Project Gutenberg's Manual of Surgery, by Alexis Thomson and Alexander Miles
This eBook is for the use of anyone anywhere at no cost and with
almost no restrictions whatsoever. You may copy it, give it away or
re-use it under the terms of the Project Gutenberg License included
with this eBook or online at www.gutenberg.org
Title: Manual of Surgery
Volume First: General Surgery. Sixth Edition.
Author: Alexis Thomson and Alexander Miles
Release Date: March 4, 2006 [EBook #17921]
Language: English
Character set encoding: ISO-8859-1
*** START OF THIS PROJECT GUTENBERG EBOOK MANUAL OF SURGERY ***
Produced by Jonathan Ingram, Laura Wisewell and the Online
Distributed Proofreading Team at http://www.pgdp.net
+--------------------------------------------------------------------+
| |
| Transcriber's note: The original text used the apothecaries' |
| symbols here rendered as [ounce] and [dram]. The substitutions |
| used for other special characters, such as the oe ligature, are |
| standard. All the special characters are preserved in the UTF-8 |
| and HTML versions of this text. |
| |
| In addition, a number of printing errors have been corrected. |
| These are marked in the HTML version only. |
| |
+--------------------------------------------------------------------+
OXFORD MEDICAL PUBLICATIONS
MANUAL OF SURGERY
BY
ALEXIS THOMSON, F.R.C.S.Ed.
_PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
SURGEON EDINBURGH ROYAL INFIRMARY
AND
ALEXANDER MILES, F.R.C.S.Ed.
SURGEON EDINBURGH ROYAL INFIRMARY
VOLUME FIRST
GENERAL SURGERY
_SIXTH EDITION REVISED_
_WITH 169 ILLUSTRATIONS_
LONDON
HENRY FROWDE and HODDER & STOUGHTON
THE _LANCET_ BUILDING
1 & 2 BEDFORD STREET, STRAND, W.C.2
First Edition 1904
Second Edition 1907
Third Edition 1909
Fourth Edition 1911
" " Second Impression 1913
Fifth Edition 1915
" " Second Impression 1919
Sixth Edition 1921
PRINTED IN GREAT BRITAIN BY
MORRISON AND GIBB LTD., EDINBURGH
PREFACE TO SIXTH EDITION
Much has happened since this Manual was last revised, and many surgical
lessons have been learned in the hard school of war. Some may yet have
to be unlearned, and others have but little bearing on the problems
presented to the civilian surgeon. Save in its broadest principles, the
surgery of warfare is a thing apart from the general surgery of civil
life, and the exhaustive literature now available on every aspect of it
makes it unnecessary that it should receive detailed consideration in a
manual for students. In preparing this new edition, therefore, we have
endeavoured to incorporate only such additions to our knowledge and
resources as our experience leads us to believe will prove of permanent
value in civil practice.
For the rest, the text has been revised, condensed, and in places
rearranged; a number of old illustrations have been discarded, and a
greater number of new ones added. Descriptions of operative procedures
have been omitted from the _Manual_, as they are to be found in the
companion volume on _Operative Surgery_, the third edition of which
appeared some months ago.
We have retained the Basle anatomical nomenclature, as extended
experience has confirmed our preference for it. For the convenience of
readers who still employ the old terms, these are given in brackets
after the new.
This edition of the _Manual_ appears in three volumes; the first being
devoted to General Surgery, the other two to Regional Surgery. This
arrangement has enabled us to deal in a more consecutive manner than
hitherto with the surgery of the Extremities, including Fractures and
Dislocations.
We have once more to express our thanks to colleagues in the Edinburgh
School and to other friends for aiding us in providing new
illustrations, and for other valuable help, as well as to our publishers
for their generosity in the matter of illustrations.
EDINBURGH,
_March_ 1921.
CONTENTS
PAGE
CHAPTER I
REPAIR 1
CHAPTER II
CONDITIONS WHICH INTERFERE WITH REPAIR 17
CHAPTER III
INFLAMMATION 31
CHAPTER IV
SUPPURATION 45
CHAPTER V
ULCERATION AND ULCERS 68
CHAPTER VI
GANGRENE 86
CHAPTER VII
BACTERIAL AND OTHER WOUND INFECTIONS 107
CHAPTER VIII
TUBERCULOSIS 133
CHAPTER IX
SYPHILIS 146
CHAPTER X
TUMOURS 181
CHAPTER XI
INJURIES 218
CHAPTER XII
METHODS OF WOUND TREATMENT 241
CHAPTER XIII
CONSTITUTIONAL EFFECTS OF INJURIES 249
CHAPTER XIV
THE BLOOD VESSELS 258
CHAPTER XV
THE LYMPH VESSELS AND GLANDS 321
CHAPTER XVI
THE NERVES 342
CHAPTER XVII
SKIN AND SUBCUTANEOUS TISSUES 376
CHAPTER XVIII
THE MUSCLES, TENDONS, AND TENDON SHEATHS 405
CHAPTER XIX
THE BURSÆ 426
CHAPTER XX
DISEASES OF BONE 434
CHAPTER XXI
DISEASES OF JOINTS 501
INDEX 547
LIST OF ILLUSTRATIONS
FIG. PAGE
1. Ulcer of Back of Hand grafted from Abdominal Wall 15
2. Staphylococcus aureus in Pus from case of Osteomyelitis 25
3. Streptococci in Pus from case of Diffuse Cellulitis 26
4. Bacillus coli communis in Pus from Abdominal Abscess 27
5. Fraenkel's Pneumococci in Pus from Empyema following 28
Pneumonia
6. Passive Hyperæmia of Hand and Forearm induced by Bier's 37
Bandage
7. Passive Hyperæmia of Finger induced by Klapp's Suction 38
Bell
8. Passive Hyperæmia induced by Klapp's Suction Bell for 39
Inflammation of Inguinal Gland
9. Diagram of various forms of Whitlow 56
10. Charts of Acute Sapræmia 61
11. Chart of Hectic Fever 62
12. Chart of Septicæmia followed by Pyæmia 63
13. Chart of Pyæmia following on Acute Osteomyelitis 65
14. Leg Ulcers associated with Varicose Veins 71
15. Perforating Ulcers of Sole of Foot 74
16. Bazin's Disease in a girl æt. 16 75
17. Syphilitic Ulcers in region of Knee 76
18. Callous Ulcer showing thickened edges 78
19. Tibia and Fibula, showing changes due to Chronic Ulcer of 80
Leg
20. Senile Gangrene of the Foot 89
21. Embolic Gangrene of Hand and Arm 92
22. Gangrene of Terminal Phalanx of Index-Finger 100
23. Cancrum Oris 103
24. Acute Bed Sores over right Buttock 104
25. Chart of Erysipelas occurring in a wound 108
26. Bacillus of Tetanus 113
27. Bacillus of Anthrax 120
28. Malignant Pustule third day after infection 122
29. Malignant Pustule fourteen days after infection 122
30. Colony of Actinomyces 126
31. Actinomycosis of Maxilla 128
32. Mycetoma, or Madura Foot 130
33. Tubercle bacilli 134
34. Tuberculous Abscess in Lumbar Region 141
35. Tuberculous Sinus injected through its opening in the 144
Forearm with Bismuth Paste
36. Spirochæte pallida 147
37. Spirochæta refrigerans from scraping of Vagina 148
38. Primary Lesion on Thumb, with Secondary Eruption on 154
Forearm
39. Syphilitic Rupia 159
40. Ulcerating Gumma of Lips 169
41. Ulceration in inherited Syphilis 170
42. Tertiary Syphilitic Ulceration in region of Knee and on 171
both Thumbs
43. Facies of Inherited Syphilis 174
44. Facies of Inherited Syphilis 175
45. Subcutaneous Lipoma 185
46. Pedunculated Lipoma of Buttock 186
47. Diffuse Lipomatosis of Neck 187
48. Zanthoma of Hands 188
49. Zanthoma of Buttock 189
50. Chondroma growing from Infra-Spinous Fossa of Scapula 190
51. Chondroma of Metacarpal Bone of Thumb 190
52. Cancellous Osteoma of Lower End of Femur 192
53. Myeloma of Shaft of Humerus 195
54. Fibro-myoma of Uterus 196
55. Recurrent Sarcoma of Sciatic Nerve 198
56. Sarcoma of Arm fungating 199
57. Carcinoma of Breast 206
58. Epithelioma of Lip 209
59. Dermoid Cyst of Ovary 213
60. Carpal Ganglion in a woman æt. 25 215
61. Ganglion on lateral aspect of Knee 216
62. Radiogram showing pellets embedded in Arm 228
63. Cicatricial Contraction following Severe Burn 236
64. Genealogical Tree of Hæmophilic Family 278
65. Radiogram showing calcareous degeneration of Arteries 284
66. Varicose Vein with Thrombosis 289
67. Extensive Varix of Internal Saphena System on Left Leg 291
68. Mixed Nævus of Nose 296
69. Cirsoid Aneurysm of Forehead 299
70. Cirsoid Aneurysm of Orbit and Face 300
71. Radiogram of Aneurysm of Aorta 303
72. Sacculated Aneurysm of Abdominal Aorta 304
73. Radiogram of Innominate Aneurysm after Treatment by 309
Moore-Corradi method
74. Thoracic Aneurysm threatening to rupture 313
75. Innominate Aneurysm in a woman 315
76. Congenital Cystic Tumour or Hygroma of Axilla 328
77. Tuberculous Cervical Gland with Abscess formation 331
78. Mass of Tuberculous Glands removed from Axilla 333
79. Tuberculous Axillary Glands 335
80. Chronic Hodgkin's Disease in boy æt. 11 337
81. Lymphadenoma in a woman æt. 44 338
82. Lympho Sarcoma removed from Groin 339
83. Cancerous Glands in Neck, secondary to Epithelioma of Lip 341
84. Stump Neuromas of Sciatic Nerve 345
85. Stump Neuromas, showing changes at ends of divided Nerves 354
86. Diffuse Enlargement of Nerves in generalised 356
Neuro-Fibromatosis
87. Plexiform Neuroma of small Sciatic Nerve 357
88. Multiple Neuro-Fibromas of Skin (Molluscum fibrosum) 358
89. Elephantiasis Neuromatosa in a woman æt. 28 359
90. Drop-Wrist following Fracture of Shaft of Humerus 365
91. To illustrate the Loss of Sensation produced by Division 367
of the Median Nerve
92. To illustrate Loss of Sensation produced by Complete 368
Division of Ulnar Nerve
93. Callosities and Corns on Sole of Foot 377
94. Ulcerated Chilblains on Fingers 378
95. Carbuncle on Back of Neck 381
96. Tuberculous Elephantiasis 383
97. Elephantiasis in a woman æt. 45 387
98. Elephantiasis of Penis and Scrotum 388
99. Multiple Sebaceous Cysts or Wens 390
100. Sebaceous Horn growing from Auricle 392
101. Paraffin Epithelioma 394
102. Rodent Cancer of Inner Canthus 395
103. Rodent Cancer with destruction of contents of Orbit 396
104. Diffuse Melanotic Cancer of Lymphatics of Skin 398
105. Melanotic Cancer of Forehead with Metastasis in Lymph 399
Glands
106. Recurrent Keloid 401
107. Subungual Exostosis 403
108. Avulsion of Tendon 410
109. Volkmann's Ischæmic Contracture 414
110. Ossification in Tendon of Ilio-psoas Muscle 417
111. Radiogram of Calcification and Ossification in Biceps and 418
Triceps
112. Ossification in Muscles of Trunk in generalised Ossifying 419
Myositis
113. Hydrops of Prepatellar Bursa 427
114. Section through Gouty Bursa 428
115. Tuberculous Disease of Sub-Deltoid Bursa 429
116. Great Enlargement of the Ischial Bursa 431
117. Gouty Disease of Bursæ 432
118. Shaft of the Femur after Acute Osteomyelitis 444
119. Femur and Tibia showing results of Acute Osteomyelitis 445
120. Segment of Tibia resected for Brodie's Abscess 449
121. Radiogram of Brodie's Abscess in Lower End of Tibia 451
122. Sequestrum of Femur after Amputation 453
123. New Periosteal Bone on Surface of Femur from Amputation 454
Stump
124. Tuberculous Osteomyelitis of Os Magnum 456
125. Tuberculous Disease of Tibia 457
126. Diffuse Tuberculous Osteomyelitis of Right Tibia 458
127. Advanced Tuberculous Disease in Region of Ankle 459
128. Tuberculous Dactylitis 460
129. Shortening of Middle Finger of Adult, the result of 461
Tuberculous Dactylitis in Childhood
130. Syphilitic Disease of Skull 463
131. Syphilitic Hyperostosis and Sclerosis of Tibia 464
132. Sabre-blade Deformity of Tibia 467
133. Skeleton of Rickety Dwarf 470
134. Changes in the Skull resulting from Ostitis Deformans 474
135. Cadaver, illustrating the alterations in the Lower Limbs 475
resulting from Ostitis Deformans
136. Osteomyelitis Fibrosa affecting Femora 476
137. Radiogram of Upper End of Femur in Osteomyelitis Fibrosa 478
138. Radiogram of Right Knee showing Multiple Exostoses 482
139. Multiple Exostoses of Limbs 483
140. Multiple Cartilaginous Exostoses 484
141. Multiple Cartilaginous Exostoses 486
142. Multiple Chondromas of Phalanges and Metacarpals 488
143. Skiagram of Multiple Chondromas 489
144. Multiple Chondromas in Hand 490
145. Radiogram of Myeloma of Humerus 492
146. Periosteal Sarcoma of Femur 493
147. Periosteal Sarcoma of Humerus 493
148. Chondro-Sarcoma of Scapula 494
149. Central Sarcoma of Femur invading Knee Joint 495
150. Osseous Shell of Osteo-Sarcoma of Femur 495
151. Radiogram of Osteo-Sarcoma of Femur 496
152. Radiogram of Chondro-Sarcoma of Humerus 497
153. Epitheliomatus Ulcer of Leg invading Tibia 499
154. Osseous Ankylosis of Femur and Tibia 503
155. Osseous Ankylosis of Knee 504
156. Caseating focus in Upper End of Fibula 513
157. Arthritis Deformans of Elbow 525
158. Arthritis Deformans of Knee 526
159. Hypertrophied Fringes of Synovial Membrane of Knee 527
160. Arthritis Deformans of Hands 529
161. Arthritis Deformans of several Joints 530
162. Bones of Knee in Charcot's Disease 533
163. Charcot's Disease of Left Knee 534
164. Charcot's Disease of both Ankles: front view 535
165. Charcot's Disease of both Ankles: back view 536
166. Radiogram of Multiple Loose Bodies in Knee-joint 540
167. Loose Body from Knee-joint 541
168. Multiple partially ossified Chondromas of Synovial 542
Membrane from Shoulder-joint
169. Multiple Cartilaginous Loose Bodies from Knee-joint 543
MANUAL OF SURGERY
CHAPTER I
REPAIR
Introduction--Process of repair--Healing by primary union--Granulation
tissue--Cicatricial tissue--Modifications of process of
repair--Repair in individual tissues--Transplantation or grafting
of tissues--Conditions--Sources of grafts--Grafting of individual
tissues--Methods.
INTRODUCTION
To prolong human life and to alleviate suffering are the ultimate
objects of scientific medicine. The two great branches of the healing
art--Medicine and Surgery--are so intimately related that it is
impossible to draw a hard-and-fast line between them, but for
convenience Surgery may be defined as "the art of treating lesions and
malformations of the human body by manual operations, mediate and
immediate." To apply his art intelligently and successfully, it is
essential that the surgeon should be conversant not only with the normal
anatomy and physiology of the body and with the various pathological
conditions to which it is liable, but also with the nature of the
process by which repair of injured or diseased tissues is effected.
Without this knowledge he is unable to recognise such deviations from
the normal as result from mal-development, injury, or disease, or
rationally to direct his efforts towards the correction or removal of
these.
PROCESS OF REPAIR
The process of repair in living tissue depends upon an inherent power
possessed by vital cells of reacting to the irritation caused by injury
or disease. The cells of the damaged tissues, under the influence of
this irritation, undergo certain proliferative changes, which are
designed to restore the normal structure and configuration of the part.
The process by which this restoration is effected is essentially the
same in all tissues, but the extent to which different tissues can carry
the recuperative process varies. Simple structures, such as skin,
cartilage, bone, periosteum, and tendon, for example, have a high power
of regeneration, and in them the reparative process may result in almost
perfect restitution to the normal. More complex structures, on the other
hand, such as secreting glands, muscle, and the tissues of the central
nervous system, are but imperfectly restored, simple cicatricial
connective tissue taking the place of what has been lost or destroyed.
Any given tissue can be replaced only by tissue of a similar kind, and
in a damaged part each element takes its share in the reparative process
by producing new material which approximates more or less closely to the
normal according to the recuperative capacity of the particular tissue.
The normal process of repair may be interfered with by various
extraneous agencies, the most important of which are infection by
disease-producing micro-organisms, the presence of foreign substances,
undue movement of the affected part, and improper applications and
dressings. The effect of these agencies is to delay repair or to prevent
the individual tissues carrying the process to the furthest degree of
which they are capable.
In the management of wounds and other diseased conditions the main
object of the surgeon is to promote the natural reparative process by
preventing or eliminating any factor by which it may be disturbed.
#Healing by Primary Union.#--The most favourable conditions for the
progress of the reparative process are to be found in a clean-cut wound
of the integument, which is uncomplicated by loss of tissue, by the
presence of foreign substances, or by infection with disease-producing
micro-organisms, and its edges are in contact. Such a wound in virtue of
the absence of infection is said to be _aseptic_, and under these
conditions healing takes place by what is called "primary union"--the
"healing by first intention" of the older writers.
#Granulation Tissue.#--The essential and invariable medium of repair in
all structures is an elementary form of new tissue known as _granulation
tissue_, which is produced in the damaged area in response to the
irritation caused by injury or disease. The vital reaction induced by
such irritation results in dilatation of the vessels of the part,
emigration of leucocytes, transudation of lymph, and certain
proliferative changes in the fixed tissue cells. These changes are
common to the processes of inflammation and repair; no hard-and-fast
line can be drawn between these processes, and the two may go on
together. It is, however, only when the proliferative changes have come
to predominate that the reparative process is effectively established by
the production of healthy granulation tissue.
_Formation of Granulation Tissue._--When a wound is made in the
integument under aseptic conditions, the passage of the knife through
the tissues is immediately followed by an oozing of blood, which soon
coagulates on the cut surfaces. In each of the divided vessels a clot
forms, and extends as far as the nearest collateral branch; and on the
surface of the wound there is a microscopic layer of bruised and
devitalised tissue. If the wound is closed, the narrow space between its
edges is occupied by blood-clot, which consists of red and white
corpuscles mixed with a quantity of fibrin, and this forms a temporary
uniting medium between the divided surfaces. During the first twelve
hours, the minute vessels in the vicinity of the wound dilate, and from
them lymph exudes and leucocytes migrate into the tissues. In from
twenty-four to thirty-six hours, the capillaries of the part adjacent to
the wound begin to throw out minute buds and fine processes, which
bridge the gap and form a firmer, but still temporary, connection
between the two sides. Each bud begins in the wall of the capillary as a
small accumulation of granular protoplasm, which gradually elongates
into a filament containing a nucleus. This filament either joins with a
neighbouring capillary or with a similar filament, and in time these
become hollow and are filled with blood from the vessels that gave them
origin. In this way a series of young _capillary loops_ is formed.
The spaces between these loops are filled by cells of various kinds, the
most important being the _fibroblasts_, which are destined to form
cicatricial fibrous tissue. These fibroblasts are large irregular
nucleated cells derived mainly from the proliferation of the fixed
connective-tissue cells of the part, and to a less extent from the
lymphocytes and other mononuclear cells which have migrated from the
vessels. Among the fibroblasts, larger multi-nucleated cells--_giant
cells_--are sometimes found, particularly when resistant substances,
such as silk ligatures or fragments of bone, are embedded in the
tissues, and their function seems to be to soften such substances
preliminary to their being removed by the phagocytes. Numerous
_polymorpho-nuclear leucocytes_, which have wandered from the vessels,
are also present in the spaces. These act as phagocytes, their function
being to remove the red corpuscles and fibrin of the original clot, and
this performed, they either pass back into the circulation in virtue of
their amoeboid movement, or are themselves eaten up by the growing
fibroblasts. Beyond this phagocytic action, they do not appear to play
any direct part in the reparative process. These young capillary loops,
with their supporting cells and fluids, constitute granulation tissue,
which is usually fully formed in from three to five days, after which it
begins to be replaced by cicatricial or scar tissue.
_Formation of Cicatricial Tissue._--The transformation of this temporary
granulation tissue into scar tissue is effected by the fibroblasts,
which become elongated and spindle-shaped, and produce in and around
them a fine fibrillated material which gradually increases in quantity
till it replaces the cell protoplasm. In this way white fibrous tissue
is formed, the cells of which are arranged in parallel lines and
eventually become grouped in bundles, constituting fully formed white
fibrous tissue. In its growth it gradually obliterates the capillaries,
until at the end of two, three, or four weeks both vessels and cells
have almost entirely disappeared, and the original wound is occupied by
cicatricial tissue. In course of time this tissue becomes consolidated,
and the cicatrix undergoes a certain amount of contraction--_cicatricial
contraction_.
_Healing of Epidermis._--While these changes are taking place in the
deeper parts of the wound, the surface is being covered over by
_epidermis_ growing in from the margins. Within twelve hours the cells
of the rete Malpighii close to the cut edge begin to sprout on to the
surface of the wound, and by their proliferation gradually cover the
granulations with a thin pink pellicle. As the epithelium increases in
thickness it assumes a bluish hue and eventually the cells become
cornified and the epithelium assumes a greyish-white colour.
_Clinical Aspects._--So long as the process of repair is not complicated
by infection with micro-organisms, there is no interference with the
general health of the patient. The temperature remains normal; the
circulatory, gastro-intestinal, nervous, and other functions are
undisturbed; locally, the part is cool, of natural colour and free from
pain.
#Modifications of the Process of Repair.#--The process of repair by
primary union, above described, is to be looked upon as the type of all
reparative processes, such modifications as are met with depending
merely upon incidental differences in the conditions present, such as
loss of tissue, infection by micro-organisms, etc.
_Repair after Loss or Destruction of Tissue._--When the edges of a wound
cannot be approximated either because tissue has been lost, for example
in excising a tumour or because a drainage tube or gauze packing has
been necessary, a greater amount of granulation tissue is required to
fill the gap, but the process is essentially the same as in the ideal
method of repair.
The raw surface is first covered by a layer of coagulated blood and
fibrin. An extensive new formation of capillary loops and fibroblasts
takes place towards the free surface, and goes on until the gap is
filled by a fine velvet-like mass of granulation tissue. This
granulation tissue is gradually replaced by young cicatricial tissue,
and the surface is covered by the ingrowth of epithelium from the edges.
This modification of the reparative process can be best studied
clinically in a recent wound which has been packed with gauze. When the
plug is introduced, the walls of the cavity consist of raw tissue with
numerous oozing blood vessels. On removing the packing on the fifth or
sixth day, the surface is found to be covered with minute, red,
papillary granulations, which are beginning to fill up the cavity. At
the edges the epithelium has proliferated and is covering over the newly
formed granulation tissue. As lymph and leucocytes escape from the
exposed surface there is a certain amount of serous or sero-purulent
discharge. On examining the wound at intervals of a few days, it is
found that the granulation tissue gradually increases in amount till the
gap is completely filled up, and that coincidently the epithelium
spreads in and covers over its surface. In course of time the epithelium
thickens, and as the granulation tissue is slowly replaced by young
cicatricial tissue, which has a peculiar tendency to contract and so to
obliterate the blood vessels in it, the scar that is left becomes
smooth, pale, and depressed. This method of healing is sometimes spoken
of as "healing by granulation"--although, as we have seen, it is by
granulation that all repair takes place.
_Healing by Union of two Granulating Surfaces._--In gaping wounds union
is sometimes obtained by bringing the two surfaces into apposition after
each has become covered with healthy granulations. The exudate on the
surfaces causes them to adhere, capillary loops pass from one to the
other, and their final fusion takes place by the further development of
granulation and cicatricial tissue.
_Reunion of Parts entirely Separated from the Body._--Small portions of
tissue, such as the end of a finger, the tip of the nose or a portion of
the external ear, accidentally separated from the body, if accurately
replaced and fixed in position, occasionally adhere by primary union.
In the course of operations also, portions of skin, fascia, or bone, or
even a complete joint may be transplanted, and unite by primary union.
_Healing under a Scab._--When a small superficial wound is exposed to
the air, the blood and serum exuded on its surface may dry and form a
hard crust or _scab_, which serves to protect the surface from external
irritation in the same way as would a dry pad of sterilised gauze. Under
this scab the formation of granulation tissue, its transformation into
cicatricial tissue, and the growth of epithelium on the surface, go on
until in the course of time the crust separates, leaving a scar.
_Healing by Blood-clot._--In subcutaneous wounds, for example tenotomy,
in amputation wounds, and in wounds made in excising tumours or in
operating upon bones, the space left between the divided tissues becomes
filled with blood-clot, which acts as a temporary scaffolding in which
granulation tissue is built up. Capillary loops grow into the coagulum,
and migrated leucocytes from the adjacent blood vessels destroy the red
corpuscles, and are in turn disposed of by the developing fibroblasts,
which by their growth and proliferation fill up the gap with young
connective tissue. It will be evident that this process only differs
from healing by primary union in the _amount_ of blood-clot that is
present.
_Presence of a Foreign Body._--When an aseptic foreign body is present
in the tissues, _e.g._ a piece of unabsorbable chromicised catgut, the
healing process may be modified. After primary union has taken place the
scar may broaden, become raised above the surface, and assume a
bluish-brown colour; the epidermis gradually thins and gives way,
revealing the softened portion of catgut, which can be pulled out in
pieces, after which the wound rapidly heals and resumes a normal
appearance.
REPAIR IN INDIVIDUAL TISSUES
_Skin and Connective Tissue._--The mode of regeneration of these tissues
under aseptic conditions has already been described as the type of ideal
repair. In highly vascular parts, such as the face, the reparative
process goes on with great rapidity, and even extensive wounds may be
firmly united in from three to five days. Where the anastomosis is less
free the process is more prolonged. The more highly organised elements
of the skin, such as the hair follicles, the sweat and sebaceous glands,
are imperfectly reproduced; hence the scar remains smooth, dry, and
hairless.
_Epithelium._--Epithelium is only reproduced from pre-existing
epithelium, and, as a rule, from one of a similar type, although
metaplastic transformation of cells of one kind of epithelium into
another kind can take place. Thus a granulating surface may be covered
entirely by the ingrowing of the cutaneous epithelium from the margins;
or islets, originating in surviving cells of sebaceous glands or sweat
glands, or of hair follicles, may spring up in the centre of the raw
area. Such islets may also be due to the accidental transference of
loose epithelial cells from the edges. Even the fluid from a blister, in
virtue of the isolated cells of the rete Malpighii which it contains, is
capable of starting epithelial growth on a granulating surface. Hairs
and nails may be completely regenerated if a sufficient amount of the
hair follicles or of the nail matrix has escaped destruction. The
epithelium of a mucous membrane is regenerated in the same way as that
on a cutaneous surface.
Epithelial cells have the power of living for some time after being
separated from their normal surroundings, and of growing again when once
more placed in favourable circumstances. On this fact the practice of
skin grafting is based (p. 11).
_Cartilage._--When an articular cartilage is divided by incision or by
being implicated in a fracture involving the articular end of a bone, it
is repaired by ordinary cicatricial fibrous tissue derived from the
proliferating cells of the perichondrium. Cartilage being a non-vascular
tissue, the reparative process goes on slowly, and it may be many weeks
before it is complete.
It is possible for a metaplastic transformation of connective-tissue
cells into cartilage cells to take place, the characteristic hyaline
matrix being secreted by the new cells. This is sometimes observed as an
intermediary stage in the healing of fractures, especially in young
bones. It may also take place in the regeneration of lost portions of
cartilage, provided the new tissue is so situated as to constitute part
of a joint and to be subjected to pressure by an opposing cartilaginous
surface. This is illustrated by what takes place after excision of
joints where it is desired to restore the function of the articulation.
By carrying out movements between the constituent parts, the fibrous
tissue covering the ends of the bones becomes moulded into shape, its
cells take on the characters of cartilage cells, and, forming a matrix,
so develop a new cartilage.
Conversely, it is observed that when articular cartilage is no longer
subjected to pressure by an opposing cartilage, it tends to be
transformed into fibrous tissue, as may be seen in deformities attended
with displacement of articular surfaces, such as hallux valgus and
club-foot.
After fractures of costal cartilage or of the cartilages of the larynx
the cicatricial tissue may be ultimately replaced by bone.
_Tendons._--When a tendon is divided, for example by subcutaneous
tenotomy, the end nearer the muscle fibres is drawn away from the other,
leaving a gap which is speedily filled by blood-clot. In the course of a
few days this clot becomes permeated by granulation tissue, the
fibroblasts of which are derived from the sheath of the tendon, the
surrounding connective tissue, and probably also from the divided ends
of the tendon itself. These fibroblasts ultimately develop into typical
tendon cells, and the fibres which they form constitute the new tendon
fibres. Under aseptic conditions repair is complete in from two to three
weeks. In the course of the reparative process the tendon and its sheath
may become adherent, which leads to impaired movement and stiffness. If
the ends of an accidentally divided tendon are at once brought into
accurate apposition and secured by sutures, they unite directly with a
minimum amount of scar tissue, and function is perfectly restored.
_Muscle._--Unstriped muscle does not seem to be capable of being
regenerated to any but a moderate degree. If the ends of a divided
striped muscle are at once brought into apposition by stitches, primary
union takes place with a minimum of intervening fibrous tissue. The
nuclei of the muscle fibres in close proximity to this young cicatricial
tissue proliferate, and a few new muscle fibres may be developed, but
any gross loss of muscular tissue is replaced by a fibrous cicatrix. It
would appear that portions of muscle transplanted from animals to fill
up gaps in human muscle are similarly replaced by fibrous tissue. When a
muscle is paralysed from loss of its nerve supply and undergoes complete
degeneration, it is not capable of being regenerated, even should the
integrity of the nerve be restored, and so its function is permanently
lost.
_Secretory Glands._--The regeneration of secretory glands is usually
incomplete, cicatricial tissue taking the place of the glandular
substance which has been destroyed. In wounds of the liver, for example,
the gap is filled by fibrous tissue, but towards the periphery of the
wound the liver cells proliferate and a certain amount of regeneration
takes place. In the kidney also, repair mainly takes place by
cicatricial tissue, and although a few collecting tubules may be
reformed, no regeneration of secreting tissue takes place. After the
operation of decapsulation of the kidney a new capsule is formed, and
during the process young blood vessels permeate the superficial parts
of the kidney and temporarily increase its blood supply, but in the
consolidation of the new fibrous tissue these vessels are ultimately
obliterated. This does not prove that the operation is useless, as the
temporary improvement of the circulation in the kidney may serve to tide
the patient over a critical period of renal insufficiency.
_Stomach and Intestine._--Provided the peritoneal surfaces are
accurately apposed, wounds of the stomach and intestine heal with great
rapidity. Within a few hours the peritoneal surfaces are glued together
by a thin layer of fibrin and leucocytes, which is speedily organised
and replaced by fibrous tissue. Fibrous tissue takes the place of the
muscular elements, which are not regenerated. The mucous lining is
restored by ingrowth from the margins, and there is evidence that some
of the secreting glands may be reproduced.
Hollow viscera, like the oesophagus and urinary bladder, in so far
as they are not covered by peritoneum, heal less rapidly.
_Nerve Tissues._--There is no trustworthy evidence that regeneration of
the tissues of the brain or spinal cord in man ever takes place. Any
loss of substance is replaced by cicatricial tissue.
The repair of _Bone_, _Blood Vessels_, and _Peripheral Nerves_ is more
conveniently considered in the chapters dealing with these structures.
#Rate of Healing.#--While the rate at which wounds heal is remarkably
constant there are certain factors that influence it in one direction or
the other. Healing is more rapid when the edges are in contact, when
there is a minimum amount of blood-clot between them, when the patient
is in normal health and the vitality of the tissues has not been
impaired. Wounds heal slightly more quickly in the young than in the
old, although the difference is so small that it can only be
demonstrated by the most careful observations.
Certain tissues take longer to heal than others: for example, a fracture
of one of the larger long bones takes about six weeks to unite, and
divided nerve trunks take much longer--about a year.
Wounds of certain parts of the body heal more quickly than others: those
of the scalp, face, and neck, for example, heal more quickly than those
over the buttock or sacrum, probably because of their greater
vascularity.
The extent of the wound influences the rate of healing; it is only
natural that a long and deep wound should take longer to heal than a
short and superficial one, because there is so much more work to be
done in the conversion of blood-clot into granulation tissue, and this
again into scar tissue that will be strong enough to stand the strain on
the edges of the wound.
THE TRANSPLANTATION OR GRAFTING OF TISSUES
Conditions are not infrequently met with in which healing is promoted
and restoration of function made possible by the transference of a
portion of tissue from one part of the body to another; the tissue
transferred is known as the _graft_ or the _transplant_. The simplest
example of grafting is the transplantation of skin.
In order that the graft may survive and have a favourable chance of
"taking," as it is called, the transplanted tissue must retain its
vitality until it has formed an organic connection with the tissue in
which it is placed, so that it may derive the necessary nourishment from
its new bed. When these conditions are fulfilled the tissues of the
graft continue to proliferate, producing new tissue elements to replace
those that are lost and making it possible for the graft to become
incorporated with the tissue with which it is in contact.
Dead tissue, on the other hand, can do neither of these things; it is
only capable of acting as a model, or, at the most, as a scaffolding for
such mobile tissue elements as may be derived from, the parent tissue
with which the graft is in contact: a portion of sterilised marine
sponge, for example, may be observed to become permeated with
granulation tissue when it is embedded in the tissues.
A successful graft of living tissue is not only capable of regeneration,
but it acquires a system of lymph and blood vessels, so that in time it
bleeds when cut into, and is permeated by new nerve fibres spreading in
from the periphery towards the centre.
It is instructive to associate the period of survival of the different
tissues of the body after death, with their capacity of being used for
grafting purposes; the higher tissues such as those of the central
nervous system and highly specialised glandular tissues like those of
the kidney lose their vitality quickly after death and are therefore
useless for grafting; connective tissues, on the other hand, such as
fat, cartilage, and bone retain their vitality for several hours after
death, so that when they are transplanted, they readily "take" and do
all that is required of them: the same is true of the skin and its
appendages.
_Sources of Grafts._--It is convenient to differentiate between
_autoplastic_ grafts, that is those derived from the same individual;
_homoplastic_ grafts, derived from another animal of the same species;
and _heteroplastic_ grafts, derived from an animal of another species.
Other conditions being equal, the prospects of success are greatest with
autoplastic grafts, and these are therefore preferred whenever possible.
There are certain details making for success that merit attention: the
graft must not be roughly handled or allowed to dry, or be subjected to
chemical irritation; it must be brought into accurate contact with the
new soil, no blood-clot intervening between the two, no movement of the
one upon the other should be possible and all infection must be
excluded; it will be observed that these are exactly the same conditions
that permit of the primary healing of wounds, with which of course the
healing of grafts is exactly comparable.
_Preservation of Tissues for Grafting._--It was at one time believed
that tissues might be taken from the operating theatre and kept in cold
storage until they were required. It is now agreed that tissues which
have been separated from the body for some time inevitably lose their
vitality, become incapable of regeneration, and are therefore unsuited
for grafting purposes. If it is intended to preserve a portion of tissue
for future grafting, it should be embedded in the subcutaneous tissue of
the abdominal wall until it is wanted; this has been carried out with
portions of costal cartilage and of bone.
INDIVIDUAL TISSUES AS GRAFTS
#The Blood# lends itself in an ideal manner to transplantation, or, as
it has long been called, _transfusion_. Being always a homoplastic
transfer, the new blood is not always tolerated by the old, in which
case biochemical changes occur, resulting in hæmolysis, which
corresponds to the disintegration of other unsuccessful homoplastic
grafts. (See article on Transfusion, _Op. Surg._, p. 37.)
#The Skin.#--The skin was the first tissue to be used for grafting
purposes, and it is still employed with greater frequency than any
other, as lesions causing defects of skin are extremely common and
without the aid of grafts are tedious in healing.
Skin grafts may be applied to a raw surface or to one that is covered
with granulations.
_Skin grafting of raw surfaces_ is commonly indicated after operations
for malignant disease in which considerable areas of skin must be
sacrificed, and after accidents, such as avulsion of the scalp by
machinery.
_Skin grafting of granulating surfaces_ is chiefly employed to promote
healing in the large defects of skin caused by severe burns; the
grafting is carried out when the surface is covered by a uniform layer
of healthy granulations and before the inevitable contraction of scar
tissue makes itself manifest. Before applying the grafts it is usual to
scrape away the granulations until the young fibrous tissue underneath
is exposed, but, if the granulations are healthy and can be rendered
aseptic, the grafts may be placed on them directly.
If it is decided to scrape away the granulations, the oozing must be
arrested by pressure with a pad of gauze, a sheet of dental rubber or
green protective is placed next the raw surface to prevent the gauze
adhering and starting the bleeding afresh when it is removed.
#Methods of Skin-Grafting.#--Two methods are employed: one in which the
epidermis is mainly or exclusively employed--epidermis or epithelial
grafting; the other, in which the graft consists of the whole thickness
of the true skin--cutis-grafting.
_Epidermis or Epithelial Grafting._--The method introduced by the late
Professor Thiersch of Leipsic is that almost universally practised. It
consists in transplanting strips of epidermis shaved from the surface of
the skin, the razor passing through the tips of the papillæ, which
appear as tiny red points yielding a moderate ooze of blood.
The strips are obtained from the front and lateral aspects of the thigh
or upper arm, the skin in those regions being pliable and comparatively
free from hairs.
They are cut with a sharp hollow-ground razor or with Thiersch's
grafting knife, the blade of which is rinsed in alcohol and kept
moistened with warm saline solution. The cutting is made easier if the
skin is well stretched and kept flat and perfectly steady, the
operator's left hand exerting traction on the skin behind, the hands of
the assistant on the skin in front, one above and the other below the
seat of operation. To ensure uniform strips being cut, the razor is kept
parallel with the surface and used with a short, rapid, sawing movement,
so that, with a little practice, grafts six or eight inches long by one
or two inches broad can readily be cut. The patient is given a general
anæsthetic, or regional anæsthesia is obtained by injections of a
solution of one per cent. novocain into the line of the lateral and
middle cutaneous nerves; the disinfection of the skin is carried out on
the usual lines, any chemical agent being finally got rid of, however,
by means of alcohol followed by saline solution.
The strips of epidermis wrinkle up on the knife and are directly
transferred to the surface, for which they should be made to form a
complete carpet, slightly overlapping the edges of the area and of one
another; some blunt instrument is used to straighten out the strips,
which are then subjected to firm pressure with a pad of gauze to express
blood and air-bells and to ensure accurate contact, for this must be as
close as that between a postage stamp and the paper to which it is
affixed.
As a dressing for the grafted area and of that also from which the
grafts have been taken, gauze soaked in _liquid paraffin_--the patent
variety known as _ambrine_ is excellent--appears to be the best; the
gauze should be moistened every other day or so with fresh paraffin, so
that, at the end of a week, when the grafts should have united, the
gauze can be removed without risk of detaching them. _Dental wax_ is
another useful type of dressing; as is also _picric acid_ solution. Over
the gauze, there is applied a thick layer of cotton wool, and the whole
dressing is kept in place by a firmly applied bandage, and in the case
of the limbs some form of splint should be added to prevent movement.
A dressing may be dispensed with altogether, the grafts being protected
by a wire cage such as is used after vaccination, but they tend to dry
up and come to resemble a scab.
When the grafts have healed, it is well to protect them from injury and
to prevent them drying up and cracking by the liberal application of
lanoline or vaseline.
The new skin is at first insensitive and is fixed to the underlying
connective tissue or bone, but in course of time (from six weeks
onwards) sensation returns and the formation of elastic tissue beneath
renders the skin pliant and movable so that it can be pinched up between
the finger and thumb.
_Reverdin's_ method consists in planting out pieces of skin not bigger
than a pin-head over a granulating surface. It is seldom employed.
_Grafts of the Cutis Vera._--Grafts consisting of the entire thickness
of the true skin were specially advocated by Wolff and are often
associated with his name. They should be cut oval or spindle-shaped, to
facilitate the approximation of the edges of the resulting wound. The
graft should be cut to the exact size of the surface it is to cover;
Gillies believes that tension of the graft favours its taking. These
grafts may be placed either on a fresh raw surface or on healthy
granulations. It is sometimes an advantage to stitch them in position,
especially on the face. The dressing and the after-treatment are the
same as in epidermis grafting.
There is a degree of uncertainty about the graft retaining its vitality
long enough to permit of its deriving the necessary nourishment from its
new surroundings; in a certain number of cases the flap dies and is
thrown off as a slough--moist or dry according to the presence or
absence of septic infection.
The technique for cutis-grafting must be without a flaw, and the asepsis
absolute; there must not only be a complete absence of movement, but
there must be no traction on the flap that will endanger its blood
supply.
Owing to the uncertainty in the results of cutis-grafting the
_two-stage_ or _indirect method_ has been introduced, and its almost
uniform success has led to its sphere of application being widely
extended. The flap is raised as in the direct method but is left
attached at one of its margins for a period ranging from 14 to 21 days
until its blood supply from its new bed is assured; the detachment is
then made complete. The blood supply of the proposed flap may influence
its selection and the way in which it is fashioned; for example, a flap
cut from the side of the head to fill a defect in the cheek, having in
its margin of attachment or pedicle the superficial temporal artery, is
more likely to take than a flap cut with its base above.
Another modification is to raise the flap but leave it connected at both
ends like the piers of a bridge; this method is well suited to defects
of skin on the dorsum of the fingers, hand and forearm, the bridge of
skin is raised from the abdominal wall and the hand is passed beneath it
and securely fixed in position; after an interval of 14 to 21 days, when
the flap is assured of its blood supply, the piers of the bridge are
divided (Fig. 1). With undermining it is usually easy to bring the
edges of the gap in the abdominal wall together, even in children; the
skin flap on the dorsum of the hand appears rather thick and
prominent--almost like the pad of a boxing-glove--for some time, but
the restoration of function in the capacity to flex the fingers is
gratifying in the extreme.
[Illustration: FIG. 1.--Ulcer of back of Hand covered by flap of skin
raised from anterior abdominal wall. The lateral edges of the flap are
divided after the graft has adhered.]
The indirect element of this method of skin-grafting may be carried
still further by transferring the flap of skin first to one part of the
body and then, after it has taken, transferring it to a third part.
Gillies has especially developed this method in the remedying of
deformities of the face caused by gunshot wounds and by petrol burns in
air-men. A rectangular flap of skin is marked out in the neck and chest,
the lateral margins of the flap are raised sufficiently to enable them
to be brought together so as to form a tube of skin: after the
circulation has been restored, the lower end of the tube is detached and
is brought up to the lip or cheek, or eyelid, where it is wanted; when
this end has derived its new blood supply, the other end is detached
from the neck and brought up to where it is wanted. In this way, skin
from the chest may be brought up to form a new forehead and eyelids.
Grafts of _mucous membrane_ are used to cover defects in the lip, cheek,
and conjunctiva. The technique is similar to that employed in
skin-grafting; the sources of mucous membrane are limited and the
element of septic infection cannot always be excluded.
_Fat._--Adipose tissue has a low vitality, but it is easily retained and
it readily lends itself to transplantation. Portions of fat are often
obtainable at operations--from the omentum, for example, otherwise the
subcutaneous fat of the buttock is the most accessible; it may be
employed to fill up cavities of all kinds in order to obtain more rapid
and sounder healing and also to remedy deformity, as in filling up a
depression in the cheek or forehead. It is ultimately converted into
ordinary connective tissue _pari passu_ with the absorption of the fat.
The _fascia lata of the thigh_ is widely and successfully used as a
graft to fill defects in the dura mater, and interposed between the
bones of a joint--if the articular cartilage has been destroyed--to
prevent the occurrence of ankylosis.
The _peritoneum_ of hydrocele and hernial sacs and of the omentum
readily lends itself to transplantation.
_Cartilage and bone_, next to skin, are the tissues most frequently
employed for grafting purposes; their sphere of action is so extensive
and includes so much of technical detail in their employment, that they
will be considered later with the surgery of the bones and joints and
with the methods of re-forming the nose.
_Tendons and blood vessels_ readily lend themselves to transplantation
and will also be referred to later.
_Muscle and nerve_, on the other hand, do not retain their vitality when
severed from their surroundings and do not functionate as grafts except
for their connective-tissue elements, which it goes without saying are
more readily obtainable from other sources.
Portions of the _ovary_ and of the _thyreoid_ have been successfully
transplanted into the subcutaneous cellular tissue of the abdominal wall
by Tuffier and others. In these new surroundings, the ovary or thyreoid
is vascularised and has been shown to functionate, but there is not
sufficient regeneration of the essential tissue elements to "carry on";
the secreting tissue is gradually replaced by connective tissue and the
special function comes to an end. Even such temporary function may,
however, tide a patient over a difficult period.
CHAPTER II
CONDITIONS WHICH INTERFERE WITH REPAIR
SURGICAL BACTERIOLOGY
Want of rest--Irritation--Unhealthy tissues--Pathogenic bacteria.
SURGICAL BACTERIOLOGY--General characters of
bacteria--Classification of bacteria--Conditions of bacterial
life--Pathogenic powers of bacteria--Results of bacterial
growth--Death of bacteria--Immunity--Antitoxic sera--Identification
of bacteria--Pyogenic bacteria.
In the management of wounds and other surgical conditions it is
necessary to eliminate various extraneous influences which tend to delay
or arrest the natural process of repair.
Of these, one of the most important is undue movement of the affected
part. "The first and great requisite for the restoration of injured
parts is _rest_," said John Hunter; and physiological and mechanical
rest as the chief of natural therapeutic agents was the theme of John
Hilton's classical work--_Rest and Pain_. In this connection it must be
understood that "rest" implies more than the mere state of physical
repose: all physiological as well as mechanical function must be
prevented as far as is possible. For instance, the constituent bones of
a joint affected with tuberculosis must be controlled by splints or
other appliances so that no movement can take place between them, and
the limb may not be used for any purpose; physiological rest may be
secured to an inflamed colon by making an artificial anus in the cæcum;
the activity of a diseased kidney may be diminished by regulating the
quantity and quality of the fluids taken by the patient.
Another source of interference with repair in wounds is _irritation_,
either by mechanical agents such as rough, unsuitable dressings,
bandages, or ill-fitting splints; or by chemical agents in the form of
strong lotions or other applications.
An _unhealthy or devitalised condition of the patient's tissues_ also
hinders the reparative process. Bruised or lacerated skin heals less
kindly than skin cut with a smooth, sharp instrument; and persistent
venous congestion of a part, such as occurs, for example, in the leg
when the veins are varicose, by preventing the access of healthy blood,
tends to delay the healing of open wounds. The existence of grave
constitutional disease, such as Bright's disease, diabetes, syphilis,
scurvy, or alcoholism, also impedes healing.
Infection by disease-producing micro-organisms or _pathogenic bacteria_
is, however, the most potent factor in disturbing the natural process of
repair in wounds.
SURGICAL BACTERIOLOGY
The influence of micro-organisms in the causation of disease, and the
rôle played by them in interfering with the natural process of repair,
are so important that the science of applied bacteriology has now come
to dominate every department of surgery, and it is from the standpoint
of bacteriology that nearly all surgical questions have to be
considered.
The term _sepsis_ as now used in clinical surgery no longer retains its
original meaning as synonymous with "putrefaction," but is employed to
denote all conditions in which bacterial infection has taken place, and
more particularly those in which pyogenic bacteria are present. In the
same way the term _aseptic_ conveys the idea of freedom from all forms
of bacteria, putrefactive or otherwise; and the term _antiseptic_ is
used to denote a power of counteracting bacteria and their products.
#General Characters of Bacteria.#--A _bacterium_ consists of a finely
granular mass of protoplasm, enclosed in a thin gelatinous envelope.
Many forms are motile--some in virtue of fine thread-like flagella, and
others through contractility of the protoplasm. The great majority
multiply by simple fission, each parent cell giving rise to two daughter
cells, and this process goes on with extraordinary rapidity. Other
varieties, particularly bacilli, are propagated by the formation of
_spores_. A spore is a minute mass of protoplasm surrounded by a dense,
tough membrane, developed in the interior of the parent cell. Spores are
remarkable for their tenacity of life, and for the resistance they offer
to the action of heat and chemical germicides.
Bacteria are most conveniently classified according to their shape. Thus
we recognise (1) those that are globular--_cocci_; (2) those that
resemble a rod--_bacilli_; (3) the spiral or wavy forms--_spirilla_.
_Cocci_ or _micrococci_ are minute round bodies, averaging about 1 µ in
diameter. The great majority are non-motile. They multiply by fission;
and when they divide in such a way that the resulting cells remain in
pairs, are called _diplococci_, of which the bacteria of gonorrhoea and
pneumonia are examples (Fig. 5). When they divide irregularly, and form
grape-like bunches, they are known as _staphylococci_, and to this
variety the commonest pyogenic or pus-forming organisms belong (Fig. 2).
When division takes place only in one axis, so that long chains are
formed, the term _streptococcus_ is applied (Fig. 3). Streptococci are
met with in erysipelas and various other inflammatory and suppurative
processes of a spreading character.
_Bacilli_ are rod-shaped bacteria, usually at least twice as long as
they are broad (Fig. 4). Some multiply by fission, others by
sporulation. Some forms are motile, others are non-motile. Tuberculosis,
tetanus, anthrax, and many other surgical diseases are due to different
forms of bacilli.
_Spirilla_ are long, slender, thread-like cells, more or less spiral or
wavy. Some move by a screw-like contraction of the protoplasm, some by
flagellæ. The spirochæte associated with syphilis (Fig. 36) is the most
important member of this group.
#Conditions of Bacterial Life.#--Bacteria require for their growth and
development a suitable food-supply in the form of proteins,
carbohydrates, and salts of calcium and potassium which they break up
into simpler elements. An alkaline medium favours bacterial growth; and
moisture is a necessary condition; spores, however, can survive the want
of water for much longer periods than fully developed bacteria. The
necessity for oxygen varies in different species. Those that require
oxygen are known as _aërobic bacilli_ or _aërobes_; those that cannot
live in the presence of oxygen are spoken of as _anaërobes_. The great
majority of bacteria, however, while they prefer to have oxygen, are
able to live without it, and are called _facultative anaërobes_.
The most suitable temperature for bacterial life is from 95° to 102° F.,
roughly that of the human body. Extreme or prolonged cold paralyses but
does not kill micro-organisms. Few, however, survive being raised to a
temperature of 134½° F. Boiling for ten to twenty minutes will kill all
bacteria, and the great majority of spores. Steam applied in an
autoclave under a pressure of two atmospheres destroys even the most
resistant spores in a few minutes. Direct sunlight, electric light, or
even diffuse daylight, is inimical to the growth of bacteria, as are
also Röntgen rays and radium emanations.
#Pathogenic Properties of Bacteria.#--We are now only concerned with
pathogenic bacteria--that is, bacteria capable of producing disease in
the human subject. This capacity depends upon two sets of factors--(1)
certain features peculiar to the invading bacteria, and (2) others
peculiar to the host. Many bacteria have only the power of living upon
dead matter, and are known as _saphrophytes_. Such as do nourish in
living tissue are, by distinction, known as _parasites_. The power a
given parasitic micro-organism has of multiplying in the body and giving
rise to disease is spoken of as its _virulence_, and this varies not
only with different species, but in the same species at different times
and under varying circumstances. The actual number of organisms
introduced is also an important factor in determining their pathogenic
power. Healthy tissues can resist the invasion of a certain number of
bacteria of a given species, but when that number is exceeded, the
organisms get the upper hand and disease results. When the organisms
gain access directly to the blood-stream, as a rule they produce their
effects more certainly and with greater intensity than when they are
introduced into the tissues.
Further, the virulence of an organism is modified by the condition of
the patient into whose tissues it is introduced. So long as a person is
in good health, the tissues are able to resist the attacks of moderate
numbers of most bacteria. Any lowering of the vitality of the
individual, however, either locally or generally, at once renders him
more susceptible to infection. Thus bruised or torn tissue is much more
liable to infection with pus-producing organisms than tissues clean-cut
with a knife; also, after certain diseases, the liability to infection
by the organisms of diphtheria, pneumonia, or erysipelas is much
increased. Even such slight depression of vitality as results from
bodily fatigue, or exposure to cold and damp, may be sufficient to turn
the scale in the battle between the tissues and the bacteria. Age is an
important factor in regard to the action of certain bacteria. Young
subjects are attacked by diphtheria, tuberculosis, acute osteomyelitis,
and some other diseases with greater frequency and severity than those
of more advanced years.
In different races, localities, environment, and seasons, the pathogenic
powers of certain organisms, such as those of erysipelas, diphtheria,
and acute osteomyelitis, vary considerably.
There is evidence that a _mixed infection_--that is, the introduction of
more than one species of organism, for example, the tubercle bacillus
and a pyogenic staphylococcus--increases the severity of the resulting
disease. If one of the varieties gain the ascendancy, the poisons
produced by the others so devitalise the tissue cells, and diminish
their power of resistance, that the virulence of the most active
organisms is increased. On the other hand, there is reason to believe
that the products of certain organisms antagonise one another--for
example, an attack of erysipelas may effect the cure of a patch of
tuberculous lupus.
Lastly, in patients suffering from chronic wasting diseases, bacteria
may invade the internal organs by the blood-stream in enormous numbers
and with great rapidity, during the period of extreme debility which
shortly precedes death. The discovery of such collections of organisms
on post-mortem examination may lead to erroneous conclusions being drawn
as to the cause of death.
#Results of Bacterial Growth.#--Some organisms, such as those of tetanus
and erysipelas, and certain of the pyogenic bacteria, show little
tendency to pass far beyond the point at which they gain an entrance to
the body. Others, on the contrary--for example, the tubercle bacillus
and the organism of acute osteomyelitis--although frequently remaining
localised at the seat of inoculation, tend to pass to distant parts,
lodging in the capillaries of joints, bones, kidney, or lungs, and there
producing their deleterious effects.
In the human subject, multiplication in the blood-stream does not occur
to any great extent. In some general acute pyogenic infections, such as
osteomyelitis, cellulitis, etc., pure cultures of staphylococci or of
streptococci may be obtained from the blood. In pneumococcal and typhoid
infections, also, the organisms may be found in the blood.
It is by the vital changes they bring about in the parts where they
settle that micro-organisms disturb the health of the patient. In
deriving nourishment from the complex organic compounds in which they
nourish, the organisms evolve, probably by means of a ferment, certain
chemical products of unknown composition, but probably colloidal in
nature, and known as _toxins_. When these poisons are absorbed into the
general circulation they give rise to certain groups of symptoms--such
as rise of temperature, associated circulatory and respiratory
derangements, interference with the gastro-intestinal functions and also
with those of the nervous system--which go to make up the condition
known as blood-poisoning, toxæmia, or _bacterial intoxication_. In
addition to this, certain bacteria produce toxins that give rise to
definite and distinct groups of symptoms--such as the convulsions of
tetanus, or the paralyses that follow diphtheria.
_Death of Bacteria._--Under certain circumstances, it would appear that
the accumulation of the toxic products of bacterial action tends to
interfere with the continued life and growth of the organisms
themselves, and in this way the natural cure of certain diseases is
brought about. Outside the body, bacteria may be killed by starvation,
by want of moisture, by being subjected to high temperature, or by the
action of certain chemical agents of which carbolic acid, the
perchloride and biniodide of mercury, and various chlorine preparations
are the most powerful.
#Immunity.#--Some persons are insusceptible to infection by certain
diseases, from which they are said to enjoy a _natural immunity_. In
many acute diseases one attack protects the patient, for a time at
least, from a second attack--_acquired immunity_.
_Phagocytosis._--In the production of immunity the leucocytes and
certain other cells play an important part in virtue of the power they
possess of ingesting bacteria and of destroying them by a process of
intra-cellular digestion. To this process Metchnikoff gave the name of
_phagocytosis_, and he recognised two forms of _phagocytes_: (1) the
_microphages_, which are the polymorpho-nuclear leucocytes of the blood;
and (2) the _macrophages_, which include the larger hyaline leucocytes,
endothelial cells, and connective-tissue corpuscles.
During the process of phagocytosis, the polymorpho-nuclear leucocytes in
the circulating blood increase greatly in numbers (_leucocytosis_), as
well as in their phagocytic action, and in the course of destroying the
bacteria they produce certain ferments which enter the blood serum.
These are known as _opsonins_ or _alexins_, and they act on the bacteria
by a process comparable to narcotisation, and render them an easy prey
for the phagocytes.
_Artificial or Passive Immunity._--A form of immunity can be induced by
the introduction of protective substances obtained from an animal which
has been actively immunised. The process by which passive immunity is
acquired depends upon the fact that as a result of the reaction between
the specific virus of a particular disease (the _antigen_) and the
tissues of the animal attacked, certain substances--_antibodies_--are
produced, which when transferred to the body of a susceptible animal
protect it against that disease. The most important of these antibodies
are the _antitoxins_. From the study of the processes by which immunity
is secured against the effects of bacterial action the serum and vaccine
methods of treating certain infective diseases have been evolved. The
_serum treatment_ is designed to furnish the patient with a sufficiency
of antibodies to neutralise the infection. The anti-diphtheritic and the
anti-tetanic act by neutralising the specific toxins of the
disease--_antitoxic serums_; the anti-streptcoccic and the serum for
anthrax act upon the bacteria--_anti-bacterial serums_.
A _polyvalent_ serum, that is, one derived from an animal which has been
immunised by numerous strains of the organism derived from various
sources, is much more efficacious than when a single strain has been
used.
_Clinical Use of Serums._--Every precaution must be taken to prevent
organismal contamination of the serum or of the apparatus by means of
which it is injected. Syringes are so made that they can be sterilised
by boiling. The best situations for injection are under the skin of the
abdomen, the thorax, or the buttock, and the skin should be purified at
the seat of puncture. If the bulk of the full dose is large, it should
be divided and injected into different parts of the body, not more than
20 c.c. being injected at one place. The serum may be introduced
directly into a vein, or into the spinal canal, _e.g._ anti-tetanic
serum. The immunity produced by injections of antitoxic sera lasts only
for a comparatively short time, seldom longer than a few weeks.
_"Serum Disease" and Anaphylaxis._--It is to be borne in mind that some
patients exhibit a supersensitiveness with regard to protective sera, an
injection being followed in a few days by the appearance of an
urticarial or erythematous rash, pain and swelling of the joints, and a
variable degree of fever. These symptoms, to which the name _serum
disease_ is applied, usually disappear in the course of a few days.
The term _anaphylaxis_ is applied to an allied condition of
supersensitiveness which appears to be induced by the injection of
certain substances, including toxins and sera, that are capable of
acting as antigens. When a second injection is given after an interval
of some days, if anaphylaxis has been established by the first dose, the
patient suddenly manifests toxic symptoms of the nature of profound
shock which may even prove fatal. The conditions which render a person
liable to develop anaphylaxis and the mechanism by which it is
established are as yet imperfectly understood.
_Vaccine Treatment._--The vaccine treatment elaborated by A. E. Wright
consists in injecting, while the disease is still active, specially
prepared dead cultures of the causative organisms, and is based on the
fact that these "vaccines" render the bacteria in the tissues less able
to resist the attacks of the phagocytes. The method is most successful
when the vaccine is prepared from organisms isolated from the patient
himself, _autogenous vaccine_, but when this is impracticable, or takes
a considerable time, laboratory-prepared polyvalent _stock vaccines_ may
be used.
_Clinical Use of Vaccines._--Vaccines should not be given while a
patient is in a negative phase, as a certain amount of the opsonin in
the blood is used up in neutralising the substances injected, and this
may reduce the opsonic index to such an extent that the vaccines
themselves become dangerous. As a rule, the propriety of using a vaccine
can be determined from the general condition of the patient. The initial
dose should always be a small one, particularly if the disease is acute,
and the subsequent dosage will be regulated by the effect produced. If
marked constitutional disturbance with rise of temperature follows the
use of a vaccine, it indicates a negative phase, and calls for a
diminution in the next dose. If, on the other hand, the local as well as
the general condition of the patient improves after the injection, it
indicates a positive phase, and the original dose may be repeated or
even increased. Vaccines are best introduced subcutaneously, a part
being selected which is not liable to pressure, as there is sometimes
considerable local reaction. Repeated doses may be necessary at
intervals of a few days.
The vaccine treatment has been successfully employed in various
tuberculous lesions, in pyogenic infections such as acne, boils,
sycosis, streptococcal, pneumococcal, and gonococcal conditions, in
infections of the accessory air sinuses, and in other diseases caused by
bacteria.
PYOGENIC BACTERIA
From the point of view of the surgeon the most important varieties of
micro-organisms are those that cause inflammation and suppuration--the
_pyogenic bacteria_. This group includes a great many species, and these
are so widely distributed that they are to be met with under all
conditions of everyday life.
The nature of the inflammatory and suppurative processes will be
considered in detail later; suffice it here to say that they are brought
about by the action of one or other of the organisms that we have now to
consider.
It is found that the _staphylococci_, which cluster into groups, tend to
produce localised lesions; while the chain-forms--_streptococci_--give
rise to diffuse, spreading conditions. Many varieties of pyogenic
bacteria have now been differentiated, the best known being the
staphylococcus aureus, the streptococcus, and the bacillus coli
communis.
[Illustration: FIG. 2.--Staphylococcus aureus in Pus from case of
Osteomyelitis. × 1000 diam. Gram's stain.]
_Staphylococcus Aureus._--This is the commonest organism found in
localised inflammatory and suppurative conditions. It varies greatly in
its virulence, and is found in such widely different conditions as skin
pustules, boils, carbuncles, and some acute inflammations of bone. As
seen by the microscope it occurs in grape-like clusters, fission of the
individual cells taking place irregularly (Fig. 2). When grown in
artificial media, the colonies assume an orange-yellow colour--hence the
name _aureus_. It is of high vitality and resists more prolonged
exposure to high temperatures than most non-sporing bacteria. It is
capable of lying latent in the tissues for long periods, for example, in
the marrow of long bones, and of again becoming active and causing a
fresh outbreak of suppuration. This organism is widely distributed: it
is found on the skin, in the mouth, and in other situations in the body,
and as it is present in the dust of the air and on all objects upon
which dust has settled, it is a continual source of infection unless
means are taken to exclude it from wounds.
The _staphylococcus albus_ is much less common than the aureus, but has
the same properties and characters, save that its growth on artificial
media assumes a white colour. It is the common cause of stitch
abscesses, the skin being its normal habitat.
[Illustration: FIG. 3.--Streptococci in Pus from an acute abscess in
subcutaneous tissue. × 1000 diam. Gram's stain.]
_Streptococcus Pyogenes._--This organism also varies greatly in its
virulence; in some instances--for example in erysipelas--it causes a
sharp attack of acute spreading inflammation, which soon subsides
without showing any tendency to end in suppuration; under other
conditions it gives rise to a generalised infection which rapidly proves
fatal. The streptococcus has less capacity of liquefying the tissues
than the staphylococcus, so that pus formation takes place more slowly.
At the same time its products are very potent in destroying the tissues
in their vicinity, and so interfering with the exudation of leucocytes
which would otherwise exercise their protective influence. Streptococci
invade the lymph spaces, and are associated with acute spreading
conditions such as phlegmonous or erysipelatous inflammations and
suppurations, lymphangitis and suppuration in lymph glands, and
inflammation of serous and synovial membranes, also with a form of
pneumonia which is prone to follow on severe operations in the mouth and
throat. Streptococci are also concerned in the production of spreading
gangrene and pyæmia.
Division takes place in one axis, so that chains of varying length are
formed (Fig. 3). It is less easily cultivated by artificial media than
the staphylococcus; it forms a whitish growth.
[Illustration: FIG. 4.--Bacillus coli communis in Urine, from a case of
Cystitis. × 1000 diam. Leishman's stain.]
_Bacillus Coli Communis._--This organism, which is a normal inhabitant
of the intestinal tract, shows a great tendency to invade any organ or
tissue whose vitality is lowered. It is causatively associated with such
conditions as peritonitis and peritoneal suppuration resulting from
strangulated hernia, appendicitis, or perforation in any part of the
alimentary canal. In cystitis, pyelitis, abscess of the kidney,
suppuration in the bile-ducts or liver, and in many other abdominal
conditions, it plays a most important part. The discharge from wounds
infected by this organism has usually a foetid, or even a fæcal odour,
and often contains gases resulting from putrefaction.
It is a small rod-shaped organism with short flagellæ, which render it
motile (Fig. 4). It closely resembles the typhoid bacillus, but is
distinguished from it by its behaviour in artificial culture media.
[Illustration: FIG. 5.--Fraenkel's Pneumococci in Pus from Empyema
following Pneumonia. × 100 diam. Stained with Muir's capsule stain.]
_Pneumo-bacteria._--Two forms of organism associated with
pneumonia--_Fraenkel's pneumococcus_ (one of the diplococci) (Fig. 5)
and _Friedländer's pneumo-bacillus_ (a short rod-shaped form)--are
frequently met with in inflammations of the serous and synovial
membranes, in suppuration in the liver, and in various other
inflammatory and suppurative conditions.
_Bacillus Typhosus._--This organism has been found in pure culture in
suppurative conditions of bone, of cellular tissue, and of internal
organs, especially during convalescence from typhoid fever. Like the
staphylococcus, it is capable of lying latent in the tissues for long
periods.
_Other Pyogenic Bacteria._--It is not necessary to do more than name
some of the other organisms that are known to be pyogenic, such as the
bacillus pyocyaneus, which is found in green and blue pus, the
micrococcus tetragenus, the gonococcus, actinomyces, the glanders
bacillus, and the tubercle bacillus. Most of these will receive further
mention in connection with the diseases to which they give rise.
#Leucocytosis.#--Most bacterial diseases, as well as certain other
pathological conditions, are associated with an increase in the number
of leucocytes in the blood throughout the circulatory system. This
condition of the blood, which is known as _leucocytosis_, is believed to
be due to an excessive output and rapid formation of leucocytes by the
bone marrow, and it probably has as its object the arrest and
destruction of the invading organisms or toxins. To increase the
resisting power of the system to pathogenic organisms, an artificial
leucocytosis may be induced by subcutaneous injection of a solution of
nucleinate of soda (16 minims of a 5 per cent. solution).
The _normal_ number of leucocytes per cubic millimetre varies in
different individuals, and in the same individual under different
conditions, from 5000 to 10,000: 7500 is a normal average, and anything
above 12,000 is considered abnormal. When leucocytosis is present, the
number may range from 12,000 to 30,000 or even higher; 40,000 is looked
upon as a high degree of leucocytosis. According to Ehrlich, the
following may be taken as the standard proportion of the various forms
of leucocytes in normal blood: polynuclear neutrophile leucocytes, 70 to
72 per cent.; lymphocytes, 22 to 25 per cent.; eosinophile cells, 2 to 4
per cent.; large mononuclear and transitional leucocytes, 2 to 4 per
cent.; mast-cells, 0.5 to 2 per cent.
In estimating the clinical importance of a leucocytosis, it is not
sufficient merely to count the aggregate number of leucocytes present. A
differential count must be made to determine which variety of cells is
in excess. In the majority of surgical affections it is chiefly the
granular polymorpho-nuclear neutrophile leucocytes that are in excess
(_ordinary leucocytosis_). In some cases, and particularly in parasitic
diseases such as trichiniasis and hydatid disease, the eosinophile
leucocytes also show a proportionate increase (_eosinophilia_). The term
_lymphocytosis_ is applied when there is an increase in the number of
circulating lymphocytes, as occurs, for example, in lymphatic leucæmia,
and in certain cases of syphilis.
Leucocytosis is met with in nearly all acute infective diseases, and in
acute pyogenic inflammatory affections, particularly in those attended
with suppuration. In exceptionally acute septic conditions the extreme
virulence of the toxins may prevent the leucocytes reacting, and
leucocytosis may be absent. The absence of leucocytosis in a disease in
which it is usually present is therefore to be looked upon as a grave
omen, particularly when the general symptoms are severe. In some cases
of malignant disease the number of leucocytes is increased to 15,000 or
20,000. A few hours after a severe hæmorrhage also there is usually a
leucocytosis of from 15,000 to 30,000, which lasts for three or four
days (Lyon). In cases of hæmorrhage the leucocytosis is increased by
infusion of fluids into the circulation. After all operations there is
at least a transient leucocytosis (_post-operative leucocytosis_)
(F. I. Dawson).
The leucocytosis begins soon after the infection manifests itself--for
example, by shivering, rigor, or rise of temperature. The number of
leucocytes rises somewhat rapidly, increases while the condition is
progressing, and remains high during the febrile period, but there is no
constant correspondence between the number of leucocytes and the height
of the temperature. The arrest of the inflammation and its resolution
are accompanied by a fall in the number of leucocytes, while the
occurrence of suppuration is attended with a further increase in their
number.
In interpreting the "blood count," it is to be kept in mind that a
_physiological leucocytosis_ occurs within three or four hours of taking
a meal, especially one rich in proteins, from 1500 to 2000 being added
to the normal number. In this _digestion leucocytosis_ the increase is
chiefly in the polynuclear neutrophile leucocytes. Immediately before
and after delivery, particularly in primiparæ, there is usually a
moderate degree of leucocytosis. If the labour is normal and the
puerperium uncomplicated, the number of leucocytes regains the normal in
about a week. Lactation has no appreciable effect on the number of
leucocytes. In new-born infants the leucocyte count is abnormally high,
ranging from 15,000 to 20,000. In children under one year of age, the
normal average is from 10,000 to 20,000.
_Absence of Leucocytosis--Leucopenia._--In certain infective diseases
the number of leucocytes in the circulating blood is abnormally
low--3000 or 4000--and this condition is known as _leucopenia_. It
occurs in typhoid fever, especially in the later stages of the disease,
in tuberculous lesions unaccompanied by suppuration, in malaria, and in
most cases of uncomplicated influenza. The occurrence of leucocytosis in
any of these conditions is to be looked upon as an indication that a
mixed infection has taken place, and that some suppurative process is
present.
The absence of leucocytosis in some cases of virulent septic poisoning
has already been referred to.
It will be evident that too much reliance must not be placed upon a
single observation, particularly in emergency cases. Whenever possible,
a series of observations should be made, the blood being examined about
four hours after meals, and about the same hour each day.
The clinical significance of the blood count in individual diseases will
be further referred to.
_The Iodine or Glycogen Reaction._--The leucocyte count may be
supplemented by staining films of the blood with a watery solution of
iodine and potassium iodide. In all advancing purulent conditions, in
septic poisonings, in pneumonia, and in cancerous growths associated
with ulceration, a certain number of the polynuclear leucocytes are
stained a brown or reddish-brown colour, due to the action of the iodine
on some substance in the cells of the nature of glycogen. This reaction
is absent in serous effusions, in unmixed tuberculous infections, in
uncomplicated typhoid fever, and in the early stages of cancerous
growths.
CHAPTER III
INFLAMMATION
Definition--Nature of inflammation from surgical point of
view--Sequence of changes in bacterial inflammation--Clinical
aspects of inflammation--General principles of treatment--Chronic
inflammation.
Inflammation may be defined as the series of vital changes that occurs
in the tissues in response to irritation. These changes represent the
reaction of the tissue elements to the irritant, and constitute the
attempt made by nature to arrest or to limit its injurious effects, and
to repair the damage done by it.
The phenomena which characterise the inflammatory reaction can be
induced by any form of irritation--such, for example, as mechanical
injury, the application of heat or of chemical substances, or the action
of pathogenic bacteria and their toxins--and they are essentially
similar in kind whatever the irritant may be. The extent to which the
process may go, however, and its effects on the part implicated and on
the system as a whole, vary with different irritants and with the
intensity and duration of their action. A mechanical, a thermal, or a
chemical irritant, acting alone, induces a degree of reaction directly
proportionate to its physical properties, and so long as it does not
completely destroy the vitality of the part involved, the changes in the
tissues are chiefly directed towards repairing the damage done to the
part, and the inflammatory reaction is not only compatible with the
occurrence of ideal repair, but may be looked upon as an integral step
in the reparative process.
The irritation caused by infection with bacteria, on the other hand, is
cumulative, as the organisms not only multiply in the tissues, but in
addition produce chemical poisons (toxins) which aggravate the
irritative effects. The resulting reaction is correspondingly
progressive, and has as its primary object the expulsion of the irritant
and the limitation of its action. If the natural protective effort is
successful, the resulting tissue changes subserve the process of repair,
but if the bacteria gain the upper hand in the struggle, the
inflammatory reaction becomes more intense, certain of the tissue
elements succumb, and the process for the time being is a destructive
one. During the stage of bacterial inflammation, reparative processes
are in abeyance, and it is only after the inflammation has been allayed,
either by natural means or by the aid of the surgeon, that repair takes
place.
In applying the antiseptic principle to the treatment of wounds, our
main object is to exclude or to eliminate the bacterial factor, and so
to prevent the inflammatory reaction going beyond the stage in which it
is protective, and just in proportion as we succeed in attaining this
object, do we favour the occurrence of ideal repair.
#Sequence of Changes in Bacterial Inflammation.#--As the form of
inflammation with which we are most concerned is that due to the action
of bacteria, in describing the process by which the protective influence
of the inflammatory reaction is brought into play, we shall assume the
presence of a bacterial irritant.
The introduction of a colony of micro-organisms is quickly followed by
an accumulation of wandering cells, and proliferation of
connective-tissue cells in the tissues at the site of infection. The
various cells are attracted to the bacteria by a peculiar chemical or
biological power known as _chemotaxis_, which seems to result from
variations in the surface tension of different varieties of cells,
probably caused by some substance produced by the micro-organisms.
Changes in the blood vessels then ensue, the arteries becoming dilated
and the rate of the current in them being for a time increased--_active
hyperæmia_. Soon, however, the rate of the blood flow becomes slower
than normal, and in course of time the current may cease (_stasis_), and
the blood in the vessels may even coagulate (_thrombosis_). Coincidently
with these changes in the vessels, the leucocytes in the blood of the
inflamed part rapidly increase in number, and they become viscous and
adhere to the vessel wall, where they may accumulate in large numbers.
In course of time the leucocytes pass through the vessel
wall--_emigration of leucocytes_--and move towards the seat of
infection, giving rise to a marked degree of _local leucocytosis_.
Through the openings by which the leucocytes have escaped from the
vessels, red corpuscles may be passively extruded--_diapedesis of red
corpuscles_. These processes are accompanied by changes in the
endothelium of the vessel walls, which result in an increased formation
of lymph, which transudes into the meshes of the connective tissue
giving rise to an _inflammatory oedema_, or, if the inflammation is on a
free surface, forming an _inflammatory exudate_. The quantity and
characters of this exudate vary in different parts of the body, and
according to the nature, virulence, and location of the organisms
causing the inflammation. Thus it may be _serous_, as in some forms of
synovitis; _sero-fibrinous_, as in certain varieties of peritonitis, the
fibrin tending to limit the spread of the inflammation by forming
adhesions; _croupous_, when it coagulates on a free surface and forms a
false membrane, as in diphtheria; _hæmorrhagic_ when mixed with blood;
or _purulent_, when suppuration has occurred. The protective effects of
the inflammatory reaction depend for the most part upon the transudation
of lymph and the emigration of leucocytes. The lymph contains the
opsonins which act on the bacteria and render them less able to resist
the attack of the phagocytes, as well as the various protective
antibodies which neutralise the toxins. The polymorph leucocytes are the
principal agents in the process of phagocytosis (p. 22), and together
with the other forms of phagocytes they ingest and destroy the bacteria.
If the attempt to repel the invading organisms is successful, the
irritant effects are overcome, the inflammation is arrested, and
_resolution_ is said to take place.
Certain of the vascular and cellular changes are now utilised to restore
the condition to the normal, and _repair_ ensues after the manner
already described. In certain situations, notably in tendon sheaths, in
the cavities of joints, and in the interior of serous cavities, for
example the pleura and peritoneum, the restoration to the normal is not
perfect, adhesions forming between the opposing surfaces.
If, however, the reaction induced by the infection is insufficient to
check the growth and spread of the organisms, or to inhibit their toxin
production, local necrosis of tissue may take place, either in the form
of suppuration or of gangrene, or the toxins absorbed into the
circulation may produce blood-poisoning, which may even prove fatal.
#Clinical Aspects of Inflammation.#--It must clearly be understood that
inflammation is not to be looked upon as a disease in itself, but rather
as an evidence of some infective process going on in the tissues in
which it occurs, and of an effort on the part of these tissues to
overcome the invading organisms and their products. The chief danger to
the patient lies, not in the reactive changes that constitute the
inflammatory process, but in the fact that he is liable to be poisoned
by the toxins of the bacteria at work in the inflamed area.
Since the days of Celsus (first century A.D.), heat, redness, swelling,
and pain have been recognised as cardinal signs of inflammation, and to
these may be added, interference with function in the inflamed part, and
general constitutional disturbance. Variations in these signs and
symptoms depend upon the acuteness of the condition, the nature of the
causative organism and of the tissue attacked, the situation of the part
in relation to the surface, and other factors.
The _heat_ of the inflamed part is to be attributed to the increased
quantity of blood present in it, and the more superficial the affected
area the more readily is the local increase of temperature detected by
the hand. This clinical point is best tested by placing the palm of the
hand and fingers for a few seconds alternately over an uninflamed and an
inflamed area, otherwise under similar conditions as to coverings and
exposure. In this way even slight differences may be recognised.
_Redness_, similarly, is due to the increased afflux of blood to the
inflamed part. The shade of colour varies with the stage of the
inflammation, being lighter and brighter in the early, hyperæmic stages,
and darker and duskier when the blood flow is slowed or when stasis has
occurred and the oxygenation of the blood is defective. In the
thrombotic stage the part may assume a purplish hue.
The _swelling_ is partly due to the increased amount of blood in the
affected part and to the accumulation of leucocytes and proliferated
tissue cells, but chiefly to the exudate in the connective
tissue--_inflammatory oedema_. The more open the structure of the tissue
of the part, the greater is the amount of swelling--witness the marked
degree of oedema that occurs in such parts as the scrotum or the eyelids.
_Pain_ is a symptom seldom absent in inflammation. _Tenderness_--that
is, pain elicited on pressure--is one of the most valuable diagnostic
signs we possess, and is often present before pain is experienced by the
patient. That the area of tenderness corresponds to the area of
inflammation is almost an axiom of surgery. Pain and tenderness are due
to the irritation of nerve filaments of the part, rendered all the more
sensitive by the abnormal conditions of their blood supply. In
inflammatory conditions of internal organs, for example the abdominal
viscera, the pain is frequently referred to other parts, usually to an
area supplied by branches from the same segment of the cord as that
supplying the inflamed part.
For purposes of diagnosis, attention should be paid to the terms in
which the patient describes his pain. For example, the pain caused by
an inflammation of the skin is usually described as of a _burning_ or
_itching_ character; that of inflammation in dense tissues like
periosteum or bone, or in encapsuled organs, as _dull_, _boring_, or
_aching_. When inflammation is passing on to suppuration the pain
assumes a _throbbing_ character, and as the pus reaches the surface, or
"points," as it is called, sharp, _darting_, or _lancinating_ pains are
experienced. Inflammation involving a nerve-trunk may cause a _boring_
or a _tingling_ pain; while the implication of a serous membrane such as
the pleura or peritoneum gives rise to a pain of a sharp, _stabbing_
character.
_Interference with the function_ of the inflamed part is always present
to a greater or less extent.
#Constitutional Disturbances.#--Under the term constitutional
disturbances are included the presence of fever or elevation of
temperature; certain changes in the pulse rate and the respiration;
gastro-intestinal and urinary disturbances; and derangements of the
central nervous system. These are all due to the absorption of toxins
into the general circulation.
_Temperature._--A marked rise of temperature is one of the most constant
and important concomitants of acute inflammatory conditions, and the
temperature chart forms a fairly reliable index of the state of the
patient. The toxins interfere with the nerve-centres in the medulla that
regulate the balance between the production and the loss of body heat.
Clinically the temperature is estimated by means of a self-registering
thermometer placed, for from one to five minutes, in close contact with
the skin in the axilla, or in the mouth. Sometimes the thermometer is
inserted into the rectum, where, however, the temperature is normally
¾° F. higher than in the axilla.
_In health_ the temperature of the body is maintained at a mean of about
98.4° F. (37° C.) by the heat-regulating mechanism. It varies from hour
to hour even in health, reaching its maximum between four and eight in
the evening, when it may rise to 99° F., and is at its lowest between
four and six in the morning, when it may be about 97° F.
The temperature is more easily disturbed in children than in adults, and
may become markedly elevated (104° or 105° F.) from comparatively slight
causes; in the aged it is less liable to change, so that a rise to 103°
or 104° F. is to be looked upon as indicating a high state of fever.
A sudden rise of temperature is usually associated with a feeling of
chilliness down the back and in the limbs, which may be so marked that
the patient shivers violently, while the skin becomes cold, pale, and
shrivelled--_cutis anserina_. This is a nervous reaction due to a want
of correspondence between the internal and the surface temperature of
the body, and is known clinically as a _rigor_. When the temperature
rises gradually the chill is usually slight and may be unobserved. Even
during the cold stage, however, the internal temperature is already
raised, and by the time the chill has passed off its maximum has been
reached.
The _pulse_ is always increased in frequency, and usually varies
directly with the height of the temperature. _Respiration_ is more
active during the progress of an inflammation; and bronchial catarrh is
common apart from any antecedent respiratory disease.
_Gastro-intestinal disturbances_ take the form of loss of appetite,
vomiting, diminished secretion of the alimentary juices, and weakening
of the peristalsis of the bowel, leading to thirst, dry, furred tongue,
and constipation. Diarrhoea is sometimes present. The _urine_ is usually
scanty, of high specific gravity, rich in nitrogenous substances,
especially urea and uric acid, and in calcium salts, while sodium
chloride is deficient. Albumin and hyaline casts may be present in cases
of severe inflammation with high temperature. The significance of
general _leucocytosis_ has already been referred to.
#General Principles of Treatment.#--The capacity of the inflammatory
reaction for dealing with bacterial infections being limited, it often
becomes necessary for the surgeon to aid the natural defensive
processes, as well as to counteract the local and general effects of the
reaction, and to relieve symptoms.
The ideal means of helping the tissues is by removing the focus of
infection, and when this can be done, as for example in a carbuncle or
an anthrax pustule, the infected area may be completely excised. When
the focus is not sufficiently limited to admit of this, the infected
tissue may be scraped away with the sharp spoon, or destroyed by
caustics or by the actual cautery. If this is inadvisable, the organisms
may be attacked by strong antiseptics, such as pure carbolic acid.
Moist dressings favour the removal of bacteria by promoting the escape
of the inflammatory exudate, in which they are washed out.
#Artificial Hyperæmia.#--When such direct means as the above are
impracticable, much can be done to aid the tissues in their struggle by
improving the condition of the circulation in the inflamed area, so as
to ensure that a plentiful supply of fresh arterial blood reaches it.
The beneficial effects of _hot fomentations and poultices_ depend on
their causing a dilatation of the vessels, and so inducing a hyperæmia
in the affected area. It has been shown experimentally that repeated,
short applications of moist heat (not exceeding 106° F.) are more
efficacious than continuous application. It is now believed that the
so-called _counter-irritants_--mustard, iodine, cantharides, actual
cautery--act in the same way; and the method of treating erysipelas by
applying a strong solution of iodine around the affected area is based
on the same principle.
[Illustration: FIG. 6.--Passive Hyperæmia of Hand and Forearm induced by
Bier's Bandage.]
While these and similar methods have long been employed in the treatment
of inflammatory conditions, it is only within comparatively recent years
that their mode of action has been properly understood, and to August
Bier belongs the credit of having put the treatment of inflammation on a
scientific and rational basis. Recognising the "beneficent intention" of
the inflammatory reaction, and the protective action of the leucocytosis
which accompanies the hyperæmic stages of the process, Bier was led to
study the effects of increasing the hyperæmia by artificial means. As a
result of his observations, he has formulated a method of treatment
which consists in inducing an artificial hyperæmia in the inflamed area,
either by obstructing the venous return from the part (_passive
hyperæmia_), or by stimulating the arterial flow through it (_active
hyperæmia_).
_Bier's Constricting Bandage._--To induce a _passive hyperæmia_ in a
limb, an elastic bandage is applied some distance above the inflamed
area sufficiently tightly to obstruct the venous return from the distal
parts without arresting in any way the inflow of arterial blood (Fig. 6).
If the constricting band is correctly applied, the parts beyond
become swollen and oedematous, and assume a bluish-red hue, but they
retain their normal temperature, the pulse is unchanged, and there is no
pain. If the part becomes blue, cold, or painful, or if any existing
pain is increased, the band has been applied too tightly. The hyperæmia
is kept up from twenty to twenty-two hours out of the twenty-four, and
in the intervals the limb is elevated to get rid of the oedema and to
empty it of impure blood, and so make room for a fresh supply of healthy
blood when the bandage is re-applied. As the inflammation subsides, the
period during which the band is kept on each day is diminished; but the
treatment should be continued for some days after all signs of
inflammation have subsided.
This method of treating acute inflammatory conditions necessitates
close supervision until the correct degree of tightness of the band has
been determined.
[Illustration: FIG. 7.--Passive Hyperæmia of Finger induced by Klapp's
Suction Bell.]
_Klapp's Suction Bells._--In inflammatory conditions to which the
constricting band cannot be applied, as for example an acute mastitis, a
bubo in the groin, or a boil on the neck, the affected area may be
rendered hyperæmic by an appropriately shaped glass bell applied over it
and exhausted by means of a suction-pump, the rarefaction of the air in
the bell determining a flow of blood into the tissues enclosed within it
(Figs. 7 and 8). The edge of the bell is smeared with vaseline, and the
suction applied for from five to ten minutes at a time, with a
corresponding interval between the applications. Each sitting lasts for
from half an hour to an hour, and the treatment may be carried out once
or twice a day according to circumstances. This apparatus acts in the
same way as the old-fashioned _dry cup_, and is more convenient and
equally efficacious.
[Illustration: FIG. 8.--Passive Hyperæmia induced by Klapp's Suction
Bell for Inflammation of Inguinal Gland.]
_Active hyperæmia_ is induced by the local application of heat,
particularly by means of hot air. It has not proved so useful in acute
inflammation as passive hyperæmia, but is of great value in hastening
the absorption of inflammatory products and in overcoming adhesions and
stiffness in tendons and joints.
_General Treatment._--The patient should be kept at rest, preferably in
bed, to diminish the general tissue waste; and the diet should be
restricted to fluids, such as milk, beef-tea, meat juices or gruel, and
these may be rendered more easily assimilable by artificial digestion if
necessary. To counteract the general effect of toxins absorbed into
the circulation, specific antitoxic sera are employed in certain forms
of infection, such as diphtheria, streptococcal septicæmia, and tetanus.
In other forms of infection, vaccines are employed to increase the
opsonic power of the blood. When such means are not available, the
circulating toxins may to some extent be diluted by giving plenty of
bland fluids by the mouth or normal salt solution by the rectum.
The elimination of the toxins is promoted by securing free action of the
emunctories. A saline purge, such as half an ounce of sulphate of
magnesium in a small quantity of water, ensures a free evacuation of the
bowels. The kidneys are flushed by such diluent drinks as equal parts of
milk and lime water, or milk with a dram of liquor calcis saccharatus
added to each tumblerful. Barley-water and "Imperial drink," which
consists of a dram and a half of cream of tartar added to a pint of
boiling water and sweetened with sugar after cooling, are also useful
and non-irritating diuretics. The skin may be stimulated by Dover's
powder (10 grains) or liquor ammoniæ acetatis in three-dram doses every
four hours.
Various drugs administered internally, such as quinine, salol,
salicylate of iron, and others, have a reputation, more or less
deserved, as internal antiseptics.
Weakness of the heart, as indicated by the condition of the pulse, is
treated by the use of such drugs as digitalis, strophanthus, or
strychnin, according to circumstances.
Gastro-intestinal disturbances are met by ordinary medical means.
Vomiting, for example, can sometimes be checked by effervescing drinks,
such as citrate of caffein, or by dilute hydrocyanic acid and bismuth.
In severe cases, and especially when the vomited matter resembles
coffee-grounds from admixture with altered blood--the so-called
post-operative hæmatemesis--the best means of arresting the vomiting is
by washing out the stomach. Thirst is relieved by rectal injections of
saline solution. The introduction of saline solution into the veins or
by the rectum is also useful in diluting and hastening the elimination
of circulating toxins.
In surgical inflammations, as a rule, nothing is gained by lowering the
temperature, unless at the same time the cause is removed. When severe
or prolonged pyrexia becomes a source of danger, the use of hot or cold
sponging, or even the cold bath, is preferable to the administration of
drugs.
_Relief of Symptoms._--For the relief of _pain_, rest is essential. The
inflamed part should be placed in a splint or other appliance which will
prevent movement, and steps must be taken to reduce its functional
activity as far as possible. Locally, warm and moist dressings, such as
a poultice or fomentation, may be used. To make a fomentation, a piece
of flannel or lint is wrung out of very hot water or antiseptic lotion
and applied under a sheet of mackintosh. Fomentations should be renewed
as often as they cool. An ordinary india-rubber bag filled with hot
water and fixed over the fomentation, by retaining the heat, obviates
the necessity of frequently changing the application. The addition of a
few drops of laudanum sprinkled on the flannel has a soothing effect.
Lead and opium lotion is a useful, soothing application employed as a
fomentation. We prefer the application of lint soaked in a 10 per cent.
aqueous or glycerine solution of ichthyol, or smeared with ichthyol
ointment (1 in 3). Belladonna and glycerine, equal parts, may be used.
Dry cold obtained by means of icebags, or by Leiter's lead tubes through
which a continuous stream of ice-cold water is kept flowing, is
sometimes soothing to the patient, but when the vessels in the inflamed
part are greatly congested its use is attended with considerable risk,
as it not only contracts the arterioles supplying the part, but also
diminishes the outflow of venous blood, and so may determine gangrene of
tissues already devitalised.
A milder form of employing cold is by means of evaporating lotions: a
thin piece of lint or gauze is applied over the inflamed part and kept
constantly moist with the lotion, the dressing being left freely exposed
to allow of continuous evaporation. A useful evaporating lotion is made
up as follows: take of chloride of ammonium, half an ounce; rectified
spirit, one ounce; and water, seven ounces.
The administration of opiates may be necessary for the relief of pain.
The accumulation of an excessive amount of inflammatory exudate may
endanger the vitality of the tissues by pressing on the blood vessels to
such an extent as to cause stasis, and by concentrating the local action
of the toxins. Under such conditions the tension should be relieved and
the exudate with its contained toxins removed by making an incision into
the inflamed tissues, and applying a suction bell. When the exudate has
collected in a synovial cavity, such as a joint or bursa, it may be
withdrawn by means of a trocar and cannula. There are other methods of
withdrawing blood and exudate from an inflamed area, for example by
leeches or wet-cupping, but they are seldom employed now.
Before applying leeches the part must be thoroughly cleansed, and if
the leech is slow to bite, may be smeared with cream. The leech is
retained in position under an inverted wine-glass or wide test-tube till
it takes hold. After it has sucked its fill it usually drops off, having
withdrawn a dram or a dram and a half of blood. If it be desirable to
withdraw more blood, hot fomentations should be applied to the bite. As
it is sometimes necessary to employ considerable pressure to stop the
bleeding, leeches should, if possible, be applied over a bone which will
furnish the necessary resistance. The use of styptics may be called for.
_Wet-cupping_ has almost entirely been superseded by the use of Klapp's
suction bells.
_General blood-letting_ consists in opening a superficial vein
(venesection) and allowing from eight to ten ounces of blood to flow
from it. It is seldom used in the treatment of surgical forms of
inflammation.
_Counter-irritants._--In deep-seated inflammations, counter-irritants
are sometimes employed in the form of mustard leaves or blisters,
according to the degree of irritation required. A mustard leaf or
plaster should not be left on longer than ten or fifteen minutes, unless
it is desired to produce a blister. Blistering may be produced by a
_cantharides plaster_, or by painting with _liquor epispasticus_. The
plaster should be left on from eight to ten hours, and if it has failed
to raise a blister, a hot fomentation should be applied to the part.
_Liquor epispasticus_, alone or mixed with equal parts of collodion, is
painted on the part with a brush. Several paintings are often required
before a blister is raised. The preliminary removal of the natural
grease from the skin favours the action of these applications.
The treatment of inflammation in special tissues and organs will be
considered in the sections devoted to regional surgery.
#Chronic Inflammation.#--A variety of types of chronic and subacute
inflammation are met with which, owing to ignorance of their causations,
cannot at present be satisfactorily classified.
The best defined group is that of the _granulomata_, which includes such
important diseases as tuberculosis and syphilis, and in which different
types of chronic inflammation are caused by infection with a specific
organism, all having the common character, however, that abundant
granulation tissue is formed in which cellular changes are more in
evidence than changes in the blood vessels, and in which the subsequent
degeneration and necrosis of the granulation tissue results in the
breaking down and destruction of the tissue in which it is formed.
Another group is that in which chronic inflammation is due to mild or
attenuated forms of pyogenic infection affecting especially the lymph
glands and the bone marrow. In the glands of the groin, for example,
associated with various forms of irritation about the external genitals,
different types of _chronic lymphadenitis_ are met with; they do not
frankly suppurate as do the acute types, but are attended with a
hyperplasia of the tissue elements which results in enlargement of the
affected glands of a persistent, and sometimes of a relapsing character.
Similar varieties of _osteomyelitis_ are met with that do not, like the
acute forms, go on to suppuration or to death of bone, but result in
thickening of the bone affected, both on the surface and in the
interior, resulting in obliteration of the medullary canal.
A third group of chronic inflammations are those that begin as an acute
pyogenic inflammation, which, instead of resolving completely, persists
in a chronic form. It does so apparently because there is some factor
aiding the organisms and handicapping the tissues, such as the presence
of a foreign body, a piece of glass or metal, or a piece of dead bone;
in these circumstances the inflammation persists in a chronic form,
attended with the formation of fibrous tissue, and, in the case of bone,
with the formation of new bone in excess. It will be evident that in
this group, chronic inflammation and repair are practically
interchangeable terms.
There are other groups of chronic inflammation, the origin of which
continues to be the subject of controversy. Reference is here made to
the chronic inflammations of the synovial membrane of joints, of tendon
sheaths and of bursæ--_chronic synovitis_, _teno-synovitis_ and
_bursitis_; of the fibrous tissues of joints--chronic forms of
_arthritis_; of the blood vessels--chronic forms of _endarteritis_ and
of _phlebitis_ and of the peripheral nerves--_neuritis_. Also in the
breast and in the prostate, with the waning of sexual life there may
occur a formation of fibrous tissue--chronic _interstitial mastitis_,
_chronic prostatitis_, having analogies with the chronic interstitial
inflammations of internal organs like the kidney--_chronic interstitial
nephritis_; and in the breast and prostate, as in the kidney, the
formation of fibrous tissue leads to changes in the secreting epithelium
resulting in the formation of cysts.
Lastly, there are still other types of chronic inflammation attended
with the formation of fibrous tissue on such a liberal scale as to
suggest analogies with new growths. The best known of these are the
systematic forms of fibromatosis met with in the central nervous system
and in the peripheral nerves--_neuro-fibromatosis_; in the submucous
coat of the stomach--_gastric fibromatosis_; and in the
colon--_intestinal fibromatosis_.
These conditions will be described with the tissues and organs in which
they occur.
In the _treatment of chronic inflammations_, pending further knowledge
as to their causation, and beyond such obvious indications as to help
the tissues by removing a foreign body or a piece of dead bone, there
are employed--empirically--a number of procedures such as the induction
of hyperæmia, exposure to the X-rays, and the employment of blisters,
cauteries, and setons. Vaccines may be had recourse to in those of
bacterial origin.
CHAPTER IV
SUPPURATION
Definition--Pus--_Varieties_--Acute circumscribed abscess--_Acute
suppuration in a wound_--_Acute Suppuration in a mucous
membrane_--Diffuse cellulitis and diffuse suppuration--
_Whitlow_--_Suppurative cellulitis in different situations_--Chronic
suppuration--Sinus, Fistula--Constitutional manifestations of
pyogenic infection--_Sapræmia_--_Septicæmia_--_Pyæmia_.
Suppuration, or the formation of pus, is one of the results of the
action of bacteria on the tissues. The invading organism is usually one
of the staphylococci, less frequently a streptococcus, and still less
frequently one of the other bacteria capable of producing pus, such as
the bacillus coli communis, the gonococcus, the pneumococcus, or the
typhoid bacillus.
So long as the tissues are in a healthy condition they are able to
withstand the attacks of moderate numbers of pyogenic bacteria of
ordinary virulence, but when devitalised by disease, by injury, or by
inflammation due to the action of other pathogenic organisms,
suppuration ensues.
It would appear, for example, that pyogenic organisms can pass through
the healthy urinary tract without doing any damage, but if the pelvis of
the kidney, the ureter, or the bladder is the seat of stone, they give
rise to suppuration. Similarly, a calculus in one of the salivary ducts
frequently results in an abscess forming in the floor of the mouth. When
the lumen of a tubular organ, such as the appendix or the Fallopian tube
is blocked also, the action of pyogenic organisms is favoured and
suppuration ensues.
#Pus.#--The fluid resulting from the process of suppuration is known
as _pus_. In its typical form it is a yellowish creamy substance, of
alkaline reaction, with a specific gravity of about 1030, and it has a
peculiar mawkish odour. If allowed to stand in a test-tube it does not
coagulate, but separates into two layers: the upper, transparent,
straw-coloured fluid, the _liquor puris_ or pus serum, closely
resembling blood serum in its composition, but containing less protein
and more cholestrol; it also contains leucin, tyrosin, and certain
albumoses which prevent coagulation.
The layer at the bottom of the tube consists for the most part of
polymorph leucocytes, and proliferated connective tissue and endothelial
cells (_pus corpuscles_). Other forms of leucocytes may be present,
especially in long-standing suppurations; and there are usually some red
corpuscles, dead bacteria, fat cells and shreds of tissue, cholestrol
crystals, and other detritus in the deposit.
If a film of fresh pus is examined under the microscope, the pus cells
are seen to have a well-defined rounded outline, and to contain a finely
granular protoplasm and a multi-partite nucleus; if still warm, the
cells may exhibit amoeboid movement. In stained films the nuclei take the
stain well. In older pus cells the outline is irregular, the protoplasm
coarsely granular, and the nuclei disintegrated, no longer taking the
stain.
_Variations from Typical Pus._--Pus from old-standing sinuses is often
watery in consistence (ichorous), with few cells. Where the granulations
are vascular and bleed easily, it becomes sanious from admixture with
red corpuscles; while, if a blood-clot be broken down and the debris
mixed with the pus, it contains granules of blood pigment and is said to
be "grumous." The _odour_ of pus varies with the different bacteria
producing it. Pus due to ordinary pyogenic cocci has a mawkish odour;
when putrefactive organisms are present it has a putrid odour; when it
forms in the vicinity of the intestinal canal it usually contains the
bacillus coli communis and has a fæcal odour.
The _colour_ of pus also varies: when due to one or other of the
varieties of the bacillus pyocyaneus, it is usually of a blue or green
colour; when mixed with bile derivatives or altered blood pigment, it
may be of a bright orange colour. In wounds inflicted with rough iron
implements from which rust is deposited, the pus often presents the same
colour.
The pus may form and collect within a circumscribed area, constituting a
localised _abscess_; or it may infiltrate the tissues over a wide
area--_diffuse suppuration_.
ACUTE CIRCUMSCRIBED ABSCESS
Any tissue of the body may be the seat of an acute abscess, and there
are many routes by which the bacteria may gain access to the affected
area. For example: an abscess in the integument or subcutaneous
cellular tissue usually results from infection by organisms which have
entered through a wound or abrasion of the surface, or along the ducts
of the skin; an abscess in the breast from organisms which have passed
along the milk ducts opening on the nipple, or along the lymphatics
which accompany these. An abscess in a lymph gland is usually due to
infection passing by way of the lymph channels from the area of skin or
mucous membrane drained by them. Abscesses in internal organs, such as
the kidney, liver, or brain, usually result from organisms carried in
the blood-stream from some focus of infection elsewhere in the body.
A knowledge of the possible avenues of infection is of clinical
importance, as it may enable the source of a given abscess to be traced
and dealt with. In suppuration in the Fallopian tube (pyosalpynx), for
example, the fact that the most common origin of the infection is in the
genital passage, leads to examination for vaginal discharge; and if none
is present, the abscess is probably due to infection carried in the
blood-stream from some primary focus about the mouth, such as a gumboil
or an infective sore throat.
The exact location of an abscess also may furnish a key to its source;
in axillary abscess, for example, if the suppuration is in the lymph
glands the infection has come through the afferent lymphatics; if in the
cellular tissue, it has spread from the neck or chest wall; if in the
hair follicles, it is a local infection through the skin.
#Formation of an Abscess.#--When pyogenic bacteria are introduced into
the tissue there ensues an inflammatory reaction, which is characterised
by dilatation of the blood vessels, exudation of large numbers of
leucocytes, and proliferation of connective-tissue cells. These
wandering cells soon accumulate round the focus of infection, and form a
protective barrier which tends to prevent the spread of the organisms
and to restrict their field of action. Within the area thus
circumscribed the struggle between the bacteria and the phagocytes takes
place, and in the process toxins are formed by the organisms, a certain
number of the leucocytes succumb, and, becoming degenerated, set free
certain proteolytic enzymes or ferments. The toxins cause
coagulation-necrosis of the tissue cells with which they come in
contact, the ferments liquefy the exudate and other albuminous
substances, and in this way _pus_ is formed.
If the bacteria gain the upper hand, this process of liquefaction which
is characteristic of suppuration, extends into the surrounding tissues,
the protective barrier of leucocytes is broken down, and the
suppurative process spreads. A fresh accession of leucocytes, however,
forms a new barrier, and eventually the spread is arrested, and the
collection of pus so hemmed in constitutes an _abscess_.
Owing to the swelling and condensation of the parts around, the pus thus
formed is under considerable pressure, and this causes it to burrow
along the lines of least resistance. In the case of a subcutaneous
abscess the pus usually works its way towards the surface, and "points,"
as it is called. Where it approaches the surface the skin becomes soft
and thin, and eventually sloughs, allowing the pus to escape.
An abscess forming in the deeper planes is prevented from pointing
directly to the surface by the firm fasciæ and other fibrous structures.
The pus therefore tends to burrow along the line of the blood vessels
and in the connective-tissue septa, till it either finds a weak spot or
causes a portion of fascia to undergo necrosis and so reaches the
surface. Accordingly, many abscess cavities resulting from deep-seated
suppuration are of irregular shape, with pouches and loculi in various
directions--an arrangement which interferes with their successful
treatment by incision and drainage.
The relief of tension which follows the bursting of an abscess, the
removal of irritation by the escape of pus, and the casting off of
bacteria and toxins, allow the tissues once more to assert themselves,
and a process of repair sets in. The walls of the abscess fall in;
granulation tissue grows into the space and gradually fills it; and
later this is replaced by cicatricial tissue. As a result of the
subsequent contraction of the cicatricial tissue, the scar is usually
depressed below the level of the surrounding skin surface.
If an abscess is prevented from healing--for example, by the presence of
a foreign body or a piece of necrosed bone--a sinus results, and from it
pus escapes until the foreign body is removed.
#Clinical Features of an Acute Circumscribed Abscess.#--In the initial
stages the usual symptoms of inflammation are present. Increased
elevation of temperature, with or without a rigor, progressive
leucocytosis, and sweating, mark the transition between inflammation and
suppuration. An increasing leucocytosis is evidence that a suppurative
process is spreading.
The local symptoms vary with the seat of the abscess. When it is
situated superficially--for example, in the breast tissue--the affected
area is hot, the redness of inflammation gives place to a dusky purple
colour, with a pale, sometimes yellow, spot where the pus is near the
surface. The swelling increases in size, the firm brawny centre becomes
soft, projects as a cone beyond the level of the rest of the swollen
area, and is usually surrounded by a zone of induration.
By gently palpating with the finger-tips over the softened area, a fluid
wave may be detected--_fluctuation_--and when present this is a certain
indication of the existence of fluid in the swelling. Its recognition,
however, is by no means easy, and various fallacies are to be guarded
against in applying this test clinically. When, for example, the walls
of the abscess are thick and rigid, or when its contents are under
excessive tension, the fluid wave cannot be elicited. On the other hand,
a sensation closely resembling fluctuation may often be recognised in
oedematous tissues, in certain soft, solid tumours such as fatty tumours
or vascular sarcomata, in aneurysm, and in a muscle when it is palpated
in its transverse axis.
When pus has formed in deeper parts, and before it has reached the
surface, oedema of the overlying skin is frequently present, and the skin
pits on pressure.
With the formation of pus the continuous burning or boring pain of
inflammation assumes a throbbing character, with occasional sharp,
lancinating twinges. Should doubt remain as to the presence of pus,
recourse may be had to the use of an exploring needle.
_Differential Diagnosis of Acute Abscess._--A practical difficulty which
frequently arises is to decide whether or not pus has actually formed.
It may be accepted as a working rule in practice that when an acute
inflammation has lasted for four or five days without showing signs of
abatement, suppuration has almost certainly occurred. In deep-seated
suppuration, marked oedema of the skin and the occurrence of rigors and
sweating may be taken to indicate the formation of pus.
There are cases on record where rapidly growing sarcomatous and
angiomatous tumours, aneurysms, and the bruises that occur in
hæmophylics, have been mistaken for acute abscesses and incised, with
disastrous results.
#Treatment of Acute Abscesses.#--The dictum of John Bell, "Where there
is pus, let it out," summarises the treatment of abscess. The extent and
situation of the incision and the means taken to drain the cavity,
however, vary with the nature, site, and relations of the abscess. In a
superficial abscess, for example a bubo, or an abscess in the breast or
face where a disfiguring scar is undesirable, a small puncture should be
made where the pus threatens to point, and a Klapp's suction bell be
applied as already described (p. 39). A drain is not necessary, and in
the intervals between the applications of the bell the part is covered
with a moist antiseptic dressing.
In abscesses deeply placed, as for example under the gluteal or pectoral
muscles, one or more incisions should be made, and the cavity drained by
glass or rubber tubes or by strips of rubber tissue.
The wound should be dressed the next day, and the tube shortened, in the
case of a rubber tube, by cutting off a portion of its outer end. On the
second day or later, according to circumstances, the tube is removed,
and after this the dressing need not be repeated oftener than every
second or third day.
Where pus has formed in relation to important structures--as, for
example, in the deeper planes of the neck--_Hilton's method_ of opening
the abscess may be employed. An incision is made through the skin and
fascia, a grooved director is gently pushed through the deeper tissues
till pus escapes along its groove, and then the track is widened by
passing in a pair of dressing forceps and expanding the blades. A tube,
or strip of rubber tissue, is introduced, and the subsequent treatment
carried out as in other abscesses. When the drain lies in proximity to a
large blood vessel, care must be taken not to leave it in position long
enough to cause ulceration of the vessel wall by pressure.
In some abscesses, such as those in the vicinity of the anus, the cavity
should be laid freely open in its whole extent, stuffed with iodoform or
bismuth gauze, and treated by the open method.
It is seldom advisable to wash out an abscess cavity, and squeezing out
the pus is also to be avoided, lest the protective zone be broken down
and the infection be diffused into the surrounding tissues.
The importance of taking precautions against further infection in
opening an abscess can scarcely be exaggerated, and the rapidity with
which healing occurs when the access of fresh bacteria is prevented is
in marked contrast to what occurs when such precautions are neglected
and further infection is allowed to take place.
_Acute Suppuration in a Wound._--If in the course of an operation
infection of the wound has occurred, a marked inflammatory reaction soon
manifests itself, and the same changes as occur in the formation of an
acute abscess take place, modified, however, by the fact that the pus
can more readily reach the surface. In from twenty-four to forty-eight
hours the patient is conscious of a sensation of chilliness, or may
even have a rigor. At the same time he feels generally out of sorts,
with impaired appetite, headache, and it may be looseness of the bowels.
His temperature rises to 100° or 101° F., and the pulse quickens to 100
or 110.
On exposing the wound it is found that the parts for some distance
around are red, glazed, and oedematous. The discoloration and swelling
are most intense in the immediate vicinity of the wound, the edges of
which are everted and moist. Any stitches that may have been introduced
are tight, and the deep ones may be cutting into the tissues. There is
heat, and a constant burning or throbbing pain, which is increased by
pressure. If the stitches be cut, pus escapes, the wound gapes, and its
surfaces are found to be inflamed and covered with pus.
The open method is the only safe means of treating such wounds. The
infected surface may be sponged over with pure carbolic acid, the excess
of which is washed off with absolute alcohol, and the wound either
drained by tubes or packed with iodoform gauze. The practice of scraping
such surfaces with the sharp spoon, squeezing or even of washing them
out with antiseptic lotions, is attended with the risk of further
diffusing the organisms in the tissue, and is only to be employed under
exceptional circumstances. Continuous irrigation of infected wounds or
their immersion in antiseptic baths is sometimes useful. The free
opening up of the wound is almost immediately followed by a fall in the
temperature. The surrounding inflammation subsides, the discharge of pus
lessens, and healing takes place by the formation of granulation
tissue--the so-called "healing by second intention."
Wound infection may take place from _catgut_ which has not been
efficiently prepared. The local and general reactions may be slight,
and, as a rule, do not appear for seven or eight days after the
operation, and, it may be, not till after the skin edges have united.
The suppuration is strictly localised to the part of the wound where
catgut was employed for stitches or ligatures, and shows little tendency
to spread. The infected part, however, is often long of healing. The
irritation in these cases is probably due to toxins in the catgut and
not to bacteria.
When suppuration occurs in connection with buried sutures of
unabsorbable materials, such as silk, silkworm gut, or silver wire, it
is apt to persist till the foreign material is cast off or removed.
Suppuration may occur in the track of a skin stitch, producing a _stitch
abscess_. The infection may arise from the material used, especially
catgut or silk, or, more frequently perhaps, from the growth of
staphylococcus albus from the skin of the patient when this has been
imperfectly disinfected. The formation of pus under these conditions may
not be attended with any of the usual signs of suppuration, and beyond
some induration around the wound and a slight tenderness on pressure
there may be nothing to suggest the presence of an abscess.
_Acute Suppuration of a Mucous Membrane._--When pyogenic organisms gain
access to a mucous membrane, such as that of the bladder, urethra, or
middle ear, the usual phenomena of acute inflammation and suppuration
ensue, followed by the discharge of pus on the free surface. It would
appear that the most marked changes take place in the submucous tissue,
causing the covering epithelium in places to die and leave small
superficial ulcers, for example in gonorrhoeal urethritis, the
cicatricial contraction of the scar subsequently leading to the
formation of stricture. When mucous glands are present in the membrane,
the pus is mixed with mucus--_muco-pus_.
DIFFUSE CELLULITIS AND DIFFUSE SUPPURATION
Cellulitis is an acute affection resulting from the introduction of some
organism--commonly the _streptococcus pyogenes_--into the cellular
connective tissue of the integument, intermuscular septa, tendon
sheaths, or other structures. Infection always takes place through a
breach of the surface, although this may be superficial and
insignificant, such as a pin-prick, a scratch, or a crack under a nail,
and the wound may have been healed for some time before the inflammation
becomes manifest. The cellulitis, also, may develop at some distance
from the seat of inoculation, the organisms having travelled by the
lymphatics.
The virulence of the organisms, the loose, open nature of the tissues in
which they develop, and the free lymphatic circulation by means of which
they are spread, account for the diffuse nature of the process.
Sometimes numbers of cocci are carried for a considerable distance from
the primary area before they are arrested in the lymphatics, and thus
several patches of inflammation may appear with healthy areas between.
The pus infiltrates the meshes of the cellular tissue, there is
sloughing of considerable portions of tissue of low vitality, such as
fat, fascia, or tendon, and if the process continues for some time
several collections of pus may form.
_Clinical Features._--The reaction in cases of diffuse cellulitis is
severe, and is usually ushered in by a distinct chill or even a rigor,
while the temperature rises to 103°, 104°, or 105° F. The pulse is
proportionately increased in frequency, and is small, feeble, and often
irregular. The face is flushed, the tongue dry and brown, and the
patient may become delirious, especially during the night. Leucocytosis
is present in cases of moderate severity; but in severe cases the
virulence of the toxins prevents reaction taking place, and leucocytosis
is absent.
The local manifestations vary with the relation of the seat of the
inflammation to the surface. When the superficial cellular tissue is
involved, the skin assumes a dark bluish-red colour, is swollen,
oedematous, and the seat of burning pain. To the touch it is firm, hot,
and tender. When the primary focus is in the deeper tissues, the
constitutional disturbance is aggravated, while the local signs are
delayed, and only become prominent when pus forms and approaches the
surface. It is not uncommon for blebs containing dark serous fluid to
form on the skin. The infection frequently spreads along the line of the
main lymph vessels of the part (_septic lymphangitis_) and may reach the
lymph glands (_septic lymphadenitis_).
With the formation of pus the skin becomes soft and boggy at several
points, and eventually breaks, giving exit to a quantity of thick
grumous discharge. Sometimes several small collections under the skin
fuse, and an abscess is formed in which fluctuation can be detected.
Occasionally gases are evolved in the tissues, giving rise to emphysema.
It is common for portions of fascia, ligaments, or tendons to slough,
and this may often be recognised clinically by a peculiar crunching or
grating sensation transmitted to the fingers on making firm pressure on
the part.
If it is not let out by incision, the pus, travelling along the lines of
least resistance, tends to point at several places on the surface, or to
open into joints or other cavities.
_Prognosis._--The occurrence of _septicæmia_ is the most serious risk,
and it is in cases of diffuse suppurative cellulitis that this form of
blood-poisoning assumes its most aggravated forms. The toxins of the
streptococci are exceedingly virulent, and induce local death of tissue
so rapidly that the protective emigration of leucocytes fails to take
place. In some cases the passage of masses of free cocci in the
lymphatics, or of infective emboli in the blood vessels, leads to the
formation of _pyogenic abscesses_ in vital organs, such as the brain,
lungs, liver, kidneys, or other viscera. _Hæmorrhage_ from erosion of
arterial or venous trunks may take place and endanger life.
_Treatment._--The treatment of diffuse cellulitis depends to a large
extent on the situation and extent of the affected area, and on the
stage of the process.
_In the limbs_, for example, where the application of a constricting
band is practicable, Bier's method of inducing passive hyperæmia yields
excellent results. If pus is formed, one or more small incisions are
made and a light moist dressing placed over the wounds to absorb the
discharge, but no drain is inserted. The whole of the inflamed area
should be covered with gauze wrung out of a 1 in 10 solution of ichthyol
in glycerine. The dressing is changed as often as necessary, and in the
intervals when the band is off, gentle active and passive movements
should be carried out to prevent the formation of adhesions. After
incisions have been made, we have found the _immersion_ of the limb, for
a few hours at a time, in a water-bath containing warm boracic lotion or
eusol a useful adjuvant to the passive hyperæmia.
_Continuous irrigation_ of the part by a slow, steady stream of lotion,
at the body temperature, such as eusol, or Dakin's solution, or boracic
acid, or frequent washing with peroxide of hydrogen, has been found of
value.
A suitably arranged splint adds to the comfort of the patient; and the
limb should be placed in the attitude which, in the event of stiffness
resulting, will least interfere with its usefulness. The elbow, for
example, should be flexed to a little less than a right angle; at the
wrist, the hand should be dorsiflexed and the fingers flexed slightly
towards the palm.
Massage, passive movement, hot and cold douching, and other measures,
may be necessary to get rid of the chronic oedema, adhesions of tendons,
and stiffness of joints which sometimes remain.
In situations where a constricting band cannot be applied, for example,
on the trunk or the neck, Klapp's suction bells may be used, small
incisions being made to admit of the escape of pus.
If these measures fail or are impracticable, it may be necessary to make
one or more free incisions, and to insert drainage-tubes, portions of
rubber dam, or iodoform worsted.
The general treatment of toxæmia must be carried out, and in cases due
to infection by streptococci, anti-streptococcic serum may be used.
In a few cases, amputation well above the seat of disease, by removing
the source of toxin production, offers the only means of saving the
patient.
WHITLOW
The clinical term whitlow is applied to an acute infection, usually
followed by suppuration, commonly met with in the fingers, less
frequently in the toes. The point of infection is often trivial--a
pin-prick, a puncture caused by a splinter of wood, a scratch, or even
an imperceptible lesion of the skin.
Several varieties of whitlow are recognised, but while it is convenient
to describe them separately, it is to be clearly understood that
clinically they merge one into another, and it is not always possible to
determine in which connective-tissue plane a given infection has
originated.
_Initial Stage._--Attention is usually first attracted to the condition
by a sensation of tightness in the finger and tenderness when the part
is squeezed or knocked against anything. In the course of a few hours
the part becomes red and swollen; there is continuous pain, which soon
assumes a throbbing character, particularly when the hand is dependent,
and may be so severe as to prevent sleep, and the patient may feel
generally out of sorts.
If a constricting band is applied at this stage, the infection can
usually be checked and the occurrence of suppuration prevented. If this
fails, or if the condition is allowed to go untreated, the inflammatory
reaction increases and terminates in suppuration, giving rise to one or
other of the forms of whitlow to be described.
_The Purulent Blister._--In the most superficial variety, pus forms
between the rete Malpighii and the stratum corneum of the skin, the
latter being raised as a blister in which fluctuation can be detected
(Fig. 9, a). This is commonly met with in the palm of the hand of
labouring men who have recently resumed work after a spell of idleness.
When the blister forms near the tip of the finger, the pus burrows under
the nail--which corresponds to the stratum corneum--raising it from its
bed.
There is some local heat and discoloration, and considerable pain and
tenderness, but little or no constitutional disturbance. Superficial
lymphangitis may extend a short distance up the forearm. By clipping
away the raised epidermis, and if necessary the nail, the pus is allowed
to escape, and healing speedily takes place.
_Whitlow at the Nail Fold._--This variety, which is met with among those
who handle septic material, occurs in the sulcus between the nail and
the skin, and is due to the introduction of infective matter at the root
of the nail (Fig. 9, b). A small focus of suppuration forms under the
nail, with swelling and redness of the nail fold, causing intense pain
and discomfort, interfering with sleep, and producing a constitutional
reaction out of all proportion to the local lesion.
To allow the pus to escape, it is necessary, under local anæsthesia, to
cut away the nail fold as well as the portion of nail in the infected
area, or, it may be, to remove the nail entirely. If only a small
opening is made in the nail it is apt to be blocked by granulations.
[Illustration: FIG. 9.--Diagram of various forms of Whitlow.
a = Purulent blister.
b = Suppuration at nail fold.
c = Subcutaneous whitlow.
d = Whitlow in sheath of flexor tendon (e). ]
_Subcutaneous Whitlow._--In this variety the infection manifests itself
as a cellulitis of the pulp of the finger (Fig. 9, c), which sometimes
spreads towards the palm of the hand. The finger becomes red, swollen,
and tense; there is severe throbbing pain, which is usually worst at
night and prevents sleep, and the part is extremely tender on pressure.
When the palm is invaded there may be marked oedema of the back of the
hand, the dense integument of the palm preventing the swelling from
appearing on the front. The pus may be under such tension that
fluctuation cannot be detected. The patient is usually able to flex the
finger to a certain extent without increasing the pain--a point which
indicates that the tendon sheaths have not been invaded. The
suppurative process may, however, spread to the tendon sheaths, or even
to the bone. Sometimes the excessive tension and virulent toxins induce
actual gangrene of the distal part, or even of the whole finger. There
is considerable constitutional disturbance, the temperature often
reaching 101° or 102° F.
The treatment consists in applying a constriction band and making an
incision over the centre of the most tender area, care being taken to
avoid opening the tendon sheath lest the infection be conveyed to it.
Moist dressings should be employed while the suppuration lasts. Carbolic
fomentations, however, are to be avoided on account of the risk of
inducing gangrene.
_Whitlow of the Tendon Sheaths._--In this form the main incidence of the
infection is on the sheaths of the flexor tendons, but it is not always
possible to determine whether it started there or spread thither from
the subcutaneous cellular tissue (Fig. 9, d). In some cases both
connective tissue planes are involved. The affected finger becomes red,
painful, and swollen, the swelling spreading to the dorsum. The
involvement of the tendon sheath is usually indicated by the patient
being unable to flex the finger, and by the pain being increased when he
attempts to do so. On account of the anatomical arrangement of the
tendon sheaths, the process may spread into the forearm--directly in the
case of the thumb and little finger, and after invading the palm in the
case of the other fingers--and there give rise to a diffuse cellulitis
which may result in sloughing of fasciæ and tendons. When the infection
spreads into the common flexor sheath under the transverse carpal
(anterior annular) ligament, it is not uncommon for the intercarpal and
wrist joints to become implicated. Impaired movement of tendons and
joints is, therefore, a common sequel to this variety of whitlow.
The _treatment_ consists in inducing passive hyperæmia by Bier's method,
and, if this is done early, suppuration may be avoided. If pus forms,
small incisions are made, under local anæsthesia, to relieve the tension
in the sheath and to diminish the risk of the tendons sloughing. No form
of drain should be inserted. In the fingers the incisions should be made
in the middle line, and in the palm they should be made over the
metacarpal bones to avoid the digital vessels and nerves. If pus has
spread under the transverse carpal ligament, the incision must be made
above the wrist. Passive movements and massage must be commenced as
early as possible and be perseveringly employed to diminish the
formation of adhesions and resulting stiffness.
_Subperiosteal Whitlow._--This form is usually an extension of the
subcutaneous or of the thecal variety, but in some cases the
inflammation begins in the periosteum--usually of the terminal phalanx.
It may lead to necrosis of a portion or even of the entire phalanx. This
is usually recognised by the persistence of suppuration long after the
acute symptoms have passed off, and by feeling bare bone with the probe.
In such cases one or more of the joints are usually implicated also, and
lateral mobility and grating may be elicited. Recovery does not take
place until the dead bone is removed, and the usefulness of the finger
is often seriously impaired by fibrous or bony ankylosis of the
interphalangeal joints. This may render amputation advisable when a
stiff finger is likely to interfere with the patient's occupation.
SUPPURATIVE CELLULITIS IN DIFFERENT SITUATIONS
_Cellulitis of the forearm_ is usually a sequel to one of the deeper
varieties of whitlow.
In the _region of the elbow-joint_, cellulitis is common around the
olecranon. It may originate as an inflammation of the olecranon bursa,
or may invade the bursa secondarily. In exceptional cases the
elbow-joint is also involved.
Cellulitis of the _axilla_ may originate in suppuration in the lymph
glands, following an infected wound of the hand, or it may spread from a
septic wound on the chest wall or in the neck. In some cases it is
impossible to discover the primary seat of infection. A firm, brawny
swelling forms in the armpit and extends on to the chest wall. It is
attended with great pain, which is increased on moving the arm, and
there is marked constitutional disturbance. When suppuration occurs, its
spread is limited by the attachments of the axillary fascia, and the pus
tends to burrow on to the chest wall beneath the pectoral muscles, and
upwards towards the shoulder-joint, which may become infected. When the
pus forms in the axillary space, the treatment consists in making free
incisions, which should be placed on the thoracic side of the axilla to
avoid the axillary vessels and nerves. If the pus spreads on to the
chest wall, the abscess should be opened below the clavicle by Hilton's
method, and a counter opening may be made in the axilla.
Cellulitis of the _sole of the foot_ may follow whitlow of the toes.
In the _region of the ankle_ cellulitis is not common; but _around the
knee_ it frequently occurs in relation to the prepatellar bursa and to
the popliteal lymph glands, and may endanger the knee-joint. It is also
met with in the _groin_ following on inflammation and suppuration of the
inguinal glands, and cases are recorded in which the sloughing process
has implicated the femoral vessels and led to secondary hæmorrhage.
Cellulitis of the scalp, orbit, neck, pelvis, and perineum will be
considered with the diseases of these regions.
CHRONIC SUPPURATION
While it is true that a chronic pyogenic abscess is sometimes met
with--for example, in the breast and in the marrow of long bones--in the
great majority of instances the formation of a chronic or cold abscess
is the result of the action of the tubercle bacillus. It is therefore
more convenient to study this form of suppuration with tuberculosis
(p. 139).
SINUS AND FISTULA
#Sinus.#--A sinus is a track leading from a focus of suppuration to a
cutaneous or mucous surface. It usually represents the path by which the
discharge escapes from an abscess cavity that has been prevented from
closing completely, either from mechanical causes or from the persistent
formation of discharge which must find an exit. A sinus is lined by
granulation tissue, and when it is of long standing the opening may be
dragged below the level of the surrounding skin by contraction of the
scar tissue around it. As a sinus will persist until the obstacle to
closure of the original abscess is removed, it is necessary that this
should be sought for. It may be a foreign body, such as a piece of dead
bone, an infected ligature, or a bullet, acting mechanically or by
keeping up discharge, and if the body is removed the sinus usually
heals. The presence of a foreign body is often suggested by a mass of
redundant granulations at the mouth of the sinus. If a sinus passes
through a muscle, the repeated contractions tend to prevent healing
until the muscle is kept at rest by a splint, or put out of action by
division of its fibres. The sinuses associated with empyema are
prevented from healing by the rigidity of the chest wall, and will only
close after an operation which admits of the cavity being obliterated.
In any case it is necessary to disinfect the track, and, it may be, to
remove the unhealthy granulations lining it, by means of the sharp
spoon, or to excise it bodily. To encourage healing from the bottom the
cavity should be packed with bismuth or iodoform gauze. The healing of
long and tortuous sinuses is often hastened by the injection of Beck's
bismuth paste (p. 145). If disfigurement is likely to follow from
cicatricial contraction--for example, in a sinus over the lower jaw
associated with a carious tooth--the sinus should be excised and the raw
surfaces approximated with stitches.
The _tuberculous sinus_ is described under Tuberculosis.
A #fistula# is an abnormal canal passing from a mucous surface to the
skin or to another mucous surface. Fistulæ resulting from suppuration
usually occur near the natural openings of mucous canals--for example,
on the cheek, as a salivary fistula; beside the inner angle of the eye,
as a lacrymal fistula; near the ear, as a mastoid fistula; or close to
the anus, as a fistula-in-ano. Intestinal fistulæ are sometimes met with
in the abdominal wall after strangulated hernia, operations for
appendicitis, tuberculous peritonitis, and other conditions. In the
perineum, fistulæ frequently complicate stricture of the urethra.
Fistulæ also occur between the bladder and vagina (_vesico-vaginal
fistula_), or between the bladder and the rectum (_recto-vesical
fistula_).
The _treatment_ of these various forms of fistula will be described in
the sections dealing with the regions in which they occur.
_Congenital fistulæ_, such as occur in the neck from imperfect closure
of branchial clefts, or in the abdomen from unobliterated foetal ducts
such as the urachus or Meckel's diverticulum, will be described in their
proper places.
CONSTITUTIONAL MANIFESTATIONS OF PYOGENIC INFECTION
We have here to consider under the terms Sapræmia, Septicæmia, and
Pyæmia certain general effects of pyogenic infection, which, although
their clinical manifestations may vary, are all associated with the
action of the same forms of bacteria. They may occur separately or in
combination, or one may follow on and merge into another.
#Sapræmia#, or septic intoxication, is the name applied to a form of
poisoning resulting from the absorption into the blood of the toxic
products of pyogenic bacteria. These products, which are of the nature
of alkaloids, act immediately on their entrance into the circulation,
and produce effects in direct proportion to the amount absorbed. As the
toxins are gradually eliminated from the body the symptoms abate, and if
no more are introduced they disappear. Sapræmia in these respects,
therefore, is comparable to poisoning by any other form of alkaloid,
such as strychnin or morphin.
_Clinical Features._--The symptoms of sapræmia seldom manifest
themselves within twenty-four hours of an operation or injury, because
it takes some time for the bacteria to produce a sufficient dose of
their poisons. The onset of the condition is marked by a feeling of
chilliness, sometimes amounting to a rigor, and a rise of temperature to
102°, 103°, or 104° F., with morning remissions (Fig. 10). The heart's
action is markedly depressed, and the pulse is soft and compressible.
The appetite is lost, the tongue dry and covered with a thin
brownish-red fur, so that it has the appearance of "dried beef." The
urine is scanty and loaded with urates. In severe cases diarrhoea and
vomiting of dark coffee-ground material are often prominent features.
Death is usually impending when the skin becomes cold and clammy, the
mucous membranes livid, the pulse feeble and fluttering, the discharges
involuntary, and when a low form of muttering delirium is present.
[Illustration: FIG. 10.--Charts of Acute sapræmia from (a) case of
crushed foot, and (b) case of incomplete abortion.]
A local form of septic infection is always present--it may be an
abscess, an infected compound fracture, or an infection of the cavity of
the uterus, for example, from a retained portion of placenta.
_Treatment._--The first indication is the immediate and complete removal
of the infected material. The wound must be freely opened, all
blood-clot, discharge, or necrosed tissue removed, and the area
disinfected by washing with sterilised salt solution, peroxide of
hydrogen, or eusol. Stronger lotions are to be avoided as being likely
to depress the tissues, and so interfere with protective phagocytosis.
On account of its power of neutralising toxins, iodoform is useful in
these cases, and is best employed by packing the wound with iodoform
gauze, and treating it by the open method, if this is possible.
The general treatment is carried out on the same lines as for other
infective conditions.
#Chronic sapræmia or Hectic Fever.#--Hectic fever differs from acute
sapræmia merely in degree. It usually occurs in connection with
tuberculous conditions, such as bone or joint disease, psoas abscess, or
empyema, which have opened externally, and have thereby become infected
with pyogenic organisms. It is gradual in its development, and is of a
mild type throughout.
[Illustration: FIG. 11.--Chart of Hectic Fever.]
The pulse is small, feeble, and compressible, and the temperature rises
in the afternoon or evening to 102° or 103° F. (Fig. 11), the cheeks
becoming characteristically flushed. In the early morning the
temperature falls to normal or below it, and the patient breaks into a
profuse perspiration, which leaves him pale, weak, and exhausted. He
becomes rapidly and markedly emaciated, even although in some cases the
appetite remains good and is even voracious.
The poisons circulating in the blood produce _waxy degeneration_ in
certain viscera, notably the liver, spleen, kidneys, and intestines. The
process begins in the arterial walls, and spreads thence to the
connective-tissue structures, causing marked enlargement of the affected
organs. Albuminuria, ascites, oedema of the lower limbs, clubbing of the
fingers, and diarrhoea are among the most prominent symptoms of this
condition.
The _prognosis_ in hectic fever depends on the completeness with which
the further absorption of toxins can be prevented. In many cases this
can only be effected by an operation which provides for free drainage,
and, if possible, the removal of infected tissues. The resulting wound
is best treated by the open method. Even advanced waxy degeneration does
not contra-indicate this line of treatment, as the diseased organs
usually recover if the focus from which absorption of toxic material is
taking place is completely eradicated.
[Illustration: FIG. 12.--Chart of case of Septicæmia followed by
Pyæmia.]
#Septicæmia.#--This form of blood-poisoning is the result of the action
of pyogenic bacteria, which not only produce their toxins at the primary
seat of infection, but themselves enter the blood-stream and are carried
to other parts, where they settle and produce further effects.
_Clinical Features._--There may be an incubation period of some hours
between the infection and the first manifestation of acute septicæmia.
In such conditions as acute osteomyelitis or acute peritonitis, we see
the most typical clinical pictures of this condition. The onset is
marked by a chill, or a rigor, which may be repeated, while the
temperature rises to 103° or 104° F., although in very severe cases the
temperature may remain subnormal throughout, the virulence of the toxins
preventing reaction. It is in the general appearance of the patient and
in the condition of the pulse that we have our best guides as to the
severity of the condition. If the pulse remains firm, full, and regular,
and does not exceed 110 or even 120, while the temperature is moderately
raised, the outlook is hopeful; but when the pulse becomes small and
compressible, and reaches 130 or more, especially if at the same time
the temperature is low, a grave prognosis is indicated. The tongue is
often dry and coated with a black crust down the centre, while the sides
are red. It is a good omen when the tongue becomes moist again. Thirst
is most distressing, especially in septicæmia of intestinal origin.
Persistent vomiting of dark-brown material is often present, and
diarrhoea with blood-stained stools is not uncommon. The urine is small
in amount, and contains a large proportion of urates. As the poisons
accumulate, the respiration becomes shallow and laboured, the face of a
dull ashy grey, the nose pinched, and the skin cold and clammy.
Capillary hæmorrhages sometimes take place in the skin or mucous
membranes; and in a certain proportion of cases cutaneous eruptions
simulating those of scarlet fever or measles appear, and are apt to lead
to errors in diagnosis. In other cases there is slight jaundice. The
mental state is often one of complete apathy, the patient failing to
realise the gravity of his condition; sometimes there is delirium.
The _prognosis_ is always grave, and depends on the possibility of
completely eradicating the focus of infection, and on the reserve force
the patient has to carry him over the period during which he is
eliminating the poison already circulating in his blood.
The _treatment_ is carried out on the same lines as in sapræmia, but it
is less likely to be successful owing to the organisms having entered
the circulation. When possible, the primary focus of infection should be
dealt with.
#Pyæmia# is a form of blood-poisoning characterised by the development
of secondary foci of suppuration in different parts of the body. Toxins
are thus introduced into the blood, not only at the primary seat of
infection, but also from each of these metastatic collections. Like
septicæmia, this condition is due to pyogenic bacteria, the
_streptococcus pyogenes_ being the commonest organism found. The primary
infection is usually in a wound--for example, a compound fracture--but
cases occur in which the point of entrance of the bacteria is not
discoverable. The dissemination of the organisms takes place through the
medium of infected emboli which form in a thrombosed vein in the
vicinity of the original lesion, and, breaking loose, are carried
thence in the blood-stream. These emboli lodge in the minute vessels of
the lungs, spleen, liver, kidneys, pleura, brain, synovial membranes, or
cellular tissue, and the bacteria they contain give rise to secondary
foci of suppuration. Secondary abscesses are thus formed in those parts,
and these in turn may be the starting-point of new emboli which give
rise to fresh areas of pus formation. The organs above named are the
commonest situations of pyæmic abscesses, but these may also occur in
the bone marrow, the substance of muscles, the heart and pericardium,
lymph glands, subcutaneous tissue, or, in fact, in any tissue of the
body. Organisms circulating in the blood are prone to lodge on the
valves of the heart and give rise to endocarditis.
[Illustration: FIG. 13.--Chart of Pyæmia following on Acute
Osteomyelitis.]
_Clinical Features._--Before antiseptic surgery was practised, pyæmia
was a common complication of wounds. In the present day it is not only
infinitely less common, but appears also to be of a less severe type.
Its rarity and its mildness may be related as cause and effect, because
it was formerly found that pyæmia contracted from a pyæmic patient was
more virulent than that from other sources.
In contrast with sapræmia and septicæmia, pyæmia is late of developing,
and it seldom begins within a week of the primary infection. The first
sign is a feeling of chilliness, or a violent rigor lasting for perhaps
half an hour, during which time the temperature rises to 103°, 104°, or
105° F. In the course of an hour it begins to fall again, and the
patient breaks into a profuse sweat. The temperature may fall several
degrees, but seldom reaches the normal. In a few days there is a second
rigor with rise of temperature, and another remission, and such attacks
may be repeated at diminishing intervals during the course of the
illness (Figs. 12 and 13). The pulse is soft, and tends to remain
abnormally rapid even when the temperature falls nearly to normal.
The face is flushed, and wears a drawn, anxious expression, and the eyes
are bright. A characteristic sweetish odour, which has been compared to
that of new-mown hay, can be detected in the breath and may pervade the
patient. The appetite is lost; there may be sickness and vomiting and
profuse diarrhoea; and the patient emaciates rapidly. The skin is
continuously hot, and has often a peculiar pungent feel. Patches of
erythema sometimes appear scattered over the body. The skin may assume a
dull sallow or earthy hue, or a bright yellow icteric tint may appear.
The conjunctivæ also may be yellow. In the latter stages of the disease
the pulse becomes small and fluttering; the tongue becomes dry and
brown; sordes collect on the teeth; and a low muttering form of delirium
supervenes.
Secondary infection of the parotid gland frequently occurs, and gives
rise to a suppurative parotitis. This condition is associated with
severe pain, gradually extending from behind the angle of the jaw on to
the face. There is also swelling over the gland, and eventually
suppuration and sloughing of the gland tissue and overlying skin.
Secondary abscesses in the lymph glands, subcutaneous tissue, or joints
are often so insidious and painless in their development that they are
only discovered accidentally. When the abscess is evacuated, healing
often takes place with remarkable rapidity, and with little impairment
of function.
The general symptoms may be simulated by an attack of malaria.
_Prognosis._--The prognosis in acute pyæmia is much less hopeless than
it once was, a considerable proportion of the patients recovering. In
acute cases the disease proves fatal in ten days or a fortnight, death
being due to toxæmia. Chronic cases often run a long course, lasting for
weeks or even months, and prove fatal from exhaustion and waxy disease
following on prolonged suppuration.
_Treatment._--In such conditions as compound fractures and severe
lacerated wounds, much can be done to avert the conditions which lead to
pyæmia, by applying a Bier's constricting bandage as soon as there is
evidence of infection having taken place, or even if there is reason to
suspect that the wound is not aseptic.
If sepsis is already established, and evidence of general infection is
present, the wound should be opened up sufficiently to admit of thorough
disinfection and drainage, and the constricting bandage applied to aid
the defensive processes going on in the tissues. If these measures fail,
amputation of the limb may be the only means of preventing further
dissemination of infective material from the primary source of
infection.
Attempts have been made to interrupt the channel along which the
infective emboli spread, by ligating or resecting the main vein of the
affected part, but this is seldom feasible except in the case of the
internal jugular vein for infection of the transverse sinus.
Secondary abscesses must be aspirated or opened and drained whenever
possible.
The general treatment is conducted on the same lines as on other forms
of pyogenic infection.
CHAPTER V
ULCERATION AND ULCERS
Definitions--Clinical examination of an ulcer--The healing
sore.--Classification of ulcers--A. According to cause:
_Traumatism_, _Imperfect circulation_, _Imperfect nerve-supply_,
_Constitutional causes_--B. According to condition: _Healing_,
_Stationary_, _Spreading_.--Treatment.
The process of _ulceration_ may be defined as the molecular or cellular
death of tissue taking place on a free surface. It is essentially of the
same nature as the process of suppuration, only that the purulent
discharge, instead of collecting in a closed cavity and forming an
abscess, at once escapes on the surface.
An _ulcer_ is an open wound or sore in which there are present certain
conditions tending to prevent it undergoing the natural process of
repair. Of these, one of the most important is the presence of
pathogenic bacteria, which by their action not only prevent healing, but
so irritate and destroy the tissues as to lead to an actual increase in
the size of the sore. Interference with the nutrition of a part by oedema
or chronic venous congestion may impede healing; as may also induration
of the surrounding area, by preventing the contraction which is such an
important factor in repair. Defective innervation, such as occurs in
injuries and diseases of the spinal cord, also plays an important part
in delaying repair. In certain constitutional conditions, too--for
example, Bright's disease, diabetes, or syphilis--the vitiated state of
the tissues is an impediment to repair. Mechanical causes, such as
unsuitable dressings or ill-fitting appliances, may also act in the same
direction.
#Clinical Examination of an Ulcer.#--In examining any ulcer, we
observe--(1) Its _base_ or _floor_, noting the presence or absence of
granulations, their disposition, size, colour, vascularity, and whether
they are depressed or elevated in relation to the surrounding parts. (2)
The _discharge_ as to quantity, consistence, colour, composition, and
odour. (3) The _edges_, noting particularly whether or not the marginal
epithelium is attempting to grow over the surface; also their shape,
regularity, thickness, and whether undermined or overlapping, everted or
depressed. (4) The _surrounding tissues_, as to whether they are
congested, oedematous, inflamed, indurated, or otherwise. (5) Whether or
not there is _pain_ or tenderness in the raw surface or its
surroundings. (6) The _part of the body_ on which it occurs, because
certain ulcers have special seats of election--for example, the varicose
ulcer in the lower third of the leg, the perforating ulcer on the sole
of the foot, and so on.
#The Healing Sore.#--If a portion of skin be excised aseptically, and no
attempt made to close the wound, the raw surface left is soon covered
over with a layer of coagulated blood and lymph. In the course of a few
days this is replaced by the growth of _granulations_, which are of
uniform size, of a pinkish-red colour, and moist with a slight serous
exudate containing a few dead leucocytes. They grow until they reach the
level of the surrounding skin, and so fill the gap with a fine velvety
mass of granulation tissue. At the edges, the young epithelium may be
seen spreading in over the granulations as a fine bluish-white pellicle,
which gradually covers the sore, becoming paler in colour as it
thickens, and eventually forming the smooth, non-vascular covering of
the cicatrix. There is no pain, and the surrounding parts are healthy.
This may be used as a type with which to compare the ulcers seen at the
bedside, so that we may determine how far, and in what particulars,
these differ from the type; and that we may in addition recognise the
conditions that have to be counteracted before the characters of the
typical healing sore are assumed.
For purposes of contrast we may indicate the characters of an open sore
in which bacterial infection with pathogenic bacteria has taken place.
The layer of coagulated blood and lymph becomes liquefied and is thrown
off, and instead of granulations being formed, the tissues exposed on
the floor of the ulcer are destroyed by the bacterial toxins, with the
formation of minute sloughs and a quantity of pus.
The discharge is profuse, thin, acrid, and offensive, and consists of
pus, broken-down blood-clot, and sloughs. The edges are inflamed,
irregular, and ragged, showing no sign of growing epithelium--on the
contrary, the sore may be actually increasing in area by the
breaking-down of the tissues at its margins. The surrounding parts are
hot, red, swollen, and oedematous; and there is pain and tenderness both
in the sore itself and in the parts around.
#Classification of Ulcers.#--The nomenclature of ulcers is much involved
and gives rise to great confusion, chiefly for the reason that no one
basis of classification has been adopted. Thus some ulcers are named
according to the causes at work in producing or maintaining them--for
example, the traumatic, the septic, and the varicose ulcer; some from
the constitutional element present, as the gouty and the diabetic ulcer;
and others according to the condition in which they happen to be when
seen by the surgeon, such as the weak, the inflamed, and the callous
ulcer.
So long as we retain these names it will be impossible to find a single
basis for classification; and yet many of the terms are so descriptive
and so generally understood that it is undesirable to abolish them. We
must therefore remain content with a clinical arrangement of ulcers,--it
cannot be called a classification,--considering any given ulcer from two
points of view: first its _cause_, and second its _present condition_.
This method of studying ulcers has the practical advantage that it
furnishes us with the main indications for treatment as well as for
diagnosis: the cause must be removed, and the condition so modified as
to convert the ulcer into an aseptic healing sore.
A. #Arrangement of Ulcers according to their Cause.#--Although any given
ulcer may be due to a combination of causes, it is convenient to
describe the following groups:
_Ulcers due to Traumatism._--Traumatism in the form of a _crush_ or
_bruise_ is a frequent cause of ulcer formation, acting either by
directly destroying the skin, or by so diminishing its vitality that it
is rendered a suitable soil for bacteria. If these gain access, in the
course of a few days the damaged area of skin becomes of a greyish
colour, blebs form on it, and it undergoes necrosis, leaving an
unhealthy raw surface when the slough separates.
_Heat_ and _prolonged exposure to the Röntgen rays_ or _to radium
emanations_ act in a similar way.
The _pressure_ of improperly padded splints or other appliances may so
far interfere with the circulation of the part pressed upon, that the
skin sloughs, leaving an open sore. This is most liable to occur in
patients who suffer from some nerve lesion--such as anterior
poliomyelitis, or injury of the spinal cord or nerve-trunks.
Splint-pressure sores are usually situated over bony prominences, such
as the malleoli, the condyles of the femur or humerus, the head of the
fibula, the dorsum of the foot, or the base of the fifth metatarsal
bone. On removing the splint, the skin of the part pressed upon is found
to be of a red or pink colour, with a pale grey patch in the centre,
which eventually sloughs and leaves an ulcer. Certain forms of
_bed-sore_ are also due to prolonged pressure.
Pressure sores are also known to have been produced artificially by
malingerers and hysterical subjects.
[Illustration: FIG. 14.--Leg Ulcers associated with Varicose Veins and
Pigmentation of the Skin.]
_Ulcers due to Imperfect Circulation._--Imperfect circulation is an
important causative factor in ulceration, especially when it is the
_venous return_ that is defective. This is best illustrated in the
so-called _leg ulcer_, which occurs most frequently on the front and
medial aspect of the lower third of the leg. At this point the
anastomosis between the superficial and deep veins of the leg is less
free than elsewhere, so that the extra stress thrown upon the surface
veins interferes with the nutrition of the skin (Hilton). The importance
of imperfect venous return in the causation of such ulcers is evidenced
by the fact that as soon as the condition of the circulation is improved
by confining the patient to bed and elevating the limb, the ulcer begins
to heal, even although all methods of local treatment have hitherto
proved ineffectual. In a considerable number of cases, but by no means
in all, this form of ulcer is associated with the presence of varicose
veins, and in such cases it is spoken of as the _varicose ulcer_ (Fig. 14).
The presence of varicose veins is frequently associated with a
diffuse brownish or bluish pigmentation of the skin of the lower third
of the leg, or with an obstinate form of dermatitis (_varicose eczema_),
and the scratching or rubbing of the part is liable to cause a breach of
the surface and permit of infection which leads to ulceration. Varicose
ulcers may also originate from the bursting of a small peri-phlebitic
abscess.
Varicose veins in immediate relation to the base of a large chronic
ulcer usually become thrombosed, and in time are reduced to fibrous
cords, and therefore in such cases hæmorrhage is not a common
complication. In smaller and more superficial ulcers, however, the
destructive process is liable to implicate the wall of the vessel before
the occurrence of thrombosis, and to lead to profuse and it may be
dangerous bleeding.
These ulcers are at first small and superficial, but from want of care,
from continued standing or walking, or from injudicious treatment, they
gradually become larger and deeper. They are not infrequently multiple,
and this, together with their depth, may lead to their being mistaken
for ulcers due to syphilis. The base of the ulcer is covered with
imperfectly formed, soft, oedematous granulations, which give off a thin
sero-purulent discharge. The edges are slightly inflamed, and show no
evidence of healing. The parts around are usually pigmented and slightly
oedematous, and as a rule there is little pain. This variety of ulcer is
particularly prone to pass into the condition known as callous.
In _anæmic_ patients, especially young girls, ulcers are occasionally
met with which have many of the clinical characters of those associated
with imperfect venous return. They are slow to heal, and tend to pass
into the condition known as weak.
_Ulcers due to Interference with Nerve-Supply._--Any interference with
the nerve-supply of the superficial tissues predisposes to ulceration.
For example, _trophic_ ulcers are liable to occur in injuries or
diseases of the spinal cord, in cerebral paralysis, in limbs weakened by
poliomyelitis, in ascending or peripheral neuritis, or after injuries of
nerve-trunks.
The _acute bed-sore_ is a rapidly progressing form of ulceration, often
amounting to gangrene, of portions of skin exposed to pressure when
their trophic nerve-supply has been interfered with.
[Illustration: FIG. 15.--Perforating Ulcers of Sole of Foot.
(From Photograph lent by Sir Montagu Cotterill.)]
The _perforating ulcer of the foot_ is a peculiar type of sore which
occurs in association with the different forms of peripheral neuritis,
and with various lesions of the brain and spinal cord, such as general
paralysis, locomotor ataxia, or syringo-myelia (Fig. 15). It also occurs
in patients suffering from glycosuria, and is usually associated with
arterio-sclerosis--local or general. Perforating ulcer is met with most
frequently under the head of the metatarsal bone of the great toe. A
callosity forms and suppuration occurs under it, the pus escaping
through a small hole in the centre. The process slowly and gradually
spreads deeper and deeper, till eventually the bone or joint is reached,
and becomes implicated in the destructive process--hence the term
"perforating ulcer." The flexor tendons are sometimes destroyed, the toe
being dorsiflexed by the unopposed extensors. The depth of the track
being so disproportionate to its superficial area, the condition closely
simulates a tuberculous sinus, for which it is liable to be mistaken.
The raw surface is absolutely insensitive, so that the probe can be
freely employed without the patient even being aware of it or suffering
the least discomfort--a significant fact in diagnosis. The cavity is
filled with effete and decomposing epidermis, which has a most offensive
odour. The chronic and intractable character of the ulcer is due to
interference with the trophic nerve-supply of the parts, and to the fact
that the epithelium of the skin grows in and lines the track leading
down to the deepest part of the ulcer and so prevents closure. While
they are commonest on the sole of the foot and other parts subjected to
pressure, perforating ulcers are met with on the sides and dorsum of the
foot and toes, on the hands, and on other parts where no pressure has
been exerted.
The _tuberculous ulcer_, so often seen in the neck, in the vicinity of
joints, or over the ribs and sternum, usually results from the bursting
through the skin of a tuberculous abscess. The base is soft, pale, and
covered with feeble granulations and grey shreddy sloughs. The edges are
of a dull blue or purple colour, and gradually thin out towards their
free margins, and in addition are characteristically undermined, so that
a probe can be passed for some distance between the floor of the ulcer
and the thinned-out edges. Thin, devitalised tags of skin often stretch
from side to side of the ulcer. The outline is irregular; small
perforations often occur through the skin, and a thin, watery discharge,
containing grey shreds of tuberculous debris, escapes.
_Bazin's Disease._--This term is applied to an affection of the skin and
subcutaneous tissue which bears certain resemblances to tuberculosis. It
is met with almost exclusively between the knee and the ankle, and it
usually affects both legs. It is commonest in girls of delicate
constitution, in whose family history there is evidence of a tuberculous
taint. The patient often presents other lesions of a tuberculous
character, notably enlarged cervical glands, and phlyctenular
ophthalmia. The tubercle bacillus has rarely been found, but we have
always observed characteristic epithelioid cells and giant cells in
sections made from the edge or floor of the ulcer.
[Illustration: FIG. 16.--Bazin's Disease in a girl æt. 16.]
The condition begins by the formation in the skin and subcutaneous
tissue of dusky or livid nodules of induration, which soften and
ulcerate, forming small open sores with ragged and undermined edges, not
unlike those resulting from the breaking down of superficial syphilitic
gummata (Fig. 16). Fresh crops of nodules appear in the neighbourhood of
the ulcers, and in turn break down. While in the nodular stage the
affection is sometimes painful, but with the formation of the ulcer the
pain subsides.
The disease runs a chronic course, and may slowly extend over a wide
area in spite of the usual methods of treatment. After lasting for some
months, or even years, however, it may eventually undergo spontaneous
cure. The most satisfactory treatment is to excise the affected tissues
and fill the gap with skin-grafts.
[Illustration: FIG. 17.--Syphilitic Ulcers in region of Knee, showing
punched-out appearance and raised indurated edges.]
The _syphilitic ulcer_ is usually formed by the breaking down of a
cutaneous or subcutaneous gumma in the tertiary stage of syphilis. When
the gummatous tissue is first exposed by the destruction of the skin or
mucous membrane covering it, it appears as a tough greyish slough,
compared to "wash leather," which slowly separates and leaves a more or
less circular, deep, punched-out gap which shows a few feeble unhealthy
granulations and small sloughs on its floor. The edges are raised and
indurated; and the discharge is thick, glairy, and peculiarly offensive.
The parts around the ulcer are congested and of a dark brown colour.
There are usually several such ulcers together, and as they tend to heal
at one part while they spread at another, the affected area assumes a
sinuous or serpiginous outline. Syphilitic ulcers may be met with in any
part of the body, but are most frequent in the upper part of the leg
(Fig. 17), especially around the knee-joint in women, and over the ribs
and sternum. On healing, they usually leave a depressed and adherent
cicatrix.
The _scorbutic ulcer_ occurs in patients suffering from scurvy, and is
characterised by its prominent granulations, which show a marked
tendency to bleed, with the formation of clots, which dry and form a
spongy crust on the surface.
In _gouty_ patients small ulcers which are exceedingly irritable and
painful are liable to occur.
_Ulcers associated with Malignant Disease._--Cancer and sarcoma when
situated in the subcutaneous tissue may destroy the overlying skin so
that the substance of the tumour is exposed. The fungating masses thus
produced are sometimes spoken of as malignant ulcers, but as they are
essentially different in their nature from all other forms of ulcers,
and call for totally different treatment, it is best to consider them
along with the tumours with which they are associated. Rodent ulcer,
which is one form of cancer of the skin, will be discussed with new
growths of the skin.
B. #Arrangement of Ulcers according to their Condition.#--Having arrived
at an opinion as to the cause of a given ulcer, and placed it in one or
other of the preceding groups, the next question to ask is, In what
condition do I find this ulcer at the present moment?
Any ulcer is in one of three states--healing, stationary, or spreading;
although it is not uncommon to find healing going on at one part while
the destructive process is extending at another.
_The Healing Condition._--The process of healing in an ulcer has already
been studied, and we have learned that it takes place by the formation
of granulation tissue, which becomes converted into connective tissue,
and is covered over by epithelium growing in from the edges.
Those ulcers which are _stationary_--that is, neither healing nor
spreading--may be in one of several conditions.
_The Weak Condition._--Any ulcer may get into a weak state from
receiving a blood supply which is defective either in quantity or in
quality. The granulations are small and smooth, and of a pale yellow or
grey colour, the discharge is small in amount, and consists of thin
serum and a few pus cells, and as this dries on the edges it forms scabs
which interfere with the growth of epithelium.
Should the part become oedematous, either from general causes, such as
heart or kidney disease, or from local causes, such as varicose veins,
the granulations share in the oedema, and there is an abundant serous
discharge.
The excessive use of moist dressings leads to a third variety of weak
ulcer--namely, one in which the granulations become large, soft, pale,
and flabby, projecting beyond the level of the skin and overlapping the
edges, which become pale and sodden. The term "proud flesh" is popularly
applied to such redundant granulations.
[Illustration: FIG. 18.--Callous Ulcer, showing thickened edges and
indurated swelling of surrounding parts.]
_The Callous Condition._--This condition is usually met with in ulcers
on the lower third of the leg, and is often associated with the presence
of varicose veins. It is chiefly met with in hospital practice. The want
of healing is mainly due to impeded venous return and to oedema and
induration of the surrounding skin and cellular tissues (Fig. 18). The
induration results from coagulation and partial organisation of the
inflammatory effusion, and prevents the necessary contraction of the
sore. The base of a callous ulcer lies at some distance below the level
of the swollen, thickened, and white edges, and presents a glazed
appearance, such granulations as are present being unhealthy and
irregular. The discharge is usually watery, and cakes in the dressing.
When from neglect and want of cleanliness the ulcer becomes inflamed,
there is considerable pain, and the discharge is purulent and often
offensive.
The prolonged hyperæmia of the tissues in relation to a callous ulcer of
the leg often leads to changes in the underlying bones. The periosteum
is abnormally thick and vascular, the superficial layers of the bone
become injected and porous, and the bones, as a whole, are thickened. In
the macerated bone "the surface is covered with irregular,
stalactite-like processes or foliaceous masses, which, to a certain
extent, follow the line of attachment of the interosseous membrane and
of the intermuscular septa" (Cathcart) (Fig. 19). When the whole
thickness of the soft tissues is destroyed by the ulcerative process,
the area of bone that comes to form the base of the ulcer projects as a
flat, porous node, which in its turn may be eroded. These changes as
seen in the macerated specimen are often mistaken for disease
originating in the bone.
[Illustration: FIG. 19.--Tibia and Fibula, showing changes due to
chronic ulcer of leg.]
The _irritable condition_ is met with in ulcers which occur, as a rule,
just above the external malleolus in women of neurotic temperament. They
are small in size and have prominent granulations, and by the aid of a
probe points of excessive tenderness may be discovered. These, Hilton
believed, correspond to exposed nerve filaments.
_Ulcers which are spreading_ may be met with in one of several
conditions.
_The Inflamed Condition._--Any ulcer may become acutely inflamed from
the access of fresh organisms, aided by mechanical irritation from
trauma, ill-fitting splints or bandages, or want of rest, or from
chemical irritants, such as strong antiseptics. The best clinical
example of an inflamed ulcer is the venereal soft sore. The base of the
ulcer becomes red and angry-looking, the granulations disappear, and a
copious discharge of thin yellow pus, mixed with blood, escapes. Sloughs
of granulation tissue or of connective tissue may form. The edges become
red, ragged, and everted, and the ulcer increases in size by spreading
into the inflamed and oedematous surrounding tissues. Such ulcers are
frequently multiple. Pain is a constant symptom, and is often severe,
and there is usually some constitutional disturbance.
The _phagedænic condition_ is the result of an ulcer being infected with
specially virulent bacteria. It occurs in syphilitic ulcers, and rapidly
leads to a widespread destruction of tissue. It is also met with in the
throat in some cases of scarlet fever, and may give rise to fatal
hæmorrhage by ulcerating into large blood vessels. All the local and
constitutional signs of a severe septic infection are present.
#Treatment of Ulcers.#--An ulcer is not only an immediate cause of
suffering to the patient, crippling and incapacitating him for his work,
but is a distinct and constant menace to his health: the prolonged
discharge reduces his strength; the open sore is a possible source of
infection by the organisms of suppuration, erysipelas, or other specific
diseases; phlebitis, with formation of septic emboli, leading to pyæmia,
is liable to occur; and in old persons it is not uncommon for ulcers of
long standing to become the seat of cancer. In addition, the offensive
odour of many ulcers renders the patient a source of annoyance and
discomfort to others. The primary object of treatment in any ulcer is to
bring it into the condition of a healing sore. When this has been
effected, nature will do the rest, provided extraneous sources of
irritation are excluded.
Steps must be taken to facilitate the venous return from the ulcerated
part, and to ensure that a sufficient supply of fresh, healthy blood
reaches it. The septic element must be eliminated by disinfecting the
ulcer and its surroundings, and any other sources of irritation must be
removed.
If the patient's health is below par, good nourishing food, tonics, and
general hygienic treatment are indicated.
_Management of a Healing Sore._--Perhaps the best dressing for a healing
sore is a layer of Lister's perforated oiled-silk protective, which is
made to cover the raw surface and the skin for about a quarter of an
inch beyond the margins of the sore. Over this three or four thicknesses
of sterilised gauze, wrung out of eusol, creolin, or sterilised water,
are applied, and covered by a pad of absorbent wool. As far as possible
the part should be kept at rest, and the position should be adjusted so
as to favour the circulation in the affected area.
The dressing may be renewed at intervals, and care must be taken to
avoid any rough handling of the sore. Any discharge that lies on the
surface should be removed by a gentle stream of lotion rather than by
wiping. The area round the sore should be cleansed before the fresh
dressing is applied.
In some cases, healing goes on more rapidly under a dressing of weak
boracic ointment (one-quarter the strength of the pharmacopoeial
preparation). The growth of epithelium may be stimulated by a 6 to 8 per
cent. ointment of scarlet-red.
Dusting powders and poultice dressings are best avoided in the treatment
of healing sores.
In extensive ulcers resulting from recent burns, if the granulations are
healthy and aseptic, skin-grafts may safely be placed on them directly.
If, however, their asepticity cannot be relied upon, it is necessary to
scrape away the superficial layer of the granulations, the young fibrous
tissue underneath being conserved, as it is sufficiently vascular to
nourish the grafts placed on it.
#Treatment of Special Varieties of Ulcers.#--Before beginning to treat a
given ulcer, two questions have to be answered--first, What are the
causative conditions present? and second, In what condition do I find
the ulcer?--in other words, In what particulars does it differ from a
healthy healing sore?
If the cause is a local one, it must be removed; if a constitutional
one, means must be taken to counteract it. This done, the condition of
the ulcer must be so modified as to bring it into the state of a healing
sore, after which it will be managed on the lines already laid down.
#Treatment in relation to the Cause of the Ulcer.#--_Traumatic
Group._--The _prophylaxis_ of these ulcers consists in excluding
bacteria, by cleansing crushed or bruised parts, and applying sterilised
dressings and properly adjusted splints. If there is reason to fear that
the disinfection has not been complete, a Bier's constricting bandage
should be applied for some hours each day. These measures will often
prevent a grossly injured portion of skin dying, and will ensure
asepticity should it do so. In the event of the skin giving way, the
same form of dressing should be continued till the slough has separated
and a healthy granulating surface is formed. The protective dressing
appropriate to a healing sore is then substituted. _Pressure sores_ are
treated on the same lines.
The treatment of ulcers caused by _burns and scalds_ will be described
later.
In _ulcers of the leg due to interference with the venous return_, the
primary indication is to elevate the limb in order to facilitate the
flow of the blood in the veins, and so admit of fresh blood reaching the
part. The limb may be placed on pillows, or the foot of the bed raised
on blocks, so that the ulcer lies on a higher level than the heart.
Should varicose veins be present, the question of operative treatment
must be considered.
When an _imperfect nerve supply_ is the main factor underlying ulcer
formation, prophylaxis is the chief consideration. In patients suffering
from spinal injuries or diseases, cerebral paralysis, or affections of
the peripheral nerves, all sources of irritation, such as ill-fitting
splints, tight bandages, moist applications, and hot bottles, should be
avoided. Any part liable to pressure, from the position of the patient
or otherwise, must be carefully protected by pads of wool, air-cushions,
or water-bags, and must be kept absolutely dry. The skin should be
hardened by daily applications of methylated spirit.
Should an ulcer form in spite of these precautions, the mildest
antiseptics must be employed for bathing and dressing it, and as far as
possible all dressings should be dry.
The _perforating ulcer_ of the foot calls for special treatment. To
avoid pressure on the sole of the foot, the patient must be confined to
bed. As the main local obstacle to healing is the down-growth of
epithelium along the sides of the ulcer, this must be removed by the
knife or sharp spoon. The base also should be excised, and any bone
which may have become involved should be gouged away, so as to leave a
healthy and vascular surface. The cavity thus formed is stuffed with
bismuth or iodoform gauze and encouraged to heal from the bottom. As the
parts are insensitive an anæsthetic is not required. After the ulcer has
healed, the patient should wear in his boot a thick felt sole with a
hole cut out opposite the situation of the cicatrix. When a joint has
been opened into, the difficulty of thoroughly getting rid of all
unhealthy and infected granulations is so great that amputation may be
advisable, but it is to be remembered that ulceration may recur in the
stump if pressure is put upon it. The treatment of any nervous disease
or glycosuria which may coexist is, of course, indicated.
Exposure of the plantar nerves by an incision behind the medial
malleolus, and subjecting them to forcible stretching, has been employed
by Chipault and others in the treatment of perforating ulcers of the
foot.
The ulcer that forms in relation to callosities on the sole of the foot
is treated by paring away all the thickened skin, after softening it
with soda fomentations, removing the unhealthy granulations, and
applying stimulating dressings.
_Treatment of Ulcers due to Constitutional Causes._--When ulcers are
associated with such diseases as tuberculosis, syphilis, diabetes,
Bright's disease, scurvy, or gout, these must receive appropriate
treatment.
The local treatment of the _tuberculous ulcer_ calls for special
mention. If the ulcer is of limited extent and situated on an exposed
part of the body, the most satisfactory method is complete removal, by
means of the knife, scissors, or sharp spoon, of the ulcerated surface
and of all the infected area around it, so as to leave a healthy surface
from which granulations may spring up. Should the raw surface left be
likely to result in an unsightly scar or in cicatricial contraction,
skin-grafting should be employed.
For extensive ulcers on the limbs, the chest wall, or on other covered
parts, or when operative treatment is contra-indicated, the use of
tuberculin and exposure to the Röntgen rays have proved beneficial. The
induction of passive hyperæmia, by Bier's or by Klapp's apparatus,
should also be used, either alone or supplementary to other measures.
No ulcerative process responds so readily to medicinal treatment as the
_syphilitic ulcer_ does to the intra-venous administration of arsenical
preparations of the "606" or "914" groups or to full doses of iodide of
potassium and mercury, and the local application of black wash. When the
ulceration has lasted for a long time, however, and is widespread and
deep, the duration of treatment is materially shortened by a thorough
scraping with the sharp spoon.
#Treatment in relation to the Condition of the Ulcer.#--_Ulcers in a
weak condition._--If the weak condition of the ulcer is due to anæmia
or kidney disease, these affections must first be treated. Locally, the
imperfect granulations should be scraped away, and some stimulating
agent applied to the raw surface to promote the growth of healthy
granulations. For this purpose the sore may be covered with gauze
smeared with a 6 to 8 per cent. ointment of scarlet-red, the surrounding
parts being protected from the irritant action of the scarlet-red by a
layer of vaseline. A dressing of gauze moistened with eusol or of
boracic lint wrung out of red lotion (2 g
Subscribe to:
Post Comments (Atom)
No comments:
Post a Comment