yellow fabric and one layer of ruby fabric such as may be obtained from any photographic-supply store. The light to be used in these lanterns may be a 1 6-candle-power incandescent light, gas, a kerosene lamp, or even a candle: a candle, however, gives such a dim light that only one sheet of yellow fabric is necessary. At the same time 622 AMERICAN PRACTICE OF SURGERY. it is not safe to expose photographic plates even to this hght for a very long time. This is especially true as regards ortho-chromatic and x-ray plates. Some form of tray in which plates may be placed is now necessary. An apparatus has been devised which consists of two or three shelves, each shelf capable of holding a tray. These shelves are placed on a base enclosed in a cabinet from which all light may be excluded by means of a light-tight door. This base, by means of transmission shafts and excentric cams, is given a rotary Fig. 196. — Dr. Calchvell'.? Dark-Room Ruby Lamp, with Bracket attached. rocking motion when connected with a small electric or other motor. By this means the trays are kept in motion, not simply from side to side, but also in a rotary manner; in this way more even development is assured. The following formukp, which have been used for several years with very satisfactory results, may be confidently recommended : Solution 1. Solution 2. Sodium sulphate (dried) 4.3'3 grains Sodium carbonate (dried) 735 grains Hydrochinon Ill " Water 16 ounces Glycin .32 " Metol 5 Potassic bromide 69 " Water (distilled) ad 16 ounces Many other developers have been tried, but they seem to be less well adapted to this kind of work. It remains a fact, however, that after an operator has become accustomed to a certain developer he can get more satisfactory results with it than with any other. The developer recommended above will keep, and may be used over several times if poured back into the bottle, which should be corked tightly. For the development of plates in which it is desired to show only the bone structure, ten parts of solution No. 1 to six of .solution No. 2 should be taken. After these solutions ha^'e been mixed, the mixture should be poured into the THE TECHNIQUE OF RADIOGRAPHIC WORK. 623 tray, in which the plate may then be placed. Great care should be taken to make the developer flow evenly and completely over the plate; if this be not done the plate will be overdeveloped in the parts that the solution first acted Fig. 197. — Illustrates underdeveloped plate of renal calculus. (The same radiograph as that .shown on p. 615). Negative so thin that even under diffused light calculi cannot be seen. (Original.) upon as compared with the rest of the plate. For this reason many operators advise the use of slow dilute developers, thereby avoiding the tendency of the image to flash up, while the high lights become overdeveloped before the shadows Fig. 19S. — Illustrates normal development of the same subject as that shown in Fig. 197. (Original.) can be fully brought out. Usually the image will appear in about fifteen seconds with this developer, and development may be continued for about six minutes. It is advisable then to look at the plate by holding it up to the ruby light; it should be placed over a sink so that the developer will not drop on the develop- ing bench. If the bones can be seen distinctly, showing quite light, develop- 624 AMERICAN PRACTICE OF SURGERY. ment has not been carried far enough and should be continued until, when the plate is held about six inches from ruby light, the bones can hardly be seen. The plate should next be rinsed in cold water. This is important. It not only checks further development, but aids the action of the fixing and hypo baths in which it must be now placed before it is exposed to white light. The hypo bath is usually acid in reaction. The developer is alkaline in reaction. If we put the plate into this acid bath with a quantity of alkaline developer on it we soon neutralize the acid and precipitate the alum, which in many baths is the hardening agent. The following hypo bath is strongly recommended by the writers, it having been given tests during hot weather under extremely harsh conditions: Sodium hyposulphite parts ii. Distilled water parts iii. Add to this solution: Sodium bisulphite, in the proportion of grains 100 to the O i. After the plate is fixed — that is, when white spots no longer appear when the plate is viewed from the reverse side — it should be allowed to remain in the fixing solution for fifteen minutes longer; this will harden the film and ■clear the plate. It should then be washed in running water for about twenty minutes, or, if running water is not at hand, it should be washed for thirty minutes in four or five changes of fresh water. The plate should then be put •on a rack to dry where dust will not be blown on it. We strongly advise the use of an electric fan for drying plates. For developing plates of joints, the chest, and, above all, for that important part of radiograph}^, the location of xenal and urethral calculi, the following mixture is advised: 8 parts of solution No. 1, 6 parts of solution No. 2, and 8 parts of cold water. To properly develop plates of suspected calculi is by no means easy, and great attention should be given to this process. We believe that it is possible to detect calculi of very small size even when they are composed principally of urates (pure uric-acid stones being rare). (Figs. 197 and 198.) If a dilute devel- oper is employed the process of development requires a longer time, but the con- trast between the softer tissues is emphasized and in most cases the outline of the kidney can be made out. The plate is allowed to develop for about ten minutes before an observation is made with the ruby light. During this time the rocker is covered and the ruby light excluded. This precaution is advisable as plates may be fogged by long exposure to ruby light. If the plate, when held before the ruby light, shows distinct outlines of the lumbar vertebrae, development is allowed to proceed for a few minutes longer or until the vertebra appear hardly dis- cernible. The plate is then fixed, washed, and dried as before. The temper- ature of the developer is of great importance. If it is too cold, that is, below 65° F., development proceeds very slowly ; if above 72° F. the plate is likely to be flat and devoid of contrast, being what is technically termed fogged. Always work THE TECHNIQUE OF RADIOGRAPHIC WORK. 625 with the developer at about the same temperature. Renew the hght iu the ruby lantern when it is below candle power; keep the developing room clean. Use distilled or rain water, when possible, for developer and use filters on the faucets which supply the water for washing the plates. Upright fixing baths and washing boxes are advised. Method of Taking Plates. After the tube has been adjusted the next step of importance is the proper arrangement of the patient; and here success or failure may occur. To ask a patient to keep still in an awkward or uncomfortable position is asking much under the best of circumstances ; and when he is actually under examination, Fig. 199. — Table for standardizing position, avoiding tlie necessity of patient lying down for leg and ankle negatives and conducing to muscular rest and therefore quiet. (See also Figs. 200 and 201.) A, Top adjustable by thumb screw, A', for upper arm, elbow, forearm, and hand. B, Rack for plate in lateral views of thigh, knee, and ankle. Clutch for holding plate seen directly below letter B. Rack attached to D. C, Rest for thigh and ankle in lateral views of thigh, knee, and lower leg. Adjustable at thumb screw c'. Fig. 200. Tube placed in these views horizontally at same level as part, while plate is perpen- dicularly held on rack B. D, Platform, adjustable by thumb screw D', for antero-posterior views of thigh, knee, lower leg, and ankle. Plate rests flat on platform, which is raised to level of chair in wliich patient sits. Top A is lifted out of its sockets, and tube placed vertically above part. D also is used for lateral position of ankle. (See Fig. 201.) A small table of thin wood, practically offering no resistance to the ar-rays, is placed under the foot in the weight-bearing position. The plate is held behind it by clutch on rack B, and the tube placed horizontally is focussed over the malleoli. Webbing straps and narrow sand-bags will be found useful in holding the parts immobile, and the ease and constancy with wliich standard views may be obtained are satisfactory. Most of the principles here combined into one table were devised as separate apparatus by Dr. L. A. Weigel, of Rochester, N. Y. VOL. I.— 40 626 AMERICAN PRACTICE OF SURGERY. surrounded by more or less apparatus it seems unreasonable to expect him ticularly women, object to lying down, able which may be used when the arm, this purpose the writers ha^T devised 201. Having arranged the patient now place the plate beneath the part the effect of which is unknown to him, to remain cjuiet. Many patients, par- se that some form of apparatus is advis- leg, or chest is to be radiographed. For the apparatus illustrated in Figs. 199 to as comfortabh- as possible we must to be radiographed, and adjust the tube Fig. 200. — Front View of Table shown in Fig. 199. at the standard distance for that part over the standard landmark, inrmobil- izing the part as completely as possible by means of sand bags, straps, or, better still, by means of the method perfected by Dr. Albers Schoenberg; that is, by means of the compression cylinder to be described later. The writers have used for j^ears several sizes of sand bags varying in weight from t^vo to twenty pounds. These, if not filled too hard, maj^ be used to hold even very sensitive parts almost perfectly quiet. It should be remembered that com- plete immobilization is absolutely essential to good radiographs. Simply ask- ing a patient to keep still is not sufficient. Immobilize the part in everj' case no matter how simple. We have said, place the tube at the standard distance for that part over the standard anatomical landmark. We feel so strongly convinced that this is essential to the intelligent interpretation of radiographs that the following scheme has been adopted and is in force at the laboratory of the Massachusetts General Hospital. THE TECHNIQUE OF RADIOGRAPHIC WORK. 627 When taking radiographs involving joints the writers adjust the anode immediately over the centre of that particular joint, and take both antero- posterior and lateral views, great care being exercised to secm-e the same posi- tion as that of the standard radiograph with which it is to be compared. We fully realize that in many cases it is impossible, owing to ankylosis, deformity, or for some other reason, so to adjust the patient that this result shall be attained, but, wherever it is possible to do this, such procedure is insisted upon, and the uniformity in radiographs thus obtained warrants the extra time and trou- ble. To convince one's self of the need of such attention to detail it is only Fig. 201.— Table in Actual Use. (See Figs. 199 and 200.) necessary to take radiographs of the head of the humerus. For example, one plate may be taken with the arm in outward rotation, and then a second one with the arm in inward rotation. A comparison of these two radiographs will show decided differences. In fact, many very different radiographs may be obtained of the same part by making comparatively slight .variations in the position. For this reason some standard position and distance- of the tube, and, whenever possible, standard position of the part, are essential. If an antero-posterior view is necessary, let it be such in reality, and not a three- quarter view, or one in which the plate was tilted a trifle, thus rendering com- parison with the standard almost useless. If the hip joint is to be radiographed, the anode is focussed over the joint as nearly as possible, the greater trochanter and the anterior superior spine being used as lanchnarks. The writers always work with the anode at least eighteen 628 AilERICAX PRACTICE OF SrRGERY, inches from the plate; if the patient is a large, fat, or muscular individual the distance ^^■ill necessarily be just so much greater — from two to four inches more. The greater the distance the less the distortion. ^Vhen taking radiographs for the localization of calculi, renal or ureteral, it is necessary to adopt the following routine procechu-e. The patient's bowels are completely evacuated, by means of Epsom salts and castor oil, twenty-four hours before the radiograph is to be taken : the patient is also requested to eat sparingly and only easily digested food during this time. This is considered Fig. 202. Fig. 203. Fig. 202 illustrates the necesf=it}- of liaA-ing the tube in a definite position Notice the difference between tliis picture and Fig. 203. (Original ) Fig. 203. — Same .subject as Fig. 202. Position of tube was changed and patient's arm rotated. (Original.) Notice difference in width of head of humerus as compared to Fig. 202. of such importance that it should be insisted upon. "When the patient is ready to be radiographed, he is placed on the table, with the shoulders elevated and the legs flexed (see Fig. 204). The compression cjdinder is then adjusted, so that the upper border of the cylinder is just le^-el with the seventh or the eighth costal cartilage. The cylinder is next pressed down firmly, then tilted upward; b}' which means the last two ribs will be made to appear on the plate, thus enabling the operator to be. sure that the entire kidney is under observation. It is always advisable to take plates of both kidneys and of the entire ureteral tract. This makes it necessary to take several plates; but, as we feel convinced that nearly all calculi may be detected by means of the .r-ray (except, possibly, uric-acid), such procedure should always be obser-\'ed in cases of suspected calculi. Great care must be observed in the interpretation of such radiographs. The illu- minating lantern (Fig. 176) should be used and the plate carefully studied. The plate should show the last two ribs, the transverse processes of the lumbar THE TECHNIQUE OF RADIOGRAPHIC WORK. 629 vertebrse, the psoas magnus, and the quadratus himborum muscles; and in patients of one hundred and seventy pounds or less the outline of the kidney should be made out. Under such conditions we believe it possible to detect very small calculi even when they are composed principally of urates. It should be remembered that sesamoid bones, vein stones, also cheesy Fig. 204. — Shows how ej-liuder may be used with ordinary rattan couch. Care must be taken to fasten the cyUnder so securely tliat respiratory movement will not move cylinder. This is necessary, as cylinder and tube holder are attached to the same support, and consequently any movement of the C3'Under will move the tube and thus spoil definition. (Original.) Apparatus adjusted for suspected renal calculi. deposits in the calyces of the kidneys have been mistaken for calculi; and we believe also that in one case a foreign body in the appendix was mistaken for a ureteral calculus. Localization of Foreign Bodies. For the localization of foreign bodies the following method may be adopted: — Whenever it is possible to do so, the foreign body should be located first by means of the fluoroscope. The fluoroscope used by the writers is illustrated 630 MIERIC.^N PRACTICE OF SURGERY. in Fig. 183, A. A diaphragm is used in connection with the tube so that only a limited field is under observation at one time; by this means the fluoroscopic localization is rendered much more accurate, as a foreign body, if one should be observed, must necessarily be confined to the area of ilhmiination, such Fig. 205. — Represents specimen with needle buried in it. Dark triangular shadow near needle is a piece of lead used as a mark (the same as that used on patient's skin). Notice the two shadows of the needle. Anode was 16f inches from plate. Shadows of needle exactly ^ inch apart. Tube was moved 3 inches to the right, then 3 inches from the left, of central point. Needle was -jj^ of an inch deep. (Original.) area being dependent upon the size of the diaphragm. (A one-inch diaphragm, at a distance of about twenty-four inches from the tube, gives a three-inch field.) The orthodiagraph, as devised by Dr. Moritz, is highly recommended for this purpose. After the foreign body has been located in one plane by means THE TECHNIQUE OF RADIOGRAPHIC WORK. 631 of the fluoroscope, such location should be marked on the skui of the patient. The plate is next to be placed in ]3osition. The anode of the x-ray tube is then focussed over the mark made on the skin. The distance of the anode from the plate is carefully measured and recorded. The ■^Titers work with the anode at a distance of fourteen inches from the plate. After the tube has been accurately focussed over the mark on the skin, which cor- responds to the foreign body, the tube is to be moved three inches to the left and an exposure made. The tube is then to be moved first back to the central or starting-point and then after- ward three inches to the right. Great care shoud be used in making the measm-ements, and the ex- posures must be made at the same distance (four- teen inches) from the plate. The plate is now to be developed, and, unless the object is lo- cated at a considerable depth from the skin, two images will appear. The distance between the two images is measured and the depth calculated (see Figs. 205 and 206). Many operators use two separate plates rather than make two exposures on one plate. This may be necessary m some cases, but, as a rule, one plate with double exposiu'e will do. The writers always fasten a piece of lead on the patient's skin somewhere near the foreign body. This object appears on the plate and is a guide to the surgeon. Dr. MacKenzie Davidson has devised a very ingenious method and apparatus for the localization of foreign bodies.' For locating foreign boches in the eye the apparatus and technique of Dr. Sweet, of Phila- delphia," may be used to advantage. Fig. 206.— Illustrates plan of cal- culation as to location of foreign body. Nos. 1 and 2 correspond to shadow of needle, and are -j inch apart — the same distance as the shadows on the plate. Nos. 3 and 4 correspond to the two positions of the tube. No. 5 corresponds to distance of anode from plate. The i:oint where the Unes intersect represents depth of body from surface next to plate. (Original.) ' Lancet, 1897, p. 1001. 2 Archives of Ophthalmology, 1898, p. 377. 632 AAIERICAN PRACTICE OF SURGERY. CojiPKESSioN Apparatus. To omit to mention in the description of an x-ray plant the compression cj'linder of Albers Schoenberg would be to omit one of the essentials to good and accm'ate radiograph}'. This ingenious device is so thoroughly descriljed and illustrated in the cata- logues of dealers in x-ray apparatus that only the principles and advantages need to be spoken of here. At the same time it will not be out of place to give here a brief description of the compression cylinders which we are in the habit Fig. 207. — Compression Diaphragm of Albers Schoenberg. It consists of an adjustable frame on a ■wooden base, with a detachable lead-lined compression cylinder (4 inches in diameter), lever arrange- ment, tube-holder, and three lead diaphragms. of using, these cylinders being modifications of Albers Schoenberg's much more elaborate apparatus. (Fig. 207.) On a previous page we have spoken of the absolute need of immobilization of the part to be radiographed. The compression cylinder fm-nishes the ideal method of immobilization. By this means the part may be completely fixed and all movement prevented, thus obviating one of the chief causes of poor plates. Secondary radiations have been spoken of as being another cause of the lack of definition, of fogged or blurred plates, .such radiations being given off to some extent by all objects with which the x-ray comes in contact. By means of the compression cylinder with its diaphragms, secondary radiations are almost com- pletely eliminated, only the more direct rays being used. (Figs. 211 and 212.) The importance of focussing the anode over the part to be radiographed has been emphasized. The compression cylinder enables the operator to do THE TECHNIQUE OF RADIOGRAPHIC WORK. 633. this very accurately, as the centre of the cylinder corresponds to the focal spot on the anode of the .r-ray tube. Its advantages are: uniformity of distance of the anode from the surface of the body, thus setting a standard distance; greatly increased definition owing to elimination of secondary radiations; better immobilization of the part exposed; and, finally, the fact that in the more compressible parts of the bod}', such as the abdomen, the cylinder enables the operator to focus the tube over the area to be observed as well as to com- press the part and thus reduce its thickness to a considerable degree. Another Fig. 208. — Shows how tube-stand tabic is used when antero-postcrior ^'icw of knee is desired. Patient is in chair, and leg is placed on adjustable table, as described under compression C5'linder. (Original.) Tlie operator may be observed behind the lead screen in which a hole 4 inches in diameter is cut. This hole is covered with lead glass ^ inch thick. advantage, and one that will appeal to the operator who has to use many plates, is the fact that with this apparatus only those which measm-e either five by seven or eight by ten inches can be employed. The cheapness and efiicienc)'' of the apparatus are features which also commend it to favorable considera- tion. It is constructed in the following manner: A board three-fourths inch in thickness, fourteen inches long, twelve inches wide is taken. In the centre of 634 a:\iericax practice of surgery. thiy board a hole three and tliree-fourths inches in diameter is cut, with a groove one-fourth inch Avide, three-sixteenths inch deep. Into this hole is set the diaphragm. The diaphragm consists of a piece of lead three-sixteenths of an inch thick, in the centre of which a circular hole one and three-fourths inch is cut. On the bottom of the board a sheet of lead three-sixteenths of an inch thick is fastened so that it covers the board to within one-half of an inch of Fig. 209. — Shows correct adjustment of tube to diaphragm. Elliptical shadow (see Fig. 210) is caused, probably, by secondary radiations, and indicates the value of diaphragms in radiograpliic work. A fluoroscope will give almost equal illumination when held IS inches from tube, it being thus impossible to detect by this means the secondary radiations. (Original.) the edges. Three cleats are fastened to the lead and are so arranged around the circular apertm-e that the cjdinder, about to be described, may be slid in or out, according as the diaphragm is to be used with c}dinder or not. One cleat is fastened near the back of the aperture so that the centre of the cylinder, when pushed in against it, must be exactly under the centre of the diaphragm ; the other two cleats are fastened so as to centre the cvlinder in the lateral direc- THE TECHNIQUE OF RADIOGRAPHIC AVORK. 635 tion. The cylinder used by tlie writers consists of a tin can, such as compressed tablets come in; this is lined with sheet lead one-eighth of an mch thick and soldered so as to be securely held to the sides of the can. Two lugs, or ears, are now fastened to the sides of the upper end of the can, these lugs fitting into the cleats on the board as described. To the top of the board are fastened Fig. 210. — Shows how necessary it is accurately to adjust tlie tube to the diaphragm; care being taken to place foca spot of cathode stream immediately over centre of diaphragm. This may be easily accomplished by placing fluorescent screen under cylinder. If complete circle with sharp, well- defined edges is seen, adjustment is correct; if illumination is elUptical, as in this figure, the tube must be moved either to the right or to the left. (Original.) Notice dark sliadow inside lower part of cir- cle, obscuring part of ulna and radius. Compare with Fig. 209. two uprights for supporting the .r-ray tube ; these uprights are five inches high, the ends of the uprights being grooved to recei^'e the x-raj tube. This cylinder, with board and tube holder, is now fastened to a very rigid upright in such a way that it can be raised or lowered at any angle in the same manner that the ordinary tube stand allows adjustment of the x-ray tube. Ab- solute rigidity of the upright is essential, as, when a radiograph of the lumbar 636 AMERICAN PRACTICE OF SURGERY. spine, for instance, is to be taken, the cj'linder is pressed down as much as the patient can stand, then fastened in front by means of a strap passing through the board to the couch (see Fig. 204). If the upright is not stiff, or if there is any play in the board arm, respiratory movement will move the apparatus which, moving the tube, will spoil the definition and thus defeat the chief aim of the compression cylinder. Figs. 204 and 207 illustrate this apparatus, with adjustable table on the same upright. The writers consider the compression cylinder essential to good radiographic work. The apparatus described has the advantages of being easily and quickly adjusted and purchasable at a reasonably low price. The cylinder being movable enables the operator to use the board alone when larger areas than that allowed by the cylinder are to be exposed. In such cases straps and sand bags are used when possible to inunobilize the parts. Stereoscopic Radiographs. The use of the stereoscope is of undoubted value in the study of the position of bone fragments and foreign bodies. It necessitates some form of stereoscope, and the taking of two negatives under exactly the same conditions as regards time of exposure and mode of development, and with the tube at the same ver- tical distance from the plate in each case. After centring the tube over the point chosen as the most desired area to be viewed, the tube, by means of a scale on the tube stand or floor, should be moved horizontally one-half inch to the right and a negative taken. This plate should then be removed and a second one substituted, with no change in the position of the part. The tube should next be moved three-fourths inch to the left or one-half inch to the left of the orig- inal central point, and the second negative should then be taken under the same conditions as regards distance and light overhead. Thus we shall obtain two negatives which give us views of the area desired from two different posi- tions corresponding roughly to the human pupils. It remains for the stereo- scope to construct the images in three dimensions. Harjiful Effects of the A'-Ray. Nearly all the measures used for the relief of suffering are capable, when used ignorantly or carelessly, of producing in time untoward effects. The a;-ray is no exception to this axiom, and the lesions which follow its use are among the most insidious and the most disastrous. Oiu- present knowledge of these matters is most incomplete. Enough, however, has been already proved to warrant very definite statements, and the evidence as to other pos- sible harmful effects is sufficiently conclusive to demand the adoption of pro- tective measures which at first sight may seem unnecessarily strenuous. THE TECHNIQUE OF RADIOGRAPHIC WORK. 637 It was early recognized that the .r-ray exerted a very definite effect upon diseased tissue, and that long or repeated exposures occasionally produced a reddening of the skin or even a deep slough, the onset of which was slow and the result of which was a tissue necrosis most obstinate in healing. This gradual appearance of the lesion many days after the patient's exposure, and the dis- covery made by many operators that the frequent short exposures to which they were constantly subjected were causing lesions on their own persons, de- monstrated the subtle cumulative effect of this new and mysterious ray. The difficulty of determining the danger point of these exposures is very great, for there are usually scarcely any subjective symptoms at the time when the patient is exposed to the ray. The mart3Tdom of those men who began their x-ray investigations soon after its discovery has been a very real one. The lesions which have resulted have been in many cases ineffaceable and have entailed an immense amount of physical and mental suffering. The danger is a positive one, and we are doing our duty neither to ourselves nor to our patients if we do not adopt measures which are known to be ade- quately protective. The x-rays derived from a static machine are somewhat less likely to produce untoward effects than those from the more powerfvil currents of the modern coil. But even the static rays are by no means innocuous. The experience of some of the most brilliant operators has shown that extremely painful lesions may be produced by this form of current, and a malignant growth may ensue in the ulcerations. Sterility.— The investigations of Dr. F. Tilden Brown, of New York, and others have seemed to show conclusively that long-continued exposure to the rays may produce at least a temporary sterility. In some cases the sperma- tozoa are rendered non-viable, and in others they entirely disappear from the semen. Whether a sterility thus produced is ever permanent, provided further exposure ceases, is still in doubt. Such a permanent change in the glandular structures seems possible. The striking absence of children in the families of .r-ray workers who have been constantly exposed to the rays without adequate protection is noteworthy. The cumulative effect is here apparently very important. Before this subject was much discussed Dr. W. L. Rollins, of Boston, called attention to the fact that the Roentgen rays have the power to cause abortion in guinea pigs. These experiments are suggestive of the necessity of exercising caution in exposing pregnant patients. It is probable that the female organs of generation are affected in very much the same manner as are tlie male when exposed to the effects of the x-ray. Cases can be multiplied in which highh^ penetrating rays have been adminis- tered for comparatively long periods of time in the neighborhood of the 638 AMERICAN PRACTICE OF SURGERY. genitalia, and yet subsequently the patients have become mothers or fathers of healthy children. It seems reasonable, therefore, to conclude that single exposures of short duration do not as a rule produce permanent sterility in either sex. Burns. — A'-raj- burns, so called, are of different degrees, from a simple ery- thema to a definite tissue necrosis which ma}' invoh-e the layers beneath the true skin. There is an individual idiosyncrasy in the matter of susceptibility, just as there is a great difference in the effects of sunlight on the skins of different persons. There may be considerable delay in the onset of symptoms. The reported intervals of five and six months seem hardly conceivable, and yet the writer has on his wrist a t3^pical scar from an x-ray burn of the first degree which did not appear until after the lapse of o^'er six months from the time of exposure. It should be stated, furthermore, that the wrist had been, as was supposed, ade- quately protected, and that no stage of erythema had been observed. The changes in the subcutaneous vessels, with the resulting irregular red mottling of the skin, has persisted now for about two years. Depilation may occur, after prolonged exposures, without definite burns. It will perhaps be noticed that many x-ray workers have lost eyebrows and eyelashes. In some cases also the nails become brittle and ridged. A trouble- some seborrhoea is a not uncommon result, and small keratoses or areas of thickened epithelium, which present the appearance of small non-sensitive calluses, are often seen, especially on the hands. Few lesions are so persistentl}^ painful or so slow in healing as the deep x-ray burns. Paradoxical as it seems, areas of malignant disease often occur in these sluggish granulations, and that, too, notwithstanding the fact that the original lesion, in these cases, owes its origin to the agent so much exploited in the cure of mahgnant growtlis. Pathology of x-Ray Burns. — Vose and Howe have made careful studies in the effects of the Roentgen ray upon cancer {Journal of Medical Research, vol. xiii.. No. 2). Their conclusions, from a study of the literature and from their own microscopic examination of tissues removed from these burned areas, are as follows : " Sections from the tissues of such burns studied by us show progres- sive changes from the surface downward, the more highl}' organized parts natu- rally showing the most marked changes or suffering most. The hair follicle and the glands are destroyed. The prickle-cell layer is increased. The cells of this layer show granular degeneration of protoplasm and proceed to necrosis. The blood cells show a reticular deposit of fibrin on their inner coats. No change of nerves was noted. These histological changes are all that may be positively claimed, since the sections of .r-ray ulcers show a purely necrotic proc- ess — increase of elastic tissue, increase of connective tissue, and colloid replace- ment." THE TECHNIQUE OF RADIOGRAPHIC WORK. 639 Protective Measures. In the light of these facts efficient protection of both the patient and the operator has become a matter not only of wisdom, but also of imperative duty. Theoretically, as Dr. W. L. Rollins early pointed out, a box of sufficient z-ray density to cut off the probably harmful rays should completely surround the active tube, the only exit for the rays being furnished by a small fenestra through which the cone of light is directed against the desired part. Practically, with our increased speed of radiography and the more perfect technique which does away with repeated trials for the purpose of securing a good plate, we cannot feel that the risk to the patient from a single exposure to a naked tube is great. Additional knowledge may well change this opinion ; and in any event the gener- ative organs should always be protected by a piece of sheet lead. As regards the operator no safeguards can be too complete. The a--ray atmosphere in which he works is in itself a baneful influence which it is impos- sible accurately to estimate. Although in years past we felt it necessary to judge the actinic cjuality of the rays by fluoroscopic inspection, we have entirely given up this test, not only on account of its unreliabilitj^, but also because of its demonstrable danger. If this method is ever used by the beginner — and we discourage even this — the fluoro- scope should be a protective one such as has been described elsewhere in this article. By careful observation of the appearance of the tube, its shade of color, the amount of current used, and especially by the reading of the milliammeter, we believe that even the beginner may learn, after a few simple trials on test plates, accurately to judge the quality of the light without the use of the fluoroscope. This inspection may be made through a peep-hole in the protective screen, which peep-hole should be covered by a thick layer of lead glass. For the fluoroscopic examination desirable in certain cases of foreign bodies or frac- tures, and in the case of thoracic or abdominal diseases, the observer should be guarded by a lead screen or a protective suit of the lead and rubber composi- tion now on the market. Of the efficient protectiveness of this latter material we are not sure. In our private office plant the arrangements are such that the current can be turned on only when the operator stands behind a permanently fixed screen, which is composed of sheet lead one-eighth of an inch thick and is placed between two layers of plate glass. A peep-hole one inch in diameter is cut in the lead. The screen is six feet high and five feet broad, and the lead is grounded by means of a wire attached to the gaspipe. In taking radiographs the long axis of the tube is placed at right angles to the screen, and the negative or cathode pole of the coil is farthest away from the operator, so that fewer rays are pro- jected in hLs direction. The grounding of the lead screen, which collects the 640 AMERICAN PRACTICE OF SURGERY. iiigh induction waves, ensures a safe disposition of this possibly harmful ele- ment. We do not consider these safeguards as unnecessarily extreme. We are dealing with a force the exact natui-e of which we do not under- stand. It is more subtle, perhaps, than any other influence in the hands of medical men, partly because it is not yet full}- understood, and partly because of its insidious -workings. The harm it is capable of doing is second only to the good its application daily accomplishes, and the efforts of those who essay its use should be earnestly directed toward making it an umnixed blessing for both patient and physician. Screen for Protecting the Operator. — The protection of the operator from the injurious effects of continued work in x-ray atmosphere is of the utmost importance, not only because of the liability to x-ray dermatitis, but also because of the possibility that the .r-rays may induce sterility, as sho-mi by Dr. F. Tilden Brown, of New York. Too much emphasis cannot be laid on this subject, and every means should be taken to avoid exposure. All fluoroscopic measures supposed to furnish information regarding the photo- graphic -^'alue of x-ray light should be abandoned and the operator should learn to judge the value of the tube in use from the color of the fluorescence, from the resistance of the parallel spark gap, by means of the milliammeter in the secondar}- circuit, and by testing the tubes radiographically as described under .r-ray tubes. The -miters use, for the operator's protection, a lead screen (Fig. 208), three-sixteenths of an inch thick, in which a window is cut. In this window is set a piece of one-fourth-inch lead glass. The operator stands behind this screen, which is about six feet high and four feet wide. Tlirough the window he observes the tube and in this manner is in all jjrobability kept from harmful effects. "\^Tien it is necessary for him to go near the machine duiing its operation he wears a lead apron, lead-fiUed gloves, both of which, as well as protective tube shields, are now on the market. When it is necessary to use the fluoroscope, as in chest observations and in locating foreign bodies, the pro- tective fluoroscope is used as described (Fig. 183, A). In view of the observations ii:iade hv Dr. F. Tilden Bro^\Ti on the question of sterility it is advisable that the bodies of all patients be protected by means of flexible lead screens or pro- tective tube shields. As the harmful effect of the rays is probably dependent upon du-ect and comparatively long exposures, we believe that the patients run no particular risk during the radiographic process. Nevertheless, in view of the lack of evidence on this point, it is advisable that the proper precautions should betaken. II. THE INTERPRETATION OF RADIOGRAPHS. In unskilled hands the therapeutic use of the x-ray includes the serious danger of burns. To the practitioner unfamiliar with normal x-ray anatomy, the interpretation of skiagraphs offers the no less serious danger of making an incorrect diagnosis and carrying out a ^•icious or useless treatment. THE INTERPRETATION OF RADIOGRAPHS. 641 There are certain definite rudimentary conditions -n-hich must be complied with if our interpretations are to be of a sufficiently trustworthy character. (1) It is preferable, whenever this can be done, to examine the plate itself rather than a print taken from it. (2) In examming a plate two factors are of great importance — the manage- ment of the light, and careful attention to the distance (from the source of light) at which the plate is held. In the first place, the light should be evenly diffused, and at the same time it should be shut off in such a manner that it shall illu- minate only the negative. The matter of proper lighting, especially to one somewhat unfamiliar with the examination of negatives, is of sufficient importance to warrant the descrip- tion of a practical illuminator (see Fig. 176). An open square box, the sides of which measure foiu- or five inches more than the edges of the largest .r-ray plate likely to be used, is painted white inside, and the antero-posterior depth at the top is made slightly less than the antero-posterior depth at the bottom, so that a plate resting in a frame applied to the front of the box will be in no danger of falling outward, and yet its posi- tion will be nearly perpendicular. A removable frame having an open space still slightly larger than the largest plate is now fitted to the open box and held in place perhaps by hinges, hooks and eyes. On the inner side of this frame, above, below, and laterally, are fastened one or more candle-shaped incan- descent bulbs lying flat along the side and having individual turn-off buttons, but wired to a common plug on the outside of the box. To the outside of this frame is fastened a revolving circle having a rabbeted opening of the exact di- mensions of the largest plate to be used. Other rabbeted frames or kits, down to the size of the smallest plate, are now fitted accurately into this and into each other, and the illuminator is then ready for use. The bulbs throw their light against the white back and sides of the box and, as a result, an almost perfectly diffused illumination, which can be regulated in intensity by turning off some of the incandescent lights, or by means of a small rheostat on the outside of the box, is refiected through the opening. The advantage of the revolving circle is at once evident when it is considered that the standard sizes of plates are all longer in one diameter than in another. Thus, for example, a pelvis on a large plate is best viewed as if the patient were standing, and hence it is desirable that the longer of the two diameters of the plate should be the horizontal one ; while in the case of a thigh the vertical diameter of the plate should be the longer one. The revolving circle obviates the necessity of con- stantly changing en masse the position of a rather bulky piece of apparatus. With the intensity of this evenly diffused light regulated according to the den- sity of the negative, the best effect, except for the finest detail, is gained by studying the negatives at some distance from the illuminator. The less evident lesions and differences of shadow are thus much easier to appreciate. A method VOL. I. — 41 642 AMERICAN PRACTICE OF SURGERY. warmly recommended by one of the best foreign interpreters is tlrat of observ- ing a negative, thus evenly illuminated, through a pair of opera glasses. A good negative is something absolutely indispensable. By this is meant a negative in which soft-part details are not obliterated and in which fine bone structure is shown. It is possible by a proper choice of the quality of the light so to control the time of exposure and method of development that soft-part lesions will be most faA^orably shown; while with more penetrating ra^'S, longer exposures, and with the development carried further, the bone structure may be emphasized. In the thinner parts a combination of both can usually be obtained. Data of Position. — We have alluded above to the importance of standard- izing our positions, and in the accurate interpretation of negatives this is of great moment. Before attempting to form any judgment we must at least have the data of position clearly in our mind. To appreciate possible dis- tortion one has simply to place his arm between a fluoroscope and an active tube and then to move the fluoroscope and arm laterally. The amount of dis- tortion thus to be observed is surprising. Comparison with the Normal. — In the medical school the student has a long and thorough training in normal histology before he is shown pathological tissue. He must dissect normal sulsjects before he can be expected to recog- nize the gross lesions. In skiagraph}' we are dealing with shadows of structures, not with the visual and tactile examination of these subjects. X-ray anatomy differs materially from that of the dissecting-room. We must learn to know the internal structure of the bones and must realize that we are looking through bodies of three dimensions and not at a single plane surface. The bony structures of children at different ages differ very much from each other and from those of adult life. Yet the adult structures are the only ones in which we receive our anatomical training, while the bone lesions of children are more common and of greater import than those of adult life. The ununited bone centres of the epiphyses have not seldom been spoken of as fractures, and the normal exostoses and bone ridges at the points of attachments of ligaments and muscles have been declared to be pathologic. It must not be forgotten that sesamoid bones often develop in other ten- dons than the flexor longus hallucis and are usually of no significance to the po.ssessor. It is of importance, therefore, that we should become familiar with normal skiagraphs of all ages and compare either mentally or actually the radiograph supposed to be pathologic with a normal one of approximately the same age. Thus only can we progress in our power safely to use the Roentgen rays as an accurate method of diagnosis. In the majority of cases the lesions are unilateral, and we have the other THE INTERPRETATION OF RADIOGRAPHS. 643 side for our most perfect normal standard. Where it is not practicable to view both sides on the same plate at the same time, symmetrical positions should be separately taken. One acts as a check upon the other, and individual idiosyncrasy does not stand for the suspected lesion. Fractures. The diagnosis of fracture is usually the easiest of x-ray interpretations. It is extremely hard, however, accurately to determine, from an x-ray plate, how outwardly deforming even a marked solution of continuity may be, or to -Subperiosteal Fracture of Radius. Faint line of solution of continmty discernible. (Or ginal.) predict how much disturbance of function the lesion is likely to cause. The necessity of having clear plates that show the bone structure well, is emphasized in the common subperiosteal solutions of continuity, in which the outline of the bone shows no irregularity (Fig. 211). In all but the subperiosteal fractures it is advisable to take at least two 644 AMERICAN PRACTICE OF SURGERY. views of the injury; and careful data relating to position must be at hand if we are to interpret the plate correctly (Figs. 212 and 213). From a medico-legal point of view the x-ray evidence of the presence of a fractiue must needs be conclusive, but any inference as to the future disturbance of function that is likely to result from a seeming malposition should be drawn with the greatest caution; indeed, such inferences should not, in om- opinion, be offered or accepted in court except in the rarest instances. Distortion may Fig. 212. Fig. 213. Figs. 212 .\xd 213. — Fracture of .\nkle, showing the Neccessity of Obtaining at least Two Views. Fig. 212, which represents a lateral view of the ankle, shows practically no deformity ; wliile the antero- posterior view (Fig. 213) reveals much displacement. (Original.) immensely exaggerate the deformity, and natm-e often restores perfect func- tion to imperfectly apposed fragments. Tuberculosis. This represents, perhaps, the most common bone disease. It is thought by many of our best pathologists to be ah\-ays primary in the bone. If this is so, the .r-rays repeatedly fail to demonstrate these early foci. It is not vnasual in the radiograph to find a distinct focus in the bone, but it is more usual to discover first the thickened capsule, later the erosion of the articular surfaces, and finally the real destruction of bone. THE INTERPRETATION OF RADIOGRAPHS. 645 The focus of disease, when found, usually gives little evidence, from the x-ray point of view, of any inflammatory bone process about it, and appears often as a thin- walled cavity containing more or less calcified matter (Fig. 214). There are other strong evidences of tuberculosis Avhere these more strikmg conditions are absent. Even before we can demonstrate the atrophy of the soft parts, which is so constant an accompaniment clinically, we are able, in Fig. 214. — Tuberculosis of last Sacral Vertebra. Irregular thin-walled cavity seea with bone destruc- tion and involvement of lumbo-sacral articulation. (Original.) the negative, to discover atrophy in the bone in the very early stages of the disease, often long before we find any distinct focus. This is of the greatest importance in the cases of early hip disease ; and here again we must have the unaffected side for comparison, preferably taken on the same plate and always with the Crookes tube focussed over the median line of the bodv. 646 AMERICAN PRACTICE OF SURGERY. The lessened shadow cast by the bone of the affected side, owing to the diminution in the hme salts and the slightly smaller diameter of the shaft, should make one very suspicious of tuberculous disease (Fig. 215). Tuberculosis in a joint before the destructive stage ensues represents a marked irritation and, of course, often stimulates epiphyseal growth. Here we find the explanation of the often-noted fact that m the early stages of tumor albus and hip disease the affected limb is actually longer than that of the sound Fig. 215. — Tuberculosis of Hip on tlie Left Side. Invoh-ement of acetabulum and head of femur. Atrophy, especially of neck, but also of shaft of bone. (Original.) side. In the negative we find, as an aid in reaching a correct interpretation, the characteristic enlargement and squaring of the epiphyses (Figs. 216 and 217). As the process advances destruction is the most characteristic feature. The bone breaks down, small sequestra are formed, dislocations occur, and detritus is thrown out, with or without circumscribed abscess formation (see Fig. 218). Finally comes repair, with new bone formation and ankylosis, or else a new joint with more or less motion and sometimes good functional adapta- bility (Fig. 219). THE INTERPRETATION OF RADIOGRAPHS. 647 Fig. 216.— Early Tuberculosis of Knee on the Right Side. No bony focus seen. Marked thicken- ing of capsule. Atrophy of structure of shafts. Characteristic enlargement and squaring of epiphyses. Compare with Fig. 217. (Original.) Fig. 217.— Quiescent Tuberculosis of Knee. Same case as that shown in Fig. 216, after treatment. Acute swelling has subsided. Some atrophy of size and structure of shafts on the right side. Ep- iphyses still squared and enlarged. (Original.) 648 AMERICAN PRACTICE OF SURGERY. In the radiographs, especially those of the smaller joints, the thinning of the cortex of the neighboring bones gives them the appearance as if their outlines had been pencilled and a fine line drawn about them. Though this occurs in other conditions of atroph}^ — as, for example, in anterior poliomyelitis — Fig. 218. — Tuberculosis of Tarsus. Destruction of scai>lioid. In^■olvement of astragalus and cuboid. Marked structural bone atrophy. (Original.) Fig. 219.— I'.iid Result of Tuberculosis of Hip on the Right Side. .A.truphy of size and structure persist. New joint cavity and weight-bearing pillar formed. Over one-lialf normal joint motions. (Original.) it is met so constantly in tuberculosis, as a result of the atrophy due to the disease, that it is almost characteristic. A form of tuberculosis called caries sicca has been described. The x-ray evidences of this condition are deep grooves in the bone at the attachment of the capsule about the anatomical neck. These THE INTERPRETATION OF RADIOGRAPHS. 649 grooves are formed from an ingrowth of tough, dry granulation tissue. The joint becomes gradually obliterated. We possess no illustrative plates. Fig. 220 — Tuberculous Dactylitis. Spin^e ventosre. The pharanges of both index fingers — the proximal on the left, the middle on the right — show cj'st-like formations with irregular and few trabeculte. (Original.) The spinffi ventosse are well illustrated by Fig. 220, which was taken from a case of a tuberculous nature. Osteomyelitis. In contrasting osteomyelitis with tuberculosis it may be said that while tuberculosis most commonly affects articular surfaces, osteomyelitis rarely does so. It is often found in close proximity to joints, but, as a rule, there is no involvement of the articular surfaces. Except in the very long standing cases in which actual disuse has a chance to play a part, we rarely find in osteomyelitis the bone atrophy which is so con- stant an accompaniment of tuberculosis (Figs. 221 and 222). There are to be seen, especially in the more chronic cases, an actual thick- ening of the bone cortex and a ring of bone about the osteomyelitic cavity, which is more resistant to the passage of the a;-ra}rs than the rest of the shaft. The sequestra found are often large and of considerable 2:-ray density. The two processes resemble each other in that they are both destructive at some stage, and also in the fact that at times they exhibit the character- istics of an almost malignant process, showing a tendency to fresh outbreaks after very long periods of apparent cure. 650 AMERICAN PRACTICE OF SURGERY. In considering the .r-ray evidences of osteomyelitis, it is perhaps better to describe types rather than stages, for osteom3^ehtis is a disease of so greatly varying an etiology that it possesses no typical stages. (1) There is a type of acute circumscribed osteomyelitis which it is often difficult to distinguish chnicalh^ from tuberculosis. The solution of the dif- ficulty constitutes one of the most satisfactory .r-ray diagnoses, for in this case Fig. 221. — Osteomyelitis. Femoral neck on the right side snows new bone deposit along outer side. No involvement of articular surface. No atrophy of shaft. (Original.) the dictvmi of the method is almost absolute and the simplification of treat- ment in the way of operative measures is very great. The disease is compara- tively common. In all the cases of this nature that we have seen, a pm-e cultiu^e of either the Staphylococcus pyogenes aureus or the Staphylococcus pyogenes albus has been obtained. The lesions which they cause are the small localized cavities THE INTERPRETATION OF RADIOGRAPHS. 651 or bone fui'uncles. They are often chronic in character, and at times are accom- panied by little external evidence of the bone process. In the radiograph the small single or multiple cavities are, as a rule, easily seen, but in certain positions they are obscured by an overlying cortex. They occm- commonl}' near the joint Fig. 222. — End Result of Osteomyelitis of Hip on the Left Side. No atrophy of size or structure. No involvement of articular surfaces. New bony overgrowtli as well as partial destruction of great trochanter. Compare with Fig. 219, (Original.) Fig. 223. — Circumscribed Osteomyelitic Bone Ca\'it}' in Lower End of Tibia and at Epiphyseal Line. "Bone Furuncle." Culture of Staphylococcus pyogenes aureus. Compare with Fig. 224. (Original.) 652 AMERICAN PRACTICE OF SURGERY. or exen at the epiphyseal hue, ami they have thickened walls of distinct out- line (Figs. 223 and 224). (2) A far more serious condition is the acute type, which is much more Fig. 224.— Post-operative Result One Year Later, in case shown in Fig. 223. Cavitj' space filled with new trabeculte. (Original.) Fig. 225. Fig. 226. Fig. 225. — Diffuse Osteomyelitis Following Measles. Great destruction of bone, the entire shaft appearing sequestrated. Much new bony overgrowth. (Original.) Fig. 226. — Diffuse Osteomyelitis Undergoing Healing Process. Large sequestrum forming. Same case as Fig. 225 and Fig. 227. (Original.) diffuse, often involving nearly the whole shaft of a bone, and is at once evident in the radiograph (Figs. 225, 226, and 227). This is the type to which the term acute infectious osteomyelitis is usually applied. THE INTERPRETATION OF RADIOGRAPHS. 653 Pig. 227.— End Result of Osteomyelitis following Measles. Same case as Fig. 225 and Fig. 226. (Original.) Tig. 228. — Chronic Osteomyelitis of Upper Portion of Tibia. Faint outline of ca\dty containing sequestrum seen. Great cortical thickening about cavitj'. (Original.) 654 AMERICAN PRACTICE OF SURGERY. (3) There are some writers who claim that there is a chronic circumscribed type of osteomyehtis — a form which is at times most obscure. In such cases the x-ray should help greatly in the diagnosis. The disease is to be distinguished from the first type only by the fact that the cavities are of large size, that they often lie in very dense bone, and that they are to be seen only in plates of great clearness and which show much bone detail (see Fig. 228). It will be noticed that, in the case here illustrated, the articular surfaces are free, but that the proximity of the joint has allowed the 2;-ray to reveal the true nature of a condition which had been treated for twenty years as rheumatic pain. 11 ^^H k 1 :^H 1 1 1' "^^^^H Fig, 22fi.— Diffusp Chronic Osteomj'elitis of Humerus. Involvement of joint. Resemblance to a malignant or specific process. Diagnosis confirmed by operation. (Original.) (4) Chronic diffuse osteomyelitis is a type more rarely encountered. Clin- ically the diagnosis is often difficult to establish; and, so far as this may be accomplished by the aid of the .r-ray, it is sometimes impossible to distinguish the disease from one of a malignant nature (Fig. 229). There may, in these cases, be so much cortical thickening that all evidences of cavity formation are completely obscured. It is here that, with the radiograph alone, the dif- ferentiation from a specific lesion may not be practicable. THE INTERPRETATION OF RADIOGRAPHS. 655 Chronic Non-Tuberculous. Arthritis. There has been much confusion, among writers on the subject of diseases of the joints, as to what terms should be apphed to the different forms of Fig. 230. — Atropliic Arthritis. General bone atrophy. Locahzed erosions and loss of substance can be seen most clearly in the carpal and radio-carpal articulations. Subluxations of phalanges. (Original.) Fig. 2.'?1. — Hypertrophic Arthritis. Overgrowths of bone seen on anterior aspect of head of tibia and superior border of patella. 656 AMERICAN PRACTICE OF SURGERY. chronic rheumatic disease. Thus, for example, some authorities class them together mider the smgle head of arthritis deformans, maintaining that they represent different stages of one and the same disease. In America, on the Fig. 232. — Atrophic Arthritis of Knee. Weak bone shadow as compared to soft parts. Normal joint space absent because of loss of cartilage substance. Erosions on under surface of patella. (Orig- inal.) Fig. 233. — Hypertrophic Arthritis. Strong bone shadow. Marked overgrowths can be most clearly seen on terminal and some mid-phalangeal articulations. Some joint surfaces destroyed by overgrowth of bone and cartilage. (Original.) other hand, there are many who regard them as more or less separate and independent diseases. So far as it is possible to judge from examinations made with the aid of the x-ra.y, the statement is warranted that the so-called THE INTERPRETATION OF RADIOGRAPHS. 657 Fig. 234 . — Hypertrophic Arthritis. Well-marked overgrowths seen on femoral condyles and on the under .surface of patella. Thickened cartilage in popliteal space. (Original.) Fig. 235. — Infectious Arthritis. Marked periarticular swelling. General diffuse atrophy, but no erosions or definite impairment of joint surfaces. No hypertrophy. (Original.) VOL. I.— 42 658 AMERICAN PRACTICE OF SURGERY. atrophic or rheumatoid arthritis and the hj-pertrophic form of the disease, or osteo-arthritis, almost always, even in the early stages, manifest distinct Fig. 236. — Infectious Arthritis. Same ease as tliat sliown in Fig. 235, but one j'ear later. Periar- ticular swelling has largely disappeared. No essential invoh-ement of joint surfaces. No hypertrophy. Some general atrophy from lack of use. (Original.) Fig. 237. — Infectious Arthritis. Complete fibrous joint ankylosis; neither atrophy nor hypertrophy. No change in articular surfaces. (Original.) and separate conditions. One represents atrophy, the other hypertrophy; one a destruction of cartilage and a loss of substance, the other thickening of THE INTERPRETATION OF RADIOGRAPHS. 659 cartilage, the deposition of lime salts, and actual outgrowth of new bone. Watched from the onset of the first symptoms the two diseases seem to differ essentially. One is occasionally superimposed upon the other just as scarlet fever may be accompanied by diphtheria. In these rather unusual cases the patients themselves will, as a rule, recognize them as distinct processes. The interpretation of the negatives, in suspected or pronounced cases of these diseases, is interesting and not difficult (see Figs. 230-234). -True Gout, fingers. Definite lo&b of hubbtance of shafts of proximal i3halange.s of index and little Several joints involved. No tophi distinguishable. (Original.) Infectious Arthritis. A large number of joint lesions, single and multiple, are unquestionably produced by some toxin or are due to a true bacterial infection. To these, Goldthwait has given the name of " infectious arthritis." It is possible to distinguish these by the x-rays, as well as clinically. Indeed, when the clinical diagnosis is in doubt, the radiograph often furnishes conclusive evidence. The joint lesion in the active stage represents neither essential atrophy nor hypertrophy of bone structures. The capsule is thickened and infiltrated. 660 A^IEMCAN PRACTICE OF SURGERY. with or without excess of fluid in the joint, but with no erosion of joint sur- faces (see Figs. 235-237). The z-rays would suggest that the so-called Still's disease represents an identical or certainly analogous process. Fig. 239. — Hereditary Sypliilitic Disease. Late manifestations. Ju.xta-epipliyseal form. Ep- iphyses little affected. Confluent areas of porosity in diaphyses of both tibice. Increase in cortical bone, and areas of bone deposit beneath the periosteum in diaphysis of femur on the right side. (Orig- inal.) Gout. True gout seems to be in a class by itself. The tophi are scarcel)^ distin- guishable in the negative, but the loss of substance of the shafts of the bones, as well as the involvement of the joint surfaces, is, in the advanced stages, characteristic (Fig. 238). In interpreting the plates of any of these chronic articular diseases, the stage of the process must be considered if confusion is to be avoided. Thus, THE INTERPRETATION OF RADIOGRAPHS. 661 Fig. 240. — Hereditary Syphilitip Disease. Diffuse cortical tliickening of mid-tibial and lower fibular shaft. New bone deposit beneath the periosteum gi\-ing rise to sabre-shaped bone. Tendency along tibial crest to the formation of so-called "bone-blisters." (Original.) Fig 241. — Periostitis Albumosa. Rough irregular bone deposit about the end of the radius, with areas of rarefaction in the diaphysis. Elbow and ankle of same case showed similar changes. (Original.) 662 AMERICAN PRACTICE OF SURGERY. an atrophic process, which has become quiescent in anj- joint, may malve feeble attempts at repair and actuall}' throw out new bone at the points of primary erosion; vice versa, a hypertrophic process, carried to the point of ankylosing a joint, may bring such pressure to bear on cartilaginous surfaces that erosions Fig. 242. — Hereditary Syphilitic Disease. Probable bone gumma in late form of the disease. Increase in cortical bone and lighter shadow of newly formed calcareous deposit on the left side. Circimiscribed lesion. (Original.) occur, and the bones, from mere disuse, show atrophy. The same holds true of the infectious types. Despite these facts, in the majoritj' of cases the .r-raj' negative is of almost conclusive value in differentiating the types and revealing the essential nature of the process. THE INTERPRETATION OF RADIOGRAPHS. 663 Syphilitic Disease. The bone lesions which occur as the result of luetic infection are numerous and varied. We shall attempt to describe the a;-ray appearances of only the common types. We have personall}'' seen few pathological appearances in the ;r-ray plates of bones taken in the secondary stage of the disease. The hereditary and con- FiG. 243. — Tertiary Syphilitic Disease. Circumscribed bone gumma. Marked increase in density of cortex; apparent invasion of tlie medulla. (Original.) genital forms and the tertiary lesions give most striking pictures and offer a large opportunity for diagnosis. The hereditary forms are divided into the early and the late, the former ap- pearing soon after birth and resembling clinically rickets. Pathologically, the condition is represented by the presence of gelatinous masses beneath the peri- 664 AMERICAN PRACTICE OF SURGERY. Fig. 244. — Hereditary Sj-philitic Disease. T},T3ical diffuse syphilitic osteomyelitis, showing in dif- ferent regions a deposit of bone beneath the periosteum, thickening of cortical bone, rough new over- growth, and bone necrosis. (Original.) Fig. 245. — Hereditary Syphilitic Disease. Same case as that shown in Fig. 244, after anti-syphUitic treatment covering a period of two yeirs. (Original.) THE INTERPRETATION OF RADIOGRAPHS. 665 osteum and at the epiph3'seal line, with sometimes true fractures or separa- tions of the epiphyses. Am.ong the other alterations there is said to be a thick- ening of the cortex and periosteum with gelatinous deposit between the two. We personally have never seen a good x-ray plate of this condition. One of the later hereditary forms of S3'philis — the juxta-epiphyseal lesions — deserves a special mention. In these lesions areas of bone necrosis accompany a deposit of bone beneath the periosteum and some thickening of the cortex. -Hereditary .Sypliilitic Disease, metacarpal bones. New deposit of bone beneatli tlie periosteum of one of the Old line of cortex seen. (Original.) Were it not for this overgrowth and for the fact that the articular surfaces are free, the condition might be confused with a diffuse tuberculosis. (See Fig. 239 ) Thickening of the cortex and the deposit of bone beneath the periosteum are the most characteristic and common evidences in the late hereditary and in the tertiary forms of the disease. They give rise, for example, to the sabre- shaped tibiee seen clinically (Fig. 240). It is by no means rare to find along the shaft of this thickened bone small areas of rarefaction with a cap of dense bone rising up over them. They have been well named by Codman "bone blisters." 666 AilERICAN PRACTICE OF SURGERY. Fig. 247. — Charcot's or Tabetic Joint. Antero-posterior ^^ew. Marked loss of substance of inner femoral condyle and tibial liead on right side. Compare more or less atropWed bone with normal unaf- fected knee on the left side. (Orisrinal. ) -Charcot's or Tabetic Joint. Semilateral view. Bone destruction with loose masses con- taining calcareous matter. Irregular articular surface of tibia. (Original.) THE INTERPRETATION OF RADIOGRAPHS. 667 The bone deposit beneath the periosteum, spoken of often as periostitis, appears as a faint locahzecl bulging along the shaft, not unlike early callus. The only conditions likely to be confused with these lesions are those which are observed in the early stages of an osteomyelitis proper or in that form of the disease which is known as periostitis albumosa (Fig. 241). The latter condition shows itself as an irregular deposit of calcareous matter outside the cortex in proximity to the joint. In the single case that has come under our observa- FiG. 249. — Exostosis Causing Fracture of Fibula. Osteoma meduUosum. (Original.) tion several bones were affected. The normal bone ridges at the points of insertion of muscles or where ligamentous structures are attached must not be mistaken for this calcareous deposit. The occasional periostitis that occurs after typhoid may resemble closely the so-called bone blisters, though without the accompanying cortical thickening. This cortical thickening is usually more marked along one side of the bone, often encroaching on the medullary cavity. The differentiation from an old osteo- myelitis, by means of the negative alone, may be difficult, and not a few cases of Paget's disease, or of osteitis deformans, have been diagnosed as of a syph- ilitic nature from the presence of this cortical thickening. Paget's disease is 668 AMERICAN PRACTICE OF SURGERY. rarely confined to one bone except in the earliest stages; syphilitic disease often is. The areas of rarefaction commonly observed in osteitis deformans are not characteristically seen in this t3q3e of specific lesion. The bone gmnmata observed in the tertiary stage of syphilis are both super- ficial and deep, the former occurring between the bone and the periosteum and causing ulceration of the cortex. These gummata may occur side bj' side, or they may merge the one into the other through radiating connecting bands. The Fig. 250. — Exostosis of Femoral Shaft. Osteoma spongiosum. (Original.) Structure of soft parts well shoiATi. deep gummata may occiu- in any part of the bone and may lead to fracture. The new bone thrown out on the side of the cortex next the lesion may be of ivoiy-like hardness, casting a very dense shadow (Figs. 242 and 243). In diffuse syphilitic osteomyelitis the bone may be doubled or tripled in volume, with numerous osteophytes (Fig. 244 and 245). Chaxcot's or tabetic joints should probably be looked upon as true arthrop- athies of perhaps neuropathic origin, rather than as evidences of active specific THE INTERPRETATION OF RADIOGRAPHS. 669 Fig. 251. — Enchondromata. Index finger of left hand shows most marked overgrowths. Small buds seen on the proximal phalanges, on the left middle finger, and on the thumb. (Original.) Fig. 252. — Medullary Sarcoma of the Tibia, of the Myelogenous or Giant-celled Variety. Marked cystic formation in the upper part of the tibia. (Original.) 670 a:\ierican practice of surgery. infection. They are most cliaracteristic in the .r-ra}^ as well as in their clinical behavior. The instabilitj^ of the part and the frequent tremor which sets in when an attempt at fixation is made, render it difficult to obtain clear radio- graphs. "\Mien they ha^-e been successfully taken thej- show great disorganiza- tion of the joint, with more or less destruction of large portions of the articular and juxta-articular bone, and the jaresence, in the joint, of apparently loose masses of detritus often containing lime salts. Fig. 253. — Osteo-sarcomaandOsteitisDeformans. Periosteal sarcoma cleA-eloping in a very advanced case of osteitis deformans (well seen in tibia). Sarcoma involves lower end of femur and popliteal space. (Original.) The boggy-feeling joint often gives a foggj'-looking radiograph (Figs. 247 and 24S). Syphilitic dactylitis perhaps deserves a separate heading. So far as our observation goes, it is not a difficult matter to confuse the disease with tuberculosis. The distinguishing features are: in syphilis there is less atrophy of structure and the articular surfaces are less often involved. If THE INTERPRETATION OF RADIOGRAPHS. 671 loss of substance occurs, the bone ulcer will present clear edges and a pimched- out appearance (Fig. 246). A tuberculous daeach end shall be sutured to its fellow. It will frequently be necessary to slit up the tendon sheaths to secure the proxi- 756 AMERICAN PRACTICE OF SURGERY. mal ends on account of muscular contraction. When this has been done the sheaths should be united by a running stitch of fine unchromicized catgut. When the wound has been made by a bright sharp instrument it can be safely closed after a careful cleaning. The superficial fascia should be closed by a running stitch of fine catgut, and finally the integument should be closed with silk or silkworm-gut sutures. A dry dressing of sterile gauze and cotton is then applied, and the hand held in a flexed position by a splint so as to keep the parts at rest in a relaxed state. If there is no unusual temperature this dressing should be left for one week, when the stitches are to be removed and a gauze dressing and the splint reapplied. As time goes by, the hand may be gradually extended so that it shall be straight by the end of the fourth week, which is about the time required for a tendon to unite. Should there be some elevation of temperature and local evidences of infection after two or three days, some of the superficial stitches must be removed and the wound treated as an infected one. Chemical disinfectants are not recommended in this class of wounds because an effort should always be made to secure primary union, and they would be more likely to prevent than to secure this result. A lacerated and contused wound is usually an infected wound and should be treated as such. A compound comminuted fracture of the leg is a good example of this kind of wound. It is presumed that the arterial and nerve supplies are not injured to such an extent as to demand amputation. The hemorrhage, if free, should be promptly controlled by forceps and catgut ligature. The sm'geon should first prepare himself, then the leg, then himself again, and finally the wound. The leg should be scrubbed, shaved, and prepared as for an operation. All infectious agents like pieces of clothing, etc., and all fragments of bone should be removed. When there is dirt in the wound the latter should be thoroughly cleansed with tincture of soap and warm water, aided by the fingers and a piece of soft gauze. Pieces of tissue that have evidently lost their circulation should be cut away. After it has been washed with soap the wound should be rinsed with warm sterile water, followed by a warm, weak solution of bichloride of mercury. It is useless to introduce the bichloride solution into a soapy wound. The fragments of bone should be adjusted and, when they cannot be held in position by splints and bandages, they should be drilled and fastened together by silver wire or strong chromicized catgut, preferably the latter. No iodoform or other powders should be put into the wound. Folded strips of rubber tissue or of gauze rolled in rubber tissue in the form of a "cigarette" drain, are so placed that they shall extend from the depths of the wound tlii'ough the skin. They should not be large or numerous. Two will usually suffice. The wound should not be plugged with iodoform or other gauze, as it prevents drainage and healing. The pliable rubber tissue is better than rubber tubes because it drains as well and does not injure the tissues by pressure, as a stiff tube ma3^ The wound when large should be partly GENERAL SURGICAL TREATMENT. 757 closed by loosely tied stitches of silkworm gut. It is not necessary to leave the wound wide open to secure drainage. The usual dry sterile dressing of gauze and absorbent cotton should be applied and the leg supported by a proper splint. The moist dressing should not be applied at first because it is often possible even in this class of cases to secure an aseptic wound, and the moisture would encourage bacterial development. It will be time enough to apply a moist dressing when suppuration is inevitable. This dry dressing may be left for four days unless there is a suggestive rise of temperature or the dressing becomes soiled. At that time, if it is apparent that an aseptic wound has been secured, the drainage material may be removed and a fresh dry dressing applied. If, on the other hand, the temperature rises or other evidences of in- fection appear, the dry dressings should be exchanged for moist ones and the wound treated as an infected one. So long as the wound remains aseptic it should not be irrigated or disturbed except for the removal of drainage materials and stitches, and the dressings should be changed only when the temperature rises or when they cause discomfort. Secondary suturing of wounds is employed in aseptic wounds that have been drained and for the approximation of granulating surfaces. When drain- age is employed where it is hoped that an aseptic wound may be secured, and the amount of drainage material used is enough to cause gaping of the wound, sutures should be introduced at the time of the first dressing and tied when the drainage material is removed. When aseptic granulating surfaces can be brought together without tension they will heal by first intention. Through-and- through sutures passing underneath the whole granulating surface should be employed when possible. It is useless to force the edges of a gaping granulat- ing wound together with sutures under tension, because the sutures will cut through and do more harm than good. Under these circumstances it is better to approximate the surfaces with strips of adhesive plaster, supplemented by a comfortably fitting bandage. Infected Wounds. — In preantiseptic da3^s most wounds were septic and suppuration was so common that it was considered a necessary part of the healing process, and "laudable pus" was spoken of as something to be sought for. At the present time suppuration is known to be a pathologic process due to the presence of certain forms of bacteria in the wound, and when suppuration occurs in an operation wound the surgeon or some of his helpers may be responsible for it. In the preantiseptic days abdominal operations were very rarely performed because they were so commonly fatal, the patients dying from peritonitis. It was not unusual in those days for a medical student to go through his whole medical course, even where there were large surgical clinics, without seeing a single abdominal operation. At the present day peritonitis following operation is almost abolished and operations are often performed for the relief of that condition. When a wound has been infected it may finally heal by what 758 AMERICAN PRACTICE OF SURGERY. is kno-mi as secondary intention. In a suppurating wound the superficial layers of new cells formed by the tissues for the healing of the wound are de- stroyed by pus microbes and their toxins and they finally help to form pus. ANlyen this process is very active, the healuig of the wotind is interfered with. When, through Nature's efforts, and with the aid of the surgeon, a favorable change takes place, the pus becomes less virulent and diminishes in quantity. The new cells become more highly organized, and healing by secondary intention gradually takes place. The pathology of inflammation is partly based upon theory, and jjathologists do not agree concerning suppuration, some claiming that it is purely pathologic, while others claim that it serves a useful purpose in com- bating invading organisms. The surgeon knows practicalh^, however, that when there are no bacteria in a wound there will be no suppuration, no matter what the character of the wound or where situated, and his best efforts are therefore put forth to prevent infection and consequent suppuration. Aside from the dangers and loss of time which attend a suppurating wound, healing by second intention is unsatisfactory because of the large scar which it leaves. Accident wounds are suspicious wounds, and many of them do not come under the surgeon's care until after suppuration is well established. The principles connected with the treatment of these wounds are the same as those for the treatment of other wounds, but the details differ somewhat. When the evi- dences of infection — heat, pain, and redness of surrounding parts — are present, the surgeon's first efforts should be to allay the inflammation, the healing of the wound being then a secondary consideration. The discharges must be allowed free exit to prevent their absorption and dissemination from causing a general infection. If the wound is a deep one it must either be drained by tubes or strips of rubber tissue or be opened widely with the knife. It must not be packed with gauze, because gauze prevents drainage. It is a common error to pack a wound with medicated gauze under the mistaken idea that it will drain it. In treating infected wounds a rational use should be made of the best antiseptic and aseptic precautions ; not that they will necessarily stop the suppuration, but that they may prevent the engrafting of another infection upon the one already existing. It is quite possible, for example, to inoculate a sup- purating wound with the streptococcus of erysipelas or with the tetanus bacillus. Our knowledge of the exact relations of associated bacteria is quite limited. In suppurating wounds the infection is usually a mixed one, but there are very few instances known when the various forms of bacteria are at warfare with each other; on the contrary, the tendency is for them to unite their forces against the resisting powers of the tissues. Persistent or repeated irrigation of a suppurating wound with strong chemical solutions does more harm than good. It does not stop the suppuration and it is liable to injure the already weakened embryonic cells of the granulation tissue. Every experienced sur- geon has observed patients with suppurating wounds which had refused to GENERAL SURGICAL TREATMENT. 759 heal under chemical irrigation, but which promptly improved after the irrigation had been discontinued. It is not practicable to use solutions strong enough or for a period sufhcientl}^ long to act as germicides, without danger of poison- ing the patient. There is a growing belief that a claret-colored solution of iodine will accomplish much toward securing the desired result. Gentle irrigation with a warm normal salt solution meets every indication, since the only benefit to be derived from irrigation is a mechanical cleansing of the wound. The advantage of the salt solution over the sterile water is that it is more grateful to the tissues. A wound so situated and so shaped that it can be cleansed by gently touching it with pieces of soft gauze will heal more promptly without irrigation of any kind. The poultice, so popular with the profession at one time and which still holds a prominent place in domestic surgery, has almost entirely given place to the moist gauze dressing. The poultice is an application soothing to an inflamed part on account of its warmth and moisture, but as usually made it is objectionable, and consequently it may become a source of danger. Salves and ointments, at one time so extensively used, have fallen into disuse because they were found to be surgically unclean; however, they can be made in such a manner as to be a clean and comfortable dressing. Some of the heavier products of petroleum make the best ointments. When properly sterilized and impregnated with sufficient carbolic acid to prevent them from becoming infected, they make a very grateful dressing for a granulating surface. They can be spread upon gauze and applied directly to the wound. A granulating wound, which has become weak under rubber tissue or moist dressings, will often improve rapidly under the above dressing. The moist gauze dressing has all the advantages of a poultice without its disadvantages. There is no clinical evidence that medicated gauze commonly has any advantage over simple sterile gauze. Surgeons who at one time used medicated gauzes quite exclusively now find that they can secure better results with the unmedicated gauze. The medicated gauzes are open to the same objections as powders and chemical solutions — weak ones may do no good, and strong ones may do harm. After the wound has been gently cleansed it should be covered with a liberal layer of sterile gauze wet in sterile water. Very weak solutions of lysol and carbolic acid will give a perfume of their own to the dressings and are harmless, but they have no perceptible therapeutic value. An ample quantity of the moistened gauze should be applied, and over this should be placed a layer of rubber tissue to retain the moisture. The advantages of the moist over the dry gauze in this class of wounds are these: they do not adhere to the wound and they absorb the discharges more quickly. Over the rubber tissue a layer of cotton should be applied, and the whole held comfortably in place by a band- age. This dressing should be changed every three or six hours according to 760 AMERICAN PRACTICE OF SURGERY. the amount and character of the discharges. Thej^ should never be permitted to become dry. A chill or a rise of temperature indicates that the wound is not adequately drained, that there is systemic infection, or that there is some other focus or a complication, all of which are conditions that call for prompt atten- tion. When the suppuration has been reduced to a minimum, the moist dress- ings should be replaced by dry ones and an effort made to secure rapid healing. When we have a granulating surface to deal with, it should be covered by strips of rubber tissue, and over the whole should be placed dry sterile gauze. When the wound is so situated or so shaped that the granulating surfaces can be approximated without tension, secondary sutures or adhesive plaster may be used for this purpose, provided the surfaces can be made sterile. It is only in exceptional cases, however, that this is possible, but it may be secured often enough to make the effort well worth while. For example, if an abdominal wound which presents clean granulating smfaces and has practically ceased suppurating be carefully dried, then thoroughly swabbed with ninety-five- per-cent carbolic acid followed by alcohol, then packed for forty-eight hours with gauze saturated with balsam of Peru, and finally closed by sutm-es or adhesive plaster, it will sometimes heal promptly, and when it does not heal at once the healing is at least hastened by this treatment. When, as sometimes happens, the rubber strips are uncomfortable, a very good and comfortable di-essing can be made of gauze saturated in a mixture of six-per-cent balsam of Peru in sterilized castor oil. A suppurating compound comminuted fractiue of the leg may be taken as an example of this variety of wound. This is a particularly dangerous variety of wound because the soft parts are usually badly injured, and because there is danger of the burrowing of pus between the muscles. In addition, the medulla of the bone is exposed, and consequently there is imminent danger that a sup- purating osteomyelitis maj^ develop. The surgeon's hands, instruments, and dressings should first be prepared. The leg should then be shaved and scrubbed with soap, warm water, and brush. Finally, the wound should be thoroughly irrigated with a warm normal salt solution. If one who has been accustomed to use a strong bichloride solution in these cases will substitute a normal salt solution he will meet with an agreeable surprise. If the surgeon believes that a chemical solution must be employed, the iodine solution is probably the safest and most efficient. All parts of the wound must be reached and gentle pressure should be made along the leg from both distal and proximal ends toward the wound to ascertain whether there is burrowing. When the original skin wound is not large enough to admit of a, free cleansing and ample drainage it should be enlarged, and when the wound does not permit free access counter- openings should be made. When burrowing is found, the pus pocket must be slit up or drained from the bottom. The wound should be gently but thor- oughly explored with the finger, and if any loose spicule of bone or foreign GENERAL SURGICAL TREATMENT. 761 matters are found they should be removed. The fragments should be adjusted and held in place by extension made by an assistant pulling on the foot until the dressings and splint are applied. Rubber tubes or folded strips of rubber tissue, preferably the latter, should be passed to the depths of the wound and allowed to project from the wound for drainage. A large dressing of sterile gauze wrung out of warm sterile water should be applied. Over this a large sheet of rubber tissue and a layer of absorbent cotton should be applied and held in place by a snug-fitting roller bandage. A comfortable splint should then be applied with some mechanical arrangement by which free access can be gained to the woimd for a change of dressings without disturbing the fragments. These dressings should be changed often enough to keep the wound clean and the dressings moist. A chill or rise of temperature always demands examina- tion of the wound and perhaps a change of dressings. The latter should be continued until such time as the wound has so improved as to permit the appli- cation of strips of rubber tissue and a dry gauze dressing. Drainage. — Drainage in some form has been employed since the days of Hippocrates. Old-time surgeons drained because they knew pus would form, later surgeons drained to prevent the formation of pus, and now we drain only when we have a suspected or infected wound or where there is unavoidable dead space. During the development of antiseptic and aseptic surgery drainage was a very common topic for discussion. Hippocrates first used drainage tubes for the treatment of empyema. Celsus and Galen used them for drainage in ascites. Ambroise Pare used gold and silver tubes. Heister first employed capillary drainage in the eighteenth century. At the beginning of abdominal surgery drainage was very extensively used, and for many years it occupied a prominent place. Surgeons then believed that peritonitis was only an excep- tional cause of death, but that death was due to the absorption of what Keith called "that red serum, the enemy of the ovariotomist." Peaslee and Keith, in 1864, were the first to recommend peritoneal drainage tlirough the vagina. About this time drainage through the rectum was tried; but from our present viewpoint we can readily understand why this proved fallacious. The soft- rubber tubes now in use were introduced by Chassaignac in 1859. Koeberle introduced perforated bulbous-ended glass tubes for peritoneal drainage in 1867, and soon after this Keith and Wells introduced straight glass tubes. These were all very popular for a time, but gradually fell into disuse because they soon became plugged and failed to drain. At that time drainage was considered a necessary part of the toilet of every wound, and more especially of an abdominal wound. Marion Sims was originally an earnest advocate of peritoneal drainage, but he was one of the first to recognize the fact that the opening of an abdomen does not necessarily indicate the need for drainage. With the development of antiseptic surgery surgeons learned that it is not the serum that endangers the patient, but the presence of bacteria. They also 762 Ai\IERICAX PRACTICE OF SURGERY. learned that drainage is a soui'ce of danger because it serves as an entrance- way for bacteria, and therefore peritoneal drainage by tubes soon began to fall into disrepute. It was still belie^-ed at this time that peritoneal drainage was very often necessary, but surgeons began to realize that the tubes were not only dangerous, but that they were inefficient. Many varieties of tubes from manjf materials were tried, onlj'^ to be discarded because of their dangers and inefficiency. Capillary drainage with gauze was next tried, but it was soon found that it will not chain pus and that it drains serum from the peritoueimi for onh^ a few hours, when its meshes become plugged and its capillarity is de- stroyed, and that ftirthermore it becomes adherent to the peritoneum. The gauze was then ^Tapped with rubber tissue to prevent adliesion, and this va- riety' of di'ainage is much in vogue to-da3^ Prophylactic abdominal ch'ainage was at one time given an extensive trial, but was found to be inefficient and dangerous. We have been guilt}' of many errors in the matter of drainage, and our sins of commission have doubtless greatly outnumbered those of omis- sion, but we were obliged to go through this experience in order to learn what is necessary and what is uimecessar}'', and what makes for good and what for ill. .\11 drainage openings become more or less infected, although all do not suppurate. The great trouble ■nith peritoneal drainage, aside from its dangers, is that it does not ch'ain. Experience and experiment have demonstrated that it is a ph5'siological and mechanical impossibility to drain the peritoneal ca\ity for more than a few hours. Drainage from tubes ceases in about twelve hom's and from gauze in twentj^-four hom-s, because thej' are invariably walled off from the general peritoneal cavity in this time. There may be some flow of serum after this time, but it comes onlj^ from the drainage track and is caused by the presence of the drain. The question of drainage is verj- important, and, unfortunatel}-, it is im- possible to lay down exact rules as to when we shall or shall not drain, because conditions vary with the patient, the envhomnent, and the operator. From our present viewpoint much of the drainage done a few years ago was unneces- sarj' and harmful, but it is quite probable that when sm'geons emplo3-ed it so extensivel}' they needed it more than we do. It is very certain that in pre- antiseptic daj-s it was very much needed. If at the present time one sm-geon uses drainage where others do not find it necessarj', it is quite possible that he needs it. The occasional operator undoubtedl}' needs it much more frequently than the regular surgeon, and it is certainly rec^uu-ed in a very much larger percentage of accident than of operation wounds. Prophylactic drainage, or drainage to prevent the formation of pus, is no longer used. The materials most frequently employed now are the soft-rubber tube of various sizes, rubber tissue, and gauze. The glass drainage tube, although in many respects excellent, is not so extensive!}' used as it was at one time, because its length cannot be regulated as easily as that of the rubber tube. GENERAL SURGICAL TREATMENT. 763 The tube should be employed where large quantities of pus and large cavities or cysts are to be drained, as for empyema and for certain conditions of the lu'inary and the gall bladder. Folded rubber tissue is superior to the tube when it is applicable, because it is more flexible, is less likely to do harm from pressure, and does not cause gaping of the wound. This material is really very efficient, because it keeps the wound open enough without overdoing it, and the discharges escape along the side of the drain. For small accident wounds, and for larger ones where suppuration is not abeady established, the rubber strips are the best material. For capillary drainage, gauze is now the favorite material, although horsehair and silkworm gut are frequentlj' used. Catgut and other absorbable materials have been disappointing as drainage materials on account of their tendency to become infected. Gauze is very commonly surrounded by rubber tissue to prevent it from adhering to the tissues; this is especially true in the peritoneal cavity. This combination of the two varieties of material affords both capillar}- and tubular drainage. The gauze drains the serum by capillary attraction, while pus and other heavy discharges escape along the side of the rubber tissue. This so-called "cigarette" drain should be made by laying a piece of sterile rubber tissue of the required size upon a table covered with a sterile towel, and upon this about four thicknesses of sterile gauze a little smaller than the sheet of rubber should be spread; then all are rolled rather loosely into a "cigarette." It should be made by the oper- ating-room nurse when she is prepared as for an operation. This makes the best drain of the kind, as it is made of alternating layers of gauze and rubber tissue with the rubber outside, and affords drainage of both kinds. It does not adhere and can be removed at any time without causing pain or injuring the granu- lations. Capillary drainage with gauze is apt to be injudiciously employed. Medicated gauze should not be used as a drain because it has no advantage over plain gauze, and the drug may do harm. Sterile gauze, like every other drainage material, is a foreign body in the wound; therefore the minimum amount that will meet the requirements should be used, and it should beremo^'ed at the earliest possible moment. When gauze is used as a packing to control hemorrhage it may be necessary to use a considerable quantity and to leave it for from four to six days or until it loosens, but this is not drainage. The ob- jections to gauze as a drainage material are these: it drains only serum and that only for a few hours: and when it is removed the act of removal may break down the granulations, causing pain and hemorrhage and furnishing a new entrance-way for bacteria. This is a particularly dangerous procedure in the peritoneum. Many lives have been imperilled by packing large quantities of gauze in the abdomen, and incautiously removing it on the third or fourth day. In superficial wounds the objections are not so potent, but the advantages are just as few. Surgeons have differed in regard to the use of gauze in the abdomen. When they have an abscess to open they carefully wall off the healthy viscera 764 AMERICAN PRACTICE OF SURGERY. with gauze before opening it because they know from experience that the pus will not go through it; then, after opening the abscess, they are apt to pack the abscess cavity with gauze, expecting the pus to drain out through it. That drainage is often necessary all agree, but that it may be an evil none can deny. Many objections can be made to a drain, but the principal ones are: that it is an irritating foreign body; that it makes an entrance- way for bacteria; that it necessitates frequent dressings; that its removal may injure the granu- lations; and that it keeps the wound open, delaying the healing process. In the abdomen the presence of a foreign body interferes with the natural resist- ance of the peritoneum, and it sometimes predisposes to hernia, fistula, and intestinal obstruction. Indications for drainage can often be met in some other way. Strict asepsis renders drainage unnecessary in most cases. A peritoneum that has been carefullj' protected from injury during an operation will drain itself much better than one that is interfered with by the presence of foreign bodies in the shape of tubes and gauze. There are usually better ways of con- trolling hemorrhage than that of filling the wound with gauze. Drainage is indicated in the presence of infection or where the chances are decidedly in favor of infection, and in the presence of much blood or cyst con- tents. As a rule, when the urinary bladder and the gall bladder are opened, drainage is indicated because they are usually infected before they are opened, and it is often necessary to make temporary provision for the escape of the contents. In large amputation wounds and after breast operations where the wound is closed, it is better to drain temporarily even when the wound is aseptic, because there is a large raw surface which in spite of the most careful hsemostasis will ooze, and serum will accumulate to fill the dead spaces — results which are unavoidable. When the lymphatics in the axilla, neck, or any similar regions are removed or destroyed by the operation, artificial drainage is very necessary for a time. These wounds will heal superficially without drainage, but the accumulation of serum and blood within will delay the healing of the deeper parts very much and maj^ lead to secondary infection. An amputation stump should have two rubber tubes, of medium size, introduced one at each angle. They should not protrude from the wound so far that they may be bent over and obstructed by the dressings, which should be of dry sterile gauze and absorbent cotton loosely applied. A stout silk thread should be fastened to each tube and left protruding beyond the dressings, so that the tubes can be withdrawn without disturbing the latter; for every change gives the patient pain and may lead to secondary infection. They should be removed in forty- eight hours. Breast wounds should be drained in the same manner, save that it is usually better to make a stab wound through the integument at the most dependent part just large enough to admit a tube. Drainage materials should be removed as soon as the discharges cease, for by this time they will have performed their fimction and wlW thenceforth only GENERAL SURGICAL TREATMENT. 765 act as foreign bodies. Where the surgeon hopes to be able to discontinue the drainage in a day or two, gauze should not be .used unless it is surrounded by rubber tissue, for otherwise its removal may be dangerous and will surely be painful. Abdominal dramage always causes peritoneal adhesions, but they may dis- appear after a time. When a wound has been closed without provision being made for drainage, and a decided rise of temperature follows, the question of secondary drainage naturally arises. A temperature of 102° or 103° F. quite frequently occurs within twenty-four hours, but this is usually an aseptic temperature clue to absorption of blood, and has no special significance. It often occurs with a simple fracture or with contusions where there is no question of infection. A temperature appearing on the second or third day and gradually rising com- monly means wound infection, and in any event the wound should then be carefully examined. The peritoneum is the most tolerant and most capable of self-drainage of all the tissues; but when once this tolerance has been arrested and cannot be resumed, the patient dies. Secondary drainage of the peritoneum in such cases is practically useless. Surgical Uses of Heat and Cold. Heat and cold have been used as therapeutic agents in surgery from time immemorial. Their use has been largelj^ empirical, based upon the fact that they relieve pain. ]\Iost of the statements concerning their effect are still empirical and difficult to prove. They are used rather indiscriminately for like conditions, heat being the favorite in winter and cold in summer, with seemingly like results. They have been favorites with the profession as well as with the laity in the treatment of inflammation in its various forms, but suice we have learned that, surgically speaking, inflanmration means the presence and activity of bacteria, our faith has been somewhat shaken, because any degree of heat or cold which will not destroy the tissues can have very little effect upon them. The mere presence of bacteria, however, is not all there is of inflamma- tion. They must be active, and for their activity certain conditions of tem- perature and blood supply must obtain. It is these conditions which we hope to influence favorably by the application of heat and cold. Since we cannot hope to destroy the bacteria by these applications, our efforts must be to assist Nature in her warfare against them. Clinical evidence concerning the effects of heat and cold is still conflicting and unreliable because observers have failed to give Nature due credit for what she will do without their aid. The more we learn concerning the conflict between bacteria and the living tissues the greater our respect for Nature's work and the more we realize that the most we can do is to be her faithful assistants. When inflammation is superficial it is rational to believe that we can render 766 AMERICAN PRACTICE OF SURGERY. some assistance by the judicious use of heat and cold, but when it is deep-seated it is difficult to understand how we can accomplish anything by their application. Many theories have been advanced concerning this matter, but none are proven. Writers will cite a long series of cases of appendicitis in which they have applied cold or heat to the abdomen with good results, and others will cite a like series in which they have kept their patients quiet in bed without applications of any kind and with equallj' good results. In the light of this evidence is it not ra- tional to conclude that, aside from the relief from pain following the application of heat or cold, the improvement noted was due to Nature's efforts aided by rest? In these few remarks on the surgical uses of heat and cold the "WTiter does not wish to assume the role of an iconoclast, but he has not cared to voice theo- ries which will not bear the test of intelligent clinical observation. The influence which local applications can have upon the body temperature cannot be great and cannot extend to any depth, but they do add materially to the patient's comfort and are seemingly helpful when judiciously handled. It is probable that we can accomplish the most good through these agents by controlling the circulation of the inflamed part. The hyperemia which follows an infection is evidence that Nature is rallying her forces for the combat with the invading enemy, but when stasis occurs, the enemy has the advantage. If by the application of heat and cold we can facilitate the flow of blood- through the part and prevent stasis we are certainly assisting Nature's efforts. These agents influence the circulation by their direct effect upon the superficial ves- sels and by stimulating the vasomotor nerves. That both heat and cold con- tract the small blood-vessels is demonstrated by their action in controlling capillary hemorrhage. The selection in each case must be left to the judg- ment of the attendant. When there is no definite indication for a choice it may safely be left to the caprice of the patient. In a few instances, however, a proper selection is very important. For example, when a hand or foot is so badly crushed that it is a question whether it can be saved or not, it would be a great mistake to apply ice, on account of its tendency to lower the vitality of the tissues. It would be a grave error to apply cold to an ulcerated cornea the vitality of which is low. Cold is the favorite in the early stages of inflam- mation when it is hoped that suppuration may be averted, but in the later stages,, when suppuration is deemed inevitable, heat should take precedence. Heat may be applied either moist or dry. When the skin is unbroken the choice may be made a matter of convenience, but, in the presence of a wound,, no application should be made which is not in strict accord with the principles of aseptic and antiseptic surgery. Moist heat in the form of a poultice is not specially objectionable when the skin is whole, save that there are many more elegant methods, but when the skin is broken moist heat is highly objectionable, because in its usual form of a poultice it is crowded with bacteria and intro- duces foreign matter into the wound. Moist heat can be best applied by means GENERAL SURGICAL TREATMENT. 767 of sterile gauze wrung out of hot water and covered by rubber tissue. The ckessings must be changed so frequently that they shall not become cold and dry, for alternating heat and cold are decidedly objectionable. Dry heat is often just as efficient as moist and can be more conveniently applied by means of a rubber bag or coil. Dry heat has been extensively em- ployed in the treatment of inflamed joints. The joint is surrounded by a metal- lic jacket, and the air within is gradually heated to the limit of endurance. This "baking" process is a very efficient means of relieving pain, but its curative effect has not been sufficiently demonstrated to gain for it an established place in treatment. Extreme heat in the form of the actual cautery has an important, although limited, place in sm-gical treatment. It was formerly much employed as a means of controlling hemorrhage, but at the present time it is rarely used for that purpose. The use of the cautery is practically limited now to the treatment of hemorrhoids. The Paquelin cautery and the soldering irons are still used, but the electric cautery is the most convenient form of instrument. Modern operating-rooms are being provided with plugs so that the electric lighting current can be utilized for this pm-pose. Cold is usually applied dry by means of an ice bag. Moist cold has no advantage over dry and is not nearly so convenient to apply. PART V. GENERAL SURGICAL PROGNOSIS, GENERAL PROGNOSIS IN SURGICAL DISEASES AND CONDITIONS. By LEONARD WOOLSEY BACON, JR., M.D., New Haven, Conn. It is the business of individual prognosis to estimate the future course of any disease present in the individual patient, to answer the questions : Will this man survive this illness, this accident? If he survives, will his recovery be complete and permanent, will he go forth whole and sound, or will he always bear with him some disabilities resulting from his present condition of disease or injury, or some tendency to relapse? If he carmot recover, how long may he expect to live, or with what permanent disabilities will he be handicapped? Passing beyond the consideration of the prognosis in the case of the indi- vidual patient, special prognosis considers the outlook of all those individuals as a group who are suffering from a particular ailment, and thus takes in, from the point of view of the several species of disease, the whole realm of medical and surgical nosology. That is to say, individual prognosis considers the outlook for A., B., and C, suffering, let us say, with appendicitis; while, passing from the individual to the group, special prognosis considers the wider subject of the out- come of appendicitis in its different forms and stages, and the results that may be expected imder different forms of treatment, expectant or operative. In this way it is the fimction of special prognosis to consider all the units of the noso- logical schedule, and to determine and weigh the prognostic factors in cancer, erysipelas, aneurism, hernia, septicaemia, mechanical trauma, etc. But, above and beyond all this, aside from the outlook for the particular pa- tient, and aside from the several species of medical or surgical disease under consideration, are the general and fundamental matters of constitution and the powers of resistance. Individual prognosis, the ultimate object of all prognostic study, depends, in the final analysis, upon the relation between the natural tendency of the specific disease with which the patient may be affected (the special prognosis) on the one hand, and the general powers of resistance of the patient on the other hand. These matters of constitution and the powers of resistance are the elements of "general prognosis," they appear as factors of prime importance in each and every case, and they are to be the theme of our study in considering 771 772 AilERICAN PRACTICE OF SURGERY. GENERAL PROGNOSIS IN SURGICAL DISEASES AND CONDITIONS. It will be well for iis, then, at the outset to indicate just what are these wide- reaching elementary conditions which affect the prognosis in all surgical dis- eases and in aU surgical conditions, and then to proceed to examine them in more detail with regard to their bearing upon special and upon individual prognosis. I. Age. — Tire most obvious of these general considerations is age. Infancy, childhood, adolescence, maturity, senility — all present factors whose prognostic import ranges throughout the whole field of medicine and surgery. II. Sex. — A second matter is sex, though the influence of sex is more obvious upon the incidence of disease than upon its prognosis. III. Constitution. — Many factors go to the making up of the constitution of the individual, and our study of this matter must be sufficiently broad to include that upon which oiu- fathers laid great stress under the caption of temperament, and to include likewise a consideration of diathesis, heredity, and race. IV. Integrity of Organs and Functions. — Integrity of organs and functions and the existence of concomitant disease will evidently demand a large share of our study, as including those factors influencing perhaps most closely the indi- vidual prognosis. V. Environment. — Lastlj', the environment of the patient will claim our at- tention, including under this term his occupation, his food, the climatic condi- tions imder which he lives, his ability to create about himself hygienic condi- tions, and his disposition, through habit or training, to observe the laws of hj'gienic living. Under these five heads — age, sex, constitution, integritj' of organs and func- tions, and enviroimient — we shall pursue the study of our theme. I. Age. (a) Infancy. — It is natirrally in the extremes of life that we look for the in- fluence of age upon surgical prognosis to be most pronounced. As indicated by Karewski,* a very energetic cell activity is characteristic of infancy and child- hood. From this fact there result, however, two apparently contrary peculiar- ities, at once an enhanced and a diminished power of resisting noxious causes. The intensity of metabolic processes in childhood occasions particularly favorable conditions for maintaining the conflict with micro-organisms and for the repair of trauma. We observe, indeed, that suppurative affections are rela- tively rare in children, and that solutions of continuity show a particularly favorable tendency to heal. In spite of the great frequency of abrasions and skin wounds, which are exposed to treatment quite opposed to the rules of mod- * Karewski: "Die Chirurgischen Krankenheiten des Kindesalters," Stuttgart, 1894. GENERAL SURGICAL PROGNOSIS. 773 ern surgery, the surgeon sees far less frequently in the infant than in the adult progressive phlegmon or general sepsis arising from these sources. Even chronic suppurative processes, such as after puberty would be followed by rapid ex- haustion, are astonishingly well borne and heal in a surprising manner. Certain chronic infectious diseases, such as tuberculosis and syphilis, seem to appear, as it were, in an attenuated form in children, and to proper therapy they yield much better results than in later life. This same condition of enhanced metabolic activity results, on the other hand, to the disadvantage of the infantile organism. Inasmuch as the main- tenance of this heightened activity is particularly dependent upon favorable and abundant local and general nutrition, it follows that all influences which acutely and considerably reduce this abundant nutrition are calculated to compromise the health or even the life of the child — a fact that applies to individual portions as well as to the whole body of the child. Impairment of blood supply and dis- turbances of innervation are the occasion of marked trophic disturbances, the former even occasioning the prompt supervention of necrosis, where in adults the same parts would have maintained their vitality. Indeed, a permanent de- pression of the general nutrition brings about a disposition to succmnb to just those dangers against which the infantile organism is otherwise so particularly well fortified. Thus we understand how it is that even slight hemorrhage in nursing children may induce either sudden death or profound cachexia, that chilling of the body during operation or prolonged narcosis may be followed by fatal results, poisonous antiseptics bring about grave conditions, pyogenic in- fections assume a virulent and dangerous type. Conditions of malnutrition in children give a great impetus to the spread of micro-organisms, manifest, for instance, in multiple abscesses and miliary tuberculosis; while the very same cause occasions that characteristic trophic disease of childhood, rickets, which has its seat at the focus of the most energetic developmental activity. These facts constitute so many indications for the regulation of our surgical treatment. While, on the one hand, they allow us within certain limits to count with more certainty than in adults upon good results in surgical treatment, and permit us to follow out, further than in adults, the trend of modern surgery toward conservative methods, on the other hand they warn us against pro- tracted operations associated with loss of blood, and admonish us to watch narcosis with a jealous eye, to give special care to the selection of our antisep- tics, and to modify in some instances our methods of operation. These general principles will lead us to certain specific precautions in the surgical treatment of infants and children. When chloroform is to be adminis- tered, we must, not allow too long an interval of fasting to precede antesthetiza- tion, lest the patient begin the operation faint from hunger. Chilling of the body, or, indeed, of any portion of it, must be scrupulously guarded against, and for the same reason, viz., on account of the effect of high temperatures upon the 774 AMERICAN PRACTICE OF SURGERY. general nutritive processes of the child, no operations but those of urgency should be undertaken during extremely hot weather. Another wise prophylac- tic measure intimately affecting surgical prognosis in children, especially in hos- pital inmates, is, according to the suggestions of D'Arcy Power, to delay an operation of any magnitude, if it be possible, until the expiration of the incuba- tion periods of those exanthematous diseases from which the child has not yet suffered. It must further be borne in mind that infants are extremely susceptible to interruptions and changes in diet, and that, except in the most urgent cases, it is well not only to correct any gastro-intestinal irregularities that may be present in an infant upon whom it is proposed to operate, but to make sure also, by actual trial, that the child can retain and digest the diet on which it is pro- posed to feed it after the operation. Save in most urgent cases plastic operations are not best performed in early infancy. The diminutive size of the parts will, in many operations, add greatly to the difficulty of their execution, will enhance the difficulty of the exact hsemo- stasis which these operations demand per se, and which is furthermore exacted by the small body weight of the patient, and will make the procedure more pro- longed and relatively more severe than in a somewhat older child. Another matter to be thought of in connection with plastic operations, and indeed with any considerable operation in the infant, is the difficulty in applying and maintaining surgical dressings in the infant, and of keeping such dressings clean. In fact, any surgical operation demanding prolonged after-care must be considered relatively unfavorable in the infant; particularly does this apply to operations on or near the natural orifices of the body. In cases where it is possible to provide properly for all these matters, there are, on the other hand, many advantages in surgical practice among infants. The ready depression of the vital forces in infancy is correlative with an equally ready recuperation. Furthermore, infants are relieved of the depressing effects of anticipation. As the infantile sensoriuni is relatively unimpressionable, they bear acute (but not -protracted) pain relatively well, and they are not so likely to suffer from nervous shock. Many operations may be done on them without an anaesthetic, and the condition of semi-ansesthesia, so perilous in the administra- tion of chloroform in adults, is relatively much less dangerous in infants. This is fortunate, because local anesthesia, with cocaine, etc., is hardly applicable in infantile surgerj'. (b) Childhood. — The general considerations which we have reviewed, as ap- plicable to surgery in infancy, become less and less applicable as the age of the patient increases. The main distinction between infancy (say the first year of life) and childhood (say the ten years next succeeding) lies, from the surgeon's point of view, first, in a slight loss of the advantages of the energetic cell activity of infancy ; and secondly, in a more than compensating gain in the stability of the nutritional processes of the older child as compared with those of the infant ; GENERAL SURGICAL PROGNOSIS. 775 while, in the third place, there is a marked accentuation in the impressionability of the sensorium; and fom-thly, the development of will power and voluntary action in the child come into active play. This change from infancy to childhood affects surgical prognosis more par- ticularly in the following ways: The intractability of spoiled children may so far interfere witli examination before and after operation and hinder the carry- ing out of necessary treatment as to affect seriously the prognosis of the case. The impressionability of the sensorium being considerably heightened, nervous shock is more common and the patient is more likely to be favorably or unfavor- ably affected by his environment. While confinement to bed may be considered a quasi-normal condition for the infant, it is not so for the older child, and chil- dren bear confinement to bed and even to the house very badly. The relative immunity of the infant to certain types of infection grows less in the older child, and we find bone disease more obdurate; the tendency to diseases of the upper air passages (adenoid growths, etc.), with their deleterious effects upon nutri- tion, very marked; and a characteristic vulnerability of the lymphatics. Still, as compared with infants, children, when these obstacles can be met and over- come, are good surgical patients, and, in view of their comparatively ready re- sponse to medication, give us perhaps, all things considered, the best prognostic showing of any age. The progressive increase of the child in stature brings with it, however, cer- tain surgical restrictions which must not be lost sight of. The growth of the long bones takes place at the epiphyseal cartilages, and these must be respected. Typical joint resections are therefore inadmissible in infancy and childhood, and amputations in continuity will almost invariably be followed by a conical stump ; while in bone disease involving the destruction of the epiphyseal cartilage, the prognosis as to the future development of the limb is distinctly bad. While the pathogenesis of lardaceous or amyloid disease is not sufficiently well determined to enable us to assert a connection with the vulnerability of the lymphatic system which we have noted as characteristic of childhood, yet the fact is observed that chronic debilitating diseases, and particularly chronic sup- purations, are prone to be followed by this sequel in childhood. (c) Adolescence. — Three factors influence general prognosis in adolescence. They are, first, a supreme impressionability of the sensorium, so that at this age the entourage of the patient acquires increased prognostic import; secondly, the liability to blood dyscrasige, especially secondary angemias; thirdly, a passing off of the relative immunity of infancy and childhood, so that diseases become more readily chronic, and chronic diseases, particularly bone diseases, exhibit a sometimes disheartening obstinacy. (d) Maturity.— In considering the prognostic import of age as bearmg upon patients in that period of life which we call maturity, full sexual development must be discounted in both sexes, and, with this, the liability of the patient to 776 .-UIERICAX PRACTICE OF SURGERY. chronic, perhaps concealed or unknown venereal mfection. Sexual excesses and abnormalities have also an effect upon general prognosis. It is in this period of life that cares, responsibilities, and burdens rest most hea^alj^ upon us, and con- sequent netirasthenia, actual or potential, is of marked prognostic import. Chronic gastric or intestinal catarrhs may so affect general bodily nutrition as to compromise gravelj' a prognosis otherwise good, and the so-called ''dyspep- sias" are most frequent in middle age. The diatheses rise from latencj- to ac- tivity diu-ing this period of life, and alcohol, morphine, tobacco, or other drugs may be exercising a chronic depressing influence upon the vitality of the patient. The exalted activity of the cellular processes of infancj^ has spent itself, and the middle-aged man or woman has lost the attendant relative immunity of the in- fant and the child, but carries perchance instead the burden of many conflicts with invasive micro-organisms, which, while won, may yet have left in the pa- tient depletion or debility as the price of \actor3^ (e) Senility. — Old age is the period when the various systems and processes of the economy begin to lose their normal balance, and atrophic and involutive processes give rise to certain characteristic conditions which are of prognostic significance. Of these perhaps the most important is the condition of the heart and of the blood-vessels, and the normal balance between their respective func- tions. We have seen how dependent upon a generous blood supplj* was the active cellular metabolism of infancy; scarceh' less sensitive to the abimdance and regularitj- of the blood supply are the tissues of the aged, in whom a con- stitutional condition bordering upon a d}'stroph3^ is to be expected, so that impau-ment of blood supph^ and disturbances of inner\^ation react similarly upon the infantile and upon the senile organism. It is on account of theu effect upon the nutritive processes of the senile tissues that chilling of the body dm-ing operations upon the aged must be scrupuloush^ avoided; and so likewise any rough handling of the tissues by ill-conducted manipulation. Special pains must be taken in the aged to avoid increasing the intravascular pressm-e, for fear of apoplectic accidents. Although the aged bear hemorrhage badly, the same absolute loss of blood in ounces, inasmuch as it bears a less proportion to the total body weight, will probably be less injurious than in the infant. On the other hand, the diminished elasticity of the senile vascular sj'stem allows capillary hemorrhage to continue longer than in j'ounger patients — a considera- tion of special moment in plastic operations and where large wounds are in question, with extensive flaps. The bronchial and pulmonarj* conditions of the aged have an important bearing on the prognosis of such cases as maj' requh'e a general antesthetic, be- cause the chronic bronchitis so prevalent in them, and the emphysema with which it is apt to be associated, are so readity exalted to the condition of bron- cho-pneumonia. The diminished impressionabilitj^ of the sensorimn in the aged is a factor GENERAL SUEGICAL PROGNOSIS. 777 favorable on the whole hi prognosis. It dimmishes the tendency to nervous shock, and it might even ui some cases allow operations ui the condition of semi- antesthesia, recognized to be so perilous in any but the extremes of life. Another characteristic senile change is of importance as regards surgical prognosis, viz., the atrophic condition of the skin. This affects seriously the chances of primary imion in operative cases, and retards greatly the healing of accidental abrasions, contusions, lacerations, and other traumata involving the cutaneous and subcutaneous tissues. Its bearing upon the prognosis of ex- tensive plastic operations in the aged is obvious. Old people do not bear well confinement in bed. The development of bed- sores is hard to prevent, and- they are of obstinate and often dangerous character when they occur. They are due to atrophy of the skin, to the absorption of the cushion of subcutaneous fat, to the degeneration of the blood-vessels, and to muscular debility preventing them from moving readily in the bed. Yet senility is meastned not alone by the years of the patient. Man has been said to be as old as his arteries, and the relative prognosis of a surgical' case in old age will depend upon the degree of senile involution presented by the patient. Senile affections of the heart, the blood-vessels, and the lungs are the most important. The aged offer but feeble resistance to microbial invasion, but under rigid asepsis modern surgery on aged subjects has furnished results surprisingly favor- able, particularly in the surgery of those pitiable sufferers from prostatic hyper- trophy, where ample drainage and careful asepsis have brightened the declining years of hundreds, whom a too timid distrust of the prognosis in surgical pro- cedure on the aged would have abandoned to the miseries of "catheter life." II. Sex. As suggested above, the sex of the patient concerns more closely the inci- dence than it does the prognosis of surgical diseases. Yet many surgeons are convinced of the greater powers of passive endurance in women. This, indeed, is in conformity with a tendency which nature shows in the females of other ani- mal species. A matter bearing weight in that direction, at least in this coimtry, is the less addiction of women to alcoholism and other excesses too readily in- dulged .in by men. To offset this is a proneness to chlorotic and anaemic condi- tions, which is more marked in women than in men. But to pass from indefinite tendencies to more specific matters, we have to consider for a moment the effect upon prognosis of the arbitrary neutralization of sex by castration. Unfortunately the data available on this point are few, and I cannot do much more than to call the reader's attention to this as a pos- sible factor in prognosis. Early castrates of either sex are rare. No statistics, so far as I know, are available as to the general powers of resistance of oopho- rectomized women as compared with those of their more forttmate sisters. 778 AMERICAN PRACTICE OF SURGERY. Though we are not considering the prognosis of the operation of castration per se, which belongs to the domain of special as opposed to that of general progno- sis, yet it is to be observed that the importance of the generative glands upon the general vital processes has been made strikingly evident since the studies provoked by Bro-mi-S^quard's experiments (with orchitic extracts), and more recently by the ill effects attending castration as a relief for "prostatism" at an age when the generative glands might be supposed to have but a diminished influence upon the general metabolism of the individual. What I have to offer further upon this subject of the relation of sex to sur- gical prognosis concerns exclusively the sexual functions of women — menstrua- tion, pregnancy, abortion, parturition, lactation, and the phenomena of the climacteric; and the consideration of these questions will lead us to adopt a reciprocal method of discussion, one to which we shall have frequent occasion to return in the course of this study, viz., the investigation, first, of the impres- sion of these several functions upon the course of surgical diseases; and then, reciprocall}', the impression exercised by surgical procedures upon these several functions. (a) Menstruation. — As to menstruation, if the old theorj^ of its being the re- sult of a general plethora had been true, it might have been conceived to have a favorable prognostic value with regard to the nutrition of the tissues in connec- tion with surgical operations ; as a matter of fact, however, menstruation, when normally performed, has but slight influence upon prognosis. This much, how- ever, may be admitted, that with normal menstruation it is not uncommon, in cases of critical illness, to see improvement apparently stimulated on the ap- pearance of the menstrual flow. It has been my habit, in operations of election upon women, to choose a time a few days after the close of the menstrual period, with a view of eliminating any possibly unfavorable effect of menstruation as a complication, till such a time as the patient might be expected to be beyond the critical stage of recov- ery ; and this in operations other than those upon the reproductive organs. In gynjecological operations proper this plan would seem to be the more entitled to consideration. On the other hand, with regard to the reciprocal effect of an operation per se upon the function of menstruation, this may be said: that the effect of a major extra-genital operation is variable and can hardly be predicted. It may hasten menstruation by a few days (perhaps the most common effect), or indeed pre- cipitate it immediately; it may retard its appearance by a few days or weeks, or indeed cause its suppression for one or more periods; or (as frequently hap- pens) it may not exert any traceable effect upon that fimction. (b) Pregnancy. — The question of pregnancy in its effect upon general sur- gical prognosis is as hard to estimate as that which we have just been consider- ing. In early pregnancy the intractable vomiting which this condition some- GENERAL SURGICAL PROGNOSIS. 779 times induces may be a factor of great importance. In advanced pregnancy the tendency to eclampsia merits consideration, particularly in primiparje, and so likewise the interference with proper respiration occasioned by the mass of the pregnant uterus in the abdomen. In operations upon the abdominal wall the severe strain upon the cicatrix must be borne in mind, especially in operations for ventral and imibilical hernia. Strangulation of inguinal and femoral hernige, due to the pressure of the gravid uterus, does not seem to occur with any such frequency as might a priori have been expected, especially when we consider the difficulty or even impos- sibility of retaining the hernia3 with a truss during the latter part of gestation. As to the effect of pregnancy upon neoplasms connected with the reproductive organs, whether the breasts or the pelvic organs, it is well kno'WTi to cause a great acceleration in their growth. Pregnancy occasionally will greatly retard the process of calcification in the healing of bony fractures, and it is said that newly healed fractures may even lose their recently deposited calcium salts upon the supervention of pregnancy. The disastrous effect of pregnancy upon osteo- malacia has been repeatedly observed. The debility arising from too frequently recurring pregnancy can best be considered as a phase of neurasthenia. The reciprocal of the cpestion of the effect of pregnancy upon surgical dis- eases is that of the effect of sm'gical diseases and operations upon pregnancy; that is, the likelihood of their producing abortion. Upon this question some interesting and instructive data are available, showing us the remarkable toler- ance exhibited by the pregnant titerus in the face of operative procediu'es of considerable magnitude, even when directed to the reproductive organs, to the immediate uterine appendages, and, mirabile dictu, to the uterus itself. Thus Gordon * relates the case of the removal of a sessile uterine fibroid, nearly as large as the uterus itself, done at the third month of pregnancy, with- out interrupting the pregnancy or apparently affecting delivery at the comple- tion of the period of gestation ; and Sylvester t removed, in the third month of pregnancy, a uterine fibroid, weighing eight and three-quarter pounds and hav- ing a pedicle two inches in diameter, with normal delivery of a living child at term. Breast amputations are related as late as the sixth and seventh month, also trachelorrhaphy; and one man J vouches for the dilatation of the internal os (sic) for the relief of hyperemesis, all without causing abortion or miscarriage. Oophorectomy has been repeatedly performed during pregnancy, and, according to A. P. Dudley,§ if it causes miscarriage it does so only by hemorrhage into the uterus, which on this account should be scrupulously guarded against. Yet the * Gordon: Trans. Maine Med. Assoc, 1889, vol. 10, pp. 99-104. t Sylvester: New England Med. Gazette (HomcEop.), Boston, 1890, vol. 25, p. 397. i Trans. Maine Med. Assoc, loc. cit. S Trans. Maine Med. Assoc, loc. dt. 7S0 .\3IERIC-\X PRACTICE OF SURGERY. fact remains that a considerable number of abortions do occm- after even extra- genital major operations, and that pehdc and abdominal operations are particu- larly likely to induce this accident. This may be due in part to the death of the foetus by intoxication from the anaesthetic rather than to the operation per se; hence the recommendation to elect ether in preference to chloroform in these cases, as being less noxious to the foetus. (c) Parturition. — The prognostic importance of parturition relates to its effect upon certain few smgical conditions, of which hernia on the one hand, and aneurisms and varices and certain ocular and cerebral conditions on the other hand, are perhaps the chief. Tliese have in common an intimate depend- ence upon the effects of the powerful contraction of the uterine and abdominal muscles, and the resultant intra-abdominal pressm^e, either directly, as in her- nia, or, as in the other conditions, through the effect of these voluntary and in- volvmtarj' musciolar contractions upon the blood pressm-e. In labor, as dming pregnancy, though tlie effect of these factors upon hernia must be regarded as unfavorable, j^et accidents of strangulation are very rarely reported in medical literatm-e. For anem-isms and varices, as well as the other ocular and intracranial conditions alluded to, the peril may be said to be directly proportional to the blood pressm-e, and maj- make the earty use of anaesthesia and the prompt resort to instrumental deliverj'^ imperative. It is the province of special prognosis to consider the outcome of the partmient act itself, and likewise to take cognizance of its effect upon the uterus and the perineum, which may or maj- not have been the seat of pre^dous plastic operations. (d) Lactation. — Lactation, except the effects of too prolonged lactation which are substantially those of neurasthenia, is of prognostic importance chiefly in proposed operations upon the breasts. Their marked increase of blood supply dm-ing this period makes the danger of troublesome hemorrhage somewhat greater. (e) The Climacteric. — As to the effects of the climacteric upon the general nervous system, they are likewise substantially those of neurasthenia, and but one important factor concerns us here, viz., the effect of the menopause upon neoplasms. The onlj- case in which its advent can be considered to have a favor- able effect is in that of uterine fibroids. In this case, while tmdoubtedly a con- siderable number of tumors of that class cease to be troublesome after the estab- lishment of the menopause, j^et this advantage is greatly offset bj' the tendency of these neoplasms, as, indeed, of many other forms of new growth, to imdergo malignant degeneration at this period of life. III. COXSTITUTIOX. In a certain sense the term "constitution" is the summation of all the ele- ments of our present studj-, as age, sex, disease, etc., are but factors making up the constitution of the individual. In a more limited sense, however, we may GENERAL SURGICAL PROGNOSIS. 781 consider the constitution of the individual to be that original fund of vitality and capacity to resist and overcome disease with which his temperament, his diathesis, his personal heredity, and his race have endowed him. (a) Temperament.— The consideration of temperament has so far gone out of fashion that even the terms in which it was discussed are now no longer com- prehended. The conception of the four principal temperaments— the sanguine, the nervous, the bilious, and the lymphatic— was doubtless the product of more or less fanciful reasoning upon erroneous data of the old humoral pathology. Nevertheless, there are certain mental, moral, and physical characteristics which present themselves in certain groups of individuals, and these, taken as a whole, have an appreciable influence upon such surgical diseases and conditions as may affect the members of that group. The sanguine temperament, fair- haired, blue-eyed, with energetic movements, may not in its pm-e type have a special prognostic coefficient of its own, yet it is possible to select, according to some more or less vague criterion, groups of individuals of whom, though they be all at the moment in equally good health, it will be possible to predicate that these, by temperament and constitution, have a better chance to recover than " have those from equally grave surgical diseases and conditions. In these, call their temperament sanguine or nervous, as you will, we can count upon the pa- tients to co-operate with the surgeon to achieve their own recovery — they make "good patients"; while in those it is recognized that, call their temperament what you will, bilious or lymphatic, the prognosis is relatively imfavorable, and they may succumb from sheer inability to summon the forces of recuperation. The first have warm extremities, active circulation, and energetic movements; the second have cold hands and feet, muddy or pale complexion, and sluggish movements. However vague these conceptions are, they have a certain undeni- able prognostic weight. (b) Diathesis. — The vagueness of our conception of temperament is slightly relieved when to it we add the likewise indefinite conception of diathesis. A proper mingling of temperament and diathesis gives us the well-recognized type known as the "habitus phthisicus." Now, though we are dealing with confess- edly shadowy and indefinite quantities when we discuss temperament and di- athesis, yet a little attention will bring to the fore one important rule of prog- nosis, to wit, where the incidence of disease corresponds to well-marked tempera- ment and diathesis, the prognosis is relatively unfavorable. For instance, the concurrence of surgical tuberculosis and the "habitus phthisicus" adds greatly to the gravity of the prognosis; the "dartrous" diathesis, coupled with the sanguine or the lymphatic temperament, together constitute a type in whom ulcerative processes will be found exceptionally obstinate ; those of bilious tem- perament and of the gouty diathesis will have calculous troubles of greater gravity than will members of the other groups, should the inciting factors of calculus formation present themselves. Yet ulcers heal kindly in those of the 782 AMERICAN PRACTICE OF SURGERY. phthisical habit ; those of the sanguine or the l3anphatic temperament and with a tendency to dartrous manifestations are less likely to have grave symptoms from calculi; and those of bilious or nervous temperament with a gout}' diath- esis are so far immune to tuberculosis that if it should establish itself the prog- nosis is far better than in those of the first group. Our modern knowledge of the role of micro-organisms in the causation of disease leads us to overlook much that was of value in the keen observations of our fathers. So much have microscopy and the so-called " laboratory methods" of diagnosis occupied the modern physicians, that little scientific study has been devoted to the analysis, deliniitation, and classification of diatheses. There is vaguely recognized by the profession of to-day a gouty (or arthritic or lith^pmic) diathesis, and the studies of Bouchard tend to group this and certain other morbid tendencies under the head of troubles due to defective oxygenation or hypometabolism. It seems to be acknowledged that the gouty diathesis is likely to entail upon its subjects arteriosclerosis and chronic nephritis, and these would have a decided prognostic significance in surgery, inasmuch as tempo- rary urinary inadequacy may easily be a sequel to anaesthesia or even to simple surgical shock. One other diathesis has acquired tolerably distinct recognition, viz., the neuropathic; and it is likewise possible to establish as a fairly distinct entity the obese diathesis. One important bearing of this latter upon surgical prognosis is with reference to its effect upon the heart, whose function may be greatly impeded by massy deposits of fat and by fatty infiltrations of the myo- cardium. A second consideration is the thickness of the subcutaneous pannic- ulus, with its heavy mass of tissue of low vitality, prone to suffer the invasion of pyogenic germs. A third is the possibility of fat embolism, when it is necessary to work in great adipose masses, e.g., in deligation of the omentum. In general, good bodily development, large bones, hard muscles, little fat, yet good body weight, and a history of freedom from previous disease — these are the indications of a good constitution, irrespective of temperament or diathesis. (c) Heredity. — Wlien we pass from the consideration of temperament and diathesis to that of heredity, Ave come upon a more stable footing, and, though the subject is one of infinite complication and dispute, yet certain facts are sufficiently clear to have a distinct bearing upon prognosis. For the most gen- eral of these facts concerning heredity we are indebted to the observations and records of life-insurance examiners, who have demonstrated the highly influ- ential distinction between long-lived families and short-lived families. The effect of this hereditary characteristic upon surgical prognosis is very obvious, and at the same time very considerable. Of secondary unportance m their influence upon surgical prognosis are syph- ilis, rheumatism, gout, tuberculosis, alcoholism, obesity, diabetes, nephritis, cancer, insanity, and epilepsy in the parents. Although the common effect of all these parental diseases is to impart to the offspring a weakened constitution. GENERAL SURGICAL PROGNOSIS. 783 yet bad heredity for one disease may not be bad heredity for all; e.g., a gouiy heredity is rather favorable than otherwise in the prognosis of surgical tuber- culosis. Heredity may determine, however, more than a mere feeble resistance to disease. It may determine a distinct locus minoris resistentice, stomach, liver, uterus, and skin showing respectively an inherited tendency to the localization of disease upon these particular organs. The heredity of malignant diseases may come under both these categories ; i.e., the transmission of the tendency to specific forms of disease, and the trans- mission of the tendency to the involvement of a particular organ. One question which suggests itself in this connection I am not able to answer for want of sta- tistics, viz., whether malignant disease shows an enhanced malignity in those predisposed by heredity as compared with those not so predisposed. We have stated it above as a law that the concurrence of temperament and diathesis with the incidence of disease is markedly unfavorable upon prognosis. When to this triad there is added a fourth factor, viz., heredity, the prognosis becomes still more unfavorable; as is illustrated in the case of tuberculosis, where, when this disease fastens upon one of the phthisical habit, a tuberculous family history adds appreciably to the gravity of the prognosis. The most patent illustration of the effect of heredity upon disease is seen in the case of hereditary hsemophilia, with its well-loiown transmission of hemor- rhagic tendency through the female line. (d) Race. — The simimation of hereditary influences is to be seen in the problems of race. Surgical prognosis in mulattoes, as indeed in most mixed races, is certainly relatively unfavorable. Concerning the African negroes of full blood, it may be affirmed that, at least in the savage state, their less highly developed nervous system renders them comparatively insensible to pain and shock. Bordier * is the authority for the statement that among the Yoloffs it is a not uncommon practice to rip the ab- domen open and handle the protruded bowels, with a view of testing the virtue of the "gri-gris" given by an itinerant marabout, and then return the exposed entrails into the abdominal cavity with apparent unconcern. This is surely con- vincmg not only of the lesser sensibility of these people to pain, but also indicates a greater immunity from the usual dangers of peritoneal infection. Similar facts can be quoted with regard to aboriginal tribes of this country, for instance, the Modocs. This combmation of circumstances— i.e., a naturally diminished pe- ripheral sensibility, coupled with a more passive condition of the mind— makes the negro a most favorable subject for all kinds of surgical treatment with or without preliminary anajsthesia. Similar testimony is offered by medical mis- sionaries concerning the Asiatics of the Pacific littoral. * Bordier, quoted in article by Matas on "Surgical Peculiarities of the Negro," in Dennis's "System of Surgery," vol. 4, p. 847. 784 AMERICAN PRACTICE OF SURGERY. The greater immunity formerly enjoyed by the negro in respect of certain diseases is rapidly disappearing, and he now not only shares the physical weak- nesses of the white race, as exliibited on this continent, but is rapidly developing previouslyunknown predispositions, which are increasing his general tribute to disease and death even to a more fatal degree than in the white race.* In one particular we must consider further the influence of race upon surgical prognosis, viz., with regard to plastic surgery in the negro. The racial tendency to keloid growths in cicatrices must always be borne in mind in planning operations of this description upon negro subjects. IV. Integrity of Organs and Functions. In considering the general prognosis of surgical diseases and conditions, great stress must be laid upon the integrity of organs and functions, and on the exist- ence of concomitant disease. This important factor meets us in all questions of surgical prognosis, whether we are considering treatment, or exploration, or the mere duration of life in a hopelessly compromised case. Evidently to consider this division of our subject with anything bordering on exhaustiveness would call for an elaborate review far exceeding the limits of our chapter, and we can touch here only on certain limited phases of the subject. Instead of taking up seriatim the maladies from which the surgical patient can suffer in any of his organs, I propose to consider but a few of these, and to consider them in their application, first, to anaesthesia, and secondly, to surgical operations proper, leaving the rest to be considered elsewhere in this work, under the special prog- nosis of the several surgical diseases, conditions, and procediu'es there discussed, or considering them to have received already sufficient general consideration in the pi'eceding paragraphs. The first part of the subject may perhaps be most simply considered in an attempt to answer the question. What morbid conditions render the administra- tion of a general anesthetic especially dangerous? while, for the second part, we shall attempt fo answer the question, What are the morbid conditions which especially enhance the dangers of surgical operations per set Some few ques- tions properly concerning general prognosis which do not come under this scheme we shall touch upon briefly at the close of this section. 1. What Morbid Conditions Render the Administration of a General An- aesthetic Especially Dangerous? — In many sm-gical procedures — indeed, it is safe to say in the majority of aseptic operations, major and minor — the chief danger to the patient lies in the administration of chloroform or ether for the purpose of ansesthetization. It is well known that certam diseases of the heart and blood-vessels, certain diseases of the kidneys, certain diseases of the lungs and bronchi, and certain morbid conditions of the nervous system render an- esthetization extra-hazardous. Let us examine these facts more closely. * Matas, loc. cit. GENERAL SURGICAL PROGNOSIS. 785 (o) Cardiac and Vascular Diseases. — The chief dangers in anaesthesia come from sinking of the blood pressure. The causes which occasion this are obviously three — acute hemorrhage, cardiac insufRciency, and general or extensive local vasomotor paresis. So obvious is the effect of acute hemorrhage that we need do no more than mention it. It is within the experience of every anaesthetist. With regard to cardiac insufficiency, it may be said that, contrary to earlier teaching, fully compensated vahailar heart disease is not so much to be dreaded by the anaesthetist as to call for anything more than a little extra care in the administration of the anaesthetic. Valvular disease with under-compensation is a condition of greater gravity, though, except in cases of aortic stenosis, the sit- uation is measurably relieved by the depletion afforded by the operative incision. The actual functionating of the organ is, after all, what counts, and a heart acutely dilated by overexertion, or constantly overstimulated by alcohol, or driven to undue frequency of rhythm by thyroidal or sympathetic disturb- ances, or weakened in its myocardiimi by the toxins of acute disease, presents perils for anaesthesia quite as considerable as those attending an obstructive or regurgitant lesion of the cardiac valves. It does not appear that mere cardiac arrhythmia, such as follows chronic abuse of coffee or tobacco, the "irritable heart" which causes so much distress and alarm to its subjects, is of great con- cern in the prognosis of anaesthesia, though it may well be that the well-recog- nized perils of semi-ana;sthesia, through its tendency to inco-ordination of the reflexes, are greater in those subject to these functional troubles of the heart. The most exquisite picture of general vasomotor paresis is seen in surgical shock, a condition in which general anaesthesia is imiversally recognized to be extremely perilous. The syncope of nervous women, the tendency to faint at the sight of blood or pain, and even a history of habitual syncope from slight causes are not, when unaccompanied by other evidences of cardiac or vascular disease, of great prognostic importance as far as concerns anaesthesia; and this because they are rather the expression of an tmduly impressionable sensorium than of a morbid vasomotor apparatus, and it is just the office of anaesthesia to abolish the sensorial impressionability, and thereby the dangers from this source are ipso facto eliminated. A much more miportant consideration is calcareous degeneration of the arteries, whereby they lose their ability to adapt their calibre to the varying demands of their blood content. (b) Renal Diseases.— Standing m an intimate and sometimes causal relation to the affections of the heart and blood-vessels are diseases of the kidneys, and, in connection with the prognosis of anesthesia, these must be considered in their reciprocal relation; i.e., both the effect of kichiey disease upon the cardio- vascular system during the comparatively brief period of surgical anaesthesia, and, per contra, the effects of anaesthetic drugs upon the diseased kidneys. It is 7S6 AJVIERICAN PRACTICE OF SITiGERY. lor lack of examination of this subject from these two points of view that we find such divergent and conflicting opuiions with regard to the relative safety of ether, chloroform, and other anaesthetic drugs. In considering the effect of chronic kidney disease upon the immediate prog- nosis of anesthesia, i.e., upon the liabilitj- of the patient to sudden death during or shorth' after the operation, we observe that the modus nocendi of chronic kid- ney disease is not through defective elimination of the ordinary urinar};- toxins, for even total suppression of renal function may contuiue some hours or days without fatally compromising the life of the individual ; nor yet in the defective elimmation by way of the kidneys of the ansesthetic which is being administered, as we have abimdant experimental proof that a large quota of its elimination is through other channels (hmgs, stomach) ; but rather through the direct effects of chronic nephritis upon the cardiac muscle and upon the walls and the vaso- motor apparatus of the arteries. The well-known chronic exaltation of blood pressure fatigues the hj'pertrophied and diseased heart, there is no reserve fund of cardiac strength to draw upon, and the adaptive function of the vasomotor apparatus is chronically inoperative; hence sudden death under either chloro- form or ether. Viewed from the opposite standpoint, we must consider the anesthetic m the line of an irritant drug, similar to tm-pentine or cantharides in its effect upon the diseased kidney. When proper weight is given to this aspect of the case, it is my opinion that the dogmatic claims regarding the superior safety of ether over chlorofrom must be revised. Ether may yield fewer cases of sudden death during or shortly after ansesthesia, but in the subjects of cardiac, vascular, and renal diseases it is probably answerable for a considerable proportion of those melancholy cases where we are told that "the operation was successful, but the patient died." (c) Diseases of the Respiratory Organs. — Concerniug the relation of diseases of the respiratory organs to the prognosis of surgical anaesthesia, we may be more brief, and we maj' summarize the situation by saying that in conditions of sub- acute and chronic inflammation of these organs, the irritant effect of anaesthetic drugs administered by inlialation must be accorded a considerable prognostic weight.* InsufHation pnemnonias are easih' induced and add largely to the peril of anaesthetization, especially when there is vomiting on the operating table. Particularly dangerous in this regard is the putrid and fecal vomit of obstruction to the alimentary' canal, whether acute or chronic. 2. What are the Morbid Conditions which Especially Enhance the Dangers of Surgical Operations " per se " ? — It will be seen that when we have disposed of those affections in which the dangers are chiefly from the ana?sthetic, we have * In the presence of latent bronchial and pulmonary inflammations, the possible advantages of the administration of ether or chloroform by the rectum might merit consideration, and so likewise the merits of "spinal anaesthesia" from subdural injections. GENERAL SURGICAL PROGNOSIS. 787 greatly limited the scope of our present inquiry; nevertheless, it will behoove us to pass briefly in review the diseases of the various organs, with particular refer- ence to their effect upon the prognosis of surgical operations per se. (a) Cardiac and Vascular Diseases.— With regard to the affections of the cir- culatory system, it may be said that valvular heart disease, especially if under- compensated, has a great effect upon the nutrition of the tissues, and interferes greatly with the capacity of the organism to protect itself against microbial invasion. On the other hand, once the operation is overpast, the rest in bed, which is demanded by the after-care of many surgical procedures, may act most favorably upon a cardiac lesion. Endarteritis is of prognostic importance, in that it compromises seriously the nutrition of the tissues. Its influence is most markedly unfavorable in the treatment of gangrene and aneurism. The pres- ence of phlebitis is of great moment, even if it does not affect directly the part to be operated upon, because it involves a possibility of extensive thrombosis, embolism, and, in the presence of sepsis, of pyaemia. .Marked hereditary hemophilia raises even the most trifling operations to a rank of extreme peril. (b) Renal Diseases. — Few surgeons will face with any satisfaction the neces- sity for operating upon parts oedematous from chronic renal disease; and this aside from the dangers connected with ana;sthesia, on account of the extreme liability of these oedematous tissues to pyogenic invasion. One weighty cotm- ter-indication to kidney operations must be borne in mind, viz., the possibility of the existence of but a single kidney (once in twenty-four hundred cases, Morris). (c) Diseases of the Respiratory Organs. — On the part of the respiratory or- gans, the connection between surgical tuberculosis and latent pulmonary phthisis is a prognostic factor of considerable moment. This is emphasized in cases of anal fistula. Careful consideration must be given to the functional capacity of the oppo- site side in all operations upon the dual organs of the body — kidneys, testicles, ovaries, special sense organs, etc. ; e.g., in the operation of thoracotomy the func- tional coefficient of the opposite half of the chest is of prime importance. Pulmonary embolism is an imtoward accident occasionally complicating even aseptic operations. It is particularly prone to follow upon pelvic operations, especially where there has been much bruising of the tissues or slight septic invasion. Either of these two factors gives occasion to extensive coagulation in the pelvic veins and sinuses, and the coagula may become detached and be swept along to the lungs in overwhelming masses. They may even prove in- stantly fatal by blocking the right side of the heart. Fat embolism is most conspicuously met with in the lungs, and gives rise to a distressing dyspnoea, lastmg until such time as the heart may be able to force through the pulmonary capillaries the embolic droplets of oil. Fat embolism 788 AMERICAN PRACTICE OF SURGERY. has been noted with relatively great frequency in the insane, as a sequel to mul- tiple contusions. It is not uncommon after extensive omental resections, but is most frequently noted alter fractures of the shaft of the long bones. The out- come of a case of fat embolism is chiefly dependent upon two factors — the amount of fat within the blood-vessels and the reseiwe power of the heart. (d) Nervous Diseases. — The degenerative diseases of the nerv^ous system have not much effect upon surgical prognosis, except those involving the anterior ganglia of the spinal nerve roots and transverse lesions of the spinal cord. In these the nutrition of the parts deriving their innervation from cord segments at or below the seat of the lesion is more or less compromised. Anterior polio- myelitis, locomotor ataxia, disseminated spmal sclerosis, and paralysis agitans do not of themselves seriously impair the outcome of such surgical treatment as may be demanded. Insanity, idiocy, and epilepsy do not greatly affect the prognosis of sm-gical treatment. As Mayo * tells us, the insane are entitled to just the same surgical treatment as the sane — no more, no less. The relative frequency of fat embo- lism m the insane has been noted above. With regard to the reciprocal effect of surgical operations upon the cerebral or mental lesion, there is little that can be stated definitely. Some few cases have been brought forward by Italian sm-geons to vindicate a traumatic origin for insanity, alleging that the neurosis was caused by a variety of surgical opera- tions; but when we examine the cases reported, we find that all the patients were strongly predisposed neuropathic subjects, with unfavorable environment, and that the operations either were upon the genital organs, or else occasioned some bodily disfigurement which gave the patient great annoyance. Yet just these conditions might evoke the neurosis in others, and the cautious surgeon might do well to bear this possibility m mind if called upon to operate in certain predisposed individuals. The effects of surgical operation upon the established neurosis are extremely problematical, and, while ernes have followed sm-gical relief of chronic peripheral irritants (pelvic and abdominal tumors, operations upon the male and female genitalia), yet, as Mayo advises, the criterion is not the probable effect upon the mental, but rather that upon the general somatic condition. In considering surgical prognosis with reference to the affections of the ner- vous system, we must take account of the subject of shock. "We have already discussed this matter with reference to the administration of the anjesthetic; we must now add a word with regard to the advisability of operative interven- tion per se. As we have already seen, shock manifests itself as a paresis of the vasomotor system. The chief danger is sinking of the blood pressure, owing, as we have said, to acute hemorrhage, to cardiac failm-e, or to vasomotor paresis. Tlie extremely bad prognosis in operations upon patients in shock is hardly due * Mayo: Med. Record, 1901, vol. 60, p. 173. GENERAL SURGICAL PROGNOSIS. 789 to the additional hemorrhage, because with modern methods of htemostasis this can, with sufficient care, be kept within very smaH limits; nor is it due to car- diac weakness strictiori sensu, because we may be dealing with a heart that is without valvular lesion, without toxic myocardial degeneration, and that may not have been fatigued by over-exactions of work. Aside, then, from the ques- tion of supporting the anesthetic, which we have already discussed elsewhere, inasmuch as we can put aside both additional hemorrhage and cardiac insuffi- ciency, in the stricter sense of that term, it follows that the problem of prognosis in conditions of shock hinges upon the ability of the vasomotor system to with- stand the additional irritation incident strictly to the further siu-gical manipula- tions, without having the vasomotor paresis deepen to complete vasomotor paralysis, which is death. For this reason full ether anesthesia will be safer than semi-angesthesia, especially than semi-ansesthesia with chloroform. It is the common consensus of railroad surgeons, who see the most cases of acute shock, that if hemorrhage has been arrested, and further irritation of the sensorium has been removed by keeping the patient at rest (with morphine if necessary) and protected from further loss of bodily heat, the prognosis is much improved by waiting for at least a partial subsidence of shock before undertaking any con- siderable surgical procedures. Neurasthenia is likewise a subject which demands reciprocal consideration. Of this question the first phase is the effect of neurasthenia upon the outcome of surgical conditions ; and the answer is that the effect is little or none, excepting in those types of neurasthenia which interfere with the general bodil}^ nutrition. To the second phase of this question, to wit, the effect of surgery upon the neurasthenia, it is very difficult to give a satisfactory answer. If the surgical operation removes an irritant antedating in its history the onset of the neuras- thenia, and one which may be deemed to be the cause of the neurasthenic condi- tion {e.g., chronic appendicitis, uterine or permeal lacerations, chronic prosta- titis), a good effect upon the neurasthenia may be expected from the operation. If the surgical troubles do not stand m a causal relation to the neurasthenia, the effect of operation per se may be to deepen, rather than to relieve, the neuras- thenia; yet it should be remembered that by skilful suggestion on the part of the physician he may array the powerful impression of a surgical operation upon the imagination of a suggestible patient, among the forces working for, rather than against, recovery from the neurasthenia. It is in so far as they in- duce in the subject oftentimes a quasi-physiological condition of neurasthenia, that menstruation, pregnancy, and the menopause may affect surgical progno- sis. Too frequently repeated pregnancy and too prolonged suckling act in the same way. Emotional conditions are not without their bearing, as is seen in the com- parative mortality of the wounded among the victors and among the vanquished . on the battlefield. 790 AMERICAN PRACTICE OF SURGERY. The effect of over-fatigue, exliaustion, exposure, and hunger is obviously unfavorable. (e) Diseases of the Alimentary Tract. — A condition of the alimentary tract most unfavorable to surgical prognosis is one where, owing to either motor or secretory distui'bances, that condition is developed which has been crudely called "stercorsemia," inasmuch as it magnifies the inevitable post-operative discomforts and disturbances to a degree which may become very serious ; vom- iting, headache, meteorism, obstinate constipation, and colic are bugbears of the abdominal sm-geon, and have a direct connection with intestinal putrefaction and absorption. On this account a certain degree of gravity attends all opera- tions done without preliminary evacuation of the alimentarj^ canal; and this explains in considerable measure the high mortality from strangulated hernia and other forms of mechanical obstruction of the intestines. Mere obstipation — that is, the loading of the bowel with large masses of hardened faeces — is of less unfavorable moment than the presence within the intestines of a much less considerable amount of fecal material in a softer and more fluid condition, per- mitting the more ready absorption of toxins generated by intestinal putrefaction. When to the products of the general putrefaction of the intestinal contents are added the specific toxms of disease, a condition which is conspicuously pres- ent in typhoid fever, the gravity of the prognosis, when operative intervention becomes imperative, is undoubtedly greatly increased. Yet surgery has recently been invoked with considerable frequency for the repair of intestinal perfora- tions in typhoid fever, and with a success which has been on the whole gratify- ing. Gesselewitsch and Wanach * collected reports of 63 operations with 11 recoveries. The most recent reports show a slightl}'' better percentage. In considering lesions of the liver in their relation to surgical prognosis, it is important to bear in mind the difficulty attending upon a proper hfemostasis in cases of cholsemia, on accoimt of the deficient coagulability of the blood. So considerable is the danger of hemorrhage from this cause that, where it is pos- sible, operations not of the greatest urgency should be postponed until after the subsidence of the cholsemia, or until the exliibition of calcium chloride or other suitable drugs shall have demonstrated a fairly satisfactory rapidity of coagula- tion upon suitable tests. In obstructions of the common duct the likelUiood of the supervention of acute hemorrhagic pancreatitis and fat necrosis is an important prognostic ele- ment. In estimating the prognosis in any disease of the chylopoietic system, the determination of the stage, in what may be called the "biliary sequence," in which the patient under consideration may find himself, is an important prog- nostic moment; that is, his chances, if he be suffering from cholecystitis, of having this develop a cholelithiasis, and this in turn an obstructive cholangitis, * Quoted in von Bergmann and Bull's "System of Practical Surgerj'," vol. iv., p. 319, New York, 1904. GENERAL SUEGICAL PROGNOSIS. 791 whence perihepatitis, pancreatitis, and, eventually, pancreatic diabetes. In questions of this kind the familj' history acquires great prognostic importance. In a family in which there may have been several diabetics, the earlier stages in the "biliary sequence" have a less favorable prognosis than when occurrmg in families not so predisposed. (/) Diseases of the Ductless Glands. — The danger in operating upon those who are the subjects of Graves' disease seems to come principally from the side of the heart. Aside from thyroidectomy and other operations directed specifically toward the cure of the disease itself, the special prognosis of which operations will be discussed elsewhere in this work, the warm extremities of sufferers from Graves' disease, due as they are to wide vascular dilatation and a rapidly flowing blood stream, are an indication of conditions favorable for the repair of the tissues, if only the heart be able to sustain the depression due to anaesthesia and the shock incident to operation. In myxoedema, on the other hand, while the danger from the side of the heart is less, the condition of the tissues is less favorable for the repair of travuna and for resistance to microbial invasion. (g) Diseases of the Blood. — In considering the bearing of the condition of the blood upon surgical prognosis, we touch upon a theme that will be handled more fully elsewhere in this work under the head of surgical hsematology (see page 555). The simple question of hfemoglobin percentage has an important bear- ing upon prognosis, especially with regard to cases which it is proposed to sub- mit to operation. For weighty observations on this point we are specially indebted to von Mikulicz. He has studied m patients, in whom conditions were otherwise favorable, but who had suffered considerable loss of blood by acute hemorrhage, the length of time necessary for the restoration of the blood mass, and he finds a period of from two to five days necessary for its restora- tion where less than one per cent of the blood in the body has been lost; while, with a loss of between three and four per cent of the blood m the body, from fourteen to thirty days are required to make good the loss of blood. These are more or less fixed data which will govern the prognosis for operations upon otherwise normal healthy individuals. A pre-existmg ansemia, indicating a deficient hematopoietic function, will add greatly to the periods of time neces- sary for blood regeneration; and, according to von Mikulicz, a hsemoglobm per- centage below 30 is a positive coimter-indication to operation, until medical treatment shall have enriched the blood to at least this critical minimum. Aside from the questions of blood mass and hajmoglobin percentage, the new science of htematocytology has brought for our use many facts bearing directly upon general si_u-gical prognosis. They can be but briefly alluded to here. The red-cell coimt is of great prognostic importance, and a diminution to anything below 3,500,000 must be considered to compromise the prognosis most seriously in all cases not due to acute hemorrhage. 792 AMERICAN PRACTICE OF SURGERY. Leaving for proper treatment elsewhere the interpretation of differential blood counts, we may mention here, because of its direct bearing upon our sub- ject, the salient points in which leucocytosis indicates the prognosis in surgical cases, and especially in pyogenic processes. 1. The degree of leucocytosis is independent of the amount of pus. 2. An increasing leucocytosis points to a spreading pyogenic process. 3. The absence of leucocytosis in the undoubted presence of pus indicates : (a) That the pus has become sterile, owing to the death of the invading bac- teria. (/S) That the pus has been thoroughly walled off by granulation tissue. (r) That the case is of the "fulminating type," and of such virulent onset that a prophylactic chemotaxis has not established itself. The slow coagulation of the blood in cholgemia and the prognostic importance of hereditary haemophilia have already been alluded to. {h) Acute Infectious Diseases. — The presence of acute infectious disease will undoubtedly counter-indicate any but the most urgent surgery. Particular stress should be laid upon measles, on account of the increased danger in antes- thesia, owing to the accompanying bronchitis; scarlet fever, on account of its intimate relation with erysipelas ; smallpox and even cliickenpox, on account of the pustular character of the eruption; and diphtheria, on account of the ex- treme probability of local wound infection. In addition to these, pertussis, be- sides the danger to the lungs from the anaesthetic, is particularly dangerous in abdominal surgery, on account of the impossibility of securing rest to the ab- dominal walls. Grippe, furthermore, is a great foe to the surgeon, as it renders its subjects particularly vulnerable to the attack of pyogenic germs. Some striking examples of this have been observed and reported by Bennett.* (i) Constitutional Diseases. — The diseases of metabolism, so-called constitu- tional diseases, which particularly concern the surgeon, are four — rickets, syph- ilis, gout, and diabetes. The relation of rickets to general prognosis is simply that of malnutrition in general, the prognosis of the specific bone lesions of rick- ets being properly a part of special prognosis. When bodily nutrition is other- wise good, wounds, so far as my observation goes, heal as well in rickety sub- jects as in others. Syphilis, if recognized and if met by suitable internal medication, need not deter the surgeon from such operative measures as may be deemed advisable; if unrecognized and untreated, it may hinder seriously the powers of repair, and operation wounds may prove to be a locus minoris resistentice, upon which a gummatous process may become engrafted with disastrous results. The con- sideration of the outcome of the surgical treatment of specific syphilitic lesions (gummata, etc.) lies in the field of special rather than in that of general prognosis. * W. H. Bennett: "Brief Notes of Some Cases of Pyjemia and Suppuration, Apparently Due to the Prevailing Epidemic of Influenza," Lancet, Lond., 1890, i., p. 200. GENERAL SURGICAL PROGNOSIS. . 793 Gout has its chief surgical interest in two points: first, the vulnerability of its subjects in presence of microbial invasion; and, secondly, the probable exist- ence of gouty nephritis, not distinguishable in its symptomatology nor in its prognostic importance from other forms of chronic nephritis. Of very special interest to the surgeon, on the other hand, is diabetes. The disastrous effects of surgical operations upon diabetics have led some to the ab- solute proscription of all operations in the presence of this disease. This extreme position we cannot, however, maintain, and it behooves us to consider this ques- tion, as we have several others that we have met, in its reciprocal relations: that is, first. What is the effect of diabetes upon surgical procedures and condi- tions? and, secondly. What is the effect of surgical procedures upon the diabetes? The first question ranges itself in a class strictly parallel with other chronic dyscrasige, such as gout, syphilis, or chronic alcoholism; and acute dyscrasise, such as scurvy and the toxaemias of acute disease, in that diabetes causes a very greatly increased vulnerability of the tissues and renders them particularly sus- ceptible to the invasion and development of pyogenic germs. Thus furuncles, carbuncles, and other phlegmonous and gangrenous processes will follow upon slight infection. Operations especially dangerous in diabetics are those, like circumcision for diabetic balano-posthitis, where rigid asepsis is difficult or im- possible. The low resistance of the tissues in diabetics is, furthermore, influ- enced by the chronic endarteritis which this disease induces. The other phase of this question, viz., the effect of surgical procedures upon the diabetic process, bears a still more forbidding aspect, and diabetic coma looms as a dreadful spectre before the surgeon called upon to operate upon dia- betic patients, and the difficulty is to find a proper criterion by which to judge of those in whom coma is likely to develop. There is no one factor that will serve to guide us, and our chief dependence must be in the summation of the different evidences of grave diabetes. Of these, the age of the patient has considerable weight; the more advanced age being in this case more favorable as regards prognosis, inasmuch as "dia- betes gravior" appears more frequently in the young, and "diabetes mitior" more frequently in the aged. The absence of the patellar reflex, though it is not conclusive evidence of a grave diabetic condition, yet must be considered an unfavorable symptom. The coexistence of albuminuria and glycosuria, and more particularly the substitution of albuminuria for a pre-existing glycosuria, are of great importance. Cachexia and emaciation do not seem to have as much weight as might be supposed, apparently well-nourished individuals of vigorous appearance succumbing as rapidly as others. Sufficient recorded observations are not available to enable us to judge as to the prognostic value of heredity in diabetes— that is, whether a diabetic patient, a member of a diabetic family, is more liable to post-operative accidents than is, cceteris paribus, a diabetic patient not so related; nor do recorded observations throw any light as to the liability 794 AMERICAN PRACTICE OF SURGERY. to post-operative accidents of diabetics whose diabetes comes as the concluding member of the "biliary sequence," as compared with those whose diabetes has had no antecedent cholelithiasis, biliary stasis, and chronic pancreatitis. Both of these points, however, merit consideration. When we consider the characteristic urinary excreta of diabetics, we can dispose of the polyuria and of the amoimt of sugar as not in themselves con- clusive, though their behavior under appropriate dietary and medicinal treat- ment is of some prognostic weight. The other characteristic excreta are acetone, aceto-acetic (diacetic) acid, and beta-oxybutyric acid. It seems, from chemical grounds, reasonable to suppose that beta-oxybutyric acid is the first of these to be formed in cases of beginning diabetic "acidosis," and that, when the disturbance of metabolism is not too severe, this is further oxidized to aceto-acetic acid, and then to acetone and car- bonic acid. With further disturbance of metabolism, the oxidation does not proceed beyond the stage of diacetic acid, which accordingly is found in the urine; while, with still further metabolic disturbance, beta-oxybutyric acid ap- pears in that secretion unchanged. Acetone, diacetic acid, and beta-oxybutyric acid in the urine are of successively important prognostic significance when it is proposed to attempt surgery upon diabetic subjects. The appearance of aceto-acetic acid and of beta-oxybutyric acid in the urine (also other acids, sethylidene lactic acid, alpha-oxypropionic acid, and transitory fatty acids found in the urine of diabetics) is the sign of beginning acidosis, and manifests itself by an increase of the excretion of ammonium in the urine, in that the acids which appear in the blood are combined with ammonium.* A quantitative estimate of ammonium in the urine might, therefore, be of prog- nostic value. The method recently suggested by Folin f is not too elaborate for clinical use in an important case. The simple examination of cover-glass preparations of the blood for free fat droplets t would also suggest itself as a reasonable precaution. Great increase in the normal fat content of the blood (0.75-0.85 per cent) is characteristic of severe diabetes, in which amounts varying from 1.276 per cent to 11.7 per cent have been encountered. In such cases fat embolism may be found post mortem, plugging the vessels of various organs, notably the brain, the lungs, and the kidneys; and this fat embolism may account for many of the untoward post- operative accidents in diabetes. The preliminary dyspnoea which ushers in dia- betic coma is probably due to this cause. To sum up, a careful surgeon, before undertaking operation upon a diabetic subject, would do well to make the following preliminary investigations : 1, The * Leube: "Medical Diagnosis," New York, 1904, p. 828. t O. Folin: Zeitschr. f. physiol. Chem., vol. xxxii., p. 575; found also in Simon's "Clinical Diagnosis," Phila., 1902. } Simon: Op. cit., p. 56. GENERAL SURGICAL PROGNOSIS. 795 age of the patient; 2, the heredity; 3, the history of previous bihary trouble; 4, the condition of the patellar reflex; 5, an examination of the blood for excess of free fat; 6, the presence of albuminuria; 7, the behavior of the polyuria and the glycosuria vmder appropriate treatment; 8, the determination of acetone, diacetic acid, and beta-oxybutyric acid; 9, if any one of these three substances is found in the urine, a determination of the total ammonium excretion. (k) Concomitant Pyogenic Disease. — Another matter calling for consideration before undertaking surgical operations is the possibility of the existence of a latent and concealed nidus of pyogenic infection outside of the field of operation, as such a smouldering process may be greatly quickened by operative manipu- lations even at some distance from such a focus, and may induce septicaemia or pyaemia, in spite of a faultless operative technique. Chronic encysted foci of osteomyelitis, and chronic but quiescent cholangitis, are particularly liable to take on such imtoward activity; but perhaps the most conspicuous case of all is when virulent pelvic inflammation develops after a simple uterine curettmg, done in the presence of a quiescent pyosalpLnx. 3. Special Disease Conditions Bearing upon General Prognosis.— Inasmuch as it is well recognized that the preliminary stages of anaesthesia — what with the struggling of the stage of excitement, and the spastic closure of the lips and glottis, and the vomiting — are often attended by a temporary rise in the blood pressure, it is well to notice in this connection certain conditions already alluded to in considering the prognostic importance of parturition, where this rise of blood pressure might occasion rupture or harmful distention of the blood-ves- sels. The principal conditions in this category are aneurisms, varices, and some intracranial affections. In the operations of cataract extraction and even simple iridectomy, the possibility of collapse of the ocular globe and escape of the vitre- ous humor through the wound must be borne in mind. Struggling of the patient during preliminary anaesthesia may greatly affect the prognosis in the case of certain thin-walled abscesses and cysts, which may burst and carry their infec- tious contents into the great serous cavities. v. Environment. Under the head of environment we must consider not only the literal mate- rial objects surrounding the patient, but we must use the term in its wider sense, so as to cover the relation established between the individual and external ob- jects, so that we may, as already suggested, include in our study of environment his occupation, his food, the climatic conditions under which he lives, his ability to create about himself hygienic conditions, and his disposition through habit or training to observe the laws of hygienic living. Yet first, in the more restricted sense of the word "environment," we should consider such questions as the prognosis in emergency or field surgery as com- 796 AMERICAN PRACTICE OF SURGERY. pared with the prognosis under liospital surromidings ; evidently manj^ cases of good prognosis under hospital conditions would have a less favorable prognosis on the battle-field or in the railroad wreck. But, on the other hand, even a well- appointed hospital is not without its own proper disadvantages ; for instance, a succession of cases of tetanus or of erysipelas occurring in a certain operating- room or hospital ward may most unfavorably affect the prognosis in a whole group of cases. Other things being equal, so far as the material surroundings of the patient are concerned, the best prognosis should obtain in the private homes of reasonably well-to-do people. Under this head of environment belongs the consideration of the social and economic status of the patient, his ability to secure good food, sufficient protec- tion, proper attention to his wants, freedom from worry and excitement — all of which may cast the balance favorably or unfavorably as regards recovery, and should, in not a few instances, determine for us the therapeutic measures to be adopted. Some social circumstances justify risks which other social circum- stances would not justify. To a typesetter or a pianist the loss of a finger joint would mean much more than to a laborer; and for a poor man with a large family, the amputation of a leg, with prompt recovery, might be a far less seri- ous disaster than conservation of the limb after months of hospitalization and invalidism. An artificial anus or a permanent gastric or urinary fistula are hor- rible afflictions where cleanliness cannot be counted upon, yet they may afford months or years of comparatively comfortable living to those who can be prop- erly waited upon or who imderstand and habitually practise a rational personal hygiene. In female patients of means and leisure, pelvic operations may be in- definitely postponed, when rest and luxury are available to mitigate surgical conditions which the harder life of less prosperous patients would make un- bearable. The personal habits of the patient bear most decidedly on prognosis. Sloth, gormandizing, sexual excesses and perversions, inordinate use of tobacco, or other stimulants or narcotics are prognostic factors of great weight. Chronic alcoholism is perhaps the one factor most generally inimical to the recovery of surgical patients in hospital practice, on account of the depraved nutrition of the tissues and their consequent low powers of resistance; on account of the dis- eased liver, kidneys, and blood-vessels of chronic inebriates; on account of the over-stimulated and unresponsive heart ; and, lastly, on account of the liability to delirium tremens. A reliable criterion by which to gauge the likelihood of the supervention of delirium tremens is nearly as difficult to establish as is a criterion for estimating the probability of diabetic coma, yet I have endeavored to assemble below the points which would seem to me to indicate special liabil- ity to this accident. They are : 1. The age of the patient, or, rather, the length of time that he has indulged the drinking habit. GENERAL SURGICAL PROGNOSIS. 797 2. The occupation of the patient. This is parallel to the "moral risk" of the life-insurance actuaries, as it gauges more or less accurately the drinking habits of the patient. Proscribed occupations are liquor-dealers, wholesale or retail; drummers for such; bartenders and other employees in breweries, distilleries, and saloons; hotel-keepers, etc. 3. The acknowledged drinking habits of the patient. Habitual drinkers who are never "drunk" are worse subjects than are periodical drunkards, save when the latter present themselves for surgical treatment at the close of a severe spree. 4. Loss of the knee-jerk is observed in the quiet stage of alcoholism. It in- dicates a considerable degree of toxaemia and is of unfavorable prognostic sig- nificance. An exaggerated knee-jerk is seen in the stage of excitement, and, if accompanied by alcoholic tremor, it is still more unfavorable than is loss of the knee-jerk. 5. The well-known tremor of the hands is most unfavorable. 6. Alcoholic gastritis indicated by morning vomiting, anorexia, and inability to retain or digest food. 7. Starvation and exposure. 8. The combination of alcoholism with any demonstrable organic lesion of the liver, lungs, or the kidneys; or any constitutional disease, such as antemia, gout, or diabetes; or any acute infectious disease, such as malaria or influenza. A final factor to be considered is climate. A tropical climate is depressing to those not habituated to it and to those who have not learned or will not practise a reasonable tropical hygiene. In such subjects surgical operations have an additional element of peril, which can be greatly reduced by removal for opera- tion to the temperate zones. The prognosis of many surgical diseases of the upper respiratory passages and of the thorax, and of many surgical affections of the urinary organs, is most favorably influenced by a dry and equable climate. The effect of sunshine and open-air life is no less marked upon surgical tubercu- losis than it is upon those tuberculous affections of the lungs and other mternal organs which come more especially xmder the care of the physician. INDEX Abdomen, inspection of, for diagnosis, 514 Abdominal aorta, diagnostic significance of pulsation in, 531 cavity, surgery of, 62 Abscess, definition of the term, 121 formation of, 121, 416 Abscesses, 128 acute, 254 burrowing, 14] cold or chronic, 141, 255 congestive, 141 embolic, 128, 129 external discharge of dead material from, 233 healing of, 103 metastatic, 129 miliary, 129 Absorbable sutures, 728 Acetone in the urine of diabetics an unfavor- able prognostic sign, 794 Acidosis in diabetic patients, 794 Acromegaly, x-Ta,y features of, 685 Actinomycosis leads to ulceration, 227 Actual cautery as a sterilizing agent, 710 Adami, J. G.; Classification of tumors, 297 Adeno-carcinoma, 346, 356 primary, in mice, 390 Adeno-fibroma, 304, 346 Adenoma, 345 alveolar, 345 its relations to glandular hyperplasia, 349 its transition to malignancy, 350 malignum or carcinomatosura, 350 of breast, 346 of kidney, 346 of prostate, 348 of suprarenal capsule, 347 of testis, 348 of thyroid, 347 of uterus, 349 papuliferous, 345 tubular, 345 Adeno-sarcoma, or cystadeno-sarcoma, 348 Adhesive plaster, 736 after abdominal operations and for ab- dominal support, 737 in closure of wounds, 738 Adrenalin in treatment of shock, 494, 495 Age as influencing diagnosis, 507 influence of, upon prognosis in surgical diseases, 772 Aged, operations upon the, 776 Agglutination thrombi, 85 Agglutinin and its action, 417 Agnew, D. Hayes, 19 Air as a source of infection, 698 Albuminuria, 568 surgical importance of, when due to pres- ence of blood in the urine, 569 Alcohol as an accessory hand disinfectant, 707 Alexin action of, 418 Alimentary tract, disorders of, in tlieir rela- tion to surgical prognosis, 790 American practice of surgery, characteristics of, 39 Ammonium excretion, total, determination of, in diabetic patients, 795 Amputation neuroma, 289 of limbs, 46 Amyloid, 194, 195 appearance of organs affected by, 196 diseases in which it is frequently found, 195 experimentally produced, 195 views of von Recklinghausen and Czerny in regard to sources of, 195 Amyloid transformation, a result of prolonged suppuration, 255 Anaemia, 234, 238 circumscribed, 239 collateral, 239 pernicious, blood-counts in, 241 from hemorrhage, 245 primary, 240, 241 secondary, 240, 244 Anaemic necrosis or infarction, 239 Anaesthesia, 63 first operation under, 63 its relation to surgical shock, 479 to facilitate diagnosis, 553 moral, 489 used for diagnostic examination, 553 Anaesthetics, administration of— circumstances under which it is especially dangerous. 784 irritant effects of, upon certain diseases, 786 800 INDEX. Anasarca, definition of, 236 Anatomical appearances as diagnostic factors, 513 Aneurism, Hunter's principles of treatment of, 39 operations for, by Wright Post, 40 traumatic, after organization of clot, 2SS Angioma, 319 arteriale racemosum, 321 fissural, 321 neuropathic, 321 senile, 321 simple hj'pertrophic, 320 Thoma's views of its etiologj', 322 traumatism a cause of, 321 Angio-sarcoma, 320, 333, 338, 340, 344 endothelial, 323, 340 perithelial, 323, 340 plexiform, 340 Ankle-clonus in diagnosis, 539 Ankle joint, radiographic study of epiphyseal development about it, 596 Ankylosis, x-rays in diagnosis of, 687 Annam ulcer, 231 Anthraeosis, 207 Antisepsis, 66 .■Antiseptic and aseptic, as discriminated in sur- gerj', 695 Antiseptic surgery, its meaning as used by Lister, 695 Antiseptics, definition of, 695 Antitoxin, its bactericidal action, 418 Ajjpendicitis, time when operative treatment was introduced, 58 Appendix vermiformis, removal of, by Thomas G. Morton, 58 statistics of diseases of, by George Lewis. 58 Argyria, 207 Arteries, "end" or "terminal," their relation to infarctions, 239 ligature of, in treatment of acute simple inflammation, 114 Arteriohths, 200 Arthritis, chronic non-tuberculous, i-av ap- pearances of, 656 Ascites, definition of, 236 Aseptic closed wounds, repair of, 261 open wounds or ulcers, repair of, 268 protection of the wound, 273 surgerj', the meaning of the term, 695 Astrocytes, derivation of, 325 Atrophia lipomatosa, 166 musculorum lipomatosa, 171 pigmentosa, 165 Atrophy, 163 as it affects certain tissues and organs, 170 brown, 171 Atrophy, caused by severance of nerve trunk, 178 degenerative, 164 discriminated from agenesia, aplasia, and hjfpoplasia, 164 from impaired nutrition, 168 from inactivity or disuse, 167 from over-activity, 167 from pressure, 168 marantic, 168 neurotrophic, 170 nutritive disorders leading to, 165 pathological, 167 phj'siological. 166 with induration, cause of, 165 Auto-intoxication exciting clironic inflam- mations, 139 Axonal reaction of Jvissl, after injury of peri- pheral nerve, 289 Babinski's reflex, diagnostic significance of, 540 Bacillus aiJrogenes capsulatus the cause of, gas-forming inflammations, 131 pyocyaneus the cause of green or blue pus, 418 Bacon, Leonard Woolsey, Jr., on general prog- nosis in surgical diseases, 771 Bacteria in the formation of pus, 253 passage of, through sound mucous mem- branes, 416 their sources and portals of entrance in surgical infections, 697 Bacterisemia, how produced, 426 in inflammation, 96 Bacterial e.xamination of blood, its utility and the necessarj' precautions, 559 infection as influenced by wound or oper- ative conditions, 701 infection, pathological changes following, 415 injury to tissues, how caused, 417 proteins and toxalbumins, their produc- tion, 417 Bactericidal agencies, sources of, 89 Bacteriolysin and its action, 417 Behla, x-bodies of, 388 BeUe\'ue Hospital Jledical College, when organized, 30 Benign and malignant growths of epithelial and connective tissue, types of. 296 Beta-oxybutyric acid in the urine of diabetics an unfavorable prognostic sign, 794 BicMoride of mercury, its use and properties as a disinfectant of the hands, 706 Bigelow, Henrj' J., 20, 50, 53 Birth-mark, 320 Bladder, diagnosis of rupture of, 550 INDEX. 801 Bladder, modes of diagnostic examination of, 551 Blastomata, 366 Blebs, 116 purulent, definition of the term, 121 Bleeding in treatment of acute simple inflam- mation, 114 Blennorrhoea, definition of the term, 121 Blisters, 116 treatment of, 117 Blood, the, 240, 555 alterations of, 240 changes in, in chronic anaemia, 245 characteristics of, in secondary anaemias, 244 diseases of, in their relation to surgical conditions, 791 in the stools, its varied appearance and sources, 572 in the urine, its significance, 571 regeneration of, after hemorrhage, 245 simple tests of, as to clot formation, fibrin formation, etc., 556 Blood corpuscles, changes in, 240 Blood examinations in differential diagnosis of primary and secondary anaemia, 557 methods found most important, 55S should be made regularly and charted, 558 Bloodgood, Joseph C, 463 Blood plates, their relation to surgical diseases, 559 Bloodless surgery, 750 Blood pressure in relation to diagnosis, 533 in shock, 468 Blood supply, regulation of, in wounds, 274 Blood-vessels, asepsis in lateral wounds of, 288 conditions modifying modes of repair in, 287 diagnostic significance of abnormalities in, 531 repair of, 287 Body fluids in general surgical disease, with special reference to their diagnostic value, 555 Boils, 128, 129 Bone, abscess of, treated by trephining, 59 caries of, 232 minute anatomy of, 279 regeneration of, 285, 286 Bone atrophy, 172 concentric, 173 excentric, 173 in ''calcareous diathesis," 174 marantic form of, 173 pressure form of, giving '' egg-shell crackle," 174 x-ray diagnosis of, 687 Bone blisters, Codman's, as seen by aid of x-rays, 665 Bone gummata, as seen by aid of x-rays, 668 Bone necrosis, 220, 222 and caries differentiated, 220 etiology of, 220 formation of involucrum, 222 from phosphorus, 221 from traumatism, 221 Bone tumors, x-ray characteristics of, 673 ■ Bones, development of, 280 extrinsic hypertrophy of, with increase in length from mechanical and chemical irritants, 161 membranous, 280 Bony callus formed iiia cartilage, 282 union, causes of failure to secure it, 284 Bowels, overloading of, in their relation to surgical prognosis, 790 Brainard, Daniel, 27 Brain sand or psammoma, 200 Brain, senile atrophy of, 177 Brashear, Walter, 60 Breast, amputation of, during pregnancy, 779 tumors of, in mice, their infectious factors, 393 Broncholiths, 200 Brooks, Harlow, 555 Brown induration resulting from passive con- gestion, 236 Bryant, Joseph D., 501 Buck, Gurdon, 52 Bullae, purulent — definition of the term, 121 Bumstead, Freeman J., 37 Buried sutures; the requirements answered by catgut, 730 Calcareous matter, deposits of, seen by aid of x-rays, 687 Calcification and analogous conditions, 198 and petrifaction contradistinguished from ossification, 200 chemico-vital theories as to its origin, 199 usually occurs in tissues already diseased or the seat of foreign bodies, 199 Calculi or concretions, 200 fecal, 203 hepatic, 200 pancreatic, 203 salivary, 203 urinary, 200, 203 Callus, disappearance of, 282 external, as related to the position of the fractured ends of bone, 284 external, its earliest stage, 281 internal or myelogenous, 281 proportioned to deformity, 285 802 INDEX. Cancer and the acute exanthemata, 388, 389 characteristics of the unknown stimulus in, 403 general arguments in favor of its infec- tious nature, 390 inclusions in, 387, 389 in mice, evidence of an acquired immu- nity, 399 in mice, its communicability, 391 in mice, its spontaneous retrogression, 398 parasitical relations of, 387, 411 summary of arguments for its infectious- ness, 409 transplantation experiments, 390 Cancer cells, an infectious factor in them, 405 bodies observed in them, 387 non-chemical nature of their x-factor, 405 their unlimited power of proliferation, 395, 404 transferrence of their infectious factor to normal epitheliiun, 393 Cancerous cachexia, 369 Caps for operative work, 721 Carbolic acid, its use as a germicide, 706 Carbuncles, 128, 129, 130 staphylococci most commonly found in, 130 Carcinoma, 361 adenomatosum, 350 alveolar, 361 character of the stroma, 360 colloid or gelatinous, 363 cylindrical-celled, 360 cylindromatosum, 363 encephaloid or medullary, 361 extension by dissemination, 364 extension by implantation, 365 extension by infiltration, 364 influence of external traumatism in its causation, 293 its development from epithelial structures, 354, 355 its histological classification, 358 its histological resemblances, 354 its mode of growth, 356 metastasis in, 364 methods of extension and metastasis, 364 myxomatodes, 363 round-celled, 359 secondary changes in, 362 scirrhous, its distinctive features, 361 squamous-celled (epithelioma), 358, 359 umbilicated, 363 whence arising, 354 Carcinoma cells, characteristics of, 356 degenerative changes in, 357 their tendency to retain the character of theparent cells, 357 Carcinomatous growth, its atypical and aber- rant character, 355 transformation of adenoma, 355 Cardiac diseases, a source of danger in admin- istration of ansesthetics, 784 Cargile membrane, uses of, 736 Caries, 210, 232 Billroth's views of the process, 232 necrotica, 232 sicca, 232 sicca, a>ray evidence of, 648 von Volkmann's views of the process, 232 Carotid, common, ligature of, 60, 61 Carpus, its development studied by radio- graphs, 579 Carson, Joseph, 7, 17 Cartilaginous exostosis, 315 Caseation, 215 a post-necrotic process, 216 miscroscopic appearances, 216 Casts in the urine, their significance, 570 Catarrhs, chronic, 141 desquamative, 116 mucous, 116 purulent, 121, 127 serous, 116 Catgut as suture material, 728, 753 Catgut preparation by Ochsner's method, 734 by other methods, 730 Catgut sterilization by the Bartlett method, 733 by the Boeckmann diy-heat method, 735 by the Claudius method as modified by Abbott, 732 by Konig's method and modifications of it, 735 by the Moschcowitz method, 732 by the New York Hospital method, 735 Cautery, its uses and modern forms, 767 Cavernoma, 321 Cell proliferation after infliction of an injury, 76, 93 its protective and sometimes imperfect features, 94 Cells, death of, necrosis and necrobiosis, 183 division of, to form new ones, 257 multiplication and differentiation of, 147 Cellular and less cellular tumors, 295 Cerebro-spinal fluid as obtained Ijj' lumbar puncture, its diagnostic value, 560 Chalicosis, 207 Charcot's or tabetic joints, .r-ray characteris- tics of, 668 Chemical substances alone may excite purulent inflammation, 126 Chemotaxis, a protective factor in inflam- mation, 84 INDEX. 803 Chest topography, diagnostic points in, 527 unifoiTnity of expansion, how interfered with, 52S Chloroform ansesthesia less dangerous in in- fants, 774 and ether, their relative influence in pro- ducing shock, 479 Chloroma, 342 Chlorosis, 241 blood-counts in, 241 changes in the blood in, 241 thrombosis a complication of, 241 Cholesteatoma, 367 Cholesterin, 192 Chondromata, 310, 313 Chondro-myxoma, 306 Chondro-myxo-sarcoma, 344 Chondro-sarcoma, 333, 344 Chordoma, 311 Chorio-epithelioma malignum, or deciduoma malignum, 368 Chromato-phoroma, 341 Chylangiomata, 323 Cicatricial tissue, its formation, 249 Cicatrix, formation of, by secondary adhesion, 252 Circulation, disturbances of the, 233 mechanism of the, 233 Cirsoid aneurysm; angioma arteriale plexi- forme; Rankenangiom, 321 Cleanliness, surgical, importance of, 272 Climacteric, the, effect of, upon neoplasms, 780 Climate, influence of, upon results of surgical operations, 797 Clinical instruction, early efforts toward, 29 Coal dust inhaled, cirrhosis anthracotica from, 208 Coal pigment, absence of, in lungs of infants, 208 Cohnheim's developmental theory of tumor growth, 293 Cold in treatment of acute simple inflamma- tion, 113 College of Physicians and Surgeons, New York, when first organized, 11 Colliciuative necrosis (red or yellow softening) of the brain, 239 Colloid struma, 347 Color as furnishing diagnostic aid, 515 Columbia College, New York, medical depart- ment of, organized, 11 Compression in treatment of acute simple inflammation,- 115 Concretions or calculi, 198 Condylomata acuminata, 331 as hyperplasia? of connective tissue, 108 Congenital malformations, x-ray appearances in, 686 Congestion, passive, final results of, 236 gross appearances at seat of, 236 Conservatism in surgery, 692 Cornea, inflammation of, 76 Cornification, 193 Cotton as a dressing, 719 Councilman's experiments on the production of pus, 253 Counter-irritants in treatment of acute simple inflammation, 114 Crile's pneumatic suit in treatment of surgical shock, 496 Crystalline and amorphous urinary deposits, their relation to calculi, 571 Cylindroma, sarcomatous, 340 Cyst contents, microscopical and chemical ex- aminations required for diagnosis, 576 Cystaderio-fibroma, 304 Cystadenoma atheromatosum, 348 mucosum, 348 ovarian, 352 Cystomata, 350, 351 and cysts, the distinction between, 350 development and characteristics of, 351 epithelial or proliferation, 350 glandular type of, 451 of the kidney, 353 ovarian, 351 papuliferous, 352, 451 Cysts of the liver, multiple congenital, 253 Dactylitis, syphilitic, x-ray features of, 670 Dark-room for developing x-ray photographs, 621 Dartmouth College, Hanover, N. H., medical department of, organized, 21 Davidge, John B., 47 Death, somatic, as distinguished from necro- biosis and necrosis, 209 Decinormal salt solution in the treatment of septicaemia and pyaemia, 443 Decubitus or bedsore, 137 Degeneration, 182 colloid, 190 distinguished from atrophy, 182 glycogenous, 194 hydropic, 190 mucinous, 191, 192 physiological and pathological, 182 reaction of, 543 Degeneration and infiltration, distinction be- tween, 183 Degenerations and infiltrations, Warthin's classification of, 183 Degenerative and necrotic inflammations, acute, 134 Delhi sore, 231 Deposits, 184 804 INDEX. Dermatitis, acute, as distinguished from ery- sipelas, 449 Dermoid cysts, 367, 368 Desault's method of treating fractures of the femur, 51 Detmold, William, 55 Diabetes, effect of, upon surgical procedures and conditions, 793 Diacetic acid in the urine of diabetics an un- favorable prognostic sign, 794 Diagnosis, general surgical, 501 special examination for, 512 Diagnostic examination of the principal sys- tems of the body, 516 Diapedesis in inflammation, 85 Diaphragm phenomenon, Litten's, 529 Diathesis, influence of, upon surgical con- ditions, 781 Digestive system, its diagnostic importance, 516 Diphtheritic inflammation, 118 Bacillus diphtheria a cause of, 135 epithelial or superficial, 135 intestinal, 135 streptococcus as a cause of, 135 Disinfectants, chemical, in skin disinfection, 705 Disinfection and sterilization, 701 Dislocations. 47 of the hip joint, remarks on, by Nathan R. Smith, 48 Dodd, Walter J., 599 Dorsey, John Syng, 17, 34, 45 "Elements of Surgery" by, 34 Dracuncular ulcer, 231 Drainage, materials and methods of, now ap- proved, 762 objections to it, and conditions where in- dicated, 764 secondary', 765 various methods employed and the re- sults, 761 Draper, William H., 16 Dressings after closing a wound, 754 Dry heat, the "baking" process, 767 Dudley, Benjamin W., 25 Dust, inhalation of, protection against, 208 Dusting powders as dressings, 722 ECCHONDROMATA, 311 Ecchondrosis physalifera, of Virchow, 311 Effusions into the body cavities, effects of, 238 Elbow joint, its development studied by ra- diographs, 582 Elephantiasis, 108, 305, 321 Embolism, retrograde, 365 Embryoid tumors or embryomata, 366 Embryological classification of tumors, objec- tions to it, 297 Emprosthotonus in tetanus, 457 Empyemata, 128 definition of the term, 121 healing of, 104 Enchondromata, 311, 312 producing metastases, 312 Endothelial cells, active functions of, in in- flammation, 86 Endothelioma, 338, 339, 340 Endothelium, vascular, its secretory powers important factors in the occurrence of oedemas, 236 Endurance, power of, greater in women, 777 Enostoses, 314 Entodermal cysts, 367 Environment, influence of, upon surgical prognosis, 795 Eosinophilia, 246 Eosinophilic marrow cells found in blood in myelocytic leuksemia, 243 Epiblastic structures, 299 Epidermoid cysts, 367 Epiphyfes, radiographic interpretation of, 578 5 1 of new-born child invisible in radiograph, / 579 Epithelial cells in urine, 570 defect in covering wounds, 274 growths, atypical, 355 pearls or cell-nests, 357 structures of typical growth, 354 Epithelioma transformed into sarcoma by transplantations, 397 Epitheliomatous transformation of chronic ul- cers, 231 Epithelium, its power of regeneration, 257 metaplasia of, 358 Epulis, 336 Erysipelas, 445 as related to pysmia, 450 bullosum, 130 constitutional symptoms of, 447 curative influence of, on other diseases, 453 diagnosis of, 448 etiology of, 445 general treatment of, 451 infectiousness of, 446 local treatment of, 451 migrans or ambulans, 447 of gangrenous type, 449 pathological anatomy of, 450 phlegmonous, 447 prognosis of, 451 prophylaxis of, 451 serum therapj^ in, 452 symptoms of, 446 traumatic, special features of, 449 Erythema simulating an erysipelatous der- matitis, 449 INDEX. 805 Esmarch bandage, 741 Ether as an adjuvant in disinfection, 708 Eve, Paul F., 29 Examination, general, of patient, 505, 507 Excretions, 567 Exercise bone, 315 Exostoses, 314 connective-tissue, 315 or osteomata, and enchondromata, as interpreted by x-rays, 671 Experimental and human wounds, differences in reparative processes in, 263 Exudates, 574 inflammatory, differences between them and passive effusions, 247 removal of, 259 varieties of, and their characters, 237, 248, 416, 574 Eye, its external parts in relation to diagnosis, 540 Face, inspection of, in diagnosis, 514 Faces, deductions to be drawn from their gross appearances, 571 value of bacterial examination of, 574 Faintness, or ischsemia of the brain, 239 Fat necrosis, 216 associated with pancreatic lesions, 217 researches of Hildebrand and Flexner, 217 microscopic characters of, 185 Fatty infiltration, 187 Fatty degeneration, causes of, 185, 187 gross appearances of, 189 microscopical appearances of, 189 presence or absence of ovaries or testes related to, 188 rationale of fat accumulation, 188 results of, 189 Felon, 128, 129 Femur, its epiphyseal development as shown by radiography, 592 treatment of fracture of, 51, 52 Fever following operation, 535 of suppuration, 535 Fibrin, its removal and changes, 260 Fibro-adenoma, 346 Fibro-lipoma, 307 Fibro-myxoma, 306 Fibro-sarcoma, 333, 335 Fibroids of the uterus, 303 removal of, during pregnancy, 779 Fibroma, 301, 302 cavernosum, 303 diffusum, 304 durum, 302, 305 intracanalicular, 304 lipomatodes, 303 lymphangiectaticum, 303 Fibroma moUe, 302 •nodular, 304 of peripheral nerves, 305 of the breast, 304 ossificum, 303 pedunculated, 303 pericanalicular, 304 petrificum, 302 plexiform (Ranken-neurom), 305 retrogressive changes in, 303 teleangiectatic, 303, 319 tuberosum, 304 Filtration experiments, significance of, 406 First intention, healing by, 100, 249, 261, 265 Fistula, 133, 255 following deep-seated infection, 419 resulting from suppuration, 121 Fitz, R. J., on perforative inflammation of the vermifonn appendix, 59 Fixation of wounded tissue, 273 Ford's experiments to prove the presence of bacteria in healthy tissues, 253 Foreign bodies, disposal of, in healing, 105 Foreign-body giant cells, 106 Fractures, immobilization essential in treat- ment of, 285 repair of, 279, 280 a--ray diagnosis of, 643 Fragilitas ossium or periosteal dysplasia, and osteogenesis imperfecta, .-c-ray features of, 685 Free-bodies, sometimes wholly organic, 200 Fungous or exuberant ulcer, 229 Furuncles, 128, 130 a result of bacterial inflammation, 418 Gaboon ulcer, 231 Gait, its diagnostic significance, 538 Gall stones, 201 Gangrene, 136 black, 137 circmnscribed, 136 diabetic, 136 diffuse, 136 dry, 136, 137, 218 emphysematous, 137 hospital, three forms of, 422 idiopathic, 136 moist, 136, 137, 218 neuropathic, 136 noma, 219 phagedenic, 136 primary, specific infections causing, 217 resulting from permanent arrest of cir- culation, 236 secondary, causation of, 218 senile, 136 synonyms, 217 thermal, 136 INDEX. Gangrene, toxic, 136 traumatic, 136 white, 137 Gangrene foudroyante, 421 Gangrenous inflammation, primary and sec- ondary, 136 Gastric juice, importance of examining it in diagnosis of carcinoma of the stomach, 562 testing its peptic capabilities, 562 Gauze as a dressing, 718 as directly applied to sterile wounds, 755, 759 bandages, 719 Gaylord, Harvey R., 3S7 Genital tract, female, secretions of, 565 male, secretions of, 566 Genito-urinary organs, consideration of, from a diagnostic point of view, 545, 550 Giant cells, mononuclear, 88 Gibson, William, 18, 34 Gigantism, an example of intrinsic congeni- tal hypertrophy, 151 Glioma, 324 and sarcoma, their relationship, 326 differentiation of various forms of, 325 durmn, 324 epend\^nal (Flexner), 326, 327 etiology of, 327 malignant, 327 moUe, 324 of the retina, description and classifica- tion, 326 results of, 327 teleangiectaticum, 324 Gliosis occurring with syringomyelia, 327 Glycosuria, its surgical significance, 569 Goitre, colloid, 191 cystic, 347 Gout, a;-ray characteristics of, 660 Granulating wounds, local infections of, 422 Granulation tissue, its character and conver- sion into scar tissue, 93, 251, 263 Granulomata, infective, as sequelae of an in- fective inflammation, 108, 144 Graves' disease, influence of, in surgical opera- tions, 791 Gross, Samuel D., 14, 27, 35 Gums, diagnostic indications which thej' fur- nish, 517 Gunn, Moses, 49 Gynaecology as a special branch of surgerj', 56 Habits as bearing on diagnosis, 509 Hsemangioma, 319, 321 arteriale, 320, 321 cavernosum, 320 simplex, 320 Hsemangioma venosum, 321 Haemochromatosis, 205 Haemocytology in its relation to surgical prog- nosis, 791 Hcemoglobin, importance of knowing percent- age of, in chlorotic anaemia, 556 in differential diagnosis of malignant and innocent neoplasms, 556 Hajmoglobinaemia, 205 Hemoglobinuria, 205 Haemophilia, hereditary, importance of, in sur- gical prognosis, 783, 792 Haemostasis, complete, a surgical principle in treatment, 273 Haemostatic forceps, 746 Hamilton, Frank H., 36 Hand steriHzation, conclusions concerning, 703, 708 Harrington's solution of bichloride of mercury for sterilizing the hands, 706 Harvard College, Cambridge, Mass., medical department of, organized, 10 Haj'ward, George, 20 Hearing, sense of, and its defects, as concerned in diagnosis, 542 Heart, atrophy of, 171 repair of injury of, 287 Heat, a symptom of irJlammation, 94 and cold, surgical uses of, 765, 766 in treatment of acute simple inflamma- tion, 113 Heat sense (thermo-aesthesia) in relation to diagnosis, 537 Hemorrhages, repeated small, leading to chronic anaemia, 245 Hemorrhagic exudate, 416 Heredity, influence of, upon surgical conditions, 782 Hernia as affected by parturition, 780 Hickey, Preston M., 578 Hip joint, Alden March's treatment of disease of, by fixation and traction, 54 amputation at, 60 disease of, 54 dislocations of, 4S Physick's method of treating disease of, 54 Sayre's splint in treatment of disease of, 55 Horsehair for sutures, 726 Howell, W. H., on the cause of shock, 464 Hyalin, epithelial, 192 resemblances and differences between it and amyloid, 197 Hydatidiform mole or myxoma chorii race- mosum, 307 Hydraemia defined, 240 Hydrocele. 236 Hydrocephalus, external, definition of, 236 internal, definition of, 236 INDEX. 807 Hydropericardium, definition of, 236 Hydrotliorax, definition of, 236 Hygroma colli congenitum, 323 Hylomata or pulp tumors, 298 HyperEemia or congestion, 234 active, causes of, 234 arterial, effects due to, 235 following infection, 415 local, passive or venous, 234 Hypernephroma, benign, 347 Hyperostosis, 314 Hypertrophy, 148 compensatory, as when fibula is thickened on weakening of tibia, 156 complemental, as between thyroid and pituitary body, 156 due to errors of metabolism, 162 extrinsic, 153, 154, 155 from chronic irritation, as intermittent pressure, 159 from failure of involution, as sometimes occurs in the thymus gland or the uterus post partum, 157 from increased nutrition, as by enlarged blood-vessels, 158 from removal of pressure, as in a micro- cephalic skull when brain is undeveloped, 159 from removal of pressure, as in the over- growth of fat about a contracted kidney, 157 influence of the ductless glands upon extrinsic, 162 intrinsic, 151 mutual relations between growth and de- velopment, 149 neurotrophic, as in a hypertrophied blad- der in children, 163 numerical, or hyperplasia, 150 quantitative, or true hypertrophy, 150 Hypoblastic structures, 299 Ichorous pus defined, 253 Icterus or javmdice, causes of, 206 Iliac, primitive, ligation of, 44 Implantation in mice, natural immunity to, 397 Inclusions in cancer, question of their para- sitic nature, 388 Indican, significance of, in urine, 569 Infants less liable to nervous shock, 774 plastic operations upon, 774 Infarct, ansmic or white, explanation of the term, 239 red or hsemorrhagic, its origin, 239 Infected wounds, 271 Infection, 696 from the mouth and upper air passages, 699 of a healing wound, 418 Infection of closed wounds, effects of, 271, 272 of wounds, conditions favorable to the development of, 699 resisted by granulation tissue, 274 sources of, and the prophylaxis against them, 696 through orifices of glands and other nat- ural openings, 697 Infections, diseased conditions favoring their development, 700 which sometimes occur in various surgical diseases and conditions, 415 Infectious arthritis, a:-ray indications of, 659 Infectious diseases, acute, influence of, upon surgical conditions, 792 Infectious venereal granuloma of the dog, 407 features distinguishing it from true ma- lignant tumors, 408 its analogies to sarcoma, 409 Infective agents — the most important bac- teria, 415 Infective granulomata, distinctions between them and tumors, 291 Infective susceptibility of different tissues, 700 Infiltrations, 194 amyloid, etiologically connected with chronic cachexias, 195 glycogenous, 203 hyaline, exact nature of, undetermined, 197 pigmentary, 203 purulent, 121 small-celled, 121 Inflammation, 71 a bodily function, fundamentally protec- tive, with varying manifestations, 81 acute degenerative and necrotic, 134 acute fibrinous, 118 acute purulent, 121 acute serous, 115 adhesive, 104 as defined by various modern authors, 75 aseptic, 110 Boerhave's conception of, 73 certain products of, 247 chronic atrophic, 144 chronic indurative, 145 chronic infections a cause of, 139 chronic intoxications a cause of, 139 chronic productive, 145 Cohnheim's conception of, 73 croupous, 118 definition of, 71 diphtheritic, 135 discrimination between pyogenesis and, 75 etiology of, 81 extracellular protective factors in, 89 INDEX. Inflammation, factors concerned in, 82 , fibrino-purulent, 122 fibrinous, 119 fluid exudate in, 90 formative, 110 gangrenous, 137 healing of, 100 kept up by repeated mechanical injury, 139 local, general effects of, upon the organ- ism, 96 local treatment of, 109, 110, 111, 112 membranous, 118 modifying influences of, 81 necrotic tissue as a cause of, 139 nervous origin of, 90 phlegmonous, 131 protective factors in the process, 8-4 purulent, 121 reparative agencies in, 253 Rokitansky's conception of, 73 sequelae of, 107 sero-purulent, 121 symptomatology, 94 table of varieties of, 97 the term as applied by Celsus, 72 variations due to modifjang factors, 80 vascular changes in, 84 Virchow's conception of, 73 Innominate artery, ligature of, 42, 43 Inspection, diagnostic data acquired by, 512 Instruments, 741 Intestinal epithelium, regeneration of, 258 Intestines, examination of, and diagnostic data obtainable from, 524 ■n-ounds of, 275, 276 Intravascular antisepsis in the treatment of septica?mia, 444 Involucrum as a periosteal reproduction, 286 Iodine as a sterilizing agent, 707 Iodoform emulsion, its use in treating cold abscesses, 723 gauze, its uses and preparation, 723 value of, as a dressing, 723 lodophilia, inferences to be drawn from, 559 Irrigation, when and how to be used, 704 Irritants, reaction of cells to them in inflam- mation, 71 IschEemia, defined, 240 and ansemia, distinction drawn between them, 238 Isodiametric cells, 359 Jackson, Charles T., 66 Jackson, James, 11 Jameson, Horatio Gates, 45 Jaundice, liEemo-hepatogenous, 206 obstructive, 206 Jefferson Jledical College of Philadelphia, when founded, 26 Joints, suppuration ■nithin, results of, 255 Jones, John, 8, 34 Kangaroo tendon for buried sutures, 730 Karj^okinesis, 257 Kelly, Howard A., 4 Keloid, idiopathic or spontaneous, 305 secondarj', sear, cicatricial, or spurious, 305 Kidney, diseases of, a source of danger in ad- ministration of anesthetics, 785, 787 epithelium of, its limited power of repair, 258 examination of, as to its mobility and pathological relations, 552 King's College, New York, medical depart- ment of, organized, 8 Knee-jerk, or patellar reflex, as a diagnostic factor, 539 loss of, in alcoholism, an unfavorable prognostic sign, 797 Knee joint, development of epiphyses about it, as shown by radiographs, 592 Ivnight, Jonathan, 22 Knives, surgical, 743 Koellicker's chromatophores, 194 Krj'oscopy of the blood and of the urine, 560 Lactation, prolonged, effects of, 780 Laudable pus, 125 Leiomyoma (myoma laevicellulare), 316 causing metastases, 319 Leontiasis ossea, an instance of localized intrinsic hj^ertrophy, 153 Lepidomata or " rind" tumors, 297 Leucocytes, assemblage of, in vicinity of in- jurjf, 76 diagnostic value of differential counts of, 558 emigration of, 85 marginal chsposition of, in inflammation, 85 removal of, by phagocytosis, 2S0 Leucocytosis, 240, 245 degree of, important in surgical prognosis, 792 diagnostic value of its presence and degree, 558 in infancy, 246 inflammatory, 246 non-pathological conditions leading to, 559 of digestion, 246 pathological, causes of, 246 physiological, 246 produced by certain drugs, 246 INDEX. 809 Leucocytosis, several counts necessary, to guard against exceptional conditions, 558 toxic, 246 Iieucopenia defined, 240 Leukaemia, acute lymphatic, characteristic symptoms of the disease, 242 acute lymphatic, or acute lymphocy- thsemia, 242 chronic lymphatic, characteristic symp- toms of the disease, 242 divided opinions as to its pathological relations, 244 features of the predominating type, 241 importance of blood examination in, 241 lymphatic, features of the leucocytosis in this disease, 242 modifications of the blood in, from in- flammatory process, 244 myelocytic, course of the disease, 242 myelocytic, diagnostic importance of the leucocytes in, 243 myelocytic, features of the blood-count in, 243 myelocytic, types of myelocytes found in this disease, 243 myelogenous, characteristic changes in bone marrow in, 243 the blood picture of, modified by use of arsenic, 244 Lewis, George, 58 Libraries, medical, in the United States, 38 Ligatures and sutures, materials employed, 724 animal, suggested by Physick, 45 carriers, 747 Lipomata, 189, 307 causation of, 310 myxomatodes, 310 retroperitoneal, 309 teleangiectatic, 319 Lipo-myxo-sarcoma, 344 Lipo-sarcoma, 333 Lips, data furnished by them in diagnosis, 516 Liquor puris, 252 Lister, Joseph, 691 Litholapaxy, developed by Bigelow, 53 Lithotomy, 53 Liver, abnormal relations of, and their diag- nostic significance, 522, 790 epithelium of, its regeneration, 258 lesions of, in their relations to surgical prognosis, 790 Liver atrophy, 181 acute yellow, 181, 206 melanaemic, 181 Locality, sense of, in relation to diagnosis, 537 Long, Crawford W., 64 Louisiana, medical department of University of, organized, 28 Low-pressure steriHzers, 716 Lungs, atrophy of, 172 LjTnph, plastic or coagulable, distinctive char- acter of, 247 organization of, in an incised wound, 248 Lymph channels, dift'usion of inflammatory products bj', 91 Lj-mph nodes, Ribbert's views regarding, 87 Lymphangioma or angioma Ipnphaticum, 319, 322^ cavemosum, 323 cystoides, 323 etiology of, 323 Lymphangitis, 422 a frequent complication of felons, 131 ascending, 92 LjTnphatic nodes, atrophy of, 180 Lymphatic sj-stem, part played by, in inflam- mation, 91 protective functions of, in inflammation, 92 Lymphocytes, appearance and source of, in inflammation, 87 Lymphocytosis, 246 Lymphogenous matastasis in inflammation, 96 LjTnpho-sarcoma, 334 LjTnphosporidium truttte, the relative sizes of its difi^erent forms, 406 Lysol as a disinfectant, 707 Macrocheilia, 323 Macroglossia, 317, 323 Malignant diseases, heredity of, 783 oedema, bacillus of (Koch), 421 Mahmi perforans, 137 Mamma, atrophy of, 182 Mamraarj^ secretion, 564 in functional inactivity, diagnostic data to be obtained from, 564 Manipulation, avoidance of, a surgical prin- ciple, 273 Manipulations, reduction of dislocations of hip joint b}^ 48 March, Alden, 53 Marrow cell of Cornil found in blood of myelo- cytic leukaemia, 243 Martin's rubber bandages, 741 Masks for operative work, 721 McBurney, Charles C, 59 McClellan, George, 26 McGraw, Theodore A., 370 Melanin, characteristics of, 342 Melano-carcinoma, 363 Melanoma, 341 Melano-sarcoma, 341 Menstruation, influence of operations upon, 778 Mental disorders, effects of operations upon, 788 Mesenchymal tissues, reproduction of, 258 810 INDEX. Mesoblastic structures, 299 Mesodermal cysts, 367 Metastases of the liver in pyaemia, 437 of the lung in pysemia, 437 of tumors, Virchow's views, 379 Metastatic calcification, or lime metastasis, 199 Methfemoglobinuria, 205 Miami Medical College, organization of, 23 Micromonas Mesnili, relations of, to sheep-pox, 406 Micro-organisms, pyogenic, 125 constantlj' present upon the skin, 126 Micturition, difficult, causes and relations' of, 548 _ diminished frequency of, its causes and significance, 546 frequent, its diagnostic indications, 546 interrupted, its causative and diagnostic relations, 548 involuntarj', its causation and diagnostic relations, 549 irrepressible, its causes and occurrence, 547 painful, causation and diagnostic impor- tance, 549 retarded, causes and diagnostic relations, 548 urgent, its causative relations, 547 Milliammeter, 616 Mitosis, 257 Mollifies ossium or halisteresis, 174 MoUuscum fibrosum, 305 Moore, James E., 691 Morgan, John, 7 Morton, Thomas G., 58 Morton, W. T. G., 64 Mother's marks, 321 Motion, its significance in diagnosis, 538 Mott, Valentine, 5, 12, 13, 42, 44 Moiise tumors, histological characteristics of those retrograding, 399 vaiying success in transplanting them, 394 Mouth, blood expelled from the, its sources and diagnostic significance, 521 Mucoid tissue, its character and relations, 306 Muco-pus defined, 253 Mucous membranes, disinfection of, 708 fibrinous exudate on, 118 superficial exudative inflammation of, 250 Mucus in the stools, its significance, 573 Muscle, absence of regeneration in, 259 as affected by atrophy, 170, 171 repair of, 287 Museums, pathological, value of, 33 Mussey, Reul^en D., 23 Myo-fibroma, 318 teleangiectatic and cavernous, 303 Myoma, 316 Myoma, etiology of, 319 histology of, 318 molle, 318 Slj'opathy, primary, or progressive muscular dystrophy, 171 Myo-sarcoma or myoma sarcomatodes, 344 Myositis ossificans, 315 Myxo-chondroma, 311 Myxoedema, influence of, in surgical conditions, 791 Myxo-lipoma, 307 Myxoma, 306 lipomatodes; lipo-raj^xoma, 306 of mucous membranes, 307 teleangiectatic, 319 Myxo-sarcoma, 307, 333, 344 NiEvus flanmieus, 320 lymphaticus, 323 prominens, 321 vasculosus, 320 Nails and screws, their disadvantages in treat- ment of fractures, 749 Narcosis, interrupted, as related to the pro- duction of shock, 475 Nasal secretion, diagnostic data from cerebro- spinal fluid foimd in it, 563 indications of pus in, 563 its study for diagnosis, 563 Neck, inspection of, in diagnosis, 514 Necrobiosis and necrosis, 208 characteristics and course of, 209 Necrosis, 213 caustics causing, 211 coagulation, 214 cold as a cause of, 211 colliquative, 215 distinguished from gangrene, 209 due to interference with blood-supply, 21 1 heat as a cause of, 211 liistological changes in, 210 inflammation as a cause of, 212 neurotrophic, 212 of bone, molecular (von Volkmann), 232 toxic agencies causative of, 212 traumatic insults causing, 210 a; -rays as a cause of, 211 Necrotic areas, healing of, 105 Needle-holders, their requirements, 745 Needles, essential features of, 744 Negro, immunity of, in respect of certain diseases, 784 Neoplasms, effect of the climacteric upon, 780 Nerves, degenerative changes in, due to toxins, bacteria, nutritive and circulatory disor- ders, 179 peripheral, degeneration associated with atrophy of, 178 INDEX. 811 Nerves, peripheral, injuries of, 2S9 rate of regeneration of, 290 Nervous diseases, effect of, upon surgical prog- nosis, 7SS Nervous system, atrophy of, 175, 176 degenerations of, primary and secondary, 176, 177 in relation to diagnosis, 535 part .played by, in inflammation, 90 repair of injuries, 290 Neurasthenia, effect ot, upon surgical condi- tions, 7S9 Neuro-epitheliomata, 326 Neuro-fibroma, 305 Neuroglia, Weigert's views of the cells of, 325 Neuroma, 328 amputation, 328 ganglionic, 329 multiple cutaneous, 329 of the central nervous system, 329 plexiform (Rankenneurom), 329 Neuropathic atrophies, muscles involved in, 171 Neurotization of sear, 290 Neutrophilic marrow-cells (Ehrlich's Markzelle) found in blood of myelocytic leukEemia, 243 Nicholls, Albert G.. 146, 291 Nichols, Edward H.. 256 Noma, 137, 220 Non-vascular tissues, effects of injury upon, 76 Nurses, training school for, inaugurated in Bellevue Hospital, 32 Nutrition, disturbances of, in connection with surgical diseases and conditions, 146 Obstipation in its relation to surgical prog- nosis, 790 Occupation as related to chagnosis, 508 Ochronosis, 194 Odontoma, 314 CEdema or dropsy, 236 acute purulent, 420 a result of general passive congestion, 237 factors determining the occurrence of, 236 inflammatory, 116, 236, 237 local, from local passive congestion, 237 lymphatic, 236 purulent, definition and etiology of, 121 results of, 238 OEdemas sometimes due to altered secreting powers of vascular endothelium, 237 CEclematous tissues, microscopical features ot, 238 ffisophagus, its examination and diagnostic data, 518 Old people, operations upon, 776 Oligaemia defined, 240 Oophorectomy, performance of, during preg- nancy, 779 Open wounds, infection of, 272 Operating gowns, 721 Operations, diseases which enhance the dan- gers of, 786 effect of, upon neurasthenia, 789 influence ot age upon, 772 influence ot menstrviation upon, 778 influence of, upon pregnancy, 778 rendered more dangerous by various dis- eases, 786 Operative facility, its dangers, 693 procedures in aid ot diagnosis, 553 Opisthotonus in tetanus, 457 Orthodiagraph, 630 Orthopedic surgery, 55 Osgood, Robert B., 599 Osteitis deformans or Paget's disease, x-ray evidences of, 674 Osteoarthropathie hypertrophiante pneumique, 686 Osteoblasts and osteoclasts, their action, 282 Osteo-chondroma, 311 Osteogenesis in chronic bone diseases, 161 Osteogenetic tissues, their repair, 280 Osteoid, development of, 281 tumors, distinguisliing characteristics ot, 315 Osteoma, 313, 314 continuous, 314 dental, 314 discontinuous, 314 eburneum, 313 spongiosum or medullary osteoma, 313 Osteomalacia, 174 x-ray features ot, 676 Osteomyelitis, chronic circumscribed, as shown by x-ray, 654 chronic diffuse, as sho-mi by x-ray, 654 diffuse sj'philitic, 668 x-ray diagnosis ot, 649 Osteophytes, 314 Osteoporosis, 165, 173 Osteopsathyrosis, or tragilitas ossium, 175 Osteo-sarcoma, 333, 344 Osteosclerosis, 162 Otoliths, 200 Ovaries, atrophy ot, 181 Ovariotomy, 61 Overproduction of tissue as a s?quela of in- flammation, 108 Pagenstecher's celluloid yarn, its prepara- tion and use in sutures, 727 Pain, 95 differences in sense ot, 537 seat of, as an element in diagnosis, 536, 537 Palate, tonsils, and pharjmx, diagnostic indi- cations furnished by, 517 812 INDEX. Palpation, its use in diagnosis, 515 Panaritium, 130 Pancreas, adenoma of, 345 Papillary naevi, 329 Papuliferous cystadeno-fibroma, 304 Papillomata, 329 etiology of, 331 intracanalicular, of the mamma, 351 of mucous surfaces, 329 of the bladder, 330 Paralytic degeneration of nerve, following in- jury, 289 Parasites to be sought for in the fteces, 573 Parker, WiUard, 15 Paronychise, 418 Parturition, effect of, upon surgical conditions, 780 Patellar reflex, absence of, in diabetes, an un- favorable prognostic sign, 793 Pathogenic bacteria, differences in the viru- lence of their infectiveness, 700 Pathology, surgical, 69 Pelvic diagnosis by rectal examination, 525 Peimsylvania, University of, organization of medical department, 11 Perinaeum, its examination for diagnosis of urinary extravasation, 550 Periosteal regeneration of a bone in likeness of the original, 286 Periosteum and endosteimi, their power to regenerate bone after death of a portion, 286 Perithelioma, malignant, 340 Peritonitis, simple, development of, 249 Pernicious anaemia, characteristic changes in the blood, 241 Peroxide of hydrogen as a cleansing agent, 70S Personal history of patient, its importance in diagnosis, 509, 510 Perthes' experiments with the .-c-ray on warts, 402 Petrifying infiltrations, 198 Phagocytosis, a protective agency in inflam- mation, 74, 89 Philadelphia, College of, organization of medi- cal department of, 7 Phleboliths, 200 Phlegmonous inflammation, 121, 418, 420 septicaemia often present with, 131 Physick, Philip Syng, 16, 54 Pigmentary deposit, biliary, 205 substances inhaled, chronic fibroid pneu- monia from, 208 Pigmentation, biliary, 203 by extraneous pigments, 193, 207 by way of the alimentarj' tract — metals, 207 by way of the lungs (pneumonokoniosis), 207 Pigmentation, cachectic, 207 conditions under which it is physiologi- cally or pathologicall}- increased, 193 from cellular activity, 193 hematogenous, 203, 204 in chloroma, 194 in jaundice or icterus, 193 of organs in which pigment exists nor- mally, 193 of the liver, 205 of the skin, by tattooing, 207 origin of the hsematogenous variety, 204 transferrence of, to spleen, from a sar- coma, 205 Pigments, autochthonous or metaljolic, 193 Pilcher, Paul Monroe, 415 Plasma cells, characteristics and source of, 88 Plasmodiophora brassica;, 388 Plaster-of-Paris bandages, how prepared and used, 738 dressings in tuberculous joints, and in fractures, 740 Plastic or fibrinous exudate, 248 Plethora, 234, 240 Pleuritis, purulent, anatomical changes in, 140 Plimmer's .bodies, 381, 388 Polycythsemia defined, 240 Pope, Charles A., 29 Port-wine stain — nEe\Tis vinosus, 320 Post, Wright, 12, 40 Potassiimi permanganate and oxalic acid or the Schatz method of sterilizing the hands, 707 Pott's method of treating fractures of femur, 51 Poultices, 759 Pregnancy, influence of, upon neoplasms of the reproductive organs, 779 influence of, upon operations, 778 Prickle cells, 359 Prognosis, general, in surgical diseases, 771 Proliferation of epithelial and connective-tissue cells, 262 Prostate, atrophy ol, 181 examination of, for diagnostic pui-poses, 550 Prostatic secretion, manner of obtaining and findings, 566 Proud flesh, 251 Psammoma, 340 Pseudo-arthrosis defined, 284 Pseudo-chylous ascites, from obstruction of thoracic duct, 237 Pseudo-hypertrophic muscular paralysis, 171 Pseudo-leuka?mia or Hodgkin's disease, 244 Pseudo-membrane in inflammation of mucous membranes, 250 Ptomains, how produced, 417 INDEX. 813 Puerperal septicaemia, local treatment of, 442 Pulse as an aid in diagnosis, 533 Pupil, Argyll-Robertson, 541 its diagnostic indications, 540 Purulent exudates, details of the examinations required, 576 removal of, 260 Purulent inflammation may be excited by simple chemical substances, 126 Pus, 121, 252 association with granulation tissue, 251 blue, 253 bonum vel laudabile, character and con- stituents of, 125, 252 cellular constituents of, 124 curdy, 253 entrance of, into the blood, 255 formation of, 416 in the urine, its sources and significance, 571 physical characteristics of, 123 production of, a protective reaction to injury, 125 red, Ferchmin's description of, 254 sanious, 253 Pustule, 121, 129 Pyajmia, 96, 433, 437 beginning of, in thrombi, 433 characteristic changes in temperature, 435 formation of metastatic abscesses, 434, 436 hemorrhagic icterus in, 436 pathological anatomy, 439 prognosis of, 438 symptoms and diagnosis, 434 Pyogenetic membrane, 104, 255 Pyogenic micro-organisms, 125, 253 lesions produced by them in wounds, 271 Questioning of patients, 502, 506 Race, influence of, upon surgical conditions, 783 Radiographic localization of foreign bodies, 629 plates, method of examining them, 641 study of ossification, 579, 582, 598 technique, 599 tests, 612 value of x-vsky tubes estimated by mil- liammeter, 616 Radiographs, interpretation of, 640 method of taking, for purpose of local- izing calculi, 628 scheme of standards used in Massachu- setts General Hospital in taking them, 626 Radiography in surgery, general considera- tions on, 599 Raynaud's disease, a;-ray appearances of, 687 Rectal diseases diagnosticated, 525 Red blood cells, importance of studying them for diagnosis, 557 their removal and changes, 260 Red-cell count of great prognostic importance in surgery, 791 Redness, a symptom of inflammation, 94 Reflexes, deep, in relation to diagnosis, 539 superficial, in relation to diagnosis, 538, 539 Reid, William W., 49 Regeneration, 256 after injury of peripheral nerve, 289 comparative power of, in different tissues, 257 effected by cell proliferation, 92 factors influencing the power of, 256 Renal diseases a source of danger in adminis- tration of ansesthetics, 785 in operations, 787 Repair, the process of, 92, 256, 259, 261 Reparative processes as they differ in experi- mental and complete fractures, 282 Resolution of inflammation, 98, 99, 259 Respiratory' acts, changes in them, and their diagnostic significance, 528 organs, diseases of, a source of danger in operations, 787 system, diagnostic data obtained from, 527 Rest in treatment of acute, simple inflamma- tion, 113 in treatment of wounds, 754 "Rests" as related to neoplasms, 293 Retractors, 748 Retrograding mouse tumors, the immune fac- tor in the blood, 400 tumors, action of 3;-ray and radium, 402 Rhabdomyoma, embryonic type of, 316 Rhabdomyo-sarcoma, 317 Rhinoliths, 200 Rickets, 677 and chondrodystrophia foetalis, .-r-ray di- agnosis between, 676 Riders' bone, 315 Risus sardonisus in tetanus, 457 Rodent ulcer, 359 Rodgers, John Kearney, 43, 44 Roentgen rays, their divergence and its re- sults in 'photographs, 578 Rubber drainage tubes, 740 gloves, their use and care, 709 tissue, how used, 741 Rush Medical College, of Chicago, founded, 27 Saliva as a source of infection, 699 diagnostic data obtainable from its ex- amination, 561 Salt solution, normal or physiological, 704 814 INDEX. Salves and ointments, 759 Sanies, a form of pus, 124 Saprsemia, 96, 423, 425 infection with proteus vulgaris, 423 Sarcomata (atj^ical meso-hylomata), 331, 333 alveolar. 334, 336 angiomatous, 338 giant -celled, 335 gross appearances, 331 in rats, transplantation of, 391 large round-celled, 334 meduUarj', 332 melanotic, spindle-celled and alveolar, 341, 342 mixed-celled, 335 myeloid, 335 of definitely organoid type, 336 of mixed type, 343 perithelial, 338 petrifjTing, 343 presenting peculiar secondary character- istics, 341 resembling carcinoma, 337 small round-celled. 333 spindle-celled, 334 teleangiectatic, 332 tubular. 336 where developed, 331 Ziegler's classification of, 333 Sarcomatous transformation in other tumors, 333 Sayre, Lewis A., 56 Scab, healing under a, 249 Scar tissue, formation of, 263 Schools, medical, first organization of, in America, 3 Scissors, 744 Scopolamine-morpliine anaesthesia, 4S0 Seaman, Valentine, 13 Seasoned tube, its radiographic value indicated bj' miUiammeter, 618 Second intention, healing by, 102, 268, 270 Secondary adhesion, healing bj-, 251, 252 Secretion.?, diagnostic value of, 561, 567 from the female genital tract, bacterial examination of, 565 Seminal secretion, diagnostic data obtained by examination of, 566 Senn's researches on the ligation of blood- vessels, 725 Sepsis, its surgical meaning, 695 Septicaemia, 96, 423 asepsis in the treatment of, 441 crj-ptogenetic, 430 due to a mixed infection, 431 etiology, 425 free drainage and irrigation in the treat- ment of, 441 Septicemia from general peritonitis. Pilcher's treatment of, 442 general treatment of, 442 illustrative cases, 428 leucocytosis in, 432 post-mortem appearances. 432 primary- prophylaxis of, 440 sj-mptoms of, 426 treatment of, 440, 443 Septico-pyaemia, 439 as a result of diffuse suppuration. 255 Sequestra, 223 their persistence, 286 Sero-fibrinous catarrh, 116 Sero-purulent catarrh, 116 Sero-pus defined, 253 Serous effusion in inflammation. 116 Serous surfaces, fibrinous exudate upon, 119 Serum or agglutinative reactions, their sur- gical diagnostic value, 560 Serum therapy in septicaemia and pyjemia, 443 Sex as bearing on diagnosis, 508 relation of, to surgical prognosis. 777 Shippen, William, Jr., 7 Shock, 463, 464 alcoholism in relation to. 4S3 amputation during, 486 and collapse, differentiation between, 491 and hemorrhage, 485 arising from operations on the kidney, 477 arising from operations on the testicle, 477 as caused by injury of the different organs, 471, 476 as caused by injuri.- of the different tissues, 470 ' ' as caused by injury of the joints. 470 as influenced by anaemia, 482 as influenced by jaundice, 484 as observed in operations on the spinal column, 478 as related to asphjTiia, 472 as related to the duration of the operation, 478 blood-pressure to be watched as an index of, 490 cardiac, 467 Crile's experimental work on, 468 diabetes as related to, 482 diagnosis of, 491 effect of, upon surgical prognosis, 788 emergenc}-, 494 etiological factors in, 490 from acute hemorrhagic pancreatitis, 484 from rupture of abdominal viscera, 485 hemorrhage an element in, 481 Howell's conclusions in regard to. 467 in abdominal operations. 475 in operations involving the diaphragm, 475 INDEX. 815 Shock, in operations on the head, 471 in operations on the neck, 472 in operations on the spleen, 476 in operations on the thorax, 473 increased by exposure to cold, 488 infants less Hable to, 774 influence of atmospheric pressure as a factor, 288 injuries of the skin in relation to, 469 in reference to auto-intoxication, 484 nephritis in relation to, 482 operative details influencing, 469 pain as bearing on the production of, 469 possible existence of, in all cases of trau- matic surgery, 488 prognosis of, 492 psychic factors in, 488 relation of, to fall in blood pressure, 465 relation of, to local infections, 483 relation of, to starvation, 484 relations of spinal ansesthesia to, 480 salt solution in treatment of, 493, 494 slight, after tracheotomy, 472 symptoms of, 492 treatment of, 493 vascular, 467 Shoulder-joint, amputation at, 59 its epiphyseal development as shown by radiograph}', 592 Siderosis, 207 Sight, sense of, in relation to diagnosis, 540 Silicosis, 207 Silk as used for sutures and ligatures, 725 Silkworm gut as material for sutures, 726 Silver wire as suture material, 727 in gynaecologj', 57 in treatment of fractures, 728 Sims, J. Marion, 57 Sinkler's reflex, 540 Sinus follo-n-ing deep-seated infection, 121, 255, 419 Skeleton, living, 171 Skill, surgical, how it can be acquired, 693 Skin, atrophy of, from distention, 180 from pressure, 180 neurotrophic, 180 physiological, 179 Skin-grafting after extensive burns, 252 Skin sterilization, 702, 708 Slough or moist eschar, 252 formation of, 233 in open wounds, 274 Sloughing or phagedenic ulcer, 229 Smell, sense of, its importance in diagnosis, 541 Smith, Nathan. 21 Smith, Alban G., 15 Smith, Henry H., 19 Smith, Joseph M., 14 Smith, Xathan R., 24, 48 Smith, Stephen, 3 Smyth, A. W., 43 Spinal cord, atrophic diseases of, 178 complete transverse injury of, 543 complete unilateral injurj' of, 543 degeneration of (compression myehtis), 177 partial lesions of, 543 Spirochteta pallida to be sought iij supposed syphilitic discharges, 566 Spleen, atrophy of, 181 in leukaemia, 244 Sponges or pads, 720 Sputum, diagnostic importance of pathological findings therein, 563, 564 Staphylococci and their effects, 417 Stay sutures, 752 Steam sterilizers, 714 Stercorsemia in its relation to surgical prog- nosis, 790 Stereoscopic radiographs, how to take them, 636 Sterilization of catgut, the Claudius or iodine method described, 731 of dressings, 713 of hands, 702 of instnmients, 711 of nail brushes, 703 of skin at seat of operation, 703 of soap, 702 of sutures and ligatures, 724 of water, apparatus for, 712 Stevens, Alexander H., 14 Stitch abscesses, 753 Stomach, atrophy of, 181 cancer of, its diagnostic features. 519 examination of and diagnostic informa- tion derived from it, 518, 520 Stomach contents, their examination and di- agnosis, 520, 521, 562, 563 Stools, diagnostic examination of, 525 St. Louis Medical College, 29 Stone, Warren, 28 Streptococci and their effects, 417 Streptococcus erysipelatis and Streptococcus pyogenes, question of their identity, 445 Subclavian artery, left, Kgation of, within the scaleni, 43 Subdiaphragmatic abscess, 128 Suppuration, 121, 250 artificial, in the treatment of pyaemia, 441 circumscribed, 254 conchtions and diseases favoring. 126 constitutional infection from, 127 development of, 122 diffuse, 255 forms of, 254 816 INDEX. Suppuration, results of, 255 when involving serous membranes, 254 Surgeon's care of his hands, 702 Surgery, American, evolution of, 3 modern, beginnings of, 691 Surgical dressings and sponges, 71S procedures, effect of, upon the diabetic process, 793 technique, essential importance of, 694 treatment, application of the principles, 750 Suture materials, 274 Sutures and other foreign bodies, 274 insoluble, 275 soluble, how disposed of, 275 Suturing of intestinal wounds; histology of the healing process, 276 of wounds; tier sutures and stay sutures, 752 Sweat, sterile and otherwise, 698 Syndesmosis defined, 284 Synostosis defined, 284 SyphUis a cause of ulceration, 226 not a bar to operative measures, 792 Syphilitic disease, x-ray appearances of bone lesions in, 663 Sypliilitic ulcers, deep, 230 superficial, 230 Taste, sense of, its alterations as influencing diagnosis, 542 Teeth, diagnostic data supplied by them, 517 Temperament, influence of, upon surgical con- ditions, 781 Temperature of the body, extreme variations in certain diseases, 534 in relation to diagnosis, 533 Tendons, repair of, 277, 278 Teratoid tumors or cysts, simple and com- plex, 366, 367, 368 Teratomata, bigerminal or ectogenous; foetus in fcetu, 366 malignant, 366, 368 monogerminal, endogenous or autochthon- ous, 366 Wartliin's classification of, 367 Testes, atrophy of, 181 Tetanus, 453 antitoxin, its employment, 460 carbolic-acid treatment of, 461 chronic, 458 conveyance of the toxins to the central nervous system, 454 cryptogenetic, 453 diagnosis of, 459 etiology, 453 facialis, 459 from Fourth-of-July gunshot wounds, 454 Tetanus, local treatment, 460 neonatorum, 458 pathology, 455 prognosis in, 459 puerperaUs, 458 symptoms, 455, 457 traumatic, 453 treatment, 459 Thiersch method of skin-grafting, 258 Third intention, repair by, 271 Thoracic-duct obstruction, causing pseudo- chylous ascites, 237 Thorax, inspection of, as furnishing diagnostic data, 514 Thrombi, healing of, 105 Thrombophlebitis treated by ligature, 441 Thrombus, its stages, 288 Tier sutures, 752 Tissues, reaction of, to injury, 76 Tongue, its diagnostic indications, 517 Touch, sense of, in relation to diagnosis, 535 Towels, as used in operations, 720 Toxic ulceration, from drugs, 227 Toxinsemia, defined, 426 in inflammation, 96 TrabeculiE, their development, 281 Trained nurse and her duties, 722 Training school for nurses inaugurated in Bellevue Hospital, 32 Translucency as an aid in diagnosis, 515 Transplantable mouse tumors, their char- acteristics, 394 Transudates, 237, 574 Transylvania University, medical department of, founded, 25 Traumatic lesions of the spinal cord from disease or injury, their effects, 544 Tubercula dolorosa, 319, 328 Tuberculosis of bone, x-ray diagnosis of, 644, 645 Tuberculous ulceration, 226, 230 Tubes, radiographic method of testing, 614 Tumor (or neoplasm) defined, 291, 292, 370 Tumor formation, 291 arguments against Cohnheim's theorj', 376 as related to unstable cell equilibrium, 293 Cheyne's views, 378 Cohnheim's theory, 374 Kelling's theory, 382 Max Borst's views, 377 results of, 368 Ribbert's views, 377 Schroeder van der Kolk's theory, 383 hypothesis of parasitism, 380 theories of, 370 Thiersch's views, 378 Tumors, benign and malignant, 294 classification of. 294, 296 INDEX. 817 Tumors, etiology of, 292 gross appearance of, 293 histioid and organoid, 295 homoplastic or heteroplastic, 296 in mice, their contagiousness and com- municability, 393 of epiblastic origin, 299 of epithelial type, 344 of hypoblastic origin, 299 of mesoblastic origin, 299 of mixed epithelial and connective-tissue types, 297 of non-epithelial type, 301 of unstriped muscle, 317 spontaneously retrograding, their his- tological characteristics identical with retrogression effected by treatment, 401 their malignancy, 379 ulceration in, 227 TJlceeatign, 210, 416 and caries, 223 complications and sequelae of, 232 etiology, 224 impaired circulation important etiologi- caUy, 224 in glanders, 227 in leprosy, 227 infection an element of, 225 pathology of, 227 phagedenic, 225 pressure a cause, 225 traumatism a common cause, 224 Ulcers, 131, 132, 41S annular, 142 callous, 142 croupous or diphtheritic, 142 eczematous, 230 fungating, 132 gouty, 143, 230 healing of, 104, 132 hemorrhagic, 132 indolent, 132, 142 irritable or painful, 143 malignant, 131, 132 microscopical appearances of, 228 oedematous, 142 perforating, 142 phagedenic, 132 pressure (decubitus), 133 raw, 142 scirrhous, 132 scorbutic, 230 serpiginous, 132, 142 sloughing, 132 spreading, 132 syphihtic, 131, 133, 143 traumatic, 133 VOL. I. — 52 Ulcers, tuberculous, 144 va:ricose, 133, 142 Ulcus elevatum hypertrophicum, 142 Ureters, their examination and diagnostic relations, 551 Urethral secretions, data obtainable by ex- amining them, 566 Uric-acid deposits in gout, 200 infarcts in the new-born, 200 Urinary calculi, 202 chemical classification of, 202 formation of, due primarily to disturbed metabolism, 202 of cystin, 203 Urinary examination for diagnosis, 545 to determine the relative activity of the two kidneys, 568 Urinary organs, relations of sundry morbid phenomena, 552 Urination, diagnostic features of modifications in the manner and frequency of the act, 546 force of the stream, its variations, 549 Urine, determination of urea and uric acid and deductions therefrom, 568 examination of, by kiyoscopy, 568 examination of, sources of error to be guarded against, 567 incontinence of, definition of the term and its diagnostic relations, 548 overflow of, its significance, 547 retention of; causes and significance, 547 Uterine epithelium, reproduction of, 258 Uterine fibroids, removal of, during preg- nancy, 779 types of, 303 Vaginal secretions, parasites to be found therein, 566 Van Leyden's bird's-eye inclusions, 388 Vascular dilatation and paralysis as related to shock, 465 Vasomotor paralysis, diagnostic features, 544 Veins, repair of injury to, 288 their pathological changes as related to diagnosis, 531 Veldt sores, 230 Venous obstruction, sequence of pathological changes from, 235, 532 Venous pressure, increased, as a cause of nedema, 237 Vermiform appendix, perforative inflamma- tion of; report by R. J. Fitz, 59 Von Mosetig-Moorhoff bone plug, its prep- aration and use 724 Wallerian degeneration, 178 Warren, John, 10 818 INDEX. Warren, John C, 19 Warren, Gen. Joseph, 10 Warthin, Aldred Scott, 71 Warts, significance of Perthes' experiments with the x-ray on, 402 Wehnelt's electrolytic interrupter, 603 Wehnelt interrupter, 605 Wells, Horace, 6-t White scar tissue, an eligible seat for skin grafts, 270 Whitlow, 128 Women, greater power of endurance in, 777 Wood, James R., 31 Wounds, accurate closure of, its importance in treatment, 273 aseptic, surgical principles associated with them, 751 contused and lacerated, 756 diphtheritis of, 135 infections of, 415, 418, 757 secondary suturing of, 757 suspected, 755 treatment of, 272, 751, 758 x-BAY anatomy, its special features, 642 x-ray appearances of subperiosteal bone de- posit compared with those of osteomyelitis and periostitis albumosa, 667 x-ray appearance of late hereditary and ter- tiary bone syphilis, 665 of diiTerent types of osteomyelitis, 650 x-ray burns, pathology and peculiarities of, 638 x-ray exposure as a cause of sterility, 637 x-ray plant, essentials of, 601 importance of the rheostat, 607 the coil, its essentials, 601 the interrupter, 603 use of alternating current or static ma- chine, 608 x-ray plates, compression apparatus used in making, description of it, 632 development of, 619 method of taking them, 625 x-ray therapy in cancerous and tuberculous disease, 600 x-ray tubes, 60S as influenced by the inverse discharge, 611 injurious methods of using, 611 methods of testing, 611 phenomena observed in the process of ■ seasoning, 610 the cathode stream, 609 the process of seasoning or ageing, 609 x-rays, harmful effects of, 636 protective measures against, 639, 640 ZUCKERGDSSLEBER, 140 COLUMBIA UNIVERSITY LIBRARIES (hsl.slx) RD 31 B84 C.1 V.1 American oractice o* ?,|;'8f,XiiiiiiiiiiiiiMiii 2002063271 i||i|ll'llill!Mll!llll!i!lllll!llllll{|l!lillll!ll li'iiii'lll pi !ll||llll!illllllill Wm iiyiSal |i}'*i*?P!! 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