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

Printed in Great Britain by
Morrison and Gibb Ltd., Edinburgh

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.

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.

The process of repair in living tissue depends upon an inherent power possessed by vital cells of reacting to the irritation caused by injury or disease. The cells of the damaged tissues, under the influence of this irritation, undergo certain proliferative changes, which are designed to restore the normal structure and configuration of the part. The process by which this restoration is effected is essentially the same in all tissues, but the extent to which different tissues can carry the recuperative process varies. Simple structures, such as skin, cartilage, bone, periosteum, and tendon, for example, have a high power of regeneration, and in them the reparative process may result in almost perfect restitution to the normal. More complex structures, on the other hand, such as secreting glands, muscle, and the tissues of the central nervous system, are but imperfectly restored, simple cicatricial connective tissue taking the place of what has been lost or destroyed. Any given tissue can be replaced only by tissue of a similar kind, and in a damaged part each element takes its share in the reparative process by producing new material which approximates more or less closely to the normal according to the recuperative capacity of the particular tissue. The normal process of repair may be interfered with by various extraneous agencies, the most important of which are infection by disease-producing micro-organisms, the presence of foreign substances, undue movement of the affected part, and improper applications and dressings. The effect of these agencies is to delay repair or to prevent the individual tissues carrying the process to the furthest degree of which they are capable.

In the management of wounds and other diseased conditions the main object of the surgeon is to promote the natural reparative process by preventing or eliminating any factor by which it may be disturbed.

Healing by Primary Union.—The most favourable conditions for the progress of the reparative process are to be found in a clean-cut wound of the integument, which is uncomplicated by loss of tissue, by the presence of foreign substances, or by infection with disease-producing micro-organisms, and its edges are in contact. Such a wound in virtue of the absence of infection is said to be aseptic, and under these conditions healing takes place by what is called “primary union”—the “healing by first intention” of the older writers.

Granulation Tissue.—The essential and invariable medium of repair in all structures is an elementary form of new tissue known as granulation tissue, which is produced in the damaged area in response to the irritation caused by injury or disease. The vital reaction induced by such irritation results in dilatation of the vessels of the part, emigration of leucocytes, transudation of lymph, and certain proliferative changes in the fixed tissue cells. These changes are common to the processes of inflammation and repair; no hard-and-fast line can be drawn between these processes, and the two may go on together. It is, however, only when the proliferative changes have come to predominate that the reparative process is effectively established by the production of healthy granulation tissue.

Formation of Granulation Tissue.—When a wound is made in the integument under aseptic conditions, the passage of the knife through the tissues is immediately followed by an oozing of blood, which soon coagulates on the cut surfaces. In each of the divided vessels a clot forms, and extends as far as the nearest collateral branch; and on the surface of the wound there is a microscopic layer of bruised and devitalised tissue. If the wound is closed, the narrow space between its edges is occupied by blood-clot, which consists of red and white corpuscles mixed with a quantity of fibrin, and this forms a temporary uniting medium between the divided surfaces. During the first twelve hours, the minute vessels in the vicinity of the wound dilate, and from them lymph exudes and leucocytes migrate into the tissues. In from twenty-four to thirty-six hours, the capillaries of the part adjacent to the wound begin to throw out minute buds and fine processes, which bridge the gap and form a firmer, but still temporary, connection between the two sides. Each bud begins in the wall of the capillary as a small accumulation of granular protoplasm, which gradually elongates into a filament containing a nucleus. This filament either joins with a neighbouring capillary or with a similar filament, and in time these become hollow and are filled with blood from the vessels that gave them origin. In this way a series of young capillary loops is formed.

The spaces between these loops are filled by cells of various kinds, the most important being the fibroblasts, which are destined to form cicatricial fibrous tissue. These fibroblasts are large irregular nucleated cells derived mainly from the proliferation of the fixed connective-tissue cells of the part, and to a less extent from the lymphocytes and other mononuclear cells which have migrated from the vessels. Among the fibroblasts, larger multi-nucleated cells—giant cells—are sometimes found, particularly when resistant substances, such as silk ligatures or fragments of bone, are embedded in the tissues, and their function seems to be to soften such substances preliminary to their being removed by the phagocytes. Numerous polymorpho-nuclear leucocytes, which have wandered from the vessels, are also present in the spaces. These act as phagocytes, their function being to remove the red corpuscles and fibrin of the original clot, and this performed, they either pass back into the circulation in virtue of their amœboid movement, or are themselves eaten up by the growing fibroblasts. Beyond this phagocytic action, they do not appear to play any direct part in the reparative process. These young capillary loops, with their supporting cells and fluids, constitute granulation tissue, which is usually fully formed in from three to five days, after which it begins to be replaced by cicatricial or scar tissue.

Formation of Cicatricial Tissue.—The transformation of this temporary granulation tissue into scar tissue is effected by the fibroblasts, which become elongated and spindle-shaped, and produce in and around them a fine fibrillated material which gradually increases in quantity till it replaces the cell protoplasm. In this way white fibrous tissue is formed, the cells of which are arranged in parallel lines and eventually become grouped in bundles, constituting fully formed white fibrous tissue. In its growth it gradually obliterates the capillaries, until at the end of two, three, or four weeks both vessels and cells have almost entirely disappeared, and the original wound is occupied by cicatricial tissue. In course of time this tissue becomes consolidated, and the cicatrix undergoes a certain amount of contraction—cicatricial contraction.

Healing of Epidermis.—While these changes are taking place in the deeper parts of the wound, the surface is being covered over by epidermis growing in from the margins. Within twelve hours the cells of the rete Malpighii close to the cut edge begin to sprout on to the surface of the wound, and by their proliferation gradually cover the granulations with a thin pink pellicle. As the epithelium increases in thickness it assumes a bluish hue and eventually the cells become cornified and the epithelium assumes a greyish-white colour.

Clinical Aspects.—So long as the process of repair is not complicated by infection with micro-organisms, there is no interference with the general health of the patient. The temperature remains normal; the circulatory, gastro-intestinal, nervous, and other functions are undisturbed; locally, the part is cool, of natural colour and free from pain.

Modifications of the Process of Repair.—The process of repair by primary union, above described, is to be looked upon as the type of all reparative processes, such modifications as are met with depending merely upon incidental differences in the conditions present, such as loss of tissue, infection by micro-organisms, etc.

Repair after Loss or Destruction of Tissue.—When the edges of a wound cannot be approximated either because tissue has been lost, for example in excising a tumour or because a drainage tube or gauze packing has been necessary, a greater amount of granulation tissue is required to fill the gap, but the process is essentially the same as in the ideal method of repair.

The raw surface is first covered by a layer of coagulated blood and fibrin. An extensive new formation of capillary loops and fibroblasts takes place towards the free surface, and goes on until the gap is filled by a fine velvet-like mass of granulation tissue. This granulation tissue is gradually replaced by young cicatricial tissue, and the surface is covered by the ingrowth of epithelium from the edges.

This modification of the reparative process can be best studied clinically in a recent wound which has been packed with gauze. When the plug is introduced, the walls of the cavity consist of raw tissue with numerous oozing blood vessels. On removing the packing on the fifth or sixth day, the surface is found to be covered with minute, red, papillary granulations, which are beginning to fill up the cavity. At the edges the epithelium has proliferated and is covering over the newly formed granulation tissue. As lymph and leucocytes escape from the exposed surface there is a certain amount of serous or sero-purulent discharge. On examining the wound at intervals of a few days, it is found that the granulation tissue gradually increases in amount till the gap is completely filled up, and that coincidently the epithelium spreads in and covers over its surface. In course of time the epithelium thickens, and as the granulation tissue is slowly replaced by young cicatricial tissue, which has a peculiar tendency to contract and so to obliterate the blood vessels in it, the scar that is left becomes smooth, pale, and depressed. This method of healing is sometimes spoken of as “healing by granulation”—although, as we have seen, it is by granulation that all repair takes place.

Healing by Union of two Granulating Surfaces.—In gaping wounds union is sometimes obtained by bringing the two surfaces into apposition after each has become covered with healthy granulations. The exudate on the surfaces causes them to adhere, capillary loops pass from one to the other, and their final fusion takes place by the further development of granulation and cicatricial tissue.

Reunion of Parts entirely Separated from the Body.—Small portions of tissue, such as the end of a finger, the tip of the nose or a portion of the external ear, accidentally separated from the body, if accurately replaced and fixed in position, occasionally adhere by primary union.

In the course of operations also, portions of skin, fascia, or bone, or even a complete joint may be transplanted, and unite by primary union.

Healing under a Scab.—When a small superficial wound is exposed to the air, the blood and serum exuded on its surface may dry and form a hard crust or scab, which serves to protect the surface from external irritation in the same way as would a dry pad of sterilised gauze. Under this scab the formation of granulation tissue, its transformation into cicatricial tissue, and the growth of epithelium on the surface, go on until in the course of time the crust separates, leaving a scar.

Healing by Blood-clot.—In subcutaneous wounds, for example tenotomy, in amputation wounds, and in wounds made in excising tumours or in operating upon bones, the space left between the divided tissues becomes filled with blood-clot, which acts as a temporary scaffolding in which granulation tissue is built up. Capillary loops grow into the coagulum, and migrated leucocytes from the adjacent blood vessels destroy the red corpuscles, and are in turn disposed of by the developing fibroblasts, which by their growth and proliferation fill up the gap with young connective tissue. It will be evident that this process only differs from healing by primary union in the amount of blood-clot that is present.

Presence of a Foreign Body.—When an aseptic foreign body is present in the tissues, e.g. a piece of unabsorbable chromicised catgut, the healing process may be modified. After primary union has taken place the scar may broaden, become raised above the surface, and assume a bluish-brown colour; the epidermis gradually thins and gives way, revealing the softened portion of catgut, which can be pulled out in pieces, after which the wound rapidly heals and resumes a normal appearance.

Skin and Connective Tissue.—The mode of regeneration of these tissues under aseptic conditions has already been described as the type of ideal repair. In highly vascular parts, such as the face, the reparative process goes on with great rapidity, and even extensive wounds may be firmly united in from three to five days. Where the anastomosis is less free the process is more prolonged. The more highly organised elements of the skin, such as the hair follicles, the sweat and sebaceous glands, are imperfectly reproduced; hence the scar remains smooth, dry, and hairless.

Epithelium.—Epithelium is only reproduced from pre-existing epithelium, and, as a rule, from one of a similar type, although metaplastic transformation of cells of one kind of epithelium into another kind can take place. Thus a granulating surface may be covered entirely by the ingrowing of the cutaneous epithelium from the margins; or islets, originating in surviving cells of sebaceous glands or sweat glands, or of hair follicles, may spring up in the centre of the raw area. Such islets may also be due to the accidental transference of loose epithelial cells from the edges. Even the fluid from a blister, in virtue of the isolated cells of the rete Malpighii which it contains, is capable of starting epithelial growth on a granulating surface. Hairs and nails may be completely regenerated if a sufficient amount of the hair follicles or of the nail matrix has escaped destruction. The epithelium of a mucous membrane is regenerated in the same way as that on a cutaneous surface.

Epithelial cells have the power of living for some time after being separated from their normal surroundings, and of growing again when once more placed in favourable circumstances. On this fact the practice of skin grafting is based (p. 11).

Cartilage.—When an articular cartilage is divided by incision or by being implicated in a fracture involving the articular end of a bone, it is repaired by ordinary cicatricial fibrous tissue derived from the proliferating cells of the perichondrium. Cartilage being a non-vascular tissue, the reparative process goes on slowly, and it may be many weeks before it is complete.

It is possible for a metaplastic transformation of connective-tissue cells into cartilage cells to take place, the characteristic hyaline matrix being secreted by the new cells. This is sometimes observed as an intermediary stage in the healing of fractures, especially in young bones. It may also take place in the regeneration of lost portions of cartilage, provided the new tissue is so situated as to constitute part of a joint and to be subjected to pressure by an opposing cartilaginous surface. This is illustrated by what takes place after excision of joints where it is desired to restore the function of the articulation. By carrying out movements between the constituent parts, the fibrous tissue covering the ends of the bones becomes moulded into shape, its cells take on the characters of cartilage cells, and, forming a matrix, so develop a new cartilage.

Conversely, it is observed that when articular cartilage is no longer subjected to pressure by an opposing cartilage, it tends to be transformed into fibrous tissue, as may be seen in deformities attended with displacement of articular surfaces, such as hallux valgus and club-foot.

After fractures of costal cartilage or of the cartilages of the larynx the cicatricial tissue may be ultimately replaced by bone.

Tendons.—When a tendon is divided, for example by subcutaneous tenotomy, the end nearer the muscle fibres is drawn away from the other, leaving a gap which is speedily filled by blood-clot. In the course of a few days this clot becomes permeated by granulation tissue, the fibroblasts of which are derived from the sheath of the tendon, the surrounding connective tissue, and probably also from the divided ends of the tendon itself. These fibroblasts ultimately develop into typical tendon cells, and the fibres which they form constitute the new tendon fibres. Under aseptic conditions repair is complete in from two to three weeks. In the course of the reparative process the tendon and its sheath may become adherent, which leads to impaired movement and stiffness. If the ends of an accidentally divided tendon are at once brought into accurate apposition and secured by sutures, they unite directly with a minimum amount of scar tissue, and function is perfectly restored.

Muscle.—Unstriped muscle does not seem to be capable of being regenerated to any but a moderate degree. If the ends of a divided striped muscle are at once brought into apposition by stitches, primary union takes place with a minimum of intervening fibrous tissue. The nuclei of the muscle fibres in close proximity to this young cicatricial tissue proliferate, and a few new muscle fibres may be developed, but any gross loss of muscular tissue is replaced by a fibrous cicatrix. It would appear that portions of muscle transplanted from animals to fill up gaps in human muscle are similarly replaced by fibrous tissue. When a muscle is paralysed from loss of its nerve supply and undergoes complete degeneration, it is not capable of being regenerated, even should the integrity of the nerve be restored, and so its function is permanently lost.

Secretory Glands.—The regeneration of secretory glands is usually incomplete, cicatricial tissue taking the place of the glandular substance which has been destroyed. In wounds of the liver, for example, the gap is filled by fibrous tissue, but towards the periphery of the wound the liver cells proliferate and a certain amount of regeneration takes place. In the kidney also, repair mainly takes place by cicatricial tissue, and although a few collecting tubules may be reformed, no regeneration of secreting tissue takes place. After the operation of decapsulation of the kidney a new capsule is formed, and during the process young blood vessels permeate the superficial parts of the kidney and temporarily increase its blood supply, but in the consolidation of the new fibrous tissue these vessels are ultimately obliterated. This does not prove that the operation is useless, as the temporary improvement of the circulation in the kidney may serve to tide the patient over a critical period of renal insufficiency.

Stomach and Intestine.—Provided the peritoneal surfaces are accurately apposed, wounds of the stomach and intestine heal with great rapidity. Within a few hours the peritoneal surfaces are glued together by a thin layer of fibrin and leucocytes, which is speedily organised and replaced by fibrous tissue. Fibrous tissue takes the place of the muscular elements, which are not regenerated. The mucous lining is restored by ingrowth from the margins, and there is evidence that some of the secreting glands may be reproduced.

Hollow viscera, like the œsophagus and urinary bladder, in so far as they are not covered by peritoneum, heal less rapidly.

Nerve Tissues.—There is no trustworthy evidence that regeneration of the tissues of the brain or spinal cord in man ever takes place. Any loss of substance is replaced by cicatricial tissue.

The repair of Bone, Blood Vessels, and Peripheral Nerves is more conveniently considered in the chapters dealing with these structures.

Rate of Healing.—While the rate at which wounds heal is remarkably constant there are certain factors that influence it in one direction or the other. Healing is more rapid when the edges are in contact, when there is a minimum amount of blood-clot between them, when the patient is in normal health and the vitality of the tissues has not been impaired. Wounds heal slightly more quickly in the young than in the old, although the difference is so small that it can only be demonstrated by the most careful observations.

Certain tissues take longer to heal than others: for example, a fracture of one of the larger long bones takes about six weeks to unite, and divided nerve trunks take much longer—about a year.

Wounds of certain parts of the body heal more quickly than others: those of the scalp, face, and neck, for example, heal more quickly than those over the buttock or sacrum, probably because of their greater vascularity.

The extent of the wound influences the rate of healing; it is only natural that a long and deep wound should take longer to heal than a short and superficial one, because there is so much more work to be done in the conversion of blood-clot into granulation tissue, and this again into scar tissue that will be strong enough to stand the strain on the edges of the wound.

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.

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.

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.

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.

The influence of micro-organisms in the causation of disease, and the rôle played by them in interfering with the natural process of repair, are so important that the science of applied bacteriology has now come to dominate every department of surgery, and it is from the standpoint of bacteriology that nearly all surgical questions have to be considered.

The term sepsis as now used in clinical surgery no longer retains its original meaning as synonymous with “putrefaction,” but is employed to denote all conditions in which bacterial infection has taken place, and more particularly those in which pyogenic bacteria are present. In the same way the term aseptic conveys the idea of freedom from all forms of bacteria, putrefactive or otherwise; and the term antiseptic is used to denote a power of counteracting bacteria and their products.

General Characters of Bacteria.—A bacterium consists of a finely granular mass of protoplasm, enclosed in a thin gelatinous envelope. Many forms are motile—some in virtue of fine thread-like flagella, and others through contractility of the protoplasm. The great majority multiply by simple fission, each parent cell giving rise to two daughter cells, and this process goes on with extraordinary rapidity. Other varieties, particularly bacilli, are propagated by the formation of spores. A spore is a minute mass of protoplasm surrounded by a dense, tough membrane, developed in the interior of the parent cell. Spores are remarkable for their tenacity of life, and for the resistance they offer to the action of heat and chemical germicides.

Bacteria are most conveniently classified according to their shape. Thus we recognise (1) those that are globular—cocci; (2) those that resemble a rod—bacilli; (3) the spiral or wavy forms—spirilla.

Cocci or micrococci are minute round bodies, averaging about 1 µ in diameter. The great majority are non-motile. They multiply by fission; and when they divide in such a way that the resulting cells remain in pairs, are called diplococci, of which the bacteria of gonorrhœa and pneumonia are examples (Fig. 5). When they divide irregularly, and form grape-like bunches, they are known as staphylococci, and to this variety the commonest pyogenic or pus-forming organisms belong (Fig. 2). When division takes place only in one axis, so that long chains are formed, the term streptococcus is applied (Fig. 3). Streptococci are met with in erysipelas and various other inflammatory and suppurative processes of a spreading character.

Bacilli are rod-shaped bacteria, usually at least twice as long as they are broad (Fig. 4). Some multiply by fission, others by sporulation. Some forms are motile, others are non-motile. Tuberculosis, tetanus, anthrax, and many other surgical diseases are due to different forms of bacilli.

Spirilla are long, slender, thread-like cells, more or less spiral or wavy. Some move by a screw-like contraction of the protoplasm, some by flagellæ. The spirochæte associated with syphilis (Fig. 36) is the most important member of this group.

Conditions of Bacterial Life.—Bacteria require for their growth and development a suitable food-supply in the form of proteins, carbohydrates, and salts of calcium and potassium which they break up into simpler elements. An alkaline medium favours bacterial growth; and moisture is a necessary condition; spores, however, can survive the want of water for much longer periods than fully developed bacteria. The necessity for oxygen varies in different species. Those that require oxygen are known as aërobic bacilli or aërobes; those that cannot live in the presence of oxygen are spoken of as anaërobes. The great majority of bacteria, however, while they prefer to have oxygen, are able to live without it, and are called facultative anaërobes.

The most suitable temperature for bacterial life is from 95° to 102° F., roughly that of the human body. Extreme or prolonged cold paralyses but does not kill micro-organisms. Few, however, survive being raised to a temperature of 134½° F. Boiling for ten to twenty minutes will kill all bacteria, and the great majority of spores. Steam applied in an autoclave under a pressure of two atmospheres destroys even the most resistant spores in a few minutes. Direct sunlight, electric light, or even diffuse daylight, is inimical to the growth of bacteria, as are also Röntgen rays and radium emanations.

Pathogenic Properties of Bacteria.—We are now only concerned with pathogenic bacteria—that is, bacteria capable of producing disease in the human subject. This capacity depends upon two sets of factors—(1) certain features peculiar to the invading bacteria, and (2) others peculiar to the host. Many bacteria have only the power of living upon dead matter, and are known as saphrophytes. Such as do nourish in living tissue are, by distinction, known as parasites. The power a given parasitic micro-organism has of multiplying in the body and giving rise to disease is spoken of as its virulence, and this varies not only with different species, but in the same species at different times and under varying circumstances. The actual number of organisms introduced is also an important factor in determining their pathogenic power. Healthy tissues can resist the invasion of a certain number of bacteria of a given species, but when that number is exceeded, the organisms get the upper hand and disease results. When the organisms gain access directly to the blood-stream, as a rule they produce their effects more certainly and with greater intensity than when they are introduced into the tissues.

Further, the virulence of an organism is modified by the condition of the patient into whose tissues it is introduced. So long as a person is in good health, the tissues are able to resist the attacks of moderate numbers of most bacteria. Any lowering of the vitality of the individual, however, either locally or generally, at once renders him more susceptible to infection. Thus bruised or torn tissue is much more liable to infection with pus-producing organisms than tissues clean-cut with a knife; also, after certain diseases, the liability to infection by the organisms of diphtheria, pneumonia, or erysipelas is much increased. Even such slight depression of vitality as results from bodily fatigue, or exposure to cold and damp, may be sufficient to turn the scale in the battle between the tissues and the bacteria. Age is an important factor in regard to the action of certain bacteria. Young subjects are attacked by diphtheria, tuberculosis, acute osteomyelitis, and some other diseases with greater frequency and severity than those of more advanced years.

In different races, localities, environment, and seasons, the pathogenic powers of certain organisms, such as those of erysipelas, diphtheria, and acute osteomyelitis, vary considerably.

There is evidence that a mixed infection—that is, the introduction of more than one species of organism, for example, the tubercle bacillus and a pyogenic staphylococcus—increases the severity of the resulting disease. If one of the varieties gain the ascendancy, the poisons produced by the others so devitalise the tissue cells, and diminish their power of resistance, that the virulence of the most active organisms is increased. On the other hand, there is reason to believe that the products of certain organisms antagonise one another—for example, an attack of erysipelas may effect the cure of a patch of tuberculous lupus.

Lastly, in patients suffering from chronic wasting diseases, bacteria may invade the internal organs by the blood-stream in enormous numbers and with great rapidity, during the period of extreme debility which shortly precedes death. The discovery of such collections of organisms on post-mortem examination may lead to erroneous conclusions being drawn as to the cause of death.

Results of Bacterial Growth.—Some organisms, such as those of tetanus and erysipelas, and certain of the pyogenic bacteria, show little tendency to pass far beyond the point at which they gain an entrance to the body. Others, on the contrary—for example, the tubercle bacillus and the organism of acute osteomyelitis—although frequently remaining localised at the seat of inoculation, tend to pass to distant parts, lodging in the capillaries of joints, bones, kidney, or lungs, and there producing their deleterious effects.

In the human subject, multiplication in the blood-stream does not occur to any great extent. In some general acute pyogenic infections, such as osteomyelitis, cellulitis, etc., pure cultures of staphylococci or of streptococci may be obtained from the blood. In pneumococcal and typhoid infections, also, the organisms may be found in the blood.

It is by the vital changes they bring about in the parts where they settle that micro-organisms disturb the health of the patient. In deriving nourishment from the complex organic compounds in which they nourish, the organisms evolve, probably by means of a ferment, certain chemical products of unknown composition, but probably colloidal in nature, and known as toxins. When these poisons are absorbed into the general circulation they give rise to certain groups of symptoms—such as rise of temperature, associated circulatory and respiratory derangements, interference with the gastro-intestinal functions and also with those of the nervous system—which go to make up the condition known as blood-poisoning, toxæmia, or bacterial intoxication. In addition to this, certain bacteria produce toxins that give rise to definite and distinct groups of symptoms—such as the convulsions of tetanus, or the paralyses that follow diphtheria.

Death of Bacteria.—Under certain circumstances, it would appear that the accumulation of the toxic products of bacterial action tends to interfere with the continued life and growth of the organisms themselves, and in this way the natural cure of certain diseases is brought about. Outside the body, bacteria may be killed by starvation, by want of moisture, by being subjected to high temperature, or by the action of certain chemical agents of which carbolic acid, the perchloride and biniodide of mercury, and various chlorine preparations are the most powerful.

Immunity.—Some persons are insusceptible to infection by certain diseases, from which they are said to enjoy a natural immunity. In many acute diseases one attack protects the patient, for a time at least, from a second attack—acquired immunity.

Phagocytosis.—In the production of immunity the leucocytes and certain other cells play an important part in virtue of the power they possess of ingesting bacteria and of destroying them by a process of intra-cellular digestion. To this process Metchnikoff gave the name of phagocytosis, and he recognised two forms of phagocytes: (1) the microphages, which are the polymorpho-nuclear leucocytes of the blood; and (2) the macrophages, which include the larger hyaline leucocytes, endothelial cells, and connective-tissue corpuscles.

During the process of phagocytosis, the polymorpho-nuclear leucocytes in the circulating blood increase greatly in numbers (leucocytosis), as well as in their phagocytic action, and in the course of destroying the bacteria they produce certain ferments which enter the blood serum. These are known as opsonins or alexins, and they act on the bacteria by a process comparable to narcotisation, and render them an easy prey for the phagocytes.

Artificial or Passive Immunity.—A form of immunity can be induced by the introduction of protective substances obtained from an animal which has been actively immunised. The process by which passive immunity is acquired depends upon the fact that as a result of the reaction between the specific virus of a particular disease (the antigen) and the tissues of the animal attacked, certain substances—antibodies—are produced, which when transferred to the body of a susceptible animal protect it against that disease. The most important of these antibodies are the antitoxins. From the study of the processes by which immunity is secured against the effects of bacterial action the serum and vaccine methods of treating certain infective diseases have been evolved. The serum treatment is designed to furnish the patient with a sufficiency of antibodies to neutralise the infection. The anti-diphtheritic and the anti-tetanic act by neutralising the specific toxins of the disease—antitoxic serums; the anti-streptcoccic and the serum for anthrax act upon the bacteria—anti-bacterial serums.

A polyvalent serum, that is, one derived from an animal which has been immunised by numerous strains of the organism derived from various sources, is much more efficacious than when a single strain has been used.

Clinical Use of Serums.—Every precaution must be taken to prevent organismal contamination of the serum or of the apparatus by means of which it is injected. Syringes are so made that they can be sterilised by boiling. The best situations for injection are under the skin of the abdomen, the thorax, or the buttock, and the skin should be purified at the seat of puncture. If the bulk of the full dose is large, it should be divided and injected into different parts of the body, not more than 20 c.c. being injected at one place. The serum may be introduced directly into a vein, or into the spinal canal, e.g. anti-tetanic serum. The immunity produced by injections of antitoxic sera lasts only for a comparatively short time, seldom longer than a few weeks.

“Serum Disease” and Anaphylaxis.—It is to be borne in mind that some patients exhibit a supersensitiveness with regard to protective sera, an injection being followed in a few days by the appearance of an urticarial or erythematous rash, pain and swelling of the joints, and a variable degree of fever. These symptoms, to which the name serum disease is applied, usually disappear in the course of a few days.

The term anaphylaxis is applied to an allied condition of supersensitiveness which appears to be induced by the injection of certain substances, including toxins and sera, that are capable of acting as antigens. When a second injection is given after an interval of some days, if anaphylaxis has been established by the first dose, the patient suddenly manifests toxic symptoms of the nature of profound shock which may even prove fatal. The conditions which render a person liable to develop anaphylaxis and the mechanism by which it is established are as yet imperfectly understood.

Vaccine Treatment.—The vaccine treatment elaborated by A. E. Wright consists in injecting, while the disease is still active, specially prepared dead cultures of the causative organisms, and is based on the fact that these “vaccines” render the bacteria in the tissues less able to resist the attacks of the phagocytes. The method is most successful when the vaccine is prepared from organisms isolated from the patient himself, autogenous vaccine, but when this is impracticable, or takes a considerable time, laboratory-prepared polyvalent stock vaccines may be used.

Clinical Use of Vaccines.—Vaccines should not be given while a patient is in a negative phase, as a certain amount of the opsonin in the blood is used up in neutralising the substances injected, and this may reduce the opsonic index to such an extent that the vaccines themselves become dangerous. As a rule, the propriety of using a vaccine can be determined from the general condition of the patient. The initial dose should always be a small one, particularly if the disease is acute, and the subsequent dosage will be regulated by the effect produced. If marked constitutional disturbance with rise of temperature follows the use of a vaccine, it indicates a negative phase, and calls for a diminution in the next dose. If, on the other hand, the local as well as the general condition of the patient improves after the injection, it indicates a positive phase, and the original dose may be repeated or even increased. Vaccines are best introduced subcutaneously, a part being selected which is not liable to pressure, as there is sometimes considerable local reaction. Repeated doses may be necessary at intervals of a few days.

The vaccine treatment has been successfully employed in various tuberculous lesions, in pyogenic infections such as acne, boils, sycosis, streptococcal, pneumococcal, and gonococcal conditions, in infections of the accessory air sinuses, and in other diseases caused by bacteria.

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.

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.

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.

Bacillus Coli Communis.—This organism, which is a normal inhabitant of the intestinal tract, shows a great tendency to invade any organ or tissue whose vitality is lowered. It is causatively associated with such conditions as peritonitis and peritoneal suppuration resulting from strangulated hernia, appendicitis, or perforation in any part of the alimentary canal. In cystitis, pyelitis, abscess of the kidney, suppuration in the bile-ducts or liver, and in many other abdominal conditions, it plays a most important part. The discharge from wounds infected by this organism has usually a fœtid, or even a fæcal odour, and often contains gases resulting from putrefaction.

It is a small rod-shaped organism with short flagellæ, which render it motile (Fig. 4). It closely resembles the typhoid bacillus, but is distinguished from it by its behaviour in artificial culture media.

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.

Inflammation may be defined as the series of vital changes that occurs in the tissues in response to irritation. These changes represent the reaction of the tissue elements to the irritant, and constitute the attempt made by nature to arrest or to limit its injurious effects, and to repair the damage done by it.

The phenomena which characterise the inflammatory reaction can be induced by any form of irritation—such, for example, as mechanical injury, the application of heat or of chemical substances, or the action of pathogenic bacteria and their toxins—and they are essentially similar in kind whatever the irritant may be. The extent to which the process may go, however, and its effects on the part implicated and on the system as a whole, vary with different irritants and with the intensity and duration of their action. A mechanical, a thermal, or a chemical irritant, acting alone, induces a degree of reaction directly proportionate to its physical properties, and so long as it does not completely destroy the vitality of the part involved, the changes in the tissues are chiefly directed towards repairing the damage done to the part, and the inflammatory reaction is not only compatible with the occurrence of ideal repair, but may be looked upon as an integral step in the reparative process.

The irritation caused by infection with bacteria, on the other hand, is cumulative, as the organisms not only multiply in the tissues, but in addition produce chemical poisons (toxins) which aggravate the irritative effects. The resulting reaction is correspondingly progressive, and has as its primary object the expulsion of the irritant and the limitation of its action. If the natural protective effort is successful, the resulting tissue changes subserve the process of repair, but if the bacteria gain the upper hand in the struggle, the inflammatory reaction becomes more intense, certain of the tissue elements succumb, and the process for the time being is a destructive one. During the stage of bacterial inflammation, reparative processes are in abeyance, and it is only after the inflammation has been allayed, either by natural means or by the aid of the surgeon, that repair takes place.

In applying the antiseptic principle to the treatment of wounds, our main object is to exclude or to eliminate the bacterial factor, and so to prevent the inflammatory reaction going beyond the stage in which it is protective, and just in proportion as we succeed in attaining this object, do we favour the occurrence of ideal repair.

Sequence of Changes in Bacterial Inflammation.—As the form of inflammation with which we are most concerned is that due to the action of bacteria, in describing the process by which the protective influence of the inflammatory reaction is brought into play, we shall assume the presence of a bacterial irritant.

The introduction of a colony of micro-organisms is quickly followed by an accumulation of wandering cells, and proliferation of connective-tissue cells in the tissues at the site of infection. The various cells are attracted to the bacteria by a peculiar chemical or biological power known as chemotaxis, which seems to result from variations in the surface tension of different varieties of cells, probably caused by some substance produced by the micro-organisms. Changes in the blood vessels then ensue, the arteries becoming dilated and the rate of the current in them being for a time increased—active hyperæmia. Soon, however, the rate of the blood flow becomes slower than normal, and in course of time the current may cease (stasis), and the blood in the vessels may even coagulate (thrombosis). Coincidently with these changes in the vessels, the leucocytes in the blood of the inflamed part rapidly increase in number, and they become viscous and adhere to the vessel wall, where they may accumulate in large numbers. In course of time the leucocytes pass through the vessel wall—emigration of leucocytes—and move towards the seat of infection, giving rise to a marked degree of local leucocytosis. Through the openings by which the leucocytes have escaped from the vessels, red corpuscles may be passively extruded—diapedesis of red corpuscles. These processes are accompanied by changes in the endothelium of the vessel walls, which result in an increased formation of lymph, which transudes into the meshes of the connective tissue giving rise to an inflammatory œdema, or, if the inflammation is on a free surface, forming an inflammatory exudate. The quantity and characters of this exudate vary in different parts of the body, and according to the nature, virulence, and location of the organisms causing the inflammation. Thus it may be serous, as in some forms of synovitis; sero-fibrinous, as in certain varieties of peritonitis, the fibrin tending to limit the spread of the inflammation by forming adhesions; croupous, when it coagulates on a free surface and forms a false membrane, as in diphtheria; hæmorrhagic when mixed with blood; or purulent, when suppuration has occurred. The protective effects of the inflammatory reaction depend for the most part upon the transudation of lymph and the emigration of leucocytes. The lymph contains the opsonins which act on the bacteria and render them less able to resist the attack of the phagocytes, as well as the various protective antibodies which neutralise the toxins. The polymorph leucocytes are the principal agents in the process of phagocytosis (p. 22), and together with the other forms of phagocytes they ingest and destroy the bacteria.

If the attempt to repel the invading organisms is successful, the irritant effects are overcome, the inflammation is arrested, and resolution is said to take place.

Certain of the vascular and cellular changes are now utilised to restore the condition to the normal, and repair ensues after the manner already described. In certain situations, notably in tendon sheaths, in the cavities of joints, and in the interior of serous cavities, for example the pleura and peritoneum, the restoration to the normal is not perfect, adhesions forming between the opposing surfaces.

If, however, the reaction induced by the infection is insufficient to check the growth and spread of the organisms, or to inhibit their toxin production, local necrosis of tissue may take place, either in the form of suppuration or of gangrene, or the toxins absorbed into the circulation may produce blood-poisoning, which may even prove fatal.

Clinical Aspects of Inflammation.—It must clearly be understood that inflammation is not to be looked upon as a disease in itself, but rather as an evidence of some infective process going on in the tissues in which it occurs, and of an effort on the part of these tissues to overcome the invading organisms and their products. The chief danger to the patient lies, not in the reactive changes that constitute the inflammatory process, but in the fact that he is liable to be poisoned by the toxins of the bacteria at work in the inflamed area.

Since the days of Celsus (first century A.D.), heat, redness, swelling, and pain have been recognised as cardinal signs of inflammation, and to these may be added, interference with function in the inflamed part, and general constitutional disturbance. Variations in these signs and symptoms depend upon the acuteness of the condition, the nature of the causative organism and of the tissue attacked, the situation of the part in relation to the surface, and other factors.

The heat of the inflamed part is to be attributed to the increased quantity of blood present in it, and the more superficial the affected area the more readily is the local increase of temperature detected by the hand. This clinical point is best tested by placing the palm of the hand and fingers for a few seconds alternately over an uninflamed and an inflamed area, otherwise under similar conditions as to coverings and exposure. In this way even slight differences may be recognised.

Redness, similarly, is due to the increased afflux of blood to the inflamed part. The shade of colour varies with the stage of the inflammation, being lighter and brighter in the early, hyperæmic stages, and darker and duskier when the blood flow is slowed or when stasis has occurred and the oxygenation of the blood is defective. In the thrombotic stage the part may assume a purplish hue.

The swelling is partly due to the increased amount of blood in the affected part and to the accumulation of leucocytes and proliferated tissue cells, but chiefly to the exudate in the connective tissue—inflammatory œdema. The more open the structure of the tissue of the part, the greater is the amount of swelling—witness the marked degree of œdema that occurs in such parts as the scrotum or the eyelids.

Pain is a symptom seldom absent in inflammation. Tenderness—that is, pain elicited on pressure—is one of the most valuable diagnostic signs we possess, and is often present before pain is experienced by the patient. That the area of tenderness corresponds to the area of inflammation is almost an axiom of surgery. Pain and tenderness are due to the irritation of nerve filaments of the part, rendered all the more sensitive by the abnormal conditions of their blood supply. In inflammatory conditions of internal organs, for example the abdominal viscera, the pain is frequently referred to other parts, usually to an area supplied by branches from the same segment of the cord as that supplying the inflamed part.

For purposes of diagnosis, attention should be paid to the terms in which the patient describes his pain. For example, the pain caused by an inflammation of the skin is usually described as of a burning or itching character; that of inflammation in dense tissues like periosteum or bone, or in encapsuled organs, as dull, boring, or aching. When inflammation is passing on to suppuration the pain assumes a throbbing character, and as the pus reaches the surface, or “points,” as it is called, sharp, darting, or lancinating pains are experienced. Inflammation involving a nerve-trunk may cause a boring or a tingling pain; while the implication of a serous membrane such as the pleura or peritoneum gives rise to a pain of a sharp, stabbing character.

Interference with the function of the inflamed part is always present to a greater or less extent.

Constitutional Disturbances.—Under the term constitutional disturbances are included the presence of fever or elevation of temperature; certain changes in the pulse rate and the respiration; gastro-intestinal and urinary disturbances; and derangements of the central nervous system. These are all due to the absorption of toxins into the general circulation.

Temperature.—A marked rise of temperature is one of the most constant and important concomitants of acute inflammatory conditions, and the temperature chart forms a fairly reliable index of the state of the patient. The toxins interfere with the nerve-centres in the medulla that regulate the balance between the production and the loss of body heat.

Clinically the temperature is estimated by means of a self-registering thermometer placed, for from one to five minutes, in close contact with the skin in the axilla, or in the mouth. Sometimes the thermometer is inserted into the rectum, where, however, the temperature is normally ¾° F. higher than in the axilla.

In health the temperature of the body is maintained at a mean of about 98.4° F. (37° C.) by the heat-regulating mechanism. It varies from hour to hour even in health, reaching its maximum between four and eight in the evening, when it may rise to 99° F., and is at its lowest between four and six in the morning, when it may be about 97° F.

The temperature is more easily disturbed in children than in adults, and may become markedly elevated (104° or 105° F.) from comparatively slight causes; in the aged it is less liable to change, so that a rise to 103° or 104° F. is to be looked upon as indicating a high state of fever.

A sudden rise of temperature is usually associated with a feeling of chilliness down the back and in the limbs, which may be so marked that the patient shivers violently, while the skin becomes cold, pale, and shrivelled—cutis anserina. This is a nervous reaction due to a want of correspondence between the internal and the surface temperature of the body, and is known clinically as a rigor. When the temperature rises gradually the chill is usually slight and may be unobserved. Even during the cold stage, however, the internal temperature is already raised, and by the time the chill has passed off its maximum has been reached.

The pulse is always increased in frequency, and usually varies directly with the height of the temperature. Respiration is more active during the progress of an inflammation; and bronchial catarrh is common apart from any antecedent respiratory disease.

Gastro-intestinal disturbances take the form of loss of appetite, vomiting, diminished secretion of the alimentary juices, and weakening of the peristalsis of the bowel, leading to thirst, dry, furred tongue, and constipation. Diarrhœa is sometimes present. The urine is usually scanty, of high specific gravity, rich in nitrogenous substances, especially urea and uric acid, and in calcium salts, while sodium chloride is deficient. Albumin and hyaline casts may be present in cases of severe inflammation with high temperature. The significance of general leucocytosis has already been referred to.

General Principles of Treatment.—The capacity of the inflammatory reaction for dealing with bacterial infections being limited, it often becomes necessary for the surgeon to aid the natural defensive processes, as well as to counteract the local and general effects of the reaction, and to relieve symptoms.

The ideal means of helping the tissues is by removing the focus of infection, and when this can be done, as for example in a carbuncle or an anthrax pustule, the infected area may be completely excised. When the focus is not sufficiently limited to admit of this, the infected tissue may be scraped away with the sharp spoon, or destroyed by caustics or by the actual cautery. If this is inadvisable, the organisms may be attacked by strong antiseptics, such as pure carbolic acid.

Moist dressings favour the removal of bacteria by promoting the escape of the inflammatory exudate, in which they are washed out.

Artificial Hyperæmia.—When such direct means as the above are impracticable, much can be done to aid the tissues in their struggle by improving the condition of the circulation in the inflamed area, so as to ensure that a plentiful supply of fresh arterial blood reaches it. The beneficial effects of hot fomentations and poultices depend on their causing a dilatation of the vessels, and so inducing a hyperæmia in the affected area. It has been shown experimentally that repeated, short applications of moist heat (not exceeding 106° F.) are more efficacious than continuous application. It is now believed that the so-called counter-irritants—mustard, iodine, cantharides, actual cautery—act in the same way; and the method of treating erysipelas by applying a strong solution of iodine around the affected area is based on the same principle.

While these and similar methods have long been employed in the treatment of inflammatory conditions, it is only within comparatively recent years that their mode of action has been properly understood, and to August Bier belongs the credit of having put the treatment of inflammation on a scientific and rational basis. Recognising the “beneficent intention” of the inflammatory reaction, and the protective action of the leucocytosis which accompanies the hyperæmic stages of the process, Bier was led to study the effects of increasing the hyperæmia by artificial means. As a result of his observations, he has formulated a method of treatment which consists in inducing an artificial hyperæmia in the inflamed area, either by obstructing the venous return from the part (passive hyperæmia), or by stimulating the arterial flow through it (active hyperæmia).

Bier's Constricting Bandage.—To induce a passive hyperæmia in a limb, an elastic bandage is applied some distance above the inflamed area sufficiently tightly to obstruct the venous return from the distal parts without arresting in any way the inflow of arterial blood (Fig. 6). If the constricting band is correctly applied, the parts beyond become swollen and œdematous, and assume a bluish-red hue, but they retain their normal temperature, the pulse is unchanged, and there is no pain. If the part becomes blue, cold, or painful, or if any existing pain is increased, the band has been applied too tightly. The hyperæmia is kept up from twenty to twenty-two hours out of the twenty-four, and in the intervals the limb is elevated to get rid of the œdema and to empty it of impure blood, and so make room for a fresh supply of healthy blood when the bandage is re-applied. As the inflammation subsides, the period during which the band is kept on each day is diminished; but the treatment should be continued for some days after all signs of inflammation have subsided.

This method of treating acute inflammatory conditions necessitates close supervision until the correct degree of tightness of the band has been determined.

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.

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.

Suppuration, or the formation of pus, is one of the results of the action of bacteria on the tissues. The invading organism is usually one of the staphylococci, less frequently a streptococcus, and still less frequently one of the other bacteria capable of producing pus, such as the bacillus coli communis, the gonococcus, the pneumococcus, or the typhoid bacillus.

So long as the tissues are in a healthy condition they are able to withstand the attacks of moderate numbers of pyogenic bacteria of ordinary virulence, but when devitalised by disease, by injury, or by inflammation due to the action of other pathogenic organisms, suppuration ensues.

It would appear, for example, that pyogenic organisms can pass through the healthy urinary tract without doing any damage, but if the pelvis of the kidney, the ureter, or the bladder is the seat of stone, they give rise to suppuration. Similarly, a calculus in one of the salivary ducts frequently results in an abscess forming in the floor of the mouth. When the lumen of a tubular organ, such as the appendix or the Fallopian tube is blocked also, the action of pyogenic organisms is favoured and suppuration ensues.

Pus.—The fluid resulting from the process of suppuration is known as pus. In its typical form it is a yellowish creamy substance, of alkaline reaction, with a specific gravity of about 1030, and it has a peculiar mawkish odour. If allowed to stand in a test-tube it does not coagulate, but separates into two layers: the upper, transparent, straw-coloured fluid, the liquor puris or pus serum, closely resembling blood serum in its composition, but containing less protein and more cholestrol; it also contains leucin, tyrosin, and certain albumoses which prevent coagulation.

The layer at the bottom of the tube consists for the most part of polymorph leucocytes, and proliferated connective tissue and endothelial cells (pus corpuscles). Other forms of leucocytes may be present, especially in long-standing suppurations; and there are usually some red corpuscles, dead bacteria, fat cells and shreds of tissue, cholestrol crystals, and other detritus in the deposit.

If a film of fresh pus is examined under the microscope, the pus cells are seen to have a well-defined rounded outline, and to contain a finely granular protoplasm and a multi-partite nucleus; if still warm, the cells may exhibit amœboid movement. In stained films the nuclei take the stain well. In older pus cells the outline is irregular, the protoplasm coarsely granular, and the nuclei disintegrated, no longer taking the stain.

Variations from Typical Pus.—Pus from old-standing sinuses is often watery in consistence (ichorous), with few cells. Where the granulations are vascular and bleed easily, it becomes sanious from admixture with red corpuscles; while, if a blood-clot be broken down and the debris mixed with the pus, it contains granules of blood pigment and is said to be “grumous.” The odour of pus varies with the different bacteria producing it. Pus due to ordinary pyogenic cocci has a mawkish odour; when putrefactive organisms are present it has a putrid odour; when it forms in the vicinity of the intestinal canal it usually contains the bacillus coli communis and has a fæcal odour.

The colour of pus also varies: when due to one or other of the varieties of the bacillus pyocyaneus, it is usually of a blue or green colour; when mixed with bile derivatives or altered blood pigment, it may be of a bright orange colour. In wounds inflicted with rough iron implements from which rust is deposited, the pus often presents the same colour.

The pus may form and collect within a circumscribed area, constituting a localised abscess; or it may infiltrate the tissues over a wide area—diffuse suppuration.

Any tissue of the body may be the seat of an acute abscess, and there are many routes by which the bacteria may gain access to the affected area. For example: an abscess in the integument or subcutaneous cellular tissue usually results from infection by organisms which have entered through a wound or abrasion of the surface, or along the ducts of the skin; an abscess in the breast from organisms which have passed along the milk ducts opening on the nipple, or along the lymphatics which accompany these. An abscess in a lymph gland is usually due to infection passing by way of the lymph channels from the area of skin or mucous membrane drained by them. Abscesses in internal organs, such as the kidney, liver, or brain, usually result from organisms carried in the blood-stream from some focus of infection elsewhere in the body.

A knowledge of the possible avenues of infection is of clinical importance, as it may enable the source of a given abscess to be traced and dealt with. In suppuration in the Fallopian tube (pyosalpynx), for example, the fact that the most common origin of the infection is in the genital passage, leads to examination for vaginal discharge; and if none is present, the abscess is probably due to infection carried in the blood-stream from some primary focus about the mouth, such as a gumboil or an infective sore throat.

The exact location of an abscess also may furnish a key to its source; in axillary abscess, for example, if the suppuration is in the lymph glands the infection has come through the afferent lymphatics; if in the cellular tissue, it has spread from the neck or chest wall; if in the hair follicles, it is a local infection through the skin.

Formation of an Abscess.—When pyogenic bacteria are introduced into the tissue there ensues an inflammatory reaction, which is characterised by dilatation of the blood vessels, exudation of large numbers of leucocytes, and proliferation of connective-tissue cells. These wandering cells soon accumulate round the focus of infection, and form a protective barrier which tends to prevent the spread of the organisms and to restrict their field of action. Within the area thus circumscribed the struggle between the bacteria and the phagocytes takes place, and in the process toxins are formed by the organisms, a certain number of the leucocytes succumb, and, becoming degenerated, set free certain proteolytic enzymes or ferments. The toxins cause coagulation-necrosis of the tissue cells with which they come in contact, the ferments liquefy the exudate and other albuminous substances, and in this way pus is formed.

If the bacteria gain the upper hand, this process of liquefaction which is characteristic of suppuration, extends into the surrounding tissues, the protective barrier of leucocytes is broken down, and the suppurative process spreads. A fresh accession of leucocytes, however, forms a new barrier, and eventually the spread is arrested, and the collection of pus so hemmed in constitutes an abscess.

Owing to the swelling and condensation of the parts around, the pus thus formed is under considerable pressure, and this causes it to burrow along the lines of least resistance. In the case of a subcutaneous abscess the pus usually works its way towards the surface, and “points,” as it is called. Where it approaches the surface the skin becomes soft and thin, and eventually sloughs, allowing the pus to escape.

An abscess forming in the deeper planes is prevented from pointing directly to the surface by the firm fasciæ and other fibrous structures. The pus therefore tends to burrow along the line of the blood vessels and in the connective-tissue septa, till it either finds a weak spot or causes a portion of fascia to undergo necrosis and so reaches the surface. Accordingly, many abscess cavities resulting from deep-seated suppuration are of irregular shape, with pouches and loculi in various directions—an arrangement which interferes with their successful treatment by incision and drainage.

The relief of tension which follows the bursting of an abscess, the removal of irritation by the escape of pus, and the casting off of bacteria and toxins, allow the tissues once more to assert themselves, and a process of repair sets in. The walls of the abscess fall in; granulation tissue grows into the space and gradually fills it; and later this is replaced by cicatricial tissue. As a result of the subsequent contraction of the cicatricial tissue, the scar is usually depressed below the level of the surrounding skin surface.

If an abscess is prevented from healing—for example, by the presence of a foreign body or a piece of necrosed bone—a sinus results, and from it pus escapes until the foreign body is removed.

Clinical Features of an Acute Circumscribed Abscess.—In the initial stages the usual symptoms of inflammation are present. Increased elevation of temperature, with or without a rigor, progressive leucocytosis, and sweating, mark the transition between inflammation and suppuration. An increasing leucocytosis is evidence that a suppurative process is spreading.

The local symptoms vary with the seat of the abscess. When it is situated superficially—for example, in the breast tissue—the affected area is hot, the redness of inflammation gives place to a dusky purple colour, with a pale, sometimes yellow, spot where the pus is near the surface. The swelling increases in size, the firm brawny centre becomes soft, projects as a cone beyond the level of the rest of the swollen area, and is usually surrounded by a zone of induration.

By gently palpating with the finger-tips over the softened area, a fluid wave may be detected—fluctuation—and when present this is a certain indication of the existence of fluid in the swelling. Its recognition, however, is by no means easy, and various fallacies are to be guarded against in applying this test clinically. When, for example, the walls of the abscess are thick and rigid, or when its contents are under excessive tension, the fluid wave cannot be elicited. On the other hand, a sensation closely resembling fluctuation may often be recognised in œdematous tissues, in certain soft, solid tumours such as fatty tumours or vascular sarcomata, in aneurysm, and in a muscle when it is palpated in its transverse axis.

When pus has formed in deeper parts, and before it has reached the surface, œdema of the overlying skin is frequently present, and the skin pits on pressure.

With the formation of pus the continuous burning or boring pain of inflammation assumes a throbbing character, with occasional sharp, lancinating twinges. Should doubt remain as to the presence of pus, recourse may be had to the use of an exploring needle.

Differential Diagnosis of Acute Abscess.—A practical difficulty which frequently arises is to decide whether or not pus has actually formed. It may be accepted as a working rule in practice that when an acute inflammation has lasted for four or five days without showing signs of abatement, suppuration has almost certainly occurred. In deep-seated suppuration, marked œdema of the skin and the occurrence of rigors and sweating may be taken to indicate the formation of pus.

There are cases on record where rapidly growing sarcomatous and angiomatous tumours, aneurysms, and the bruises that occur in hæmophylics, have been mistaken for acute abscesses and incised, with disastrous results.

Treatment of Acute Abscesses.—The dictum of John Bell, “Where there is pus, let it out,” summarises the treatment of abscess. The extent and situation of the incision and the means taken to drain the cavity, however, vary with the nature, site, and relations of the abscess. In a superficial abscess, for example a bubo, or an abscess in the breast or face where a disfiguring scar is undesirable, a small puncture should be made where the pus threatens to point, and a Klapp's suction bell be applied as already described (p. 39). A drain is not necessary, and in the intervals between the applications of the bell the part is covered with a moist antiseptic dressing.

In abscesses deeply placed, as for example under the gluteal or pectoral muscles, one or more incisions should be made, and the cavity drained by glass or rubber tubes or by strips of rubber tissue.

The wound should be dressed the next day, and the tube shortened, in the case of a rubber tube, by cutting off a portion of its outer end. On the second day or later, according to circumstances, the tube is removed, and after this the dressing need not be repeated oftener than every second or third day.

Where pus has formed in relation to important structures—as, for example, in the deeper planes of the neck—Hilton's method of opening the abscess may be employed. An incision is made through the skin and fascia, a grooved director is gently pushed through the deeper tissues till pus escapes along its groove, and then the track is widened by passing in a pair of dressing forceps and expanding the blades. A tube, or strip of rubber tissue, is introduced, and the subsequent treatment carried out as in other abscesses. When the drain lies in proximity to a large blood vessel, care must be taken not to leave it in position long enough to cause ulceration of the vessel wall by pressure.

In some abscesses, such as those in the vicinity of the anus, the cavity should be laid freely open in its whole extent, stuffed with iodoform or bismuth gauze, and treated by the open method.

It is seldom advisable to wash out an abscess cavity, and squeezing out the pus is also to be avoided, lest the protective zone be broken down and the infection be diffused into the surrounding tissues.

The importance of taking precautions against further infection in opening an abscess can scarcely be exaggerated, and the rapidity with which healing occurs when the access of fresh bacteria is prevented is in marked contrast to what occurs when such precautions are neglected and further infection is allowed to take place.

Acute Suppuration in a Wound.—If in the course of an operation infection of the wound has occurred, a marked inflammatory reaction soon manifests itself, and the same changes as occur in the formation of an acute abscess take place, modified, however, by the fact that the pus can more readily reach the surface. In from twenty-four to forty-eight hours the patient is conscious of a sensation of chilliness, or may even have a rigor. At the same time he feels generally out of sorts, with impaired appetite, headache, and it may be looseness of the bowels. His temperature rises to 100° or 101° F., and the pulse quickens to 100 or 110.

On exposing the wound it is found that the parts for some distance around are red, glazed, and œdematous. The discoloration and swelling are most intense in the immediate vicinity of the wound, the edges of which are everted and moist. Any stitches that may have been introduced are tight, and the deep ones may be cutting into the tissues. There is heat, and a constant burning or throbbing pain, which is increased by pressure. If the stitches be cut, pus escapes, the wound gapes, and its surfaces are found to be inflamed and covered with pus.

The open method is the only safe means of treating such wounds. The infected surface may be sponged over with pure carbolic acid, the excess of which is washed off with absolute alcohol, and the wound either drained by tubes or packed with iodoform gauze. The practice of scraping such surfaces with the sharp spoon, squeezing or even of washing them out with antiseptic lotions, is attended with the risk of further diffusing the organisms in the tissue, and is only to be employed under exceptional circumstances. Continuous irrigation of infected wounds or their immersion in antiseptic baths is sometimes useful. The free opening up of the wound is almost immediately followed by a fall in the temperature. The surrounding inflammation subsides, the discharge of pus lessens, and healing takes place by the formation of granulation tissue—the so-called “healing by second intention.”

Wound infection may take place from catgut which has not been efficiently prepared. The local and general reactions may be slight, and, as a rule, do not appear for seven or eight days after the operation, and, it may be, not till after the skin edges have united. The suppuration is strictly localised to the part of the wound where catgut was employed for stitches or ligatures, and shows little tendency to spread. The infected part, however, is often long of healing. The irritation in these cases is probably due to toxins in the catgut and not to bacteria.

When suppuration occurs in connection with buried sutures of unabsorbable materials, such as silk, silkworm gut, or silver wire, it is apt to persist till the foreign material is cast off or removed.

Suppuration may occur in the track of a skin stitch, producing a stitch abscess. The infection may arise from the material used, especially catgut or silk, or, more frequently perhaps, from the growth of staphylococcus albus from the skin of the patient when this has been imperfectly disinfected. The formation of pus under these conditions may not be attended with any of the usual signs of suppuration, and beyond some induration around the wound and a slight tenderness on pressure there may be nothing to suggest the presence of an abscess.

Acute Suppuration of a Mucous Membrane.—When pyogenic organisms gain access to a mucous membrane, such as that of the bladder, urethra, or middle ear, the usual phenomena of acute inflammation and suppuration ensue, followed by the discharge of pus on the free surface. It would appear that the most marked changes take place in the submucous tissue, causing the covering epithelium in places to die and leave small superficial ulcers, for example in gonorrhœal urethritis, the cicatricial contraction of the scar subsequently leading to the formation of stricture. When mucous glands are present in the membrane, the pus is mixed with mucus—muco-pus.

Cellulitis is an acute affection resulting from the introduction of some organism—commonly the streptococcus pyogenes—into the cellular connective tissue of the integument, intermuscular septa, tendon sheaths, or other structures. Infection always takes place through a breach of the surface, although this may be superficial and insignificant, such as a pin-prick, a scratch, or a crack under a nail, and the wound may have been healed for some time before the inflammation becomes manifest. The cellulitis, also, may develop at some distance from the seat of inoculation, the organisms having travelled by the lymphatics.

The virulence of the organisms, the loose, open nature of the tissues in which they develop, and the free lymphatic circulation by means of which they are spread, account for the diffuse nature of the process. Sometimes numbers of cocci are carried for a considerable distance from the primary area before they are arrested in the lymphatics, and thus several patches of inflammation may appear with healthy areas between.

The pus infiltrates the meshes of the cellular tissue, there is sloughing of considerable portions of tissue of low vitality, such as fat, fascia, or tendon, and if the process continues for some time several collections of pus may form.

Clinical Features.—The reaction in cases of diffuse cellulitis is severe, and is usually ushered in by a distinct chill or even a rigor, while the temperature rises to 103°, 104°, or 105° F. The pulse is proportionately increased in frequency, and is small, feeble, and often irregular. The face is flushed, the tongue dry and brown, and the patient may become delirious, especially during the night. Leucocytosis is present in cases of moderate severity; but in severe cases the virulence of the toxins prevents reaction taking place, and leucocytosis is absent.

The local manifestations vary with the relation of the seat of the inflammation to the surface. When the superficial cellular tissue is involved, the skin assumes a dark bluish-red colour, is swollen, œdematous, and the seat of burning pain. To the touch it is firm, hot, and tender. When the primary focus is in the deeper tissues, the constitutional disturbance is aggravated, while the local signs are delayed, and only become prominent when pus forms and approaches the surface. It is not uncommon for blebs containing dark serous fluid to form on the skin. The infection frequently spreads along the line of the main lymph vessels of the part (septic lymphangitis) and may reach the lymph glands (septic lymphadenitis).

With the formation of pus the skin becomes soft and boggy at several points, and eventually breaks, giving exit to a quantity of thick grumous discharge. Sometimes several small collections under the skin fuse, and an abscess is formed in which fluctuation can be detected. Occasionally gases are evolved in the tissues, giving rise to emphysema. It is common for portions of fascia, ligaments, or tendons to slough, and this may often be recognised clinically by a peculiar crunching or grating sensation transmitted to the fingers on making firm pressure on the part.

If it is not let out by incision, the pus, travelling along the lines of least resistance, tends to point at several places on the surface, or to open into joints or other cavities.

Prognosis.—The occurrence of septicæmia is the most serious risk, and it is in cases of diffuse suppurative cellulitis that this form of blood-poisoning assumes its most aggravated forms. The toxins of the streptococci are exceedingly virulent, and induce local death of tissue so rapidly that the protective emigration of leucocytes fails to take place. In some cases the passage of masses of free cocci in the lymphatics, or of infective emboli in the blood vessels, leads to the formation of pyogenic abscesses in vital organs, such as the brain, lungs, liver, kidneys, or other viscera. Hæmorrhage from erosion of arterial or venous trunks may take place and endanger life.

Treatment.—The treatment of diffuse cellulitis depends to a large extent on the situation and extent of the affected area, and on the stage of the process.

In the limbs, for example, where the application of a constricting band is practicable, Bier's method of inducing passive hyperæmia yields excellent results. If pus is formed, one or more small incisions are made and a light moist dressing placed over the wounds to absorb the discharge, but no drain is inserted. The whole of the inflamed area should be covered with gauze wrung out of a 1 in 10 solution of ichthyol in glycerine. The dressing is changed as often as necessary, and in the intervals when the band is off, gentle active and passive movements should be carried out to prevent the formation of adhesions. After incisions have been made, we have found the immersion of the limb, for a few hours at a time, in a water-bath containing warm boracic lotion or eusol a useful adjuvant to the passive hyperæmia.

Continuous irrigation of the part by a slow, steady stream of lotion, at the body temperature, such as eusol, or Dakin's solution, or boracic acid, or frequent washing with peroxide of hydrogen, has been found of value.

A suitably arranged splint adds to the comfort of the patient; and the limb should be placed in the attitude which, in the event of stiffness resulting, will least interfere with its usefulness. The elbow, for example, should be flexed to a little less than a right angle; at the wrist, the hand should be dorsiflexed and the fingers flexed slightly towards the palm.

Massage, passive movement, hot and cold douching, and other measures, may be necessary to get rid of the chronic œdema, adhesions of tendons, and stiffness of joints which sometimes remain.

In situations where a constricting band cannot be applied, for example, on the trunk or the neck, Klapp's suction bells may be used, small incisions being made to admit of the escape of pus.

If these measures fail or are impracticable, it may be necessary to make one or more free incisions, and to insert drainage-tubes, portions of rubber dam, or iodoform worsted.

The general treatment of toxæmia must be carried out, and in cases due to infection by streptococci, anti-streptococcic serum may be used.

In a few cases, amputation well above the seat of disease, by removing the source of toxin production, offers the only means of saving the patient.

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.

Subcutaneous Whitlow.—In this variety the infection manifests itself as a cellulitis of the pulp of the finger (Fig. 9, c), which sometimes spreads towards the palm of the hand. The finger becomes red, swollen, and tense; there is severe throbbing pain, which is usually worst at night and prevents sleep, and the part is extremely tender on pressure. When the palm is invaded there may be marked œdema of the back of the hand, the dense integument of the palm preventing the swelling from appearing on the front. The pus may be under such tension that fluctuation cannot be detected. The patient is usually able to flex the finger to a certain extent without increasing the pain—a point which indicates that the tendon sheaths have not been invaded. The suppurative process may, however, spread to the tendon sheaths, or even to the bone. Sometimes the excessive tension and virulent toxins induce actual gangrene of the distal part, or even of the whole finger. There is considerable constitutional disturbance, the temperature often reaching 101° or 102° F.

The treatment consists in applying a constriction band and making an incision over the centre of the most tender area, care being taken to avoid opening the tendon sheath lest the infection be conveyed to it. Moist dressings should be employed while the suppuration lasts. Carbolic fomentations, however, are to be avoided on account of the risk of inducing gangrene.

Whitlow of the Tendon Sheaths.—In this form the main incidence of the infection is on the sheaths of the flexor tendons, but it is not always possible to determine whether it started there or spread thither from the subcutaneous cellular tissue (Fig. 9, d). In some cases both connective tissue planes are involved. The affected finger becomes red, painful, and swollen, the swelling spreading to the dorsum. The involvement of the tendon sheath is usually indicated by the patient being unable to flex the finger, and by the pain being increased when he attempts to do so. On account of the anatomical arrangement of the tendon sheaths, the process may spread into the forearm—directly in the case of the thumb and little finger, and after invading the palm in the case of the other fingers—and there give rise to a diffuse cellulitis which may result in sloughing of fasciæ and tendons. When the infection spreads into the common flexor sheath under the transverse carpal (anterior annular) ligament, it is not uncommon for the intercarpal and wrist joints to become implicated. Impaired movement of tendons and joints is, therefore, a common sequel to this variety of whitlow.

The treatment consists in inducing passive hyperæmia by Bier's method, and, if this is done early, suppuration may be avoided. If pus forms, small incisions are made, under local anæsthesia, to relieve the tension in the sheath and to diminish the risk of the tendons sloughing. No form of drain should be inserted. In the fingers the incisions should be made in the middle line, and in the palm they should be made over the metacarpal bones to avoid the digital vessels and nerves. If pus has spread under the transverse carpal ligament, the incision must be made above the wrist. Passive movements and massage must be commenced as early as possible and be perseveringly employed to diminish the formation of adhesions and resulting stiffness.

Subperiosteal Whitlow.—This form is usually an extension of the subcutaneous or of the thecal variety, but in some cases the inflammation begins in the periosteum—usually of the terminal phalanx. It may lead to necrosis of a portion or even of the entire phalanx. This is usually recognised by the persistence of suppuration long after the acute symptoms have passed off, and by feeling bare bone with the probe. In such cases one or more of the joints are usually implicated also, and lateral mobility and grating may be elicited. Recovery does not take place until the dead bone is removed, and the usefulness of the finger is often seriously impaired by fibrous or bony ankylosis of the interphalangeal joints. This may render amputation advisable when a stiff finger is likely to interfere with the patient's occupation.

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.

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.—A sinus is a track leading from a focus of suppuration to a cutaneous or mucous surface. It usually represents the path by which the discharge escapes from an abscess cavity that has been prevented from closing completely, either from mechanical causes or from the persistent formation of discharge which must find an exit. A sinus is lined by granulation tissue, and when it is of long standing the opening may be dragged below the level of the surrounding skin by contraction of the scar tissue around it. As a sinus will persist until the obstacle to closure of the original abscess is removed, it is necessary that this should be sought for. It may be a foreign body, such as a piece of dead bone, an infected ligature, or a bullet, acting mechanically or by keeping up discharge, and if the body is removed the sinus usually heals. The presence of a foreign body is often suggested by a mass of redundant granulations at the mouth of the sinus. If a sinus passes through a muscle, the repeated contractions tend to prevent healing until the muscle is kept at rest by a splint, or put out of action by division of its fibres. The sinuses associated with empyema are prevented from healing by the rigidity of the chest wall, and will only close after an operation which admits of the cavity being obliterated. In any case it is necessary to disinfect the track, and, it may be, to remove the unhealthy granulations lining it, by means of the sharp spoon, or to excise it bodily. To encourage healing from the bottom the cavity should be packed with bismuth or iodoform gauze. The healing of long and tortuous sinuses is often hastened by the injection of Beck's bismuth paste (p. 145). If disfigurement is likely to follow from cicatricial contraction—for example, in a sinus over the lower jaw associated with a carious tooth—the sinus should be excised and the raw surfaces approximated with stitches.

The tuberculous sinus is described under Tuberculosis.

A fistula is an abnormal canal passing from a mucous surface to the skin or to another mucous surface. Fistulæ resulting from suppuration usually occur near the natural openings of mucous canals—for example, on the cheek, as a salivary fistula; beside the inner angle of the eye, as a lacrymal fistula; near the ear, as a mastoid fistula; or close to the anus, as a fistula-in-ano. Intestinal fistulæ are sometimes met with in the abdominal wall after strangulated hernia, operations for appendicitis, tuberculous peritonitis, and other conditions. In the perineum, fistulæ frequently complicate stricture of the urethra.

Fistulæ also occur between the bladder and vagina (vesico-vaginal fistula), or between the bladder and the rectum (recto-vesical fistula).

The treatment of these various forms of fistula will be described in the sections dealing with the regions in which they occur.

Congenital fistulæ, such as occur in the neck from imperfect closure of branchial clefts, or in the abdomen from unobliterated fœtal ducts such as the urachus or Meckel's diverticulum, will be described in their proper places.

We have here to consider under the terms Sapræmia, Septicæmia, and Pyæmia certain general effects of pyogenic infection, which, although their clinical manifestations may vary, are all associated with the action of the same forms of bacteria. They may occur separately or in combination, or one may follow on and merge into another.

Sapræmia, or septic intoxication, is the name applied to a form of poisoning resulting from the absorption into the blood of the toxic products of pyogenic bacteria. These products, which are of the nature of alkaloids, act immediately on their entrance into the circulation, and produce effects in direct proportion to the amount absorbed. As the toxins are gradually eliminated from the body the symptoms abate, and if no more are introduced they disappear. Sapræmia in these respects, therefore, is comparable to poisoning by any other form of alkaloid, such as strychnin or morphin.

Clinical Features.—The symptoms of sapræmia seldom manifest themselves within twenty-four hours of an operation or injury, because it takes some time for the bacteria to produce a sufficient dose of their poisons. The onset of the condition is marked by a feeling of chilliness, sometimes amounting to a rigor, and a rise of temperature to 102°, 103°, or 104° F., with morning remissions (Fig. 10). The heart's action is markedly depressed, and the pulse is soft and compressible. The appetite is lost, the tongue dry and covered with a thin brownish-red fur, so that it has the appearance of “dried beef.” The urine is scanty and loaded with urates. In severe cases diarrhœa and vomiting of dark coffee-ground material are often prominent features. Death is usually impending when the skin becomes cold and clammy, the mucous membranes livid, the pulse feeble and fluttering, the discharges involuntary, and when a low form of muttering delirium is present.

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.

The pulse is small, feeble, and compressible, and the temperature rises in the afternoon or evening to 102° or 103° F. (Fig. 11), the cheeks becoming characteristically flushed. In the early morning the temperature falls to normal or below it, and the patient breaks into a profuse perspiration, which leaves him pale, weak, and exhausted. He becomes rapidly and markedly emaciated, even although in some cases the appetite remains good and is even voracious.

The poisons circulating in the blood produce waxy degeneration in certain viscera, notably the liver, spleen, kidneys, and intestines. The process begins in the arterial walls, and spreads thence to the connective-tissue structures, causing marked enlargement of the affected organs. Albuminuria, ascites, œdema of the lower limbs, clubbing of the fingers, and diarrhœa are among the most prominent symptoms of this condition.

The prognosis in hectic fever depends on the completeness with which the further absorption of toxins can be prevented. In many cases this can only be effected by an operation which provides for free drainage, and, if possible, the removal of infected tissues. The resulting wound is best treated by the open method. Even advanced waxy degeneration does not contra-indicate this line of treatment, as the diseased organs usually recover if the focus from which absorption of toxic material is taking place is completely eradicated.

Septicæmia.—This form of blood-poisoning is the result of the action of pyogenic bacteria, which not only produce their toxins at the primary seat of infection, but themselves enter the blood-stream and are carried to other parts, where they settle and produce further effects.

Clinical Features.—There may be an incubation period of some hours between the infection and the first manifestation of acute septicæmia. In such conditions as acute osteomyelitis or acute peritonitis, we see the most typical clinical pictures of this condition. The onset is marked by a chill, or a rigor, which may be repeated, while the temperature rises to 103° or 104° F., although in very severe cases the temperature may remain subnormal throughout, the virulence of the toxins preventing reaction. It is in the general appearance of the patient and in the condition of the pulse that we have our best guides as to the severity of the condition. If the pulse remains firm, full, and regular, and does not exceed 110 or even 120, while the temperature is moderately raised, the outlook is hopeful; but when the pulse becomes small and compressible, and reaches 130 or more, especially if at the same time the temperature is low, a grave prognosis is indicated. The tongue is often dry and coated with a black crust down the centre, while the sides are red. It is a good omen when the tongue becomes moist again. Thirst is most distressing, especially in septicæmia of intestinal origin. Persistent vomiting of dark-brown material is often present, and diarrhœa with blood-stained stools is not uncommon. The urine is small in amount, and contains a large proportion of urates. As the poisons accumulate, the respiration becomes shallow and laboured, the face of a dull ashy grey, the nose pinched, and the skin cold and clammy. Capillary hæmorrhages sometimes take place in the skin or mucous membranes; and in a certain proportion of cases cutaneous eruptions simulating those of scarlet fever or measles appear, and are apt to lead to errors in diagnosis. In other cases there is slight jaundice. The mental state is often one of complete apathy, the patient failing to realise the gravity of his condition; sometimes there is delirium.

The prognosis is always grave, and depends on the possibility of completely eradicating the focus of infection, and on the reserve force the patient has to carry him over the period during which he is eliminating the poison already circulating in his blood.

The treatment is carried out on the same lines as in sapræmia, but it is less likely to be successful owing to the organisms having entered the circulation. When possible, the primary focus of infection should be dealt with.

Pyæmia is a form of blood-poisoning characterised by the development of secondary foci of suppuration in different parts of the body. Toxins are thus introduced into the blood, not only at the primary seat of infection, but also from each of these metastatic collections. Like septicæmia, this condition is due to pyogenic bacteria, the streptococcus pyogenes being the commonest organism found. The primary infection is usually in a wound—for example, a compound fracture—but cases occur in which the point of entrance of the bacteria is not discoverable. The dissemination of the organisms takes place through the medium of infected emboli which form in a thrombosed vein in the vicinity of the original lesion, and, breaking loose, are carried thence in the blood-stream. These emboli lodge in the minute vessels of the lungs, spleen, liver, kidneys, pleura, brain, synovial membranes, or cellular tissue, and the bacteria they contain give rise to secondary foci of suppuration. Secondary abscesses are thus formed in those parts, and these in turn may be the starting-point of new emboli which give rise to fresh areas of pus formation. The organs above named are the commonest situations of pyæmic abscesses, but these may also occur in the bone marrow, the substance of muscles, the heart and pericardium, lymph glands, subcutaneous tissue, or, in fact, in any tissue of the body. Organisms circulating in the blood are prone to lodge on the valves of the heart and give rise to endocarditis.

Clinical Features.—Before antiseptic surgery was practised, pyæmia was a common complication of wounds. In the present day it is not only infinitely less common, but appears also to be of a less severe type. Its rarity and its mildness may be related as cause and effect, because it was formerly found that pyæmia contracted from a pyæmic patient was more virulent than that from other sources.

In contrast with sapræmia and septicæmia, pyæmia is late of developing, and it seldom begins within a week of the primary infection. The first sign is a feeling of chilliness, or a violent rigor lasting for perhaps half an hour, during which time the temperature rises to 103°, 104°, or 105° F. In the course of an hour it begins to fall again, and the patient breaks into a profuse sweat. The temperature may fall several degrees, but seldom reaches the normal. In a few days there is a second rigor with rise of temperature, and another remission, and such attacks may be repeated at diminishing intervals during the course of the illness (Figs. 12 and 13). The pulse is soft, and tends to remain abnormally rapid even when the temperature falls nearly to normal.

The face is flushed, and wears a drawn, anxious expression, and the eyes are bright. A characteristic sweetish odour, which has been compared to that of new-mown hay, can be detected in the breath and may pervade the patient. The appetite is lost; there may be sickness and vomiting and profuse diarrhœa; and the patient emaciates rapidly. The skin is continuously hot, and has often a peculiar pungent feel. Patches of erythema sometimes appear scattered over the body. The skin may assume a dull sallow or earthy hue, or a bright yellow icteric tint may appear. The conjunctivæ also may be yellow. In the latter stages of the disease the pulse becomes small and fluttering; the tongue becomes dry and brown; sordes collect on the teeth; and a low muttering form of delirium supervenes.

Secondary infection of the parotid gland frequently occurs, and gives rise to a suppurative parotitis. This condition is associated with severe pain, gradually extending from behind the angle of the jaw on to the face. There is also swelling over the gland, and eventually suppuration and sloughing of the gland tissue and overlying skin.

Secondary abscesses in the lymph glands, subcutaneous tissue, or joints are often so insidious and painless in their development that they are only discovered accidentally. When the abscess is evacuated, healing often takes place with remarkable rapidity, and with little impairment of function.

The general symptoms may be simulated by an attack of malaria.

Prognosis.—The prognosis in acute pyæmia is much less hopeless than it once was, a considerable proportion of the patients recovering. In acute cases the disease proves fatal in ten days or a fortnight, death being due to toxæmia. Chronic cases often run a long course, lasting for weeks or even months, and prove fatal from exhaustion and waxy disease following on prolonged suppuration.

Treatment.—In such conditions as compound fractures and severe lacerated wounds, much can be done to avert the conditions which lead to pyæmia, by applying a Bier's constricting bandage as soon as there is evidence of infection having taken place, or even if there is reason to suspect that the wound is not aseptic.

If sepsis is already established, and evidence of general infection is present, the wound should be opened up sufficiently to admit of thorough disinfection and drainage, and the constricting bandage applied to aid the defensive processes going on in the tissues. If these measures fail, amputation of the limb may be the only means of preventing further dissemination of infective material from the primary source of infection.

Attempts have been made to interrupt the channel along which the infective emboli spread, by ligating or resecting the main vein of the affected part, but this is seldom feasible except in the case of the internal jugular vein for infection of the transverse sinus.

Secondary abscesses must be aspirated or opened and drained whenever possible.

The general treatment is conducted on the same lines as on other forms of pyogenic infection.

The process of ulceration may be defined as the molecular or cellular death of tissue taking place on a free surface. It is essentially of the same nature as the process of suppuration, only that the purulent discharge, instead of collecting in a closed cavity and forming an abscess, at once escapes on the surface.

An ulcer is an open wound or sore in which there are present certain conditions tending to prevent it undergoing the natural process of repair. Of these, one of the most important is the presence of pathogenic bacteria, which by their action not only prevent healing, but so irritate and destroy the tissues as to lead to an actual increase in the size of the sore. Interference with the nutrition of a part by œdema or chronic venous congestion may impede healing; as may also induration of the surrounding area, by preventing the contraction which is such an important factor in repair. Defective innervation, such as occurs in injuries and diseases of the spinal cord, also plays an important part in delaying repair. In certain constitutional conditions, too—for example, Bright's disease, diabetes, or syphilis—the vitiated state of the tissues is an impediment to repair. Mechanical causes, such as unsuitable dressings or ill-fitting appliances, may also act in the same direction.

Clinical Examination of an Ulcer.—In examining any ulcer, we observe—(1) Its base or floor, noting the presence or absence of granulations, their disposition, size, colour, vascularity, and whether they are depressed or elevated in relation to the surrounding parts. (2) The discharge as to quantity, consistence, colour, composition, and odour. (3) The edges, noting particularly whether or not the marginal epithelium is attempting to grow over the surface; also their shape, regularity, thickness, and whether undermined or overlapping, everted or depressed. (4) The surrounding tissues, as to whether they are congested, œdematous, inflamed, indurated, or otherwise. (5) Whether or not there is pain or tenderness in the raw surface or its surroundings. (6) The part of the body on which it occurs, because certain ulcers have special seats of election—for example, the varicose ulcer in the lower third of the leg, the perforating ulcer on the sole of the foot, and so on.

The Healing Sore.—If a portion of skin be excised aseptically, and no attempt made to close the wound, the raw surface left is soon covered over with a layer of coagulated blood and lymph. In the course of a few days this is replaced by the growth of granulations, which are of uniform size, of a pinkish-red colour, and moist with a slight serous exudate containing a few dead leucocytes. They grow until they reach the level of the surrounding skin, and so fill the gap with a fine velvety mass of granulation tissue. At the edges, the young epithelium may be seen spreading in over the granulations as a fine bluish-white pellicle, which gradually covers the sore, becoming paler in colour as it thickens, and eventually forming the smooth, non-vascular covering of the cicatrix. There is no pain, and the surrounding parts are healthy.

This may be used as a type with which to compare the ulcers seen at the bedside, so that we may determine how far, and in what particulars, these differ from the type; and that we may in addition recognise the conditions that have to be counteracted before the characters of the typical healing sore are assumed.

For purposes of contrast we may indicate the characters of an open sore in which bacterial infection with pathogenic bacteria has taken place. The layer of coagulated blood and lymph becomes liquefied and is thrown off, and instead of granulations being formed, the tissues exposed on the floor of the ulcer are destroyed by the bacterial toxins, with the formation of minute sloughs and a quantity of pus.

The discharge is profuse, thin, acrid, and offensive, and consists of pus, broken-down blood-clot, and sloughs. The edges are inflamed, irregular, and ragged, showing no sign of growing epithelium—on the contrary, the sore may be actually increasing in area by the breaking-down of the tissues at its margins. The surrounding parts are hot, red, swollen, and œdematous; and there is pain and tenderness both in the sore itself and in the parts around.

Classification of Ulcers.—The nomenclature of ulcers is much involved and gives rise to great confusion, chiefly for the reason that no one basis of classification has been adopted. Thus some ulcers are named according to the causes at work in producing or maintaining them—for example, the traumatic, the septic, and the varicose ulcer; some from the constitutional element present, as the gouty and the diabetic ulcer; and others according to the condition in which they happen to be when seen by the surgeon, such as the weak, the inflamed, and the callous ulcer.

So long as we retain these names it will be impossible to find a single basis for classification; and yet many of the terms are so descriptive and so generally understood that it is undesirable to abolish them. We must therefore remain content with a clinical arrangement of ulcers,—it cannot be called a classification,—considering any given ulcer from two points of view: first its cause, and second its present condition. This method of studying ulcers has the practical advantage that it furnishes us with the main indications for treatment as well as for diagnosis: the cause must be removed, and the condition so modified as to convert the ulcer into an aseptic healing sore.

A. Arrangement of Ulcers according to their Cause.—Although any given ulcer may be due to a combination of causes, it is convenient to describe the following groups:

Ulcers due to Traumatism.—Traumatism in the form of a crush or bruise is a frequent cause of ulcer formation, acting either by directly destroying the skin, or by so diminishing its vitality that it is rendered a suitable soil for bacteria. If these gain access, in the course of a few days the damaged area of skin becomes of a greyish colour, blebs form on it, and it undergoes necrosis, leaving an unhealthy raw surface when the slough separates.

Heat and prolonged exposure to the Röntgen rays or to radium emanations act in a similar way.

The pressure of improperly padded splints or other appliances may so far interfere with the circulation of the part pressed upon, that the skin sloughs, leaving an open sore. This is most liable to occur in patients who suffer from some nerve lesion—such as anterior poliomyelitis, or injury of the spinal cord or nerve-trunks. Splint-pressure sores are usually situated over bony prominences, such as the malleoli, the condyles of the femur or humerus, the head of the fibula, the dorsum of the foot, or the base of the fifth metatarsal bone. On removing the splint, the skin of the part pressed upon is found to be of a red or pink colour, with a pale grey patch in the centre, which eventually sloughs and leaves an ulcer. Certain forms of bed-sore are also due to prolonged pressure.

Pressure sores are also known to have been produced artificially by malingerers and hysterical subjects.

Ulcers due to Imperfect Circulation.—Imperfect circulation is an important causative factor in ulceration, especially when it is the venous return that is defective. This is best illustrated in the so-called leg ulcer, which occurs most frequently on the front and medial aspect of the lower third of the leg. At this point the anastomosis between the superficial and deep veins of the leg is less free than elsewhere, so that the extra stress thrown upon the surface veins interferes with the nutrition of the skin (Hilton). The importance of imperfect venous return in the causation of such ulcers is evidenced by the fact that as soon as the condition of the circulation is improved by confining the patient to bed and elevating the limb, the ulcer begins to heal, even although all methods of local treatment have hitherto proved ineffectual. In a considerable number of cases, but by no means in all, this form of ulcer is associated with the presence of varicose veins, and in such cases it is spoken of as the varicose ulcer (Fig. 14). The presence of varicose veins is frequently associated with a diffuse brownish or bluish pigmentation of the skin of the lower third of the leg, or with an obstinate form of dermatitis (varicose eczema), and the scratching or rubbing of the part is liable to cause a breach of the surface and permit of infection which leads to ulceration. Varicose ulcers may also originate from the bursting of a small peri-phlebitic abscess.

Varicose veins in immediate relation to the base of a large chronic ulcer usually become thrombosed, and in time are reduced to fibrous cords, and therefore in such cases hæmorrhage is not a common complication. In smaller and more superficial ulcers, however, the destructive process is liable to implicate the wall of the vessel before the occurrence of thrombosis, and to lead to profuse and it may be dangerous bleeding.

These ulcers are at first small and superficial, but from want of care, from continued standing or walking, or from injudicious treatment, they gradually become larger and deeper. They are not infrequently multiple, and this, together with their depth, may lead to their being mistaken for ulcers due to syphilis. The base of the ulcer is covered with imperfectly formed, soft, œdematous granulations, which give off a thin sero-purulent discharge. The edges are slightly inflamed, and show no evidence of healing. The parts around are usually pigmented and slightly œdematous, and as a rule there is little pain. This variety of ulcer is particularly prone to pass into the condition known as callous.

In anæmic patients, especially young girls, ulcers are occasionally met with which have many of the clinical characters of those associated with imperfect venous return. They are slow to heal, and tend to pass into the condition known as weak.

Ulcers due to Interference with Nerve-Supply.—Any interference with the nerve-supply of the superficial tissues predisposes to ulceration. For example, trophic ulcers are liable to occur in injuries or diseases of the spinal cord, in cerebral paralysis, in limbs weakened by poliomyelitis, in ascending or peripheral neuritis, or after injuries of nerve-trunks.

The acute bed-sore is a rapidly progressing form of ulceration, often amounting to gangrene, of portions of skin exposed to pressure when their trophic nerve-supply has been interfered with.

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.

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.

The syphilitic ulcer is usually formed by the breaking down of a cutaneous or subcutaneous gumma in the tertiary stage of syphilis. When the gummatous tissue is first exposed by the destruction of the skin or mucous membrane covering it, it appears as a tough greyish slough, compared to “wash leather,” which slowly separates and leaves a more or less circular, deep, punched-out gap which shows a few feeble unhealthy granulations and small sloughs on its floor. The edges are raised and indurated; and the discharge is thick, glairy, and peculiarly offensive. The parts around the ulcer are congested and of a dark brown colour. There are usually several such ulcers together, and as they tend to heal at one part while they spread at another, the affected area assumes a sinuous or serpiginous outline. Syphilitic ulcers may be met with in any part of the body, but are most frequent in the upper part of the leg (Fig. 17), especially around the knee-joint in women, and over the ribs and sternum. On healing, they usually leave a depressed and adherent cicatrix.

The scorbutic ulcer occurs in patients suffering from scurvy, and is characterised by its prominent granulations, which show a marked tendency to bleed, with the formation of clots, which dry and form a spongy crust on the surface.

In gouty patients small ulcers which are exceedingly irritable and painful are liable to occur.

Ulcers associated with Malignant Disease.—Cancer and sarcoma when situated in the subcutaneous tissue may destroy the overlying skin so that the substance of the tumour is exposed. The fungating masses thus produced are sometimes spoken of as malignant ulcers, but as they are essentially different in their nature from all other forms of ulcers, and call for totally different treatment, it is best to consider them along with the tumours with which they are associated. Rodent ulcer, which is one form of cancer of the skin, will be discussed with new growths of the skin.

B. Arrangement of Ulcers according to their Condition.—Having arrived at an opinion as to the cause of a given ulcer, and placed it in one or other of the preceding groups, the next question to ask is, In what condition do I find this ulcer at the present moment?

Any ulcer is in one of three states—healing, stationary, or spreading; although it is not uncommon to find healing going on at one part while the destructive process is extending at another.

The Healing Condition.—The process of healing in an ulcer has already been studied, and we have learned that it takes place by the formation of granulation tissue, which becomes converted into connective tissue, and is covered over by epithelium growing in from the edges.

Those ulcers which are stationary—that is, neither healing nor spreading—may be in one of several conditions.

The Weak Condition.—Any ulcer may get into a weak state from receiving a blood supply which is defective either in quantity or in quality. The granulations are small and smooth, and of a pale yellow or grey colour, the discharge is small in amount, and consists of thin serum and a few pus cells, and as this dries on the edges it forms scabs which interfere with the growth of epithelium.

Should the part become œdematous, either from general causes, such as heart or kidney disease, or from local causes, such as varicose veins, the granulations share in the œdema, and there is an abundant serous discharge.

The excessive use of moist dressings leads to a third variety of weak ulcer—namely, one in which the granulations become large, soft, pale, and flabby, projecting beyond the level of the skin and overlapping the edges, which become pale and sodden. The term “proud flesh” is popularly applied to such redundant granulations.

The Callous Condition.—This condition is usually met with in ulcers on the lower third of the leg, and is often associated with the presence of varicose veins. It is chiefly met with in hospital practice. The want of healing is mainly due to impeded venous return and to œdema and induration of the surrounding skin and cellular tissues (Fig. 18). The induration results from coagulation and partial organisation of the inflammatory effusion, and prevents the necessary contraction of the sore. The base of a callous ulcer lies at some distance below the level of the swollen, thickened, and white edges, and presents a glazed appearance, such granulations as are present being unhealthy and irregular. The discharge is usually watery, and cakes in the dressing. When from neglect and want of cleanliness the ulcer becomes inflamed, there is considerable pain, and the discharge is purulent and often offensive.

The prolonged hyperæmia of the tissues in relation to a callous ulcer of the leg often leads to changes in the underlying bones. The periosteum is abnormally thick and vascular, the superficial layers of the bone become injected and porous, and the bones, as a whole, are thickened. In the macerated bone “the surface is covered with irregular, stalactite-like processes or foliaceous masses, which, to a certain extent, follow the line of attachment of the interosseous membrane and of the intermuscular septa” (Cathcart) (Fig. 19). When the whole thickness of the soft tissues is destroyed by the ulcerative process, the area of bone that comes to form the base of the ulcer projects as a flat, porous node, which in its turn may be eroded. These changes as seen in the macerated specimen are often mistaken for disease originating in the bone.

The irritable condition is met with in ulcers which occur, as a rule, just above the external malleolus in women of neurotic temperament. They are small in size and have prominent granulations, and by the aid of a probe points of excessive tenderness may be discovered. These, Hilton believed, correspond to exposed nerve filaments.

Ulcers which are spreading may be met with in one of several conditions.

The Inflamed Condition.—Any ulcer may become acutely inflamed from the access of fresh organisms, aided by mechanical irritation from trauma, ill-fitting splints or bandages, or want of rest, or from chemical irritants, such as strong antiseptics. The best clinical example of an inflamed ulcer is the venereal soft sore. The base of the ulcer becomes red and angry-looking, the granulations disappear, and a copious discharge of thin yellow pus, mixed with blood, escapes. Sloughs of granulation tissue or of connective tissue may form. The edges become red, ragged, and everted, and the ulcer increases in size by spreading into the inflamed and œdematous surrounding tissues. Such ulcers are frequently multiple. Pain is a constant symptom, and is often severe, and there is usually some constitutional disturbance.

The phagedænic condition is the result of an ulcer being infected with specially virulent bacteria. It occurs in syphilitic ulcers, and rapidly leads to a widespread destruction of tissue. It is also met with in the throat in some cases of scarlet fever, and may give rise to fatal hæmorrhage by ulcerating into large blood vessels. All the local and constitutional signs of a severe septic infection are present.

Treatment of Ulcers.—An ulcer is not only an immediate cause of suffering to the patient, crippling and incapacitating him for his work, but is a distinct and constant menace to his health: the prolonged discharge reduces his strength; the open sore is a possible source of infection by the organisms of suppuration, erysipelas, or other specific diseases; phlebitis, with formation of septic emboli, leading to pyæmia, is liable to occur; and in old persons it is not uncommon for ulcers of long standing to become the seat of cancer. In addition, the offensive odour of many ulcers renders the patient a source of annoyance and discomfort to others. The primary object of treatment in any ulcer is to bring it into the condition of a healing sore. When this has been effected, nature will do the rest, provided extraneous sources of irritation are excluded.

Steps must be taken to facilitate the venous return from the ulcerated part, and to ensure that a sufficient supply of fresh, healthy blood reaches it. The septic element must be eliminated by disinfecting the ulcer and its surroundings, and any other sources of irritation must be removed.

If the patient's health is below par, good nourishing food, tonics, and general hygienic treatment are indicated.

Management of a Healing Sore.—Perhaps the best dressing for a healing sore is a layer of Lister's perforated oiled-silk protective, which is made to cover the raw surface and the skin for about a quarter of an inch beyond the margins of the sore. Over this three or four thicknesses of sterilised gauze, wrung out of eusol, creolin, or sterilised water, are applied, and covered by a pad of absorbent wool. As far as possible the part should be kept at rest, and the position should be adjusted so as to favour the circulation in the affected area.

The dressing may be renewed at intervals, and care must be taken to avoid any rough handling of the sore. Any discharge that lies on the surface should be removed by a gentle stream of lotion rather than by wiping. The area round the sore should be cleansed before the fresh dressing is applied.

In some cases, healing goes on more rapidly under a dressing of weak boracic ointment (one-quarter the strength of the pharmacopœial preparation). The growth of epithelium may be stimulated by a 6 to 8 per cent. ointment of scarlet-red.

Dusting powders and poultice dressings are best avoided in the treatment of healing sores.

In extensive ulcers resulting from recent burns, if the granulations are healthy and aseptic, skin-grafts may safely be placed on them directly. If, however, their asepticity cannot be relied upon, it is necessary to scrape away the superficial layer of the granulations, the young fibrous tissue underneath being conserved, as it is sufficiently vascular to nourish the grafts placed on it.

Treatment of Special Varieties of Ulcers.—Before beginning to treat a given ulcer, two questions have to be answered—first, What are the causative conditions present? and second, In what condition do I find the ulcer?—in other words, In what particulars does it differ from a healthy healing sore?

If the cause is a local one, it must be removed; if a constitutional one, means must be taken to counteract it. This done, the condition of the ulcer must be so modified as to bring it into the state of a healing sore, after which it will be managed on the lines already laid down.

Treatment in relation to the Cause of the Ulcer.—Traumatic Group.—The prophylaxis of these ulcers consists in excluding bacteria, by cleansing crushed or bruised parts, and applying sterilised dressings and properly adjusted splints. If there is reason to fear that the disinfection has not been complete, a Bier's constricting bandage should be applied for some hours each day. These measures will often prevent a grossly injured portion of skin dying, and will ensure asepticity should it do so. In the event of the skin giving way, the same form of dressing should be continued till the slough has separated and a healthy granulating surface is formed. The protective dressing appropriate to a healing sore is then substituted. Pressure sores are treated on the same lines.

The treatment of ulcers caused by burns and scalds will be described later.

In ulcers of the leg due to interference with the venous return, the primary indication is to elevate the limb in order to facilitate the flow of the blood in the veins, and so admit of fresh blood reaching the part. The limb may be placed on pillows, or the foot of the bed raised on blocks, so that the ulcer lies on a higher level than the heart. Should varicose veins be present, the question of operative treatment must be considered.

When an imperfect nerve supply is the main factor underlying ulcer formation, prophylaxis is the chief consideration. In patients suffering from spinal injuries or diseases, cerebral paralysis, or affections of the peripheral nerves, all sources of irritation, such as ill-fitting splints, tight bandages, moist applications, and hot bottles, should be avoided. Any part liable to pressure, from the position of the patient or otherwise, must be carefully protected by pads of wool, air-cushions, or water-bags, and must be kept absolutely dry. The skin should be hardened by daily applications of methylated spirit.

Should an ulcer form in spite of these precautions, the mildest antiseptics must be employed for bathing and dressing it, and as far as possible all dressings should be dry.

The perforating ulcer of the foot calls for special treatment. To avoid pressure on the sole of the foot, the patient must be confined to bed. As the main local obstacle to healing is the down-growth of epithelium along the sides of the ulcer, this must be removed by the knife or sharp spoon. The base also should be excised, and any bone which may have become involved should be gouged away, so as to leave a healthy and vascular surface. The cavity thus formed is stuffed with bismuth or iodoform gauze and encouraged to heal from the bottom. As the parts are insensitive an anæsthetic is not required. After the ulcer has healed, the patient should wear in his boot a thick felt sole with a hole cut out opposite the situation of the cicatrix. When a joint has been opened into, the difficulty of thoroughly getting rid of all unhealthy and infected granulations is so great that amputation may be advisable, but it is to be remembered that ulceration may recur in the stump if pressure is put upon it. The treatment of any nervous disease or glycosuria which may coexist is, of course, indicated.

Exposure of the plantar nerves by an incision behind the medial malleolus, and subjecting them to forcible stretching, has been employed by Chipault and others in the treatment of perforating ulcers of the foot.

The ulcer that forms in relation to callosities on the sole of the foot is treated by paring away all the thickened skin, after softening it with soda fomentations, removing the unhealthy granulations, and applying stimulating dressings.

Treatment of Ulcers due to Constitutional Causes.—When ulcers are associated with such diseases as tuberculosis, syphilis, diabetes, Bright's disease, scurvy, or gout, these must receive appropriate treatment.

The local treatment of the tuberculous ulcer calls for special mention. If the ulcer is of limited extent and situated on an exposed part of the body, the most satisfactory method is complete removal, by means of the knife, scissors, or sharp spoon, of the ulcerated surface and of all the infected area around it, so as to leave a healthy surface from which granulations may spring up. Should the raw surface left be likely to result in an unsightly scar or in cicatricial contraction, skin-grafting should be employed.

For extensive ulcers on the limbs, the chest wall, or on other covered parts, or when operative treatment is contra-indicated, the use of tuberculin and exposure to the Röntgen rays have proved beneficial. The induction of passive hyperæmia, by Bier's or by Klapp's apparatus, should also be used, either alone or supplementary to other measures.

No ulcerative process responds so readily to medicinal treatment as the syphilitic ulcer does to the intra-venous administration of arsenical preparations of the “606” or “914” groups or to full doses of iodide of potassium and mercury, and the local application of black wash. When the ulceration has lasted for a long time, however, and is widespread and deep, the duration of treatment is materially shortened by a thorough scraping with the sharp spoon.

Treatment in relation to the Condition of the Ulcer.—Ulcers in a weak condition.—If the weak condition of the ulcer is due to anæmia or kidney disease, these affections must first be treated. Locally, the imperfect granulations should be scraped away, and some stimulating agent applied to the raw surface to promote the growth of healthy granulations. For this purpose the sore may be covered with gauze smeared with a 6 to 8 per cent. ointment of scarlet-red, the surrounding parts being protected from the irritant action of the scarlet-red by a layer of vaseline. A dressing of gauze moistened with eusol or of boracic lint wrung out of red lotion (2 grains of sulphate of zinc, and 10 minims of compound tincture of lavender, to an ounce of water), and covered with a layer of gutta-percha tissue, is also useful.

When the condition has resulted from the prolonged use of moist dressings, these must be stopped, the redundant granulations clipped away with scissors, the surface rubbed with silver nitrate or sulphate of copper (blue-stone), and dry dressings applied.

When the ulcer has assumed the characters of a healing sore, skin-grafts may be applied to hasten cicatrisation.

Ulcers in a callous condition call for treatment in three directions—(1) The infective element must be eliminated. When the ulcer is foul, relays of charcoal poultices (three parts of linseed meal to one of charcoal), maintained for thirty-six to forty-eight hours, are useful as a preliminary step. The base of the ulcer and the thickened edges should then be freely scraped with a sharp spoon, and the resulting raw surface sponged over with undiluted carbolic acid or iodine, after which an antiseptic dressing is applied, and changed daily till healthy granulations appear. (2) The venous return must be facilitated by elevation of the limb and massage. (3) The induration of the surrounding parts must be got rid of before contraction of the sore is possible. For this purpose the free application of blisters, as first recommended by Syme, leaves little to be desired. Liquor epispasticus painted over the parts, or a large fly-blister (emplastrum cantharidis) applied all round the ulcer, speedily disperses the inflammatory products which cause the induration. The use of elastic pressure or of strapping, of hot-air baths, or the making of multiple incisions in the skin around the ulcer, fulfils the same object.

As soon as the ulcer assumes the characters of a healing sore, it should be covered with skin-grafts, which furnish a much better cicatrix than that which forms when the ulcer is allowed to heal without such aid.

A more radical method of treatment consists in excising the whole ulcer, including its edges and about a quarter of an inch of the surrounding tissue, as well as the underlying fibrous tissue, and grafting the raw surface.

Ambulatory Treatment.—When the circumstances of the patient forbid his lying up in bed, the healing of the ulcer is much delayed. He should be instructed to take every possible opportunity of placing the limb in an elevated position, and must constantly wear a firm bandage of elastic webbing. This webbing is porous and admits of evaporation of the skin and wound secretions—an advantage it has over Martin's rubber bandage. The bandage should extend from the toes to well above the knee, and should always be applied while the patient is in the recumbent position with the leg elevated, preferably before getting out of bed in the morning. Additional support is given to the veins if the bandage is applied as a figure of eight.

We have found the following method satisfactory in out-patient practice. The patient lying on a couch, the limb is raised about eighteen inches and kept in this position for five minutes—till the excess of blood has left it. With the limb still raised, the ulcer with the surrounding skin is covered with a layer, about half an inch thick, of finely powdered boracic acid, and the leg, from foot to knee, excluding the sole, is enveloped in a thick layer of wood-wool wadding. This is held in position by ordinary cotton bandages, painted over with liquid starch; while the starch is drying the limb is kept elevated. With this appliance the patient may continue to work, and the dressing does not require to be changed oftener than once in three or four weeks (W. G. Richardson).

When an ulcer becomes acutely inflamed as a result of superadded infection, antiseptic measures are employed to overcome the infection, and ichthyol or other soothing applications may be used to allay the pain.

The phagedænic ulcer calls for more energetic means of disinfection; the whole of the affected surface is touched with the actual cautery at a white heat, or is painted with pure carbolic acid. Relays of charcoal poultices are then applied until the spread of the disease is arrested.

For the irritable ulcer the most satisfactory treatment is complete excision and subsequent skin-grafting.

Gangrene or mortification is the process by which a portion of tissue dies en masse, as distinguished from the molecular or cellular death which constitutes ulceration. The dead portion is known as a slough.

In this chapter we shall confine our attention to the process as it affects the limbs and superficial parts, leaving gangrene of the viscera to be described in regional surgery.

Two distinct types of gangrene are met with, which, from their most obvious point of difference, are known respectively as dry and moist, and there are several clinical varieties of each type.

Speaking generally, it may be said that dry gangrene is essentially due to a simple interference with the blood supply of a part; while the main factor in the production of moist gangrene is bacterial infection.

The cardinal signs of gangrene are: change in the colour of the part, coldness, loss of sensation and motor power, and, lastly, loss of pulsation in the arteries.

Dry Gangrene or Mummification is a comparatively slow form of local death due, as a rule, to a diminution in the arterial blood supply of the affected part, resulting from such causes as the gradual narrowing of the lumen of the arteries by disease of their coats, or the blocking of the main vessel by an embolus.

As the fluids in the tissues are lost by evaporation the part becomes dry and shrivelled, and as the skin is usually intact, infection does not take place, or if it does, the want of moisture renders the part an unsuitable soil, and the organisms do not readily find a footing. Any spread of the process that may take place is chiefly influenced by the anatomical distribution of the blocked arteries, and is arrested as soon as it reaches an area rich in anastomotic vessels. The dead portion is then cast off, the irritation resulting from the contact of the dead with the still living tissue inducing the formation of granulations on the proximal side of the junction, and these by slowly eating into the dead portion produce a furrow—the line of demarcation—which gradually deepens until complete separation is effected. As the muscles and bones have a richer blood supply than the integument, the death of skin and subcutaneous tissues extends higher than that of muscles and bone, with the result that the stump left after spontaneous separation is conical, the end of the bone projecting beyond the soft parts.

Clinical Features.—The part undergoing mortification becomes colder than normal, the temperature falling to that of the surrounding atmosphere. In many instances, but not in all, the onset of the process is accompanied by severe neuralgic pain in the part, probably due to anæmia of the nerves, to neuritis, or to the irritation of the exposed axis cylinders by the dead and dying tissues around them. This pain soon ceases and gives place to a complete loss of sensation. The dead part becomes dry, horny, shrivelled, and semi-transparent—at first of a dark brown, but finally of a black colour, from the dissemination of blood pigment throughout the tissues. There is no putrefaction, and therefore no putrid odour; and the condition being non-infective, there is not necessarily any constitutional disturbance. In itself, therefore, dry gangrene does not involve immediate risk to life; the danger lies in the fact that the breach of surface at the line of demarcation furnishes a possible means of entrance for bacteria, which may lead to infective complications.

Moist Gangrene is an acute process, the dead part retaining its fluids and so affording a favourable soil for the development of bacteria. The action of the organisms and their toxins on the adjacent tissues leads to a rapid and wide spread of the process. The skin becomes moist and macerated, and bullæ, containing dark-coloured fluid or gases, form under the epidermis. The putrefactive gases evolved cause the skin to become emphysematous and crepitant and produce an offensive odour. The tissues assume a greenish-black colour from the formation in them of a sulphide of iron resulting from decomposition of the blood pigment. Under certain conditions the dead part may undergo changes resembling more closely those of ordinary post-mortem decomposition. Owing to its nature the spread of the gangrene is seldom arrested by the natural protective processes, and it usually continues until the condition proves fatal from the absorption of toxins into the circulation.

The clinical features vary in the different varieties of moist gangrene, but the local results of bacterial action and the constitutional disturbance associated with toxin absorption are present in all; the prognosis therefore is grave in the extreme.

From what has been said, it will be gathered that in dry gangrene there is no urgent call for operation to save the patient's life, the primary indication being to prevent the access of bacteria to the dead part, and especially to the surface exposed at the line of demarcation. In moist gangrene, on the contrary, organisms having already obtained a footing, immediate removal of the dead and dying tissues, as a rule, offers the only hope of saving life.

While the varieties of gangrene included in this group depend primarily on interference with the circulation, it is to be borne in mind that the clinical course of the affection may be profoundly influenced by superadded infection with micro-organisms. Although the bacteria do not play the most important part in producing tissue necrosis, their subsequent introduction is an accident of such importance that it may change the whole aspect of affairs and convert a dry form of gangrene into one of the moist type. Moreover, the low state of vitality of the tissues, and the extreme difficulty of securing and maintaining asepsis, make it a sequel of great frequency.

Senile Gangrene.—Senile gangrene is the commonest example of local death produced by a gradual diminution in the quantity of blood passing through the parts, as a result of arterio-sclerosis or other chronic disease of the arteries leading to diminution of their calibre. It is the most characteristic example of the dry type of gangrene. As the term indicates, it occurs in old persons, but the patient's age is to be reckoned by the condition of his arteries rather than by the number of his years. Thus the vessels of a comparatively young man who has suffered from syphilis and been addicted to alcohol are more liable to atheromatous degeneration leading to this form of gangrene than are those of a much older man who has lived a regular and abstemious life. This form of gangrene is much more common in men than in women. While it usually attacks only one foot, it is not uncommon for the other foot to be affected after an interval, and in some cases it is bilateral from the outset. It must clearly be understood that any form of gangrene may occur in old persons, the term senile being here restricted to that variety which results from arterio-sclerosis.

Clinical Features.—The commonest seat of the disease is in the toes, especially the great toe, whence it spreads up the foot to the heel, or even to the leg (Fig. 20). There is often a history of some slight injury preceding its onset. The vitality of the tissues is so low that the balance between life and death may be turned by the most trivial injury, such as a cut while paring a toe-nail or a corn, a blister caused by an ill-fitting shoe or the contact of a hot-bottle. In some cases the actual gangrene is determined by thrombosis of the popliteal or tibial arteries, which are already narrowed by obliterating endarteritis.

It is common to find that the patient has been troubled for a long time before the onset of definite signs of gangrene, with cold feet, with tingling and loss of feeling, or a peculiar sensation as if walking on cotton wool.

The first evidence of the death of the part varies in different cases. Sometimes a dark-blue spot appears on the medial side of the great toe and gradually increases in size; or a blister containing blood-stained fluid may form. Streaks or patches of dark-blue mottling appear higher up on the foot or leg. In other cases a small sore surrounded by a congested areola forms in relation to the nail and refuses to heal. Such sores on the toes of old persons are always to be looked upon with suspicion and treated with the greatest care; and the urine should be examined for sugar. There is often severe, deep-seated pain of a neuralgic character, with cramps in the limb, and these may persist long after a line of demarcation has formed. The dying part loses sensibility to touch and becomes cold and shrivelled.

All the physical appearances and clinical symptoms associated with dry gangrene supervene, and the dead portion is delimited by a line of demarcation. If this forms slowly and irregularly it indicates a very unsatisfactory condition of the circulation; while, if it forms quickly and decidedly, the presumption is that the circulation in the parts above is fairly good. The separation of the dead part is always attended with the risk of infection taking place, and should this occur, the temperature rises and other evidences of toxæmia appear.

Prophylaxis.—The toes and feet of old people, the condition of whose circulation predisposes them to gangrene, should be protected from slight injuries such as may be received while paring nails, cutting corns, or wearing ill-fitting boots. The patient should also be warned of the risk of exposure to cold, the use of hot-bottles, and of placing the feet near a fire. Attempts have been made to improve the peripheral circulation by establishing an anastomosis between the main artery of a limb and its companion vein, so that arterial blood may reach the peripheral capillaries—reversal of the circulation—but the clinical results have proved disappointing. (See Op. Surg., p. 29.)

Treatment.—When there is evidence that gangrene has occurred, the first indication is to prevent infection by purifying the part, and after careful drying to wrap it in a thick layer of absorbent and antiseptic wool, retained in place by a loosely applied bandage. A slight degree of elevation of the limb is an advantage, but it must not be sufficient to diminish the amount of blood entering the part. Hot-bottles are to be used with the utmost caution. As absolute dryness is essential, ointments or other greasy dressings are to be avoided, as they tend to prevent evaporation from the skin. Opium should be given freely to alleviate pain. Stimulation is to be avoided, and the patient should be carefully dieted.

When the gangrene is limited to the toes in old and feeble patients, some surgeons advocate the expectant method of treatment, waiting for a line of demarcation to form and allowing the dead part to be separated. This takes place so slowly, however, that it necessitates the patient being laid up for many weeks, or even months; and we agree with the majority in advising early amputation.

In this connection it is worthy of note that there are certain points at which gangrene naturally tends to become arrested—namely, at the highly vascular areas in the neighbourhood of joints. Thus gangrene of the great toe often stops when it reaches the metatarso-phalangeal joint; or if it trespasses this limit it may be arrested either at the tarso-metatarsal or at the ankle joint. If these be passed, it usually spreads up the leg to just below the knee before signs of arrestment appear. Further, it is seen from pathological specimens that the spread is greater on the dorsal than on the plantar aspect, and that the death of skin and subcutaneous tissues extends higher than that of bone and muscle.

These facts furnish us with indications as to the seat and method of amputation. Experience has proved that in senile gangrene of the lower extremity the most reliable and satisfactory results are obtained by amputating in the region of the knee, care being taken to perform the operation so as to leave the prepatellar anastomosis intact by retaining the patella in the anterior flap. The most satisfactory operation in these cases is Gritti's supra-condylar amputation. Hæmorrhage is easily controlled by digital pressure, and the use of a tourniquet should be dispensed with, as the constriction of the limb is liable to interfere with the vitality of the flaps.

When the tibial vessels can be felt pulsating at the ankle it may be justifiable, if the patient urgently desires it, to amputate lower than the knee; but there is considerable risk of gangrene recurring in the stump and necessitating a second operation.

That amputation for senile gangrene performed between the ankle and the knee seldom succeeds, is explained by the fact that the vascular obstruction is usually in the upper part of the posterior tibial artery, and the operation is therefore performed through tissues with an inadequate blood supply. It is not uncommon, indeed, on amputating above the knee, to find even the popliteal artery plugged by a clot. This should be removed at the amputation by squeezing the vessel from above downward by a “milking” movement, or by “catheterising the artery” with the aid of a cannula with a terminal aperture.

It is to be borne in mind that the object of amputation in these cases is merely to remove the gangrenous part, and so relieve the patient of the discomfort and the risks from infection which its presence involves. While it is true that in many of these patients the operation is borne remarkably well, it must be borne in mind that those who suffer from senile gangrene are of necessity bad lives, and a guarded opinion should be expressed as to the prospects of survival. The possibility of the disease developing in the other limb has already been referred to.

Embolic Gangrene (Fig. 21).—This is the most typical form of gangrene resulting from the sudden occlusion of the main artery of a part, whether by the impaction of an embolus or the formation of a thrombus in its lumen, when the collateral circulation is not sufficiently free to maintain the vitality of the tissues.

There is sudden pain at the site of impaction of the embolus, and the pulses beyond are lost. The limb becomes cold, numb, insensitive, and powerless. It is often pale at first—hence the term “white gangrene” sometimes applicable to the early appearances, which closely resemble those presented by the limb of a corpse.

If the part is aseptic it shrivels, and presents the ordinary features of dry gangrene. It is liable, however, especially in the lower extremity and when the veins also are obstructed, to become infected and to assume the characters of the moist type.

The extent of the gangrene depends upon the site of impaction of the embolus, thus if the abdominal aorta becomes suddenly occluded by an embolus at its bifurcation, the obstruction of the iliacs and femorals induces symmetrical gangrene of both extremities as high as the inguinal ligaments. When gangrene follows occlusion of the external iliac or of the femoral artery above the origin of its deep branch, the death of the limb extends as high as the middle or upper third of the thigh. When the femoral below the origin of its deep branch or the popliteal artery is obstructed, the veins remaining pervious, the anastomosis through the profunda is sufficient to maintain the vascular supply, and gangrene does not necessarily follow. The rupture of a popliteal aneurysm, however, by compressing the vein and the articular branches, usually determines gangrene. When an embolus becomes impacted at the bifurcation of the popliteal, if gangrene ensues it usually spreads well up the leg.

When the axillary artery is the seat of embolic impaction, and gangrene ensues, the process usually reaches the middle of the upper arm. Gangrene following the blocking of the brachial at its bifurcation usually extends as far as the junction of the lower and middle thirds of the forearm.

Gangrene due to thrombosis or embolism is sometimes met with in patients recovering from typhus, typhoid, or other fevers, such as that associated with child-bed. It occurs in peripheral parts, such as the toes, fingers, nose, or ears.

Treatment.—The general treatment of embolic gangrene is the same as that for the senile form. Success has followed opening the artery and removing the embolus. The artery is exposed at the seat of impaction and, having been clamped above and below, a longitudinal opening is made and the clot carefully extracted with the aid of forceps; it is sometimes unexpectedly long (one recorded from the femoral artery measured nearly 34 inches); the wound in the artery is then sewn up with fine silk soaked in paraffin. When amputation is indicated, it must be performed sufficiently high to ensure a free vascular supply to the flaps.

Gangrene following Ligation of Arteries.—After the ligation of an artery in its continuity—for example, in the treatment of aneurysm—the limb may for some days remain in a condition verging on gangrene, the distal parts being cold, devoid of sensation, and powerless. As the collateral circulation is established, the vitality of the tissues is gradually restored and these symptoms pass off. In some cases, however,—and especially in the lower extremity—gangrene ensues and presents the same characters as those resulting from embolism. It tends to be of the dry type. The occlusion of the vein as well as the artery is not found to increase the risk of gangrene.

Gangrene from Mechanical Constriction of the Vessels of the part.—The application of a bandage or plaster-of-Paris case too tightly, or of a tourniquet for too long a time, has been known to lead to death of the part beyond; but such cases are rare, as are also those due to the pressure of a fractured bone or of a tumour on a large artery or vein. When gangrene occurs from such causes, it tends to be of the moist type.

Much commoner is it to meet with localised areas of necrosis due to the excessive pressure of splints over bony prominences, such as the lateral malleolus, the medial condyle of the humerus, or femur, or over the dorsum of the foot. This is especially liable to occur when the nutrition of the skin is depressed by any interference with its nerve-supply, such as follows injuries to the spine or peripheral nerves, disease of the brain, or acute anterior poliomyelitis. When the splint is removed the skin pressed upon is found to be of a pale yellow or grey colour, and is surrounded by a ring of hyperæmia. If protected from infection, the clinical course is that of dry gangrene.

Bed-sores, which are closely allied to pressure sores, will be described at the end of this chapter.

When a localised portion of tissue, for example, a piece of skin, is so severely crushed or bruised that its blood vessels are occluded and its structure destroyed, it dies, and, if not infected with bacteria, dries up, and the shrivelled brown skin is slowly separated by the growth of granulation tissue beneath and around it.

Fingers, toes, or even considerable portions of limbs may in the same way be suddenly destroyed by severe trauma, and undergo mummification. If organisms gain access, typical moist gangrene may ensue, or changes similar to those of ordinary post-mortem decomposition may take place.

Treatment.—The first indication is to exclude bacteria by purifying the damaged part and its surroundings, and applying dry, non-irritating dressings.

When these measures are successful, dry gangrene ensues. The raw surface left after the separation of the dead skin may be allowed to heal by granulation, or may be covered by skin-grafts. In the case of a finger or a limb it is not necessary to wait until spontaneous separation takes place, as this is often a slow process. When a well-marked line of demarcation has formed, amputation may be performed just sufficiently far above it to enable suitable flaps to be made.

The end of a stump, after spontaneous separation of the gangrenous portion, requires to be trimmed, sufficient bone being removed to permit of the soft parts coming together.

If moist gangrene supervenes, amputation must be performed without delay, and at a higher level.

Gangrene from Heat, Chemical Agents, and Cold.—Severe burns and scalds may be followed by necrosis of tissue. So long as the parts are kept absolutely dry—as, for example, by the picric acid method of treatment—the grossly damaged portions of tissue undergo dry gangrene; but when wet or oily dressings are applied and organisms gain access, moist gangrene follows.

Strong chemical agents, such as caustic potash, nitric or sulphuric acid, may also induce local tissue necrosis, the general appearances of the lesions produced being like those of severe burns. The resulting sloughs are slow to separate, and leave deep punched-out cavities which are long of healing.

Carbolic Gangrene.—Carbolic acid, even in comparatively weak solution, is liable to induce dry gangrene when applied as a fomentation to a finger, especially in women and children. Thrombosis occurs in the blood vessels of the part, which at first is pale and soft, but later becomes dark and leathery. On account of the anæsthetic action of carbolic acid, the onset of the process is painless, and the patient does not realise his danger. A line of demarcation soon forms, but the dead part separates very slowly.

Gangrene from Frost-bite.—It is difficult to draw the line between the third degree of chilblain and the milder forms of true frost-bite; the difference is merely one of degree. Frost-bite affects chiefly the toes and fingers—especially the great toe and the little finger—the ears, and the nose. In this country it is seldom seen except in members of the tramp class, who, in addition to being exposed to cold by sleeping in the open air, are ill-fed and generally debilitated. The condition usually manifests itself after the parts, having been subjected to extreme cold, are brought into warm surroundings. The first symptom is numbness in the part, followed by a sense of weight, tingling, and finally by complete loss of sensation. The part attacked becomes white and bleached-looking, feels icy cold, and is insensitive to touch. Either immediately, or, it may be, not for several days, it becomes discoloured and swollen, and finally contracts and shrivels. Above the dead area the limb may be the seat of excruciating pain. The dead portion is cast off, as in other forms of dry gangrene, by the formation of a line of demarcation.

To prevent the occurrence of gangrene from frost-bite it is necessary to avoid the sudden application of heat. The patient should be placed in a cold room, and the part rubbed with snow, or put in a cold bath, and have light friction applied to it. As the circulation is restored the general surroundings and the local applications are gradually made warmer. Elevation of the part, wrapping it in cotton wool, and removal to a warmer room, are then permissible, and stimulants and warm drinks may be given with caution. When by these means the occurrence of gangrene is averted, recovery ensues, its onset being indicated by the white parts assuming a livid red hue and becoming the seat of an acute burning sensation.

A condition known as Trench feet was widely prevalent amongst the troops in France during the European War. Although allied to frost-bite, cold appears to play a less important part in its causation than humidity and constriction of the limbs producing ischæmia of the feet. Changes were found in the endothelium of the blood vessels, the axis cylinders of nerves, and the muscles. The condition does not occur in civil life.

Diabetic Gangrene.—This form of gangrene is prone to occur in persons over fifty years of age who suffer from glycosuria. The arteries are often markedly diseased. In some cases the existence of the glycosuria is unsuspected before the onset of the gangrene, and it is only on examining the urine that the cause of the condition is discovered. The gangrenous process seldom begins as suddenly as that associated with embolism, and, like senile gangrene, which it may closely simulate in its early stages, it not infrequently begins after a slight injury to one of the toes. It but rarely, however, assumes the dry, shrivelling type, as a rule being attended with swelling, œdema, and dusky redness of the foot, and severe pain. According to Paget, the dead part remains warm longer than in other forms of senile gangrene; there is a greater tendency for patches of skin at some distance from the primary seat of disease to become gangrenous, and for the death of tissue to extend upwards in the subcutaneous planes, leaving the overlying skin unaffected. The low vitality of the tissues favours the growth of bacteria, and if these gain access, the gangrene assumes the characters of the moist type and spreads rapidly.

The rules for amputation are the same as those governing the treatment of senile gangrene, the level at which the limb is removed depending upon whether the gangrene is of the dry or moist type. The general treatment for diabetes must, of course, be employed whether amputation is performed or not. Paget recommended that the dietetic treatment should not be so rigid as in uncomplicated diabetes, and that opium should be given freely.

The prognosis even after amputation is unfavourable. In many cases the patient dies with symptoms of diabetic coma within a few days of the operation; or, if he survives this, he may eventually succumb to diabetes. In others there is sloughing of the flaps and death results from toxæmia. Occasionally the other limb becomes gangrenous. On the other hand, the glycosuria may diminish or may even disappear after amputation.

Gangrene associated with Spasm of Blood Vessels.—Raynaud's Disease, or symmetrical gangrene, is supposed to be due to spasm of the arterioles, resulting from peripheral neuritis. It occurs oftenest in women, between the ages of eighteen and thirty, who are the subjects of uterine disorders, anæmia, or chlorosis. Cold is an aggravating factor, as the disease is commonest during the winter months. The digits of both hands or the toes of both feet are simultaneously attacked, and the disease seldom spreads beyond the phalanges or deeper than the skin.

The first evidence is that the fingers become cold, white, and insensitive to touch and pain. These attacks of local syncope recur at varying intervals for months or even years. They last for a few minutes or even for some hours, and as they pass off the parts become hyperæmic and painful.

A more advanced stage of the disease is known as local asphyxia. The circulation through the fingers becomes exceedingly sluggish, and the parts assume a dull, livid hue. There is swelling and burning or shooting pain. This may pass off in a few days, or may increase in severity, with the formation of bullæ, and end in dry gangrene. As a rule, the slough which forms is comparatively small and superficial, but it may take some months to separate. The condition tends to recur in successive winters.

The treatment consists in remedying any nervous or uterine disorder that may be present, keeping the parts warm by wrapping them in cotton wool, and in the use of hot-air or electric baths, the parts being immersed in water through which a constant current is passed. When gangrene occurs, it is treated on the same lines as other forms of dry gangrene, but if amputation is called for it is only with a view to removing the dead part.

Angio-sclerotic Gangrene.—A form of gangrene due to angio-sclerosis is occasionally met with in young persons, even in children. It bears certain analogies to Raynaud's disease in that spasm of the vessels plays a part in determining the local death.

The main arteries are narrowed by hyperplastic endarteritis followed by thrombosis, and similar changes are found in the veins. The condition is usually met with in the feet, but the upper extremity may be affected, and is attended with very severe pain, rendering sleep impossible.

The patient is liable to sudden attacks of numbness, tingling and weakness of the limbs which pass off with rest—intermittent claudication. During these attacks the large arteries—femoral, brachial, and subclavian—can be felt as firm cords, while pulsation is lost in the peripheral vessels. Gangrene eventually ensues, is attended with great pain and runs a slow course. It is treated on the same lines as Raynaud's disease.

Gangrene from Ergot.—Gangrene may occur from interference with blood supply, the result of tetanic contraction of the minute vessels, such as results in ill-nourished persons who eat large quantities of coarse rye bread contaminated with the claviceps purpurea and containing the ergot of rye. It has also occurred in the fingers of patients who have taken ergot medicinally over long periods. The gangrene, which attacks the toes, fingers, ears, or nose, is preceded by formication, numbness, and pains in the parts to be affected, and is of the dry variety.

In this country it is usually met with in sailors off foreign ships, whose dietary largely consists of rye bread. Trivial injuries may be the starting-point, the anæsthesia produced by the ergotin preventing the patient taking notice of them. Alcoholism is a potent predisposing cause.

As it is impossible to predict how far the process will spread, it is advisable to wait for the formation of a line of demarcation before operating, and then to amputate immediately above the dead part.

The acute bacillary forms of gangrene all assume the moist type from the first, and, spreading rapidly, result in extensive necrosis of tissue, and often end fatally.

The infection is usually a mixed one in which anaërobic bacteria predominate. The anaërobe most constantly present is the bacillus ærogenes capsulatus, usually in association with other anaërobes, and sometimes with pyogenic diplo- and streptococci. According to the mode of action of the associated organisms and the combined effects of their toxins on the tissues, the gangrenous process presents different pathological and clinical features. Some combinations, for example, result in a rapidly spreading cellulitis with early necrosis of connective tissue accompanied by thrombosis throughout the capillary and venous circulation of the parts implicated; other combinations cause great œdema of the part, and others again lead to the formation of gases in the tissues, particularly in the muscles.

These different effects do not appear to be due to a specific action of any one of the organisms present, but to the combined effect of a particular group living in symbiosis.

According as the cellulitic, the œdematous, or the gaseous characteristics predominate, the clinical varieties of bacillary gangrene may be separately described, but it must be clearly understood that they frequently overlap and cannot always be distinguished from one another.

Clinical Varieties of Bacillary Gangrene.—Acute infective gangrene is the form most commonly met with in civil practice. It may follow such trivial injuries as a pin-prick or a scratch, the signs of acute cellulitis rapidly giving place to those of a spreading gangrene. Or it may ensue on a severe railway, machinery, or street accident, when lacerated and bruised tissues are contaminated with gross dirt. Often within a few hours of the injury the whole part rapidly becomes painful, swollen, œdematous, and tense. The skin is at first glazed, and perhaps paler than normal, but soon assumes a dull red or purplish hue, and bullæ form on the surface. Putrefactive gases may be evolved in the tissues, and their presence is indicated by emphysematous crackling when the part is handled. The spread of the disease is so rapid that its progress is quite visible from hour to hour, and may be traced by the occurrence of red lines along the course of the lymphatics of the limb. In the most acute cases the death of the affected part takes place so rapidly that the local changes indicative of gangrene have not time to occur, and the fact that the part is dead may be overlooked.

Rigors may occur, but the temperature is not necessarily raised—indeed, it is sometimes subnormal. The pulse is small, feeble, rapid, and irregular. Unless amputation is promptly performed, death usually follows within thirty-six or forty-eight hours. Even early operation does not always avert the fatal issue, because the quantity of toxin absorbed and its extreme virulence are often more than even a robust subject can outlive.

Treatment.—Every effort must be made to purify all such wounds as are contaminated by earth, street dust, stable refuse, or other forms of gross dirt. Devitalised and contaminated tissue is removed with the knife or scissors and the wound purified with antiseptics of the chlorine group or with hydrogen peroxide. If there is a reasonable prospect that infection has been overcome, the wound may be at once sutured, but if this is doubtful it is left open and packed or irrigated.

When acute gangrene has set in no treatment short of amputation is of any avail, and the sooner this is done, the greater is the hope of saving the patient. The limb must be amputated well beyond the apparent limits of the infected area, and stringent precautions must be taken to avoid discharge from the already gangrenous area reaching the operation wound. An assistant or nurse, who is to take no other part in the operation, is told off to carry out the preliminary purification, and to hold the limb during the operation.

Malignant Œdema.—This form of acute gangrene has been defined as “a spreading inflammatory œdema attended with emphysema, and ultimately followed by gangrene of the skin and adjacent parts.” The predominant organism is the bacillus of malignant œdema or vibrion septique of Pasteur, which is found in garden soil, dung, and various putrefying substances. It is anaërobic, and occurs as long, thick rods with somewhat rounded ends and several laterally placed flagella. Spores, which have a high power of resistance, form in the centre of the rods, and bulge out the sides so as to give the organisms a spindle-shaped outline. Other pathogenic organisms are also present and aid the specific bacillus in its action.

At the bedside it is difficult, if not impossible, to distinguish it from acute infective gangrene. Both follow on the same kinds of injury and run an exceedingly rapid course. In malignant œdema, however, the incidence of the disease is mainly on the superficial parts, which become œdematous and emphysematous, and acquire a marbled appearance with the veins clearly outlined. Early disappearance of sensation is a particularly grave symptom. Bullæ form on the skin, and the tissues have “a peculiar heavy but not putrid odour.” The constitutional effects are extremely severe, and death may ensue within a few hours.

Acute Emphysematous or Gas Gangrene was prevalent in certain areas at various periods during the European War. It follows infection of lacerated wounds with the bacillus ærogenes capsulatus, usually in combination with other anaërobes, and its main incidence is on the muscles, which rapidly become infiltrated with gas that spreads throughout the whole extent of the muscle, disintegrating its fibres and leading to necrosis. The gangrenous process spreads with appalling rapidity, the limb becoming enormously swollen, painful, and crepitant or even tympanitic. Patches of coppery or purple colour appear on the skin, and bullæ containing blood-stained serum form on the surface. The toxæmia is profound, and the face and lips assume a characteristic cyanosis. The condition is attended with a high mortality. Only in the early stages and when the infection is limited are local measures successful in arresting the spread; in more severe cases amputation is the only means of saving life.

Cancrum Oris or Noma.—This disease is believed to be due to a specific bacillus, which occurs in long delicate rods, and is chiefly found at the margin of the gangrenous area. It is prone to attack unhealthy children from two to five years of age, especially during their convalescence from such diseases as measles, scarlet fever, or typhoid, but may attack adults when they are debilitated. It is most common in the mouth, but sometimes occurs on the vulva. In the mouth it begins as an ulcerative stomatitis, more especially affecting the gums or inner aspect of the cheek. The child lies prostrated, and from the open mouth foul-smelling saliva, streaked with blood, escapes; the face is of an ashy-grey colour, the lips dark and swollen. On the inner aspect of the cheek is a deeply ulcerated surface, with sloughy shreds of dark-brown or black tissue covering its base; the edges are irregular, firm, and swollen, and the surrounding mucous membrane is infiltrated and œdematous. In the course of a few hours a dark spot appears on the outer aspect of the cheek, and rapidly increases in size; towards the centre it is black, shading off through blue and grey into a dark-red area which extends over the cheek (Fig. 23). The tissue implicated is at first firm and indurated, but as it loses its vitality it becomes doughy and sodden. Finally a slough forms, and, when it separates, the cheek is perforated.

Meanwhile the process spreads inside the mouth, and the gums, the floor of the mouth, or even the jaws, may become gangrenous and the teeth fall out. The constitutional disturbance is severe, the temperature raised, and the pulse feeble and rapid.

The extremely fœtid odour which pervades the room or even the house the patient occupies, is usually sufficient to suggest the diagnosis of cancrum oris. The odour must not be mistaken for that due to decomposition of sordes on the teeth and gums of a debilitated patient.

The prognosis is always grave in the extreme, the main risks being general toxæmia and septic pneumonia. When recovery takes place there is serious deformity, and considerable portions of the jaws may be lost by necrosis.

Treatment.—The only satisfactory treatment is thorough removal under an anæsthetic of all the sloughy tissue, with the surrounding zone in which the organisms are active. This is most efficiently accomplished by the knife or scissors, cutting until the tissue bleeds freely, after which the raw surface is painted with undiluted carbolic acid and dressed with iodoform gauze. It may be necessary to remove large pieces of bone when the necrotic process has implicated the jaws. The mouth must be constantly sprayed with peroxide of hydrogen, and washed out with a disinfectant and deodorant lotion, such as Condy's fluid. The patient's general condition calls for free stimulation.

The deformity resulting from these necessarily heroic measures is not so great as might be expected, and can be further diminished by plastic operations, which should be undertaken before cicatricial contraction has occurred.

Bed-sores are most frequently met with in old and debilitated patients, or in those whose tissues are devitalised by acute or chronic diseases associated with stagnation of blood in the peripheral veins. Any interference with the nerve-supply of the skin, whether from injury or disease of the central nervous system or of the peripheral nerves, strongly predisposes to the formation of bed-sores. Prolonged and excessive pressure over a bony prominence, especially if the parts be moist with skin secretions, urine, or wound discharges, determines the formation of a sore. Excoriations, which may develop into true bed-sores, sometimes form where two skin surfaces remain constantly apposed, as in the region of the scrotum or labium, under pendulous mammæ, or between fingers or toes confined in a splint.

Clinical Features.—Two clinical varieties are met with—the acute and the chronic bed-sore.

The acute bed-sore usually occurs over the sacrum or buttock. It develops rapidly after spinal injuries and in the course of certain brain diseases. The part affected becomes red and congested, while the surrounding parts are œdematous and swollen, blisters form, and the skin loses its vitality (Fig. 24).

In advanced cases of general paralysis of the insane, a peculiar form of acute bed-sore beginning as a blister, and passing on to the formation of a black, dry eschar, which slowly separates, occurs on such parts as the medial side of the knee, the angle of the scapula, and the heel.

The chronic bed-sore begins as a dusky reddish purple patch, which gradually becomes darker till it is almost black. The parts around are œdematous, and a blister may form. This bursts and exposes the papillæ of the skin, which are of a greenish hue. A tough greyish-black slough forms, and is slowly separated. It is not uncommon for the gangrenous area to continue to spread both in width and in depth till it reaches the periosteum or bone. Bed-sores over the sacrum sometimes implicate the vertebral canal and lead to spinal meningitis, which usually proves fatal.

In old and debilitated patients the septic absorption taking place from a bed-sore often proves a serious complication of other surgical conditions. From this cause, for example, old people may succumb during the treatment of a fractured thigh.

The granulating surface left on the separation of the slough tends to heal comparatively rapidly.

Prevention of Bed-sores.—The first essential in the prevention of bed-sores is the regular changing of the patient's position, so that no one part of the body is continuously pressed upon for any length of time. Ring-pads of wool, air-cushions, or water-beds are necessary to remove pressure from prominent parts. Absolute dryness of the skin is all-important. At least once a day, the sacrum, buttocks, shoulder-blades, heels, elbows, malleoli, or other parts exposed to pressure, must be sponged with soap and water, thoroughly dried, and then rubbed with methylated spirit, which is allowed to dry on the skin. Dusting the part with boracic acid powder not only keeps it dry, but prevents the development of bacteria in the skin secretions.

In operation cases, care must be taken that irritating chemicals used to purify the skin do not collect under the patient and remain in contact with the skin of the sacrum and buttocks during the time he is on the operating-table. There is reason to believe that the so-called “post-operation bed-sore” may be due to such causes. A similar result has been known to follow soiling of the sheets by the escape of a turpentine enema.

Treatment.—Once a bed-sore has formed, every effort must be made to prevent its spread. Alcohol is used to cleanse the broken surface, and dry absorbent dressings are applied and frequently changed. It is sometimes found necessary to employ moist or oily substances, such as boracic poultices, eucalyptus ointment, or balsam of Peru, to facilitate the separation of sloughs, or to promote the growth of granulations. In patients who are not extremely debilitated the slough may be excised, the raw surface scraped, and then painted with iodine.

Skin-grafting is sometimes useful in covering in the large raw surface left after separation or removal of sloughs.

Erysipelas, popularly known as “rose,” is an acute spreading infective disease of the skin or of a mucous membrane due to the action of a streptococcus. Infection invariably takes place through an abrasion of the surface, although this may be so slight that it escapes observation even when sought for. The streptococci are found most abundantly in the lymph spaces just beyond the swollen margin of the inflammatory area, and in the serous blebs which sometimes form on the surface.

Clinical Features.—Facial erysipelas is the commonest clinical variety, infection usually occurring through some slight abrasion in the region of the mouth or nose, or from an operation wound in this area. From this point of origin the inflammation may spread all over the face and scalp as far back as the nape of the neck. It stops, however, at the chin, and never extends on to the front of the neck. There is great œdema of the face, the eyes becoming closed up, and the features unrecognisable. The inflammation may spread to the meninges, the intracranial venous sinuses, the eye, or the ear. In some cases the erysipelas invades the mucous membrane of the mouth, and spreads to the fauces and larynx, setting up an œdema of the glottis which may prove dangerous to life.

Erysipelas occasionally attacks an operation wound that has become septic; and it may accompany septic infection of the genital tract in puerperal women, or the separation of the umbilical cord in infants (erysipelas neonatorum). After an incubation period, which varies from fifteen to sixty hours, the patient complains of headache, pains in the back and limbs, loss of appetite, nausea, and frequently there is vomiting. He has a chill or slight rigor, initiating a rise of temperature to 103°, 104°, or 105° F.; and a full bounding pulse of about 100 (Fig. 25). The tongue is foul, the breath heavy, and, as a rule, the bowels are constipated. There is frequently albuminuria, and occasionally nocturnal delirium. A moderate degree of leucocytosis (15,000 to 20,000) is usually present.

Around the seat of inoculation a diffuse red patch forms, varying in hue from a bright scarlet to a dull brick-red. The edges are slightly raised above the level of the surrounding skin, as may readily be recognised by gently stroking the part from the healthy towards the affected area. The skin is smooth, tense, and glossy, and presents here and there blisters filled with serous fluid. The local temperature is raised, and the part is the seat of a burning sensation and is tender to the touch, the most tender area being the actively spreading zone which lies about half an inch beyond the red margin.

The disease tends to spread spasmodically and irregularly, and the direction and extent of its progress may be recognised by mapping out the peripheral zone of tenderness. Red streaks appear along the lines of the superficial lymph vessels, and the deep lymphatics may sometimes be palpated as firm, tender cords. The neighbouring glands, also, are generally enlarged and tender.

The disease lasts for from two or three days to as many weeks, and relapses are frequent. Spontaneous resolution usually takes place, but the disease may prove fatal from absorption of toxins, involvement of the brain or meninges, or from general streptococcal infection.

Complications.—Diffuse suppurative cellulitis is the most serious local complication, and results from a mixed infection with other pyogenic bacteria. Small localised superficial abscesses may form during the convalescent stage. They are doubtless due to the action of skin bacteria, which attack the tissues devitalised by the erysipelas. A persistent form of œdema sometimes remains after recurrent attacks of erysipelas, especially when they affect the face or the lower extremity, a condition which is referred to with elephantiasis.

Treatment.—The first indication is to endeavour to arrest the spread of the process. We have found that by painting with linimentum iodi, a ring half an inch broad, about an inch in front of the peripheral tender zone—not the red margin—an artificial leucocytosis is produced, and the advancing streptococci are thereby arrested. Several coats of the iodine are applied, one after the other, and this is repeated daily for several days, even although the erysipelas has not overstepped the ring. Success depends upon using the liniment of iodine (the tincture is not strong enough), and in applying it well in front of the disease. To allay pain the most useful local applications are ichthyol ointment (1 in 6), or lead and opium fomentations.

The general treatment consists in attending to the emunctories, in administrating quinine in small—two-grain—doses every four hours, or salicylate of iron (2–5 gr. every three hours), and in giving plenty of fluid nourishment. It is worthy of note that the anti-streptococcic serum has proved of less value in the treatment of erysipelas than might have been expected, probably because the serum is not made from the proper strain of streptococcus.

It is not necessary to isolate cases of erysipelas, provided the usual precautions against carrying infection from one patient to another are rigidly carried out.

Diphtheria is an acute infective disease due to the action of a specific bacterium, the bacillus diphtheriæ or Klebs-Löffler bacillus. The disease is usually transmitted from one patient to another, but it may be contracted from cats, fowls, or through the milk of infected cows. Cases have occurred in which the surgeon has carried the infection from one patient to another through neglect of antiseptic precautions. The incubation period varies from two to seven days.

Clinical Features.—In pharyngeal diphtheria, on the first or second day of the disease, redness and swelling of the mucous membrane of the pharynx, tonsils, and palate are well marked, and small, circular greenish or grey patches of false membrane, composed of necrosed epithelium, fibrin, leucocytes, and red blood corpuscles, begin to appear. These rapidly increase in area and thickness, till they coalesce and form a complete covering to the parts. In the pharynx the false membrane is less adherent to the surface than it is when the disease affects the air-passages. The diphtheritic process may spread from the pharynx to the nasal cavities, causing blocking of the nares, with a profuse ichorous discharge from the nostrils, and sometimes severe epistaxis. The infection may spread along the nasal duct to the conjunctiva. The middle ear also may become involved by spread along the auditory (Eustachian) tube.

The lymph glands behind the angle of the jaw enlarge and become tender, and may suppurate from superadded infection. There is pain on swallowing, and often earache; and the patient speaks with a nasal accent. He becomes weak and anæmic, and loses his appetite. There is often albuminuria. Leucocytosis is usually well marked before the injection of antitoxin; after the injection there is usually a diminution in the number of leucocytes. The false membrane may separate and be cast off, after which the patient gradually recovers. Death may take place from gradual failure of the heart's action or from syncope during some slight exertion.

Laryngeal Diphtheria.—The disease may arise in the larynx, although, as a rule, it spreads thence from the pharynx. It first manifests itself by a short, dry, croupy cough, and hoarseness of the voice. The first difficulty in breathing usually takes place during the night, and once it begins, it rapidly gets worse. Inspiration becomes noisy, sometimes stridulous or metallic or sibilant, and there is marked indrawing of the epigastrium and lower intercostal spaces. The hoarseness becomes more marked, the cough more severe, and the patient restless. The difficulty of breathing occurs in paroxysms, which gradually increase in frequency and severity, until at length the patient becomes asphyxiated. The duration of the disease varies from a few hours to four or five days.

After the acute sypmtoms have passed off, various localised paralyses may develop, affecting particularly the nerves of the palatal and orbital muscles, less frequently the lower limbs.

Diagnosis.—The finding of the Klebs-Löffler bacillus is the only conclusive evidence of the disease. The bacillus may be obtained by swabbing the throat with a piece of aseptic—not antiseptic—cotton wool or clean linen rag held in a pair of forceps, and rotated so as to entangle portions of the false membrane or exudate. The swab thus obtained is placed in a test-tube, previously sterilised by having had some water boiled in it, and sent to a laboratory for investigation. To identify the bacillus a piece of the membrane from the swab is rubbed on a cover glass, dried, and stained with methylene blue or other basic stain; or cultures may be made on agar or other suitable medium. When a bacteriological examination is impossible, or when the clinical features do not coincide with the results obtained, the patient should always be treated on the assumption that he suffers from diphtheria. So much doubt exists as to the real nature of membranous croup and its relationship to true diphtheria, that when the diagnosis between the two is uncertain the safest plan is to treat the case as one of diphtheria.

In children, diphtheria may occur on the vulva, vagina, prepuce, or glans penis, and give rise to difficulty in diagnosis, which is only cleared up by demonstration of the bacillus.

Treatment.—An attempt may be made to destroy or to counteract the organisms by swabbing the throat with strong antiseptic solutions, such as 1 in 1000 corrosive sublimate or 1 in 30 carbolic acid, or by spraying with peroxide of hydrogen.

The antitoxic serum is our sheet-anchor in the treatment of diphtheria, and recourse should be had to its use as early as possible.

Difficulty of swallowing may be met by the use of a stomach tube passed either through the mouth or nose. When this is impracticable, nutrient enemata are called for.

In laryngeal diphtheria, the interference with respiration may call for intubation of the larynx, or tracheotomy, but the antitoxin treatment has greatly diminished the number of cases in which it becomes necessary to have recourse to these measures.

Intubation consists in introducing through the mouth into the larynx a tube which allows the patient to breathe freely during the period while the membrane is becoming separated and thrown off. This is best done with the apparatus of O'Dwyer; but when this instrument is not available, a simple gum-elastic catheter with a terminal opening (as suggested by Macewen and Annandale) may be employed.

When intubation is impracticable, the operation of tracheotomy is called for if the patient's life is endangered by embarrassment of respiration. Unless the patient is in hospital with skilled assistance available, tracheotomy is the safer of the two procedures.

Tetanus is a disease resulting from infection of a wound by a specific micro-organism, the bacillus tetani, and characterised by increased reflex excitability, hypertonus, and spasm of one or more groups of voluntary muscles.

Etiology and Morbid Anatomy.—The tetanus bacillus, which is a perfect anaërobe, is widely distributed in nature and can be isolated from garden earth, dung-heaps, and stable refuse. It is a slender rod-shaped bacillus, with a single large spore at one end giving it the shape of a drum-stick (Fig. 26). The spores, which are the active agents in producing tetanus, are highly resistant to chemical agents, retain their vitality in a dry condition, and even survive boiling for five minutes.

The organism does not readily establish itself in the human body, and seems to flourish best when it finds a nidus in necrotic tissue and is accompanied by aërobic organisms, which, by using up the oxygen in the tissues, provide for it a suitable environment. The presence of a foreign body in the wound seems to favour its action. The infection is for all practical purposes a local one, the symptoms of the disease being due to the toxins produced in the wound of infection acting upon the central nervous system.

The toxin acts principally on the nerve centres in the spinal medulla, to which it travels from the focus of infection by way of the nerve fibres supplying the voluntary muscles. Its first effect on the motor ganglia of the cord is to render them hypersensitive, so that they are excited by mild stimuli, which under ordinary conditions would produce no reaction. As the toxin accumulates the reflex arc is affected, with the result that when a stimulus reaches the ganglia a motor discharge takes place, which spreads by ascending and descending collaterals to the reflex apparatus of the whole cord. As the toxin spreads it causes both motor hyper-tonus and hyper-excitability, which accounts for the tonic contraction and the clonic spasms characteristic of tetanus.

Clinical Varieties of Tetanus.—Acute or Fulminating Tetanus.—This variety is characterised by the shortness of the incubation period, the rapidity of its progress, the severity of its symptoms, and its all but universally fatal issue in spite of treatment, death taking place in from one to four days. The characteristic symptoms may appear within three or four days of the infliction of the wound, but the incubation period may extend to three weeks, and the wound may be quite healed before the disease declares itself—delayed tetanus. Usually, however, the wound is inflamed and suppurating, with ragged and sloughy edges. A slight feverish attack may mark the onset of the tetanic condition, or the patient may feel perfectly well until the spasms begin. If careful observations be made, it may be found that the muscles in the immediate neighbourhood of the wound are the first to become contracted; but in the majority of instances the patient's first complaint is of pain and stiffness in the muscles of mastication, notably the masseter, so that he has difficulty in opening the mouth—hence the popular name “lock-jaw.” The muscles of expression soon share in the rigidity, and the face assumes a taut, mask-like aspect. The angles of the mouth may be retracted, producing a grinning expression known as the risus sardonicus.

The next muscles to become stiff and painful are those of the neck, especially the sterno-mastoid and trapezius. The patient is inclined to attribute the pain and stiffness to exposure to cold or rheumatism. At an early stage the diaphragm and the muscles of the anterior abdominal wall become contracted; later the muscles of the back and thorax are involved; and lastly those of the limbs. Although this is the typical order of involvement of the different groups of muscles, it is not always adhered to.

To this permanent tonic contraction of the muscles there are soon added clonic spasms. These spasms are at first slight and transient, with prolonged intervals between the attacks, but rapidly tend to become more frequent, more severe, and of longer duration, until eventually the patient simply passes out of one seizure into another.

The distribution of the spasms varies in different cases: in some it is confined to particular groups of muscles, such as those of the neck, back, abdominal walls, or limbs; in others all these groups are simultaneously involved.

When the muscles of the back become spasmodically contracted, the body is raised from the bed, sometimes to such an extent that the patient rests only on his heels and occiput—the position of opisthotonos. Lateral arching of the body from excessive action of the muscles on one side—pleurosthotonos—is not uncommon, the arching usually taking place towards the side on which the wound of infection exists. Less frequently the body is bent forward so that the knees and chin almost meet (emprosthotonos). Sometimes all the muscles simultaneously become rigid, so that the body assumes a statuesque attitude (orthotonos). When the thoracic muscles, including the diaphragm, are thrown into spasm, the patient experiences a distressing sensation as if he were gripped in a vice, and has extreme difficulty in getting breath. Between the attacks the limbs are kept rigidly extended. The clonic spasms may be so severe as to rupture muscles or even to fracture one of the long bones.

As time goes on, the clonic exacerbations become more and more frequent, and the slightest external stimulus, such as the feeling of the pulse, a whisper in the room, a noise in the street, a draught of cold air, the effort to swallow, a question addressed to the patient or his attempt to answer, is sufficient to determine an attack. The movements are so forcible and so continuous that the nurse has great difficulty in keeping the bedclothes on the patient, or even in keeping him in bed.

The general condition of the patient is pitiful in the extreme. He is fully conscious of the gravity of the disease, and his mind remains clear to the end. The suffering induced by the cramp-like spasms of the muscles keeps him in a constant state of fearful apprehension of the next seizure, and he is unable to sleep until he becomes utterly exhausted.

The temperature is moderately raised (100° to 102° F.), or may remain normal throughout. Shortly before death very high temperatures (110° F.) have been recorded, and it has been observed that the thermometer sometimes continues to rise after death, and may reach as high as 112° F. or more.

The pulse corresponds with the febrile condition. It is accelerated during the spasms, and may become exceedingly rapid and feeble before death, probably from paralysis of the vagus. Sudden death from cardiac paralysis or from cardiac spasm is not uncommon.

The respiration is affected in so far as the spasms of the respiratory muscles produce dyspnœa, and a feeling of impending suffocation which adds to the horrors of the disease.

One of the most constant symptoms is a copious perspiration, the patient being literally bathed in sweat. The urine is diminished in quantity, but as a rule is normal in composition; as in other acute infective conditions, albumen and blood may be present. Retention of urine may result from spasm of the urethral muscles, and necessitate the use of the catheter.

The fits may cease some time before death, or, on the other hand, death may occur during a paroxysm from fixation of the diaphragm and arrest of respiration.

Differential Diagnosis.—There is little difficulty, as a rule, in diagnosing a case of fulminating tetanus, but there are several conditions with which it may occasionally be confused. In strychnin poisoning, for example, the spasms come on immediately after the patient has taken a toxic dose of the drug; they are clonic in character, but the muscles are relaxed between the fits. If the dose is not lethal, the spasms soon cease. In hydrophobia a history of having been bitten by a rabid animal is usually forthcoming; the spasms, which are clonic in character, affect chiefly the muscles of respiration and deglutition, and pass off entirely in the intervals between attacks. Certain cases of hæmorrhage into the lateral ventricles of the brain also simulate tetanus, but an analysis of the symptoms will prevent errors in diagnosis. Cerebro-spinal meningitis and basal meningitis present certain superficial resemblances to tetanus, but there is no trismus, and the spasms chiefly affect the muscles of the neck and back. Hysteria and catalepsy may assume characters resembling those of tetanus, but there is little difficulty in distinguishing between these diseases. Lastly, in the tetany of children, or that following operations on the thyreoid gland, the spasms are of a jerking character, affect chiefly the hands and fingers, and yield to medicinal treatment.

Chronic Tetanus.—The difference between this and acute tetanus is mainly one of degree. Its incubation period is longer, it is more slow and insidious in its progress, and it never reaches the same degree of severity. Trismus is the most marked and constant form of spasm; and while the trunk muscles may be involved, those of respiration as a rule escape. Every additional day the patient lives adds to the probability of his ultimate recovery. When the disease does prove fatal, it is from exhaustion, and not from respiratory or cardiac spasm. The usual duration is from six to ten weeks.

Delayed Tetanus.—During the European War acute tetanus occasionally developed many weeks or even months after a patient had been injured, and when the original wound had completely healed. It usually followed some secondary operation, e.g., for the removal of a foreign body, or the breaking down of adhesions, which aroused latent organisms.

Local Tetanus.—This term is applied to a form of the disease in which the hypertonus and spasms are localised to the muscles in the vicinity of the wound. It usually occurs in patients who have had prophylactic injections of anti-tetanic serum, the toxins entering the blood being probably neutralised by the antibodies in circulation, while those passing along the motor nerves are unaffected.

When it occurs in the limbs, attention is usually directed to the fact by pain accompanying the spasms; the muscles are found to be hard and there are frequent twitchings of the limb. A characteristic reflex is present in the lower extremity, namely, extension of the foot and leg when the sole is tickled.

Cephalic Tetanus is another localised variety which follows injury in the distribution of the facial nerve. It is characterised by the occurrence on the same side as the injury, of facial spasm, rapidly followed by more or less complete paralysis of the muscles of expression, with unilateral trismus and difficulty in swallowing. Other cranial nerves, particularly the oculomotor and the hypoglossal, may also be implicated. A remarkable feature of this condition is that although the muscles are irresponsive to ordinary physiological stimuli, they are thrown into spasm by the abnormal impulses of tetanus.

Trismus.—This term is used to denote a form of tetanic spasm limited to the muscles of mastication. It is really a mild form of chronic tetanus, and the prognosis is favourable. It must not be confused with the fixation of the jaw sometimes associated with a wisdom-tooth gumboil, with tonsillitis, or with affections of the temporo-mandibular articulation.

Tetanus neonatorum is a form of tetanus occurring in infants of about a week old. Infection takes place through the umbilicus, and manifests itself clinically by spasms of the muscles of mastication. It is almost invariably fatal within a few days.

Prophylaxis.—Experience in the European War has established the fact that the routine injection of anti-tetanic serum to all patients with lacerated and contaminated wounds greatly reduces the frequency of tetanus. The sooner the serum is given after the injury, the more certain is its effect; within twenty-four hours 1500 units injected subcutaneously is sufficient for the initial dose; if a longer period has elapsed, 2000 to 3000 units should be given intra-muscularly, as this ensures more rapid absorption. A second injection is given a week after the first.

The wound must be purified in the usual way, and all instruments and appliances used for operations on tetanic patients must be immediately sterilised by prolonged boiling.

Treatment.—When tetanus has developed the main indications are to prevent the further production of toxins in the wound, and to neutralise those that have been absorbed into the nervous system. Thorough purification with antiseptics, excision of devitalised tissues, and drainage of the wound are first carried out. To arrest the absorption of toxins intra-muscular injections of 10,000 units of serum are given daily into the muscles of the affected limb, or directly into the nerve trunks leading from the focus of infection, in the hope of “blocking” the nerves with antitoxin and so preventing the passage of toxins towards the spinal cord.

To neutralise the toxins that have already reached the spinal cord, 5000 units should be injected intra-thecally daily for four or five days, the foot of the bed being raised to enable the serum to reach the upper parts of the cord.

The quantity of toxin circulating in the blood is so small as to be practically negligible, and the risk of anaphylactic shock attending intra-venous injection outweighs any benefit likely to follow this procedure.

Baccelli recommends the injection of 20 c.c. of a 1 in 100 solution of carbolic acid into the subcutaneous tissues every four hours during the period that the contractions persist. Opinions vary as to the efficiency of this treatment. The intra-thecal injection of 10 c.c. of a 15 per cent. solution of magnesium sulphate has proved beneficial in alleviating the severity of the spasms, but does not appear to have a curative effect.

To conserve the patient's strength by preventing or diminishing the severity of the spasms, he should be placed in a quiet room, and every form of disturbance avoided. Sedatives, such as bromides, paraldehyde, or opium, must be given in large doses. Chloral is perhaps the best, and the patient should rarely have less than 150 grains in twenty-four hours. When he is unable to swallow, it should be given by the rectum. The administration of chloroform is of value in conserving the strength of the patient, by abolishing the spasms, and enabling the attendants to administer nourishment or drugs either through a stomach tube or by the rectum. Extreme elevation of temperature is met by tepid sponging. It is necessary to use the catheter if retention of urine occurs.

Hydrophobia is an acute infective disease following on the bite of a rabid animal. It most commonly follows the bite or lick of a rabid dog or cat. The virus appears to be communicated through the saliva of the animal, and to show a marked affinity for nerve tissues; and the disease is most likely to develop when the patient is infected on the face or other uncovered part, or in a part richly endowed with nerves.

A dog which has bitten a person should on no account be killed until its condition has been proved one way or the other. Should rabies develop and its destruction become necessary, the head and spinal cord should be retained and forwarded, packed in ice, to a competent observer. Much anxiety to the person bitten and to his friends would be avoided if these rules were observed, because in many cases it will be shown that the animal did not after all suffer from rabies, and that the patient consequently runs no risk. If, on the other hand, rabies is proved to be present, the patient should be submitted to the Pasteur treatment.

Clinical Features.—There is almost always a history of the patient having been bitten or licked by an animal supposed to suffer from rabies. The incubation period averages about forty days, but varies from a fortnight to seven or eight months, and is shorter in young than in old persons. The original wound has long since healed, and beyond a slight itchiness or pain shooting along the nerves of the part, shows no sign of disturbance. A few days of general malaise, with chills and giddiness precede the onset of the acute manifestations, which affect chiefly the muscles of deglutition and respiration. One of the earliest signs is that the patient has periodically a sudden catch in his breathing “resembling what often occurs when a person goes into a cold bath.” This is due to spasm of the diaphragm, and is frequently accompanied by a loud-sounding hiccough, likened by the laity to the barking of a dog. Difficulty in swallowing fluids may be the first symptom.

The spasms rapidly spread to all the muscles of deglutition and respiration, so that the patient not only has the greatest difficulty in swallowing, but has a constant sense of impending suffocation. To add to his distress, a copious secretion of viscid saliva fills his mouth. Any voluntary effort, as well as all forms of external stimuli, only serve to aggravate the spasms which are always induced by the attempt to swallow fluid, or even by the sound of running water.

The temperature is raised; the pulse is small, rapid, and intermittent; and the urine may contain sugar and albumen.

The mind may remain clear to the end, or the patient may have delusions, supposing himself to be surrounded by terrifying forms. There is always extreme mental agitation and despair, and the sufferer is in constant fear of his impending fate. Happily the inevitable issue is not long delayed, death usually occurring in from two to four days from the onset. The symptoms of the disease are so characteristic that there is no difficulty in diagnosis. The only condition with which it is liable to be confused is the variety of cephalic tetanus in which the muscles of deglutition are specially involved—the so-called tetanus hydrophobicus.

Prophylaxis.—The bite of an animal suspected of being rabid should be cauterised at once by means of the actual or Paquelin cautery, or by a strong chemical escharotic such as pure carbolic acid, after which antiseptic dressings are applied.

It is, however, to Pasteur's preventive inoculation that we must look for our best hope of averting the onset of symptoms. “It may now be taken as established that a grave responsibility rests on those concerned if a person bitten by a mad animal is not subjected to the Pasteur treatment” (Muir and Ritchie).

This method is based on the fact that the long incubation period of the disease admits of the patient being inoculated with a modified virus producing a mild attack, which protects him from the natural disease.

Treatment.—When the symptoms have once developed they can only be palliated. The patient must be kept absolutely quiet and free from all sources of irritation. The spasms may be diminished by means of chloral and bromides, or by chloroform inhalation.

Anthrax is a comparatively rare disease, communicable to man from certain of the lower animals, such as sheep, oxen, horses, deer, and other herbivora. In animals it is characterised by symptoms of acute general poisoning, and, from the fact that it produces a marked enlargement of the spleen, is known in veterinary surgery as “splenic fever.”

The bacillus anthracis (Fig. 27), the largest of the known pathogenic bacteria, occurs in groups or in chains made up of numerous bacilli, each bacillus measuring from 6 to 8 µ in length. The organisms are found in enormous numbers throughout the bodies of animals that have died of anthrax, and are readily recognised and cultivated. Sporulation only takes place outside the body, probably because free oxygen is necessary to the process. In the spore-free condition, the organisms are readily destroyed by ordinary germicides, and by the gastric juice. The spores, on the other hand, have a high degree of resistance. Not only do they remain viable in the dry state for long periods, even up to a year, but they survive boiling for five minutes, and must be subjected to dry heat at 140° C. for several hours before they are destroyed.

Clinical Varieties of Anthrax.—In man, anthrax may manifest itself in one of three clinical forms.

It may be transmitted by means of spores or bacilli directly from a diseased animal to those who, by their occupation or otherwise, are brought into contact with it—for example, shepherds, butchers, veterinary surgeons, or hide-porters. Infection may occur on the face by the use of a shaving-brush contaminated by spores. The path of infection is usually through an abrasion of the skin, and the primary manifestations are local, constituting what is known as the malignant pustule.

In other cases the disease is contracted through the inhalation of the dried spores into the respiratory passages. This occurs oftenest in those who work amongst wool, fur, and rags, and a form of acute pneumonia of great virulence ensues. This affection is known as wool-sorter's disease, and is almost universally fatal.

There is reason to believe that infection may also take place by means of spores ingested into the alimentary canal in meat or milk derived from diseased animals, or in infected water.

Clinical Features of Malignant Pustule.—We shall here confine ourselves to the consideration of the local lesion as it occurs in the skin—the malignant pustule.

The point of infection is usually on an uncovered part of the body, such as the face, hands, arms, or back of the neck, and the wound may be exceedingly minute. After an incubation period varying from a few hours to several days, a reddish nodule resembling a small boil appears at the seat of inoculation, the immediately surrounding skin becomes swollen and indurated, and over the indurated area there appear a number of small vesicles containing serum, which at first is clear but soon becomes blood-stained (Fig. 28). Coincidently the subcutaneous tissue for a considerable distance around becomes markedly œdematous, and the skin red and tense. Within a few hours, blood is extravasated in the centre of the indurated area, the blisters burst, and a dark brown or black eschar, composed of necrosed skin and subcutaneous tissue and altered blood, forms (Fig. 29). Meanwhile the induration extends, fresh vesicles form and in turn burst, and the eschar increases in size. The neighbouring lymph glands soon become swollen and tender. The affected part is hot and itchy, but the patient does not complain of great pain. There is a moderate degree of constitutional disturbance, with headache, nausea, and sometimes shivering.

If the infection becomes generalised—anthracæmia—the temperature rises to 103° or 104° F., the pulse becomes feeble and rapid, and other signs of severe blood-poisoning appear: vomiting, diarrhœa, pains in the limbs, headache and delirium, and the condition proves fatal in from five to eight days.

Differential Diagnosis.—When the malignant pustule is fully developed, the central slough with the surrounding vesicles and the widespread œdema are characteristic. The bacillus can be obtained from the peripheral portion of the slough, from the blisters, and from the adjacent lymph vessels and glands. The occupation of the patient may suggest the possibility of anthrax infection.

Prophylaxis.—Any wound suspected of being infected with anthrax should at once be cauterised with caustic potash, the actual cautery, or pure carbolic acid.

Treatment.—The best results hitherto obtained have followed the use of the anti-anthrax serum introduced by Sclavo. The initial dose is 40 c.c., and if the serum is given early in the disease, the beneficial effects are manifest in a few hours. Favourable results have also followed the use of pyocyanase, a vaccine prepared from the bacillus pyocyaneus.

By some it is recommended that the local lesion should be freely excised; others advocate cauterisation of the affected part with solid caustic potash till all the indurated area is softened. Gräf has had excellent results by the latter method in a large series of cases, the œdema subsiding in about twenty-four hours and the constitutional symptoms rapidly improving. Wolff and Wiewiorowski, on the other hand, have had equally good results by simply protecting the local lesion with a mild antiseptic dressing, and relying upon general treatment.

The general treatment consists in feeding and stimulating the patient as freely as possible. Quinine, in 5 to 10 grain doses every four hours, and powdered ipecacuanha, in 40 to 60 grain doses every four hours, have also been employed with apparent benefit.

Glanders is due to the action of a specific bacterium, the bacillus mallei, which resembles the tubercle bacillus, save that it is somewhat shorter and broader, and does not stain by Gram's method. It requires higher temperatures for its cultivation than the tubercle bacillus, and its growth on potato is of a characteristic chocolate-brown colour, with a greenish-yellow ring at the margin of the growth. The bacillus mallei retains its vitality for long periods under ordinary conditions, but is readily killed by heat and chemical agents. It does not form spores.

Clinical Features.—Both in the lower animals and in man the bacillus gives rise to two distinct types of disease—acute glanders, and chronic glanders or farcy.

Acute Glanders is most commonly met with in the horse and in other equine animals, horned cattle being immune. It affects the septum of the nose and adjacent parts, firm, translucent, greyish nodules containing lymphoid and epithelioid cells appearing in the mucous membrane. These nodules subsequently break down in the centre, forming irregular ulcers, which are attended with profuse discharge, and marked inflammatory swelling. The cervical lymph glands, as well as the lungs, spleen, and liver, may be the seat of secondary nodules.

In man, acute glanders is commoner than the chronic variety. Infection always takes place through an abraded surface, and usually on one of the uncovered parts of the body—most commonly the skin of the hands, arms, or face; or on the mucous membrane of the mouth, nose, or eye. The disease has been acquired by accidental inoculation in the course of experimental investigations in the laboratory, and proved fatal. The incubation period is from three to five days.

The local manifestations are pain and swelling in the region of the infected wound, with inflammatory redness around it and along the lines of the superficial lymphatics. In the course of a week, small, firm nodules appear, and are rapidly transformed into pustules. These may occur on the face and in the vicinity of joints, and may be mistaken for the eruption of small-pox.

After breaking down, these pustules give rise to irregular ulcers, which by their confluence lead to extensive destruction of skin. Sometimes the nasal mucous membrane becomes affected, and produces a discharge—at first watery, but later sanious and purulent. Necrosis of the bones of the nose may take place, in which case the discharge becomes peculiarly offensive. In nearly every case metastatic abscesses form in different parts of the body, such as the lungs, joints, or muscles.

During the development of the disease the patient feels ill, complains of headache and pains in the limbs, the temperature rises to 104° or even to 106° F., and assumes a pyæmic type. The pulse becomes rapid and weak. The tongue is dry and brown. There is profuse sweating, albuminuria, and often insomnia with delirium. Death may take place within a week, but more frequently occurs during the second or third week.

Differential Diagnosis.—There is nothing characteristic in the site of the primary lesion in man, and the condition may, during the early stages, be mistaken for a boil or carbuncle, or for any acute inflammatory condition. Later, the disease may simulate acute articular rheumatism, or may manifest all the symptoms of acute septicæmia or pyæmia. The diagnosis is established by the recognition of the bacillus. Veterinary surgeons attach great importance to the mallein test as a means of diagnosis in animals, but in the human subject its use is attended with considerable risk and is not to be recommended.

Treatment.—Excision of the primary nodule, followed by the application of the thermo-cautery and sponging with pure carbolic acid, should be carried out, provided the condition is sufficiently limited to render complete removal practicable.

When secondary abscesses form in accessible situations, they must be incised, disinfected, and drained. The general treatment is carried out on the same lines as in other acute infective diseases.

Chronic Glanders.—In the horse the chronic form of glanders is known as farcy, and follows infection through an abrasion of the skin, involving chiefly the superficial lymph vessels and glands. The lymphatics become indurated and nodular, constituting what veterinarians call farcy pipes and farcy buds.

In man also the clinical features of the chronic variety of the disease are somewhat different from those of the acute form. Here, too, infection takes place through a broken cutaneous surface, and leads to a superficial lymphangitis with nodular thickening of the lymphatics (farcy buds). The neighbouring glands soon become swollen and indurated. The primary lesion meanwhile inflames, suppurates, and, after breaking down, leaves a large, irregular ulcer with thickened edges and a foul, purulent or bloody discharge. The glands break down in the same way, and lead to wide destruction of skin, and the resulting sinuses and ulcers are exceedingly intractable. Secondary deposits in the subcutaneous tissue, the muscles, and other parts, are not uncommon, and the nasal mucous membrane may become involved. The disease often runs a chronic course, extending to four or five months, or even longer. Recovery takes place in about 50 per cent. of cases, but the convalescence is prolonged, and at any time the disease may assume the characters of the acute variety and speedily prove fatal.

The differential diagnosis is often difficult, especially in the chronic nodules, in which it may be impossible to demonstrate the bacillus. The ulcerated lesions of farcy have to be distinguished from those of tubercle, syphilis, and other forms of infective granuloma.

Treatment.—Limited areas of disease should be completely excised. The general condition of the patient must be improved by tonics, good food, and favourable hygienic surroundings. In some cases potassium iodide acts beneficially.

Actinomycosis is a chronic disease due to the action of an organism somewhat higher in the vegetable scale than ordinary bacteria—the streptothrix actinomyces or ray fungus.

Etiology and Morbid Anatomy.—The actinomyces, which has never been met with outside the body, gives rise in oxen, horses, and other animals to tumour-like masses composed of granulation tissue; and in man to chronic suppurative processes which may result in a condition resembling chronic pyæmia. The actinomyces is more complex in structure than other pathogenic organisms, and occurs in the tissues in the form of small, round, semi-translucent bodies, about the size of a pin-head or less, and consisting of colonies of the fungus. On account of their yellow tint they are spoken of as “sulphur grains.” Each colony is made up of a series of thin, interlacing, and branching filaments, some of which are broken up so as to form masses or chains of cocci; and around the periphery of the colony are elongated, pear-shaped, hyaline, club-like bodies (Fig. 30).

Infection is believed to be conveyed by the husks of cereals, especially barley; and the organism has been found adhering to particles of grain embedded in the tissues of animals suffering from the disease. In the human subject there is often a history of exposure to infection from such sources, and the disease is said to be most common during the harvesting months.

Around each colony of actinomyces is a zone of granulation tissue in which suppuration usually occurs, so that the fungus comes to lie in a bath of greenish-yellow pus. As the process spreads these purulent foci become confluent and form abscess cavities. When metastasis takes place, as it occasionally does, the fungus is transmitted by the blood vessels, as in pyæmia.

Clinical features.—In man the disease may be met with in the skin, the organisms gaining access through an abrasion, and spreading by the formation of new nodules in the same way as tuberculosis.

The region of the mouth and jaws is one of the commonest sites of surgical actinomycosis. Infection takes place, as a rule, along the side of a carious tooth, and spreads to the lower jaw. A swelling is slowly and insidiously developed, but when the loose connective tissue of the neck becomes infiltrated, the spread is more rapid. The whole region becomes infiltrated and swollen, and the skin ultimately gives way and free suppuration occurs, resulting in the formation of sinuses. The characteristic greenish-grey or yellow granules are seen in the pus, and when examined microscopically reveal the colonies of actinomyces.

Less frequently the maxilla becomes affected, and the disease may spread to the base of the skull and brain. The vertebræ may become involved by infection taking place through the pharynx or œsophagus, and leading to a condition simulating tuberculous disease of the spine. When it implicates the intestinal canal and its accessory glands, the lungs, pleura, and bronchial tubes, or the brain, the disease is not amenable to surgical treatment.

Differential Diagnosis.—The conditions likely to be mistaken for surgical actinomycosis are sarcoma, tubercle, and syphilis. In the early stages the differential diagnosis is exceedingly difficult. In many cases it is only possible when suppuration has occurred and the fungus can be demonstrated.

The slow destruction of the affected tissue by suppuration, the absence of pain, tenderness, and redness, simulate tuberculosis, but the absence of glandular involvement helps to distinguish it.

Syphilitic lesions are liable to be mistaken for actinomycosis, all the more that in both diseases improvement follows the administration of iodides. When it affects the lower jaw, in its early stages, actinomycosis may closely simulate a periosteal sarcoma.

The recognition of the fungus is the crucial point in diagnosis.

Prognosis.—Spontaneous cure rarely occurs. When the disease implicates internal organs, it is almost always fatal. On external parts the destructive process gradually spreads, and the patient eventually succumbs to superadded septic infection. When, from its situation, the primary focus admits of removal, the prognosis is more favourable.

Treatment.—The surgical treatment is early and free removal of the affected tissues, after which the wound is cauterised by the actual cautery, and sponged over with pure carbolic acid. The cavity is packed with iodoform gauze, no attempt being made to close the wound.

Success has attended the use of a vaccine prepared from cultures of the organism; and the X-rays and radium, combined with the administration of iodides in large doses, or with intra-muscular injections of a 10 per cent. solution of cacodylate of soda, have proved of benefit.

Mycetoma, or Madura Foot.—Mycetoma is a chronic disease due to an organism resembling that of actinomycosis, but not identical with it. It is endemic in certain tropical countries, and is most frequently met with in India. Infection takes place through an abrasion of the skin, and the disease usually occurs on the feet of adult males who work barefooted in the fields.

Clinical Features.—The disease begins on the foot as an indurated patch, which becomes discoloured and permeated by black or yellow nodules containing the organism. These nodules break down by suppuration, and numerous minute abscesses lined by granulation tissues are thus formed. In the pus are found yellow particles likened to fish-roe, or black pigmented granules like gunpowder. Sinuses form, and the whole foot becomes greatly swollen and distorted by flattening of the sole and dorsiflexion of the toes. Areas of caries or necrosis occur in the bones, and the disease gradually extends up the leg (Fig. 32). There is but little pain, and no glandular involvement or constitutional disturbance. The disease runs a prolonged course, sometimes lasting for twenty or thirty years. Spontaneous cure never takes place, and the risk to life is that of prolonged suppuration.

If the disease is localised, it may be removed by the knife or sharp spoon, and the part afterwards cauterised. As a rule, amputation well above the disease is the best line of treatment. Unlike actinomycosis, this disease does not appear to be benefited by iodides.

Delhi Boil.—Synonyms—Aleppo boil, Biskra button, Furunculus orientalis, Natal sore.

Delhi boil is a chronic inflammatory disease, most commonly met with in India, especially towards the end of the wet season. The disease occurs oftenest on the face, and is believed to be due to an organism, although this has not been demonstrated. The infection is supposed to be conveyed through water used for washing, or by the bites of insects.

Clinical Features.—A red spot, resembling the mark of a mosquito bite, appears on the affected part, and is attended with itching. After becoming papular and increasing to the size of a pea, desquamation takes place, leaving a dull-red surface, over which in the course of several weeks there develops a series of small yellowish-white spots, from which serum exudes, and, drying, forms a thick scab. Under this scab the skin ulcerates, leaving small oval sores with sharply bevelled edges, and an uneven floor covered with yellow or sanious pus. These sores vary in number from one to forty or fifty. They may last for months and then heal spontaneously, or may continue to spread until arrested by suitable treatment. There is no enlargement of adjacent glands, and but little inflammatory reaction in the surrounding tissues; nor is there any marked constitutional disturbance. Recovery is often followed by cicatricial contraction leading to deformity of the face.

The treatment consists in destroying the original papule by the actual cautery, acid nitrate of mercury, or pure carbolic acid. The ulcers should be scraped with the sharp spoon, and cauterised.

Chigoe.—Chigoe or jigger results from the introduction of the eggs of the sand-flea (Pulex penetrans) into the tissues. It occurs in tropical Africa, South America, and the West Indies. The impregnated female flea remains attached to the part till the eggs mature, when by their irritation they cause localised inflammation with pustules or vesicles on the surface. Children are most commonly attacked, particularly about the toe-nails and on the scrotum. The treatment consists in picking out the insect with a blunt needle, special care being taken not to break it up. The puncture is then cauterised. The application of essential oils to the feet acts as a preventive.

Poisoning by Insects.—The bites of certain insects, such as mosquitoes, midges, different varieties of flies, wasps, and spiders, may be followed by serious complications. The effects are mainly due to the injection of an irritant acid secretion, the exact nature of which has not been ascertained.

The local lesion is a puncture, surrounded by a zone of hyperæmia, wheals, or vesicles, and is associated with burning sensations and itching which usually pass off in a few hours, but may recur at intervals, especially when the patient is warm in bed. Scratching also reproduces the local signs and symptoms. Where the connective tissue is loose—for example, in the eyelid or scrotum—there is often considerable swelling; and in the mouth and fauces this may lead to œdema of the glottis, which may prove fatal.

The treatment consists in the local application of dilute alkalies such as ammonia water, solutions of carbonate or bicarbonate of soda, or sal-volatile. Weak carbolic lotions, or lead and opium lotion, are useful in allaying the local irritation. One of the best means of neutralising the poison is to apply to the sting a drop of a mixture containing equal parts of pure carbolic acid and liquor ammoniæ.

Free stimulation is called for when severe constitutional symptoms are present.

Snake-Bites.—We are here only concerned with the injuries inflicted by the venomous varieties of snakes, the most important of which are the hooded snakes of India, the rattle-snakes of America, the horned snakes of Africa, the viper of Europe, and the adder of the United Kingdom.

While the virulence of these creatures varies widely, they are all capable of producing in a greater or less degree symptoms of acute poisoning in man and other animals. By means of two recurved fangs attached to the upper jaw, and connected by a duct with poison-secreting glands, they introduce into their prey a thick, transparent, yellowish fluid, of acid reaction, probably of the nature of an albumose, and known as the venom.

The clinical features resulting from the injection of the venom vary directly in intensity with the amount of the poison introduced, and the rapidity with which it reaches the circulating blood, being most marked when it immediately enters a large vein. The poison is innocuous when taken into the stomach.

Locally the snake inflicts a double wound, passing vertically into the subcutaneous tissue; the edges of the punctures are ecchymosed, and the adjacent vessels the seat of thrombosis. Immediately there is intense pain, and considerable swelling with congestion, which tends to spread towards the trunk. Extensive gangrene may ensue. There is no special involvement of the lymphatics.

The general symptoms may come on at once if the snake is a particularly venomous one, or not for some hours if less virulent. In the majority of viper or adder bites the constitutional disturbance is slight and transient, if it appears at all. Snake-bites in children are particularly dangerous.

The patient's condition is one of profound shock with faintness, giddiness, dimness of sight, and a feeling of great terror. The pupils dilate, the skin becomes moist with a clammy sweat, and nausea with vomiting, sometimes of blood, ensues. High fever, cramps, loss of sensation, hæmaturia, and melæna are among the other symptoms that may be present. The pulse becomes feeble and rapid, the respiratory nerve centres are profoundly depressed, and delirium followed by coma usually precedes the fatal issue, which may take place in from five to forty-eight hours. If the patient survives for two days the prognosis is favourable.

Treatment.—A broad ligature should be tied tightly round the limb above the seat of infection, to prevent the poison passing into the general circulation, and bleeding from the wound should be encouraged. The application of an elastic bandage from above downward to empty the blood out of the infected portion of the limb has been recommended. The whole of the bite should at once be excised, and crystals of permanganate of potash rubbed into the wound until it is black, or peroxide of hydrogen applied with the object of destroying the poison by oxidation.

The general treatment consists in free stimulation with whisky, brandy, ammonia, digitalis, etc. Hypodermic injections of strychnin in doses sufficiently large to produce a slight degree of poisoning by the drug are particularly useful. The most rational treatment, when it is available, is the use of the antivenin introduced by Fraser and Calmette.

Tuberculosis occurs more frequently in some situations than in others; it is common, for example, in lymph glands, in bones and joints, in the peritoneum, the intestine, the kidney, prostate and testis, and in the skin and subcutaneous cellular tissue; it is seldom met with in the breast or in muscles, and it rarely affects the ovary, the pancreas, the parotid, or the thyreoid.

Tubercle bacilli vary widely in their virulence, and they are more tenacious of life than the common pyogenic bacteria. In a dry state, for example, they can retain their vitality for months; and they can also survive immersion in water for prolonged periods. They resist the action of the products of putrefaction for a considerable time, and are not destroyed by digestive processes in the stomach and intestine. They may be killed in a few minutes by boiling, or by exposure to steam under pressure, or by immersion for less than a minute in 1 in 20 carbolic lotion.

Methods of Infection.—In marked contrast to what obtains in the infective diseases that have already been described, tuberculosis rarely results from the infection of a wound. In exceptional instances, however, this does occur, and in illustration of the fact may be cited the case of a servant who cut her finger with a broken spittoon containing the sputum of her consumptive master; the wound subsequently showed evidence of tuberculous infection, which ultimately spread up along the lymph vessels of the arm. Pathologists, too, whose hands, before the days of rubber gloves, were frequently exposed to the contact of tuberculous tissues and pus, were liable to suffer from a form of tuberculosis of the skin of the finger, known as anatomical tubercle. Slight wounds of the feet in children who go about barefoot in towns sometimes become infected with tubercle. Operation wounds made with instruments contaminated with tuberculous material have also been known to become infected. It is highly probable that the common form of tuberculosis of the skin known as “lupus” arises by direct infection from without.

In the vast majority of cases the tubercle bacillus gains entrance to the body by way of the mucous surfaces, the organisms being either inhaled or swallowed; those inhaled are mostly derived from the human subject, those swallowed, from cattle. Bacilli, whether inhaled or swallowed, are especially apt to lodge about the pharynx and pass to the pharyngeal lymphoid tissue and tonsils, and by way of the lymph vessels to the glands. The glands most frequently infected in this way are the cervical glands, and those within the cavity of the chest—particularly the bronchial glands at the root of the lung. From these, infection extends at any later period in life to the bones, joints, and internal organs.

There is reason to believe that the organisms may lie in a dormant condition for an indefinite period in these glands, and only become active long afterwards, when some depression of the patient's health produces conditions which favour their growth. When the organisms become active in this way, the tuberculous tissue undergoes softening and disintegration, and the infective material, by bursting into an adjacent vein, may enter the blood-stream, in which it is carried to distant parts of the body. In this way a general tuberculosis may be set up, or localised foci of tuberculosis may develop in the tissues in which the organisms lodge. Many tuberculous patients are to be regarded as possessing in their bronchial glands, or elsewhere, an internal store of bacilli, to which the disease for which advice is sought owes its origin, and from which similar outbreaks of tuberculosis may originate in the future.

The alimentary mucous membrane, especially that of the lower ileum and cæcum, is exposed to infection by swallowed sputum and by food materials, such as milk, containing tubercle bacilli. The organisms may lodge in the mucous membrane and cause tuberculous ulceration, or they may be carried through the wall of the bowel into the lacteals, along which they pass to the mesenteric glands where they become arrested and give rise to tuberculous disease.

Relationship of Tuberculosis to Trauma.—Any tissue whose vitality has been lowered by injury or disease furnishes a favourable nidus for the lodgment and growth of tubercle bacilli. The injury or disease, however, is to be looked upon as determining the localisation of the tuberculous lesion rather than as an essential factor in its causation. In a person, for example, in whose blood tubercle bacilli are circulating and reaching every tissue and organ of the body, the occurrence of tuberculous disease in a particular part may be determined by the depression of the tissues resulting from an injury of that part. There can be no doubt that excessive movement and jarring of a limb aggravates tuberculous disease of a joint; also that an injury may light up a focus that has been long quiescent, but we do not agree with those—Da Costa, for example—who maintain that injury may be a determining cause of tuberculosis. The question is not one of mere academic interest, but one that may raise important issues in the law courts.

Human and Bovine Tuberculosis.—The frequency of the bovine bacillus in the abdominal and in the glandular and osseous tuberculous lesions of children would appear to justify the conclusion that the disease is transmissible from the ox to the human subject, and that the milk of tuberculous cows is probably a common vehicle of transmission.

Changes in the Tissues following upon the successful Lodgment of Tubercle Bacilli.—The action of the bacilli on the tissues results in the formation of granulation tissue comprising characteristic tissue elements and with a marked tendency to undergo caseation.

The recognition of the characteristic elements, with or without caseation, is usually sufficient evidence of the tuberculous nature of any portion of tissue examined for diagnostic purposes. The recognition of the bacillus itself by appropriate methods of staining makes the diagnosis a certainty; but as it is by no means easy to identify the organism in many forms of surgical tuberculosis, it may be necessary to have recourse to experimental inoculation of susceptible animals such as guinea-pigs.

The changes subsequent to the formation of tuberculous granulation tissue are liable to many variations. It must always be borne in mind that although the bacilli have effected a lodgment and have inaugurated disease, the relation between them and the tissues remains one of mutual antagonism; which of them is to gain and keep the upper hand in the conflict depends on their relative powers of resistance.

If the tissues prevail, there ensues a process of repair. In the immediate vicinity of the area of infection young connective tissue, and later, fibrous tissue, is formed. This may replace the tuberculous tissue and bring about repair—a fibrous cicatrix remaining to mark the scene of the previous contest. Scars of this nature are frequently discovered at the apex of the lung after death in persons who have at one time suffered from pulmonary phthisis. Under other circumstances, the tuberculous tissue that has undergone caseation, or even calcification, is only encapsulated by the new fibrous tissue, like a foreign body. Although this may be regarded as a victory for the tissues, the cure, if such it may be called, is not necessarily a permanent one, for at any subsequent period, if the part affected is disturbed by injury or through some other influence, the encapsulated tubercle may again become active and get the upper hand of the tissues, and there results a relapse or recrudescence of the disease. This tendency to relapse after apparent cure is a notable feature of tuberculous disease as it is met with in the spine, or in the hip-joint, and it necessitates a prolonged course of treatment to give the best chance of a lasting cure.

If, however, at the inauguration of the tuberculous disease the bacilli prevail, the infection tends to spread into the tissues surrounding those originally infected, and more and more tuberculous granulation tissue is formed. Finally the tuberculous tissue breaks down and liquefies, resulting in the formation of a cold abscess. In their struggle with the tissues, tubercle bacilli receive considerable support and assistance from any pyogenic organisms that may be present. A tuberculous infection may exhibit its aggressive qualities in a more serious manner by sending off detachments of bacilli, which are carried by the lymphatics to the nearest glands, or by the blood-stream to more distant, and it may be to all, parts of the body. When the infection is thus generalised, the condition is called general tuberculosis. Considering the extraordinary frequency of localised forms of surgical tuberculosis, general dissemination of the disease is rare.

The clinical features of surgical tuberculosis will be described with the individual tissues and organs, as they vary widely according to the situation of the lesion.

The general treatment consists in combating the adverse influences that have been mentioned as increasing the liability to tuberculous infection. Within recent years the value of the “open-air” treatment has been widely recognised. An open-air life, even in the centre of a city, may be followed by marked improvement, especially in the hospital class of patient, whose home surroundings tend to favour the progress of the disease. The purer air of places away from centres of population is still better; and, according to the idiosyncrasies of the individual patient, mountain air or that of the sea coast may be preferred. In view of the possible discomforts and gastric disturbance which may attend a sea-voyage, this should be recommended to patients suffering from tuberculous lesions with more caution than has hitherto been exercised. The diet must be a liberal one, and should include those articles which are at the same time easily digested and nourishing, especially proteids and fats; milk obtained from a reliable source and underdone butcher-meat are among the best. When the ordinary nourishment taken is insufficient, it may be supplemented by such articles as malt extract, stout, and cod-liver oil. The last is specially beneficial in patients who do not take enough fat in other forms. It is noteworthy that many tuberculous patients show an aversion to fat.

For the use of tuberculin in diagnosis and for the vaccine treatment of tuberculosis the reader is referred to text-books on medicine.

In addition to increasing the resisting power of the patient, it is important to enable the fluids of the body, so altered, to come into contact with the tuberculous focus. One of the obstacles to this is that the focus is often surrounded by tissues or fluids which have been almost entirely deprived of bactericidal substances. In the case of caseated glands in the neck, for example, it is obvious that the removal of this inert material is necessary before the tissues can be irrigated with fluids of high bactericidal value. Again, in tuberculous ascites the abdominal cavity is filled with a fluid practically devoid of anti-bacterial substances, so that the bacilli are able to thrive and work their will on the tissues. When the stagnant fluid is got rid of by laparotomy, the parts are immediately douched with lymph charged with protective substances, the bactericidal power of which may be many times that of the fluid displaced.

It is probable that the beneficial influence of counter-irritants, such as blisters, and exposure to the Finsen light and other forms of rays, is to be attributed in part to the increased flow of blood to the infected tissues.

Artificial Hyperæmia.—As has been explained, the induction of hyperæmia by the method devised by Bier, constitutes one of our most efficient means of combating bacterial infection. The treatment of tuberculosis on this plan has been proved by experience to be a valuable addition to our therapeutic measures, and the simplicity of its application has led to its being widely adopted in practice. It results in an increase in the reactive changes around the tuberculous focus, an increase in the immigration of leucocytes, and infiltration with the lymphocytes.

The constricting bandage should be applied at some distance above the seat of infection; for instance, in disease of the wrist, it is put on above the elbow, and it must not cause pain either where it is applied or in the diseased part. The bandage is only applied for a few hours each day, either two hours at a time or twice a day for one hour, and, while it is on, all dressings are removed save a piece of sterile gauze over any wound or sinus that may be present. The process of cure takes a long time—nine or even twelve months in the case of a severe joint affection.

In cases in which a constricting bandage is inapplicable, for example, in cold abscesses, tuberculous glands or tendon sheaths, Klapp's suction bell is employed. The cup is applied for five minutes at a time and then taken off for three minutes, and this is repeated over a period of about three-quarters of an hour. The pus is allowed to escape by a small incision, and no packing or drain should be introduced.

It has been found that tuberculous lesions tend to undergo cure when the infected tissues are exposed to the rays of the sun—heliotherapy—therefore whenever practicable this therapeutic measure should be had recourse to.

Since the introduction of the methods of treatment described above, and especially by their employment at an early stage in the disease, the number of cases of tuberculosis requiring operative interference has greatly diminished. There are still circumstances, however, in which an operation is required; for example, in disease of the lymph glands for the removal of inert masses of caseous material, in disease of bone for the removal of sequestra, or in disease of joints to improve the function of the limb. It is to be understood, however, that operative treatment must always be preceded by and combined with other therapeutic measures.

The caseation of tuberculous granulation tissue and its liquefaction is a slow and insidious process, and is unattended with the classical signs of inflammation—hence the terms “cold” and “chronic” applied to the tuberculous abscess.

In a cold abscess, such as that which results from tuberculous disease of the vertebræ, the clinical appearances are those of a soft, fluid swelling without heat, redness, pain, or fever. When toxic symptoms are present, they are usually due to a mixed infection.

A tuberculous abscess results from the disintegration and liquefaction of tuberculous granulation tissue which has undergone caseation. Fluid and cells from the adjacent blood vessels exude into the cavity, and lead to variations in the character of its contents. In some cases the contents consist of a clear amber-coloured fluid, in which are suspended fragments of caseated tissue; in others, of a white material like cream-cheese. From the addition of a sufficient number of leucocytes, the contents may resemble the pus of an ordinary abscess.

The wall of the abscess is lined with tuberculous granulation tissue, the inner layers of which are undergoing caseation and disintegration, and present a shreddy appearance; the outer layers consist of tuberculous tissue which has not yet undergone caseation. The abscess tends to increase in size by progressive liquefaction of the inner layers, caseation of the outer layers, and the further invasion of the surrounding tissues by tubercle bacilli. In this way a tuberculous abscess is capable of indefinite extension and increase in size until it reaches a free surface and ruptures externally. The direction in which it spreads is influenced by the anatomical arrangement of the tissues, and possibly to some extent by gravity, and the abscess may reach the surface at a considerable distance from its seat of origin. The best illustration of this is seen in the psoas abscess, which may originate in the dorsal vertebræ, extend downwards within the sheath of the psoas muscle, and finally appear in the thigh.

Clinical Features.—The insidious development of the tuberculous abscess is one of its characteristic features. The swelling may attain a considerable size without the patient being aware of its existence, and, as a matter of fact, it is often discovered accidentally. The absence of toxæmia is to be associated with the incapacity of the wall of the abscess to permit of absorption; this is shown also by the fact that when even a large quantity of iodoform is inserted into the cavity of the abscess, there are no symptoms of poisoning. The abscess varies in size from a small cherry to a cavity containing several pints of pus. Its shape also varies; it is usually that of a flattened sphere, but it may present pockets or burrows running in various directions. Sometimes it is hour-glass or dumb-bell shaped, as is well illustrated in the region of the groin in disease of the spine or pelvis, where there may be a large sac occupying the venter ilii, and a smaller one in the thigh, the two communicating by a narrow channel under Poupart's ligament. By pressing with the fingers the pus may be displaced from one compartment to the other. The usual course of events is that the abscess progresses slowly, and finally reaches a free surface—generally the skin. As it does so there may be some pain, redness, and local elevation of temperature. Fluctuation becomes evident and superficial, and the skin becomes livid and finally gives way. If the case is left to nature, the discharge of pus continues, and the track opening on the skin remains as a sinus. The persistence of suppuration is due to the presence in the wall of the abscess and of the sinus, of tuberculous granulation tissue, which, so long as it remains, continues to furnish discharge, and so prevents healing. Sooner or later pyogenic organisms gain access to the sinus, and through it to the wall of the abscess. They tend further to depress the resisting power of the tissues, and thereby aggravate and perpetuate the tuberculous disease. This superadded infection with pyogenic organisms exposes the patient to the further risks of septic intoxication, especially in the form of hectic fever and septicæmia, and increases the liability to general tuberculosis, and to waxy degeneration of the internal organs. The mixed infection is chiefly responsible for the pyrexia, sweating, and emaciation which the laity associate with consumptive disease. A tuberculous abscess may in one or other of these ways be a cause of death.

Residual abscess is the name given to an abscess that makes its appearance months, or even years, after the apparent cure of tuberculous disease—as, for example, in the hip-joint or spine. It is called residual because it has its origin in the remains of the original disease.

Diagnosis.—A cold abscess is to be diagnosed from a syphilitic gumma, a cyst, and from lipoma and other soft tumours. The differential diagnosis of these affections will be considered later; it is often made easier by recognising the presence of a lesion that is likely to cause a cold abscess, such as tuberculous disease of the spine or of the sacro-iliac joint. When it is about to burst externally, it may be difficult to distinguish a tuberculous abscess from one due to infection with pyogenic organisms. Even when the abscess is opened, the appearances of the pus may not supply the desired information, and it may be necessary to submit it to bacteriological examination. When the pus is found to be sterile, it is usually safe to assume that the condition is tuberculous, as in other forms of suppuration the causative organisms can usually be recognised. Experimental inoculation will establish a definite diagnosis, but it implies a delay of two to three weeks.

Treatment.—The tuberculous abscess may recede and disappear under general treatment. Many surgeons advise that so long as the abscess is quiescent it should be left alone. All agree, however, that if it shows a tendency to spread, to increase in size, or to approach the skin or a mucous membrane, something should be done to avoid the danger of its bursting and becoming infected with pyogenic organisms. Simple evacuation of the abscess by a hollow needle may suffice, or bismuth or iodoform may be introduced after withdrawal of the contents.

Evacuation of the Abscess and Injection of iodoform.—The iodoform is employed in the form of a 10 per cent. solution in ether or the same proportion suspended in glycerin. Either form becomes sterile soon after it is prepared. Its curative effects would appear to depend upon the liberation of iodine, which restrains the activity of the bacilli, and upon its capacity for irritating the tissues and so inducing a protective leucocytosis, and also of stimulating the formation of scar tissue. An anæsthetic is rarely called for, except in children. The abscess is first evacuated by means of a large trocar and cannula introduced obliquely through the overlying soft parts, avoiding any part where the skin is thin or red. If the cannula becomes blocked with caseous material, it may be cleared with a probe, or a small quantity of saline solution is forced in by the syringe. The iodoform is injected by means of a glass-barrelled syringe, which is firmly screwed on to the cannula. The amount injected varies with the size of the abscess and the age of the patient; it may be said to range from two or three drams in the case of children to several ounces in large abscesses in adults. The cannula is withdrawn, the puncture is closed by a Michel's clip, and a dressing applied so as to exert a certain amount of compression. If the abscess fills up again, the procedure should be repeated; in doing so, the contents show the coloration due to liberated iodine. When the contents are semi-solid, and cannot be withdrawn even through a large cannula, an incision must be made, and, after the cavity has been emptied, the iodoform is introduced through a short rubber tube attached to the syringe. Experience has shown that even large abscesses, such as those associated with spinal disease, may be cured by iodoform injection, and this even when rupture of the abscess on the skin surface has appeared to be imminent.

Another method of treatment which is less popular now than it used to be, and which is chiefly applicable in abscesses of moderate size, is by incision of the abscess and removal of the tuberculous tissue in its wall with the sharp spoon. An incision is made which will give free access to the interior of the abscess, so that outlying pockets or recesses may not be overlooked. After removal of the pus, the wall of the abscess is scraped with the Volkmann spoon or with Barker's flushing spoon, to get rid of the tuberculous tissue with which it is lined. In using the spoon, care must be taken that its sharp edge does not perforate the wall of a vein or other important structure. Any debris which may adhere to the walls is removed by rubbing with dry gauze. The oozing of blood is arrested by packing the cavity for a few minutes with gauze. After the packing is removed, iodoform powder is rubbed into the raw surface. The soft parts divided by the incision are sutured in layers so as to ensure primary union. If, on the other hand, there is fear of a mixed infection, especially in abscesses near the rectum or anus, it is safer to treat it by the open method, packing the cavity with iodoform worsted or bismuth gauze, which is renewed at intervals of a week or ten days as the cavity heals from the bottom.

Another method is to incise the abscess, cleanse the cavity with gauze, irrigate with Carrel-Dakin solution and pack with gauze smeared with the dilute non-toxic B.I.P.P. (bismuth and iodoform 2 parts, vaseline 12 parts, hard paraffin, sufficient to give the consistence of butter). The wound is closed with “bipped” silk sutures; one of these—the “waiting suture”—is left loose to permit of withdrawal of the gauze after forty-eight hours; the waiting suture is then tied, and delayed primary union is thus effected.

When the skin over the abscess is red, thin, and about to give way, as is frequently the case when the abscess is situated in the subcutaneous cellular tissue, any skin which is undermined and infected with tubercle should be removed with the scissors at the same time that the abscess is dealt with.

In abscesses treated by the open method, when the cavity has become lined with healthy granulations, it may be closed by secondary suture, or, if the granulating surface is flush with the skin, healing may be hastened by skin-grafting.

If the tuberculous abscess has burst and left a sinus, this is apt to persist because of the presence of tuberculous tissue in its wall, and of superadded pyogenic infection, or because it serves as an avenue for the escape of discharge from a focus of tubercle in a bone or a lymph gland.

The treatment varies with the conditions present, and must include measures directed to the lesion from which the sinus has originated. The extent and direction of any given sinus may be demonstrated by the use of the probe, or, more accurately, by injecting the sinus with a paste consisting of white vaseline containing 10 to 30 per cent. of bismuth subcarbonate, and following its track with the X-rays (Fig. 35).

It was found by Beck of Chicago that the injection of bismuth paste is frequently followed by healing of the sinus, and that, if one injection fails to bring about a cure, repeating the injection every second day may be successful. Some caution must be observed in this treatment, as symptoms of poisoning have been observed to follow its use. If they manifest themselves, an injection of warm olive oil should be given; the oil, left in for twelve hours or so, forms an emulsion with the bismuth, which can be withdrawn by aspiration. Iodoform suspended in glycerin may be employed in a similar manner. When these and other non-operative measures fail, and the whole track of the sinus is accessible, it should be laid open, scraped, and packed with bismuth or iodoform gauze until it heals from the bottom.

The tuberculous ulcer is described in the chapter on ulcers.

Syphilis is an infective disease due to the entrance into the body of a specific virus. It is nearly always communicated from one individual to another by contact infection, the discharge from a syphilitic lesion being the medium through which the virus is transmitted, and the seat of inoculation is almost invariably a surface covered by squamous epithelium. The disease was unknown in Europe before the year 1493, when it was introduced into Spain by Columbus' crew, who were infected in Haiti, where the disease had been endemic from time immemorial (Bloch).

The granulation tissue which forms as a result of the reaction of the tissues to the presence of the virus is chiefly composed of lymphocytes and plasma cells, along with an abundant new formation of capillary blood vessels. Giant cells are not uncommon, but the endothelioid cells, which are so marked a feature of tuberculous granulation tissue, are practically absent.

When syphilis is communicated from one individual to another by contact infection, the condition is spoken of as acquired syphilis, and the first visible sign of the disease appears at the site of inoculation, and is known as the primary lesion. Those who have thus acquired the disease may transmit it to their offspring, who are then said to suffer from inherited syphilis.

The Virus of Syphilis.—The cause of syphilis, whether acquired or inherited, is the organism, described by Schaudinn and Hoffman, in 1905, under the name of spirochæta pallida or spironema pallidum. It is a delicate, thread-like spirilla, in length averaging from 8 to 10 µ and in width about 0.25 µ, and is distinguished from other spirochætes by its delicate shape, its dead-white appearance, together with its closely twisted spiral form, with numerous undulations (10 to 26), which are perfectly regular, and are characteristic in that they remain the same during rest and in active movement (Fig. 36). In a fresh specimen, such as a scraping from a hard chancre suspended in a little salt solution, it shows active movements. The organism is readily destroyed by heat, and perishes in the absence of moisture. It has been proved experimentally that it remains infective only up to six hours after its removal from the body. Noguchi has succeeded in obtaining pure cultures from the infected tissues of the rabbit.

The spirochæte may be recognised in films made by scraping the deeper parts of the primary lesion, from papules on the skin, or from blisters artificially raised on lesions of the skin or on the immediately adjacent portion of healthy skin. It is readily found in the mucous patches and condylomata of the secondary period. It is best stained by Giemsa's method, and its recognition is greatly aided by the use of the ultra-microscope.

The spirochæte has been demonstrated in every form of syphilitic lesion, and has been isolated from the blood—with difficulty—and from lymph withdrawn by a hollow needle from enlarged lymph glands. The saliva of persons suffering from syphilitic lesions of the mouth also contains the organism.

In tertiary lesions there is greater difficulty in demonstrating the spirochæte, but small numbers have been found in the peripheral parts of gummata and in the thickened patches in syphilitic disease of the aorta. Noguchi and Moore have discovered the spirochæte in the brain in a number of cases of general paralysis of the insane. The spirochæte may persist in the body for a long time after infection; its presence has been demonstrated as long as sixteen years after the original acquisition of the disease.

In inherited syphilis the spirochæte is present in enormous numbers throughout all the organs and fluids of the body.

Considerable interest attaches to the observations of Metchnikoff, Roux, and Neisser, who have succeeded in conveying syphilis to the chimpanzee and other members of the ape tribe, obtaining primary and secondary lesions similar to those observed in man, and also containing the spirochæte. In animals the disease has been transmitted by material from all kinds of syphilitic lesions, including even the blood in the secondary and tertiary stages of the disease. The primary lesion is in the form of an indurated papule, in every respect resembling the corresponding lesion in man, and associated with enlargement and induration of the lymph glands. The primary lesion usually appears about thirty days after inoculation, to be followed, in about half the cases, by secondary manifestations, which are usually of a mild character; in no instance has any tertiary lesion been observed. The severity of the affection amongst apes would appear to be in proportion to the nearness of the relationship of the animal to the human subject. The eye of the rabbit is also susceptible to inoculation from syphilitic lesions; the material in a finely divided state is introduced into the anterior chamber of the eye.

Attempts to immunise against the disease have so far proved negative, but Metchnikoff has shown that the inunction of the part inoculated with an ointment containing 33 per cent. of calomel, within one hour of infection, suffices to neutralise the virus in man, and up to eighteen hours in monkeys. He recommends the adoption of this procedure in the prophylaxis of syphilis.

Noguchi has made an emulsion of dead spirochætes which he calls luetin, and which gives a specific reaction resembling that of tuberculin in tuberculosis, a papule or a pustule forming at the site of the intra-dermal injection. It is said to be most efficacious in the tertiary and latent forms of syphilis, which are precisely those forms in which the diagnosis is surrounded with difficulties.

In the vast majority of cases, infection takes place during the congress of the sexes. Delicate, easily abraded surfaces are then brought into contact, and the discharge from lesions containing the virus is placed under favourable conditions for conveying the disease from one person to the other. In the male the possibility of infection taking place is increased if the virus is retained under cover of a long and tight prepuce, and if there are abrasions on the surface with which it comes in contact. The frequency with which infection takes place on the genitals during sexual intercourse warrants syphilis being considered a venereal disease, although there are other ways in which it may be contracted.

Some of these imply direct contact—such, for example, as kissing, the digital examination of syphilitic patients by doctors or nurses, or infection of the surgeon's fingers while operating upon a syphilitic patient. In suckling, a syphilitic wet nurse may infect a healthy infant, or a syphilitic infant may infect a healthy wet nurse. In other cases the infection is by indirect contact, the virus being conveyed through the medium of articles contaminated by a syphilitic patient—such, for example, as surgical instruments, tobacco pipes, wind instruments, table utensils, towels, or underclothing. Physiological secretions, such as saliva, milk, or tears, are not capable of communicating the disease unless contaminated by discharge from a syphilitic sore. While the saliva itself is innocuous, it can be, and often is, contaminated by the discharge from mucous patches or other syphilitic lesions in the mouth and throat, and is then a dangerous medium of infection. Unless these extra-genital sources of infection are borne in mind, there is a danger of failing to recognise the primary lesion of syphilis in unusual positions, such as the lip, finger, or nipple. When the disease is thus acquired by innocent transfer, it is known as syphilis insontium.

Stages or Periods of Syphilis.—Following the teaching of Ricord, it is customary to divide the life-history of syphilis into three periods or stages, referred to, for convenience, as primary, secondary, and tertiary. This division is to some extent arbitrary and artificial, as the different stages overlap one another, and the lesions of one stage merge insensibly into those of another. Wide variations are met with in the manifestations of the secondary stage, and histologically there is no valid distinction to be drawn between secondary and tertiary lesions.

The primary period embraces the interval that elapses between the initial infection and the first constitutional manifestations,—roughly, from four to eight weeks,—and includes the period of incubation, the development of the primary sore, and the enlargement of the nearest lymph glands.

The secondary period varies in duration from one to two years, during which time the patient is liable to suffer from manifestations which are for the most part superficial in character, affecting the skin and its appendages, the mucous membranes, and the lymph glands.

The tertiary period has no time-limit except that it follows upon the secondary, so that during the remainder of his life the patient is liable to suffer from manifestations which may affect the deeper tissues and internal organs as well as the skin and mucous membranes.

Primary Syphilis.—The period of incubation represents the interval that elapses between the occurrence of infection and the appearance of the primary lesion at the site of inoculation. Its limits may be stated as varying from two to six weeks, with an average of from twenty-one to twenty-eight days. While the disease is incubating, there is nothing to show that infection has occurred.

The Primary Lesion.—The incubation period having elapsed, there appears at the site of inoculation a circumscribed area of infiltration which represents the reaction of the tissues to the entrance of the virus. The first appearance is that of a sharply defined papule, rarely larger than a split pea. Its surface is at first smooth and shiny, but as necrosis of the tissue elements takes place in the centre, it becomes concave, and in many cases the epithelium is shed, and an ulcer is formed. Such an ulcer has an elevated border, sharply cut edges, an indurated base, and exudes a scanty serous discharge; its surface is at first occupied by yellow necrosed tissue, but in time this is replaced by smooth, pale-pink granulation tissue; finally, epithelium may spread over the surface, and the ulcer heals. As a rule, the patient suffers little discomfort, and may even be ignorant of the existence of the lesion, unless, as a result of exposure to mechanical or septic irritation, ulceration ensues, and the sore becomes painful and tender, and yields a purulent discharge. The primary lesion may persist until the secondary manifestations make their appearance, that is, for several weeks.

It cannot be emphasised too strongly that the induration of the primary lesion, which has obtained for it the name of “hard chancre,” is its most important characteristic. It is best appreciated when the sore is grasped from side to side between the finger and thumb. The sensation on grasping it has been aptly compared to that imparted by a nodule of cartilage, or by a button felt through a layer of cloth. The evidence obtained by touch is more valuable than that obtained by inspection, a fact which is made use of in the recognition of concealed chancres—that is, those which are hidden by a tight prepuce. The induration is due not only to the dense packing of the connective-tissue spaces with lymphocytes and plasma cells, but also to the formation of new connective-tissue elements. It is most marked in chancres situated in the furrow between the glans and the prepuce.

In the male, the primary lesion specially affects certain situations, and the appearances vary with these: (1) On the inner aspect of the prepuce, and in the fold between the prepuce and the glans; in the latter situation the induration imparts a “collar-like” rigidity to the prepuce, which is most apparent when it is rolled back over the corona. (2) At the orifice of the prepuce the primary lesion assumes the form of multiple linear ulcers or fissures, and as each of these is attended with infiltration, the prepuce cannot be pulled back—a condition known as syphilitic phimosis. (3) On the glans penis the infiltration may be so superficial that it resembles a layer of parchment, but if it invades the cavernous tissue there is a dense mass of induration. (4) On the external aspect of the prepuce or on the skin of the penis itself. (5) At either end of the torn frænum, in the form of a diamond-shaped ulcer raised above the surroundings. (6) In relation to the meatus and canal of the urethra, in either of which situations the swelling and induration may lead to narrowing of the urethra, so that the urine is passed with pain and difficulty and in a minute stream; stricture results only in the exceptional cases in which the chancre has ulcerated and caused destruction of tissue. A chancre within the orifice of the urethra is rare, and, being concealed from view, it can only be recognised by the discharge from the meatus and by the induration felt between the finger and thumb on palpating the urethra.

In the female, the primary lesion is not so typical or so easily recognised as in men; it is usually met with on the labia; the induration is rarely characteristic and does not last so long. The primary lesion may take the form of condylomata. Indurated œdema, with brownish-red or livid discoloration of one or both labia, is diagnostic of syphilis.

The hard chancre is usually solitary, but sometimes there are two or more; when there are several, they are individually smaller than the solitary chancre.

It is the exception for a hard chancre to leave a visible scar, hence, in examining patients with a doubtful history of syphilis, little reliance can be placed on the presence or absence of a scar on the genitals. When the primary lesion has taken the form of an open ulcer with purulent discharge, or has sloughed, there is a permanent scar.

Infection of the adjacent lymph glands is usually found to have taken place by the time the primary lesion has acquired its characteristic induration. Several of the glands along Poupart's ligament, on one or on both sides, become enlarged, rounded, and indurated; they are usually freely movable, and are rarely sensitive unless there is superadded septic infection. The term bullet-bubo has been applied to them, and their presence is of great value in diagnosis. In a certain number of cases, one of the main lymph vessels on the dorsum of the penis is transformed into a fibrous cord easily recognisable on palpation, and when grasped between the fingers appears to be in size and consistence not unlike the vas deferens.

Concealed chancre is the term applied when one or more chancres are situated within the sac of a prepuce which cannot be retracted. If the induration is well marked, the chancre can be palpated through the prepuce, and is tender on pressure. As under these conditions it is impossible for the patient to keep the parts clean, septic infection becomes a prominent feature, the prepuce is œdematous and inflamed, and there is an abundant discharge of pus from its orifice. It occasionally happens that the infection assumes a virulent character and causes sloughing of the prepuce—a condition known as phagedæna. The discharge is then foul and blood-stained, and the prepuce becomes of a dusky red or purple colour, and may finally slough, exposing the glans.

Extra-genital or Erratic Chancres (Fig. 38).—Erratic chancre is the term applied by Jonathan Hutchinson to the primary lesion of syphilis when it appears on parts of the body other than the genitals. It differs in some respects from the hard chancre as met with on the penis; it is usually larger, the induration is more diffused, and the enlarged glands are softer and more sensitive. The glands in nearest relation to the sore are those first affected, for example, the epitrochlear or axillary glands in chancre of the finger; the submaxillary glands in chancre of the lip or mouth; or the pre-auricular gland in chancre of the eyelid or forehead. In consequence of their divergence from the typical chancre, and of their being often met with in persons who, from age, surroundings, or moral character, are unlikely subjects of venereal disease, the true nature of erratic chancres is often overlooked until the persistence of the lesion, its want of resemblance to anything else, or the onset of constitutional symptoms, determines the diagnosis of syphilis. A solitary, indolent sore occurring on the lip, eyelid, finger, or nipple, which does not heal but tends to increase in size, and is associated with induration and enlargement of the adjacent glands, is most likely to be the primary lesion of syphilis.

[1] From A System of Syphilis, vol. ii., edited by D'Arcy Power and J. Keogh Murphy, Oxford Medical Publications.

The Soft Sore, Soft Chancre, or Chancroid.—The differential diagnosis of syphilis necessitates the consideration of the soft sore, soft chancre, or chancroid, which is also a common form of venereal disease, and is due to infection with a virulent pus-forming bacillus, first described by Ducrey in 1889. Ducrey's bacillus occurs in the form of minute oval rods measuring about 1.5 µ in length, which stain readily with any basic aniline dye, but are quickly decolorised by Gram's method. They are found mixed with other organisms in the purulent discharge from the sore, and are chiefly arranged in small groups or in short chains. Soft sores are always contracted by direct contact from another individual, and the incubation period is a short one of from two to five days. They are usually situated in the vicinity of the frænum, and, in women, about the labia minora or fourchette; they probably originate in abrasions in these situations. They appear as pustules, which are rapidly converted into small, acutely inflamed ulcers with sharply cut, irregular margins, which bleed easily and yield an abundant yellow purulent discharge. They are devoid of the induration of syphilis, are painful, and nearly always multiple, reproducing themselves in successive crops by auto-inoculation. Soft sores are often complicated by phimosis and balanitis, and they frequently lead to infection of the glands in the groin. The resulting bubo is ill-defined, painful, and tender, and suppuration occurs in about one-fourth of the cases. The overlying skin becomes adherent and red, and suppuration takes place either in the form of separate foci in the interior of the individual glands, or around them; in the latter case, on incision, the glands are found lying bathed in pus. Ducrey's bacillus is found in pure culture in the pus. Sometimes other pyogenic organisms are superadded. After the bubo has been opened the wound may take on the characters of a soft sore.

Treatment.—Soft sores heal rapidly when kept clean. If concealed under a tight prepuce, an incision should be made along the dorsum to give access to the sores. They should be washed with eusol, and dusted with a mixture of one part iodoform and two parts boracic or salicylic acid, or, when the odour of iodoform is objected to, of equal parts of boracic acid and carbonate of zinc. Immersion of the penis in a bath of eusol for some hours daily is useful. The sore is then covered with a piece of gauze kept in position by drawing the prepuce over it, or by a few turns of a narrow bandage. Sublimed sulphur frequently rubbed into the sore is recommended by C. H. Mills. If the sores spread in spite of this, they should be painted with cocaine and then cauterised. When the glands in the groin are infected, the patient must be confined to bed, and a dressing impregnated with ichthyol and glycerin (10 per cent.) applied; the repeated use of a suction bell is of great service. Harrison recommends aspiration of a bubonic abscess, followed by injection of 1 in 20 solution of tincture of iodine into the cavity; this is in turn aspirated, and then 1 or 2 c.c. of the solution injected and left in. This is repeated as often as the cavity refills. It is sometimes necessary to let the pus out by one or more small incisions and continue the use of the suction bell.

Diagnosis of Primary Syphilis.—In cases in which there is a history of an incubation period of from three to five weeks, when the sore is indurated, persistent, and indolent, and attended with bullet-buboes in the groin, the diagnosis of primary syphilis is not difficult. Owing, however, to the great importance of instituting treatment at the earliest possible stage of the infection, an effort should be made to establish the diagnosis without delay by demonstrating the spirochæte. Before any antiseptic is applied, the margin of the suspected sore is rubbed with gauze, and the serum that exudes on pressure is collected in a capillary tube and sent to a pathologist for microscopical examination. A better specimen can sometimes be obtained by puncturing an enlarged lymph gland with a hypodermic needle, injecting a few minims of sterile saline solution and then aspirating the blood-stained fluid.

The Wassermann test must not be relied upon for diagnosis in the early stage, as it does not appear until the disease has become generalised and the secondary manifestations are about to begin. The practice of waiting in doubtful cases before making a diagnosis until secondary manifestations appear is to be condemned.

Extra-genital chancres, e.g. sores on the fingers of doctors or nurses, are specially liable to be overlooked, if the possibility of syphilis is not kept in mind.

It is important to bear in mind the possibility of a patient having acquired a mixed infection with the virus of soft chancre, which will manifest itself a few days after infection, and the virus of syphilis, which shows itself after an interval of several weeks. This occurrence was formerly the source of much confusion in diagnosis, and it was believed at one time that syphilis might result from soft sores, but it is now established that syphilis does not follow upon soft sores unless the virus of syphilis has been introduced at the same time. The practitioner must be on his guard, therefore, when a patient asks his advice concerning a venereal sore which has appeared within a few days of exposure to infection. Such a patient is naturally anxious to know whether he has contracted syphilis or not, but neither a positive nor a negative answer can be given—unless the spirochæte can be identified.

Syphilis is also to be diagnosed from epithelioma, the common form of cancer of the penis. It is especially in elderly patients with a tight prepuce that the induration of syphilis is liable to be mistaken for that associated with epithelioma. In difficult cases the prepuce must be slit open.

Difficulty may occur in the diagnosis of primary syphilis from herpes, as this may appear as late as ten days after connection; it commences as a group of vesicles which soon burst and leave shallow ulcers with a yellow floor; these disappear quickly on the use of an antiseptic dusting powder.

Apprehensive patients who have committed sexual indiscretions are apt to regard as syphilitic any lesion which happens to be located on the penis—for example, acne pustules, eczema, psoriasis papules, boils, balanitis, or venereal warts.

The local treatment of the primary sore consists in attempting to destroy the organisms in situ. An ointment made up of calomel 33 parts, lanoline 67 parts, and vaseline 10 parts (Metchnikoff's cream) is rubbed into the sore several times a day. If the surface is unbroken, it may be dusted lightly with a powder composed of equal parts of calomel and carbonate of zinc. A gauze dressing is applied, and the penis and scrotum should be supported against the abdominal wall by a triangular handkerchief or bathing-drawers; if there is inflammatory œdema the patient should be confined to bed.

In concealed chancres with phimosis, the sac of the prepuce should be slit up along the dorsum to admit of the ointment being applied. If phagedæna occurs, the prepuce must be slit open along the dorsum, or if sloughing, cut away, and the patient should have frequent sitz baths of weak sublimate lotion. When the chancre is within the meatus, iodoform bougies are inserted into the urethra, and the urine should be rendered bland by drinking large quantities of fluid.

General treatment is considered on p. 149.

Secondary Syphilis.—The following description of secondary syphilis is based on the average course of the disease in untreated cases. The onset of constitutional symptoms occurs from six to twelve weeks after infection, and the manifestations are the result of the entrance of the virus into the general circulation, and its being carried to all parts of the body. The period during which the patient is liable to suffer from secondary symptoms ranges from six months to two years.

In some cases the general health is not disturbed; in others the patient is feverish and out of sorts, losing appetite, becoming pale and anæmic, complaining of lassitude, incapacity for exertion, headache, and pains of a rheumatic type referred to the bones. There is a moderate degree of leucocytosis, but the increase is due not to the polymorpho-nuclear leucocytes but to lymphocytes. In isolated cases the temperature rises to 101° or 102° F. and the patient loses flesh. The lymph glands, particularly those along the posterior border of the sterno-mastoid, become enlarged and slightly tender. The hair comes out, eruptions appear on the skin and mucous membranes, and the patient may suffer from sore throat and affections of the eyes. The local lesions are to be regarded as being of the nature of reactions against accumulations of the parasite, lymphocytes and plasma cells being the elements chiefly concerned in the reactive process.

Affections of the Skin are among the most constant manifestations. An evanescent macular rash, not unlike that of measles—roseola—is the first to appear, usually in from six to eight weeks from the date of infection; it is widely diffused over the trunk, and the original dull rose-colour soon fades, leaving brownish stains, which in time disappear. It is usually followed by a papular eruption, the individual papules being raised above the surface of the skin, smooth or scaly, and as they are due to infiltration of the skin they are more persistent than the roseoles. They vary in size and distribution, being sometimes small, hard, polished, and closely aggregated like lichen, sometimes as large as a shilling-piece, with an accumulation of scales on the surface like that seen in psoriasis. The co-existence of scaly papules and faded roseoles is very suggestive of syphilis.

Other types of eruption are less common, and are met with from the third month onwards. A pustular eruption, not unlike that of acne, is sometimes a prominent feature, but is not characteristic of syphilis unless it affects the scalp and forehead and is associated with the remains of the papular eruption. The term ecthyma is applied when the pustules are of large size, and, after breaking on the surface, give rise to superficial ulcers; the discharge from the ulcer often dries up and forms a scab or crust which is continually added to from below as the ulcer extends in area and depth. The term rupia is applied when the crusts are prominent, dark in colour, and conical in shape, roughly resembling the shell of a limpet. If the crust is detached, a sharply defined ulcer is exposed, and when this heals it leaves a scar which is usually circular, thin, white, shining like satin, and the surrounding skin is darkly pigmented; in the case of deep ulcers, the scar is depressed and adherent (Fig. 39).

In the later stages there may occur a form of creeping or spreading ulceration of the skin of the face, groin, or scrotum, healing at one edge and spreading at another like tuberculous lupus, but distinguished from this by its more rapid progress and by the pigmentation of the scar.

Condylomata are more characteristic of syphilis than any other type of skin lesion. They are papules occurring on those parts of the body where the skin is habitually moist, and especially where two skin surfaces are in contact. They are chiefly met with on the external genitals, especially in women, around the anus, beneath large pendulous mammæ, between the toes, and at the angles of the mouth, and in these situations their development is greatly favoured by neglect of cleanliness. They present the appearance of well-defined circular or ovoid areas in which the skin is thickened and raised above the surface; they are covered with a white sodden epidermis, and furnish a scanty but very infective discharge. Under the influence of irritation and want of rest, as at the anus or at the angle of the mouth, they are apt to become fissured and superficially ulcerated, and the discharge then becomes abundant and may crust on the surface, forming yellow scabs. At the angle of the mouth the condylomatous patches may spread to the cheek, and when they ulcerate may leave fissure-like scars radiating from the mouth—an appearance best seen in inherited syphilis (Fig. 44).

The Appendages of the Skin.—The hair loses its gloss, becomes dry and brittle, and readily falls out, either as an exaggeration of the normal shedding of the hair, or in scattered areas over the scalp (syphilitic alopœcia). The hair is not re-formed in the scars which result from ulcerated lesions of the scalp. The nail-folds occasionally present a pustular eruption and superficial ulceration, to which the name syphilitic onychia has been applied; more commonly the nails become brittle and ragged, and they may even be shed.

The Mucous Membranes, and especially those of the mouth and throat, suffer from lesions similar to those met with on the skin. On a mucous surface the papular eruption assumes the form of mucous patches, which are areas with a congested base covered with a thin white film of sodden epithelium like wet tissue-paper. They are best seen on the inner aspect of the cheeks, the soft palate, uvula, pillars of the fauces, and tonsils. In addition to mucous patches, there may be a number of small, superficial, kidney-shaped ulcers, especially along the margins of the tongue and on the tonsils. In the absence of mucous patches and ulcers, the sore throat may be characterised by a bluish tinge of the inflamed mucous membrane and a thin film of shed epithelium on the surface. Sometimes there is an elongated sinuous film which has been likened to the track of a snail. In the larynx the presence of congestion, œdema, and mucous patches may be the cause of persistent hoarseness. The tongue often presents a combination of lesions, including ulcers, patches where the papillæ are absent, fissures, and raised white papules resembling warts, especially towards the centre of the dorsum. These lesions are specially apt to occur in those who smoke, drink undiluted alcohol or spirits, or eat hot condiments to excess, or who have irregular, sharp-cornered teeth. At a later period, and in those who are broken down in health from intemperance or other cause, the sore throat may take the form of rapidly spreading, penetrating ulcers in the soft palate and pillars of the fauces, which may lead to extensive destruction of tissue, with subsequent scars and deformity highly characteristic of previous syphilis.

In the Bones, lesions occur which assume the clinical features of an evanescent periostitis, the patient complaining of nocturnal pains over the frontal bone, sternum, tibiæ, and ulnæ, and localised tenderness on tapping over these bones.

In the Joints, a serous synovitis or hydrops may occur, chiefly in the knee, on one or on both sides.

The Affections of the Eyes, although fortunately rare, are of great importance because of the serious results which may follow if they are not recognised and treated. Iritis is the commonest of these, and may occur in one or in both eyes, one after the other, from three to eight months after infection. The patient complains of impairment of sight and of frontal or supraorbital pain. The eye waters and is hypersensitive, the iris is discoloured and reacts sluggishly to light, and there is a zone of ciliary congestion around the cornea. The appearance of minute white nodules or flakes of lymph at the margin of the pupil is especially characteristic of syphilitic iritis. When adhesions have formed between the iris and the structures in relation to it, the pupil dilates irregularly under atropin. Although complete recovery is to be expected under early and energetic treatment, if neglected, iritis may result in occlusion of the pupil and permanent impairment or loss of sight.

The other lesions of the eye are much rarer, and can only be discovered on ophthalmoscopic examination.

The virus of syphilis exerts a special influence upon the Blood Vessels, exciting a proliferation of the endothelial lining which results in narrowing of their lumen, endarteritis, and a perivascular infiltration in the form of accumulations of plasma cells around the vessels and in the lymphatics that accompany them.

In the Brain, in the later periods of secondary and in tertiary syphilis, changes occur as a result of the narrowing of the lumen of the arteries, or of their complete obliteration by thrombosis. By interfering with the nutrition of those parts of the brain supplied by the affected arteries, these lesions give rise to clinical features of which severe headache and paralysis are the most prominent.

Affections of the Spinal Cord are extremely rare, but paraplegia from myelitis has been observed.

Lastly, attention must be directed to the remarkable variations observed in different patients. Sometimes the virulent character of the disease can only be accounted for by an idiosyncrasy of the patient. Constitutional symptoms, particularly pyrexia and anæmia, are most often met with in young women. Patients over forty years of age have greater difficulty in overcoming the infection than younger adults. Malarial and other infections, and the conditions attending life in tropical countries, from the debility which they cause, tend to aggravate and prolong the disease, which then assumes the characters of what has been called malignant syphilis. All chronic ailments have a similar influence, and alcoholic intemperance is universally regarded as a serious aggravating factor.

Diagnosis of Secondary Syphilis.—A routine examination should be made of the parts of the body which are most often affected in this disease—the scalp, mouth, throat, posterior cervical glands, and the trunk, the patient being stripped and examined by daylight. Among the diagnostic features of the skin affections the following may be mentioned: They are frequently, and sometimes to a marked degree, symmetrical; more than one type of eruption—papules and pustules, for example—are present at the same time; there is little itching; they are at first a dull-red colour, but later present a brown pigmentation which has been likened to the colour of raw ham; they exhibit a predilection for those parts of the forehead and neck which are close to the roots of the hair; they tend to pass off spontaneously; and they disappear rapidly under treatment.

Serum Diagnosis—Wassermann Reaction.—Wassermann found that if an extract of syphilitic liver rich in spirochætes is mixed with the serum from a syphilitic patient, a large amount of complement is fixed. The application of the test is highly complicated and can only be carried out by an expert pathologist. For the purpose he is supplied with from 5 c.c. to 10 c.c. of the patient's blood, withdrawn under aseptic conditions from the median basilic vein by means of a serum syringe, and transferred to a clean and dry glass tube. There is abundant evidence that the Wassermann test is a reliable means of establishing a diagnosis of syphilis.

A definitely positive reaction can usually be obtained between the fifteenth and thirtieth day after the appearance of the primary lesion, and as time goes on it becomes more marked. During the secondary period the reaction is practically always positive. In the tertiary stage also it is positive except in so far as it is modified by the results of treatment. In para-syphilitic lesions such as general paralysis and tabes a positive reaction is almost always present. In inherited syphilis the reaction is positive in every case. A positive reaction may be present in other diseases, for example, frambesia, trypanosomiasis, and leprosy.

As the presence of the reaction is an evidence of the activity of the spirochætes, repeated applications of the test furnish a valuable means of estimating the efficacy of treatment. The object aimed at is to change a persistently positive reaction to a permanently negative one.

Treatment of Syphilis.—In the treatment of syphilis the two main objects are to maintain the general health at the highest possible standard, and to introduce into the system therapeutic agents which will inhibit or destroy the invading parasite.

The second of these objects has been achieved by the researches of Ehrlich, who, in conjunction with his pupil, Hata, has built up a compound, the dihydrochloride of dioxydiamido-arseno-benzol, popularly known as salvarsan or “606.” Other preparations, such as kharsivan, arseno-billon, and diarsenol, are chemically equivalent to salvarsan, containing from 27 to 31 per cent. of arsenic, and are equally efficient. The full dose is 0.6 grm. All these members of the “606” group form an acid solution when dissolved in water, and must be rendered alkaline before being injected. As subcutaneous and intra-muscular injections cause considerable pain, and may cause sloughing of the tissues, “606” preparations must be injected intravenously. Ehrlich has devised a preparation—neo-salvarsan, or “914,” which is more easily prepared and forms a neutral solution. It contains from 18 to 20 per cent. of arsenic. Neo-kharsivan, novo-arseno-billon, and neo-diarsenol belong to the “914” group, the full dosage of which is 0.9 grm. As subcutaneous and intra-muscular injections of the “914” group are not painful, and even more efficient than intravenous injections, the administration is simpler.

Galyl, luargol, and other preparations act in the same way as the “606” and “914” groups.

The “606” preparations may be introduced into the veins by injection or by means of an apparatus which allows the solution to flow in by gravity. The left median basilic vein is selected, and a platino-iridium needle with a short point and a bore larger than that of the ordinary hypodermic syringe is used. The needle is passed for a few millimetres along the vein, and the solution is then slowly introduced; before withdrawing the needle some saline is run in to diminish the risk of thrombosis.

The “914” preparations may be injected either into the subcutaneous tissue of the buttock or into the substance of the gluteus muscle. The part is then massaged for a few minutes, and the massage is repeated daily for a few days.

No hard-and-fast rules can be laid down as to what constitutes a complete course of treatment. Harrison recommends as a minimum course of one of the “914” preparations in early primary cases an initial dose of 0.45 grm. given intra-muscularly or into the deep subcutaneous tissue; the same dose a week later; 0.6 grm. the following week; then miss a week and give 9.6 grms. on two successive weeks; then miss two weeks and give 0.6 grm. on two more successive weeks.

When a positive Wassermann reaction is present before treatment is commenced, the above course is prolonged as follows: for three weeks is given a course of potassium iodide, after which four more weekly injections of 0.6 grm. of “914” are given.

With each injection of “914” after the first, throughout the whole course 1 grain of mercury is injected intra-muscularly.

In the course of a few hours, there is usually some indisposition, with a feeling of chilliness and slight rise of temperature; these symptoms pass off within twenty-four hours, and in a few days there is a decided improvement of health. Three or four days after an intra-muscular injection there may be pain and stiffness in the gluteal region.

These preparations are the most efficient therapeutic agents that have yet been employed in the treatment of syphilis.

The manifestations of the disease disappear with remarkable rapidity. Observations show that the spirochætes lose their capacity for movement within an hour or two of the administration, and usually disappear altogether in from twenty-four to thirty-six hours. Wassermann's reaction usually yields a negative result in from three weeks to two months, but later may again become positive. Subsequent doses of the arsenical preparation are therefore usually indicated, and should be given in from 7 to 21 days according to the dose.

When syphilis occurs in a pregnant woman, she should be given in the early months an ordinary course of “914,” followed by 10-grain doses of potassium iodide twice daily. The injections may be repeated two months later, and during the remainder of the pregnancy 2-grain mercury pills are given twice daily (A. Campbell). The presence of albumen in the urine contra-indicates arsenical treatment.

It need scarcely be pointed out that the use of powerful drugs like “606” and “914” is not free from risk; it may be mentioned that each dose contains nearly three grains of arsenic. Before the administration the patient must be overhauled; its administration is contra-indicated in the presence of disease of the heart and blood vessels, especially a combination of syphilitic aortitis and sclerosis of the coronary arteries, with degeneration of the heart muscle; in affections of the central nervous system, especially advanced paralysis, and in such disturbances of metabolism as are associated with diabetes and Bright's disease. Its use is not contra-indicated in any lesion of active syphilis.

The administration is controlled by the systematic examination of the urine for arsenic.

The Administration of Mercury.—The success of the arsenical preparations has diminished the importance of mercury in the treatment of syphilis, but it is still used to supplement the effect of the injections. The amount of mercury to be given in any case must be proportioned to the idiosyncrasies of the patient, and it is advisable, before commencing the treatment, to test his urine and record his body-weight. The small amount of mercury given at the outset is gradually increased. If the body-weight falls, or if the gums become sore and the breath foul, the mercury should be stopped for a time. If salivation occurs, the drinking of hot water and the taking of hot baths should be insisted upon, and half-dram doses of the alkaline sulphates prescribed.

Methods of Administering Mercury.—(1) By the Mouth.—This was for long the most popular method in this country, the preparation usually employed being grey powder, in pills or tablets, each of which contains one grain of the powder. Three of these are given daily in the first instance, and the daily dose is increased to five or even seven grains till the standard for the individual patient is arrived at. As the grey powder alone sometimes causes irritation of the bowels, it should be combined with iron, as in the following formula: Hydrarg. c. cret. gr. 1; ferri sulph. exsiccat. gr. 1 or 2.

(2) By Inunction.—Inunction consists in rubbing into the pores of the skin an ointment composed of equal parts of 20 per cent. oleate of mercury and lanolin. Every night after a hot bath, a dram of the ointment (made up by the chemist in paper packets) is rubbed for fifteen minutes into the skin where it is soft and comparatively free from hairs. When the patient has been brought under the influence of the mercury, inunction may be replaced by one of the other methods, of administering the drug.

(3) By Intra-muscular Injection.—This consists in introducing the drug by means of a hypodermic syringe into the substance of the gluteal muscles. The syringe is made of glass, and has a solid glass piston; the needle of platino-iridium should be 5 cm. long and of a larger calibre than the ordinary hypodermic needle. The preparation usually employed consists of: metallic mercury or calomel 1 dram, lanolin and olive oil each 2 drams; it must be warmed to allow of its passage through the needle. Five minims—containing one grain of metallic mercury—represent a dose, and this is injected into the muscles above and behind the great trochanter once a week. The contents of the syringe are slowly expressed, and, after withdrawing the needle, gentle massage of the buttock should be employed. Four courses each of ten injections are given the first year, three courses of the same number during the second and third years, and two courses during the fourth year (Lambkin).

The General Health.—The patient must lead a regular life and cultivate the fresh-air habit, which is as beneficial in syphilis as in tuberculosis. Anæmia, malaria, and other sources of debility must receive appropriate treatment. The diet should be simple and easily digested, and should include a full supply of milk. Alcohol is prohibited. The excretory organs are encouraged to act by the liberal drinking of hot water between meals, say five or six tumblerfuls in the twenty-four hours. The functions of the skin are further aided by frequent hot baths, and by the wearing of warm underclothing. While the patient should avoid exposure to cold, and taxing his energies by undue exertion, he should be advised to take exercise in the open air. On account of the liability to lesions of the mouth and throat, he should use tobacco in moderation, his teeth should be thoroughly overhauled by the dentist, and he should brush them after every meal, using an antiseptic tooth powder or wash. The mouth and throat should be rinsed out night and morning with a solution of chlorate of potash and alum, or with peroxide of hydrogen.

Treatment of the Local Manifestations.—The skin lesions are treated on the same lines as similar eruptions of other origin. As local applications, preparations of mercury are usually selected, notably the ointments of the red oxide of mercury, ammoniated mercury, or oleate of mercury (5 per cent.), or the mercurial plaster introduced by Unna. In the treatment of condylomata the greatest attention must be paid to cleanliness and dryness. After washing and drying the affected patches, they are dusted with a powder consisting of equal parts of calomel and carbonate of zinc; and apposed skin surfaces, such as the nates or labia, are separated by sublimate wool. In the ulcers of later secondary syphilis, crusts are got rid of in the first instance by means of a boracic poultice, after which a piece of lint or gauze cut to the size of the ulcer and soaked in black wash is applied and covered with oil-silk. If the ulcer tends to spread in area or in depth, it should be scraped with a sharp spoon, and painted over with acid nitrate of mercury, or a local hyperæmia may be induced by Klapp's suction apparatus.

In lesions of the mouth and throat, the teeth should be attended to; the best local application is a solution of chromic acid—10 grains to the ounce—painted on with a brush once daily. If this fails, the lesions may be dusted with calomel the last thing at night. For deep ulcers of the throat the patient should gargle frequently with chlorine water or with perchloride of mercury (1 in 2000); if the ulcer continues to spread it should be painted with acid nitrate of mercury.

In the treatment of iritis the eyes are shaded from the light and completely rested, and the pupil is well dilated by atropin to prevent adhesions. If there is much pain, a blister may be applied to the temple.

The Relations of Syphilis to Marriage.—Before the introduction of the Ehrlich-Hata treatment no patient was allowed to marry until three years had elapsed after the disappearance of the last manifestation. While marriage might be entered upon under these conditions without risk of the husband infecting the wife, the possibility of his conveying the disease to the offspring cannot be absolutely excluded. It is recommended, as a precautionary measure, to give a further mercurial course of two or three months' duration before marriage, and an intravenous injection of an arsenical preparation.

Intermediate Stage.—After the dying away of the secondary manifestations and before the appearance of tertiary lesions, the patient may present certain symptoms which Hutchinson called reminders. These usually consist of relapses of certain of the affections of the skin, mouth, or throat, already described. In the skin, they may assume the form of peeling patches in the palms, or may appear as spreading and confluent circles of a scaly papular eruption, which if neglected may lead to the formation of fissures and superficial ulcers. Less frequently there is a relapse of the eye affections, or of paralytic symptoms from disease of the cerebral arteries.

Tertiary Syphilis.—While the manifestations of primary and secondary syphilis are common, those of the tertiary period are by comparison rare, and are observed chiefly in those who have either neglected treatment or who have had their powers of resistance lowered by privation, by alcoholic indulgence, or by tropical disease.

It is to be borne in mind that in a certain proportion of men and in a larger proportion of women, the patient has no knowledge of having suffered from syphilis. Certain slight but important signs may give the clue in a number of cases, such as irregularity of the pupils or failure to react to light, abnormality of the reflexes, and the discovery of patches of leucoplakia on the tongue, cheek, or palate.

The general character of tertiary manifestations may be stated as follows: They attack by preference the tissues derived from the mesoblastic layer of the embryo—the cellular tissue, bones, muscles, and viscera. They are often localised to one particular tissue or organ, such, for example, as the subcutaneous cellular tissue, the bones, or the liver, and they are rarely symmetrical. They are usually aggressive and persistent, with little tendency to natural cure, and they may be dangerous to life, because of the destructive changes produced in such organs as the brain or the larynx. They are remarkably amenable to treatment if instituted before the stage which is attended with destruction of tissue is reached. Early tertiary lesions may be infective, and the disease may be transmitted by the discharges from them; but the later the lesions the less is the risk of their containing an infective virus.

The most prominent feature of tertiary syphilis consists in the formation of granulation tissue, and this takes place on a scale considerably larger than that observed in lesions of the secondary period. The granulation tissue frequently forms a definite swelling or tumour-like mass (syphiloma), which, from its peculiar elastic consistence, is known as a gumma. In its early stages a gumma is a firm, semi-translucent greyish or greyish-red mass of tissue; later it becomes opaque, yellow, and caseous, with a tendency to soften and liquefy. The gumma does harm by displacing and replacing the normal tissue elements of the part affected, and by involving these in the degenerative changes, of the nature of caseation and necrosis, which produce the destructive lesions of the skin, mucous membranes, and internal organs. This is true not only of the circumscribed gumma, but of the condition known as gummatous infiltration or syphilitic cirrhosis, in which the granulation tissue is diffused throughout the connective-tissue framework of such organs as the tongue or liver. Both the gummatous lesions and the fibrosis of tertiary syphilis are directly excited by the spirochætes.

The life-history of an untreated gumma varies with its environment. When protected from injury and irritation in the substance of an internal organ such as the liver, it may become encapsulated by fibrous tissue, and persist in this condition for an indefinite period, or it may be absorbed and leave in its place a fibrous cicatrix. In the interior of a long bone it may replace the rigid framework of the shaft to such an extent as to lead to pathological fracture. If it is near the surface of the body—as, for example, in the subcutaneous or submucous cellular tissue, or in the periosteum of a superficial bone, such as the palate, the skull, or the tibia—the tissue of which it is composed is apt to undergo necrosis, in which the overlying skin or mucous membrane frequently participates, the result being an ulcer—the tertiary syphilitic ulcer (Figs. 40 and 41).

Tertiary Lesions of the Skin and Subcutaneous Cellular Tissue.—The clinical features of a subcutaneous gumma are those of an indolent, painless, elastic swelling, varying in size from a pea to an almond or walnut. After a variable period it usually softens in the centre, the skin over it becomes livid and dusky, and finally separates as a slough, exposing the tissue of the gumma, which sometimes appears as a mucoid, yellowish, honey-like substance, more frequently as a sodden, caseated tissue resembling wash-leather. The caseated tissue of a gumma differs from that of a tuberculous lesion in being tough and firm, of a buff colour like wash-leather, or whitish, like boiled fish. The degenerated tissue separates slowly and gradually, and in untreated cases may be visible for weeks in the floor of the ulcer.

The tertiary ulcer may be situated anywhere, but is most frequently met with on the leg, especially in the region of the knee (Fig. 42) and over the calf. There may be one or more ulcers, and also scars of antecedent ulcers. The edges are sharply cut, as if punched out; the margins are rounded in outline, firm, and congested; the base is occupied by gummatous tissue, or, if this has already separated and sloughed out, by unhealthy granulations and a thick purulent discharge. When the ulcer has healed it leaves a scar which is depressed, and if over a bone, is adherent to it. The features of the tertiary ulcer, however, are not always so characteristic as the above description would imply. It is to be diagnosed from the “leg ulcer,” which occurs almost exclusively on the lower third of the leg; from Bazin's disease (p. 74); from the ulcers that result from certain forms of malignant disease, such as rodent cancer, and from those met with in chronic glanders.

Gummatous Infiltration of the Skin (“Syphilitic Lupus”).—This is a lesion, met with chiefly on the face and in the region of the external genitals, in which the skin becomes infiltrated with granulation tissue so that it is thickened, raised above the surface, and of a brownish-red colour. It appears as isolated nodules, which may fuse together; the epidermis becomes scaly and is shed, giving rise to superficial ulcers which are usually covered by crusted discharge. The disease tends to spread, creeping over the skin with a serpiginous, crescentic, or horse-shoe margin, while the central portion may heal and leave a scar. From the fact of its healing in the centre while it spreads at the margin, it may resemble tuberculous disease of the skin. It can usually be differentiated by observing that the infiltration is on a larger scale; the progress is much more rapid, involving in the course of months an area which in the case of tuberculosis would require as many years; the scars are sounder and are less liable to break down again; and the disease rapidly yields to anti-syphilitic treatment.

Tertiary lesions of mucous membrane and of the submucous cellular tissue are met with chiefly in the tongue, nose, throat, larynx, and rectum. They originate as gummata or as gummatous infiltrations, which are liable to break down and lead to the formation of ulcers which may prove locally destructive, and, in such situations as the larynx, even dangerous to life. In the tongue the tertiary ulcer may prove the starting-point of cancer; and in the larynx or rectum the healing of the ulcer may lead to cicatricial stenosis.

Tertiary lesions of the bones and joints, of the muscles, and of the internal organs, will be described under these heads. The part played by syphilis in the production of disease of arteries and of aneurysm will be referred to along with diseases of blood vessels.

Treatment.—The most valuable drugs for the treatment of the manifestations of the tertiary period are the arsenical preparations and the iodides of sodium and potassium. On account of their depressing effects, the latter are frequently prescribed along with carbonate of ammonium. The dose is usually a matter of experiment in each individual case; 5 grains three times a day may suffice, or it may be necessary to increase each dose to 20 or 25 grains. The symptoms of iodism which may follow from the smaller doses usually disappear on giving a larger amount of the drug. It should be taken after meals, with abundant water or other fluid, especially if given in tablet form. It is advisable to continue the iodides for from one to three months after the lesions for which they are given have cleared up. If the potassium salt is not tolerated, it may be replaced by the ammonium or sodium iodide.

Local Treatment.—The absorption of a subcutaneous gumma is often hastened by the application of a fly-blister. When a gumma has broken on the surface and caused an ulcer, this is treated on general principles, with a preference, however, for applications containing mercury or iodine, or both. If a wet dressing is required to cleanse the ulcer, black wash may be used; if a powder to promote dryness, one containing iodoform; if an ointment is indicated, the choice lies between the red oxide of mercury or the dilute nitrate of mercury ointment, and one consisting of equal parts of lanolin and vaselin with 2 per cent. of iodine. Deep ulcers, and obstinate lesions of the bones, larynx, and other parts may be treated by excision or scraping with the sharp spoon.

Second Attacks of Syphilis.—Instances of re-infection of syphilis have been recorded with greater frequency since the more general introduction of arsenical treatment. A remarkable feature in such cases is the shortness of the interval between the original infection and the alleged re-infection; in a recent series of twenty-eight cases, this interval was less than a year. Another feature of interest is that when patients in the tertiary stage of syphilis are inoculated with the virus from lesions from these in the primary and secondary stage lesions of the tertiary type are produced.

Reference may be made to the relapsing false indurated chancre, described by Hutchinson and by Fournier, as it may be the source of difficulty in diagnosis. A patient who has had an infecting chancre one or more years before, may present a slightly raised induration on the penis at or close to the site of his original sore. This relapsed induration is often so like that of a primary chancre that it is impossible to distinguish between them, except by the history. If there has been a recent exposure to venereal infection, it is liable to be regarded as the primary lesion of a second attack of syphilis, but the further progress shows that neither bullet-buboes nor secondary manifestations develop. These facts, together with the disappearance of the induration under treatment, make it very likely that the lesion is really gummatous in character.

One of the most striking features of syphilis is that it may be transmitted from infected parents to their offspring, the children exhibiting the manifestations that characterise the acquired form of the disease.

The more recent the syphilis in the parent, the greater is the risk of the disease being communicated to the offspring; so that if either parent suffers from secondary syphilis the infection is almost inevitably transmitted.

While it is certain that either parent may be responsible for transmitting the disease to the next generation, the method of transmission is not known. In the case of a syphilitic mother it is most probable that the infection is conveyed to the fœtus by the placental circulation. In the case of a syphilitic father, it is commonly believed that the infection is conveyed to the ovum through the seminal fluid at the moment of conception. If a series of children, one after the other, suffer from inherited syphilis, it is almost invariably the case that the mother has been infected.

In contrast to the acquired form, inherited syphilis is remarkable for the absence of any primary stage, the infection being a general one from the outset. The spirochæte is demonstrated in incredible numbers in the liver, spleen, lung, and other organs, and in the nasal secretion, and, from any of these, successful inoculations in monkeys can readily be made. The manifestations differ in degree rather than in kind from those of the acquired disease; the difference is partly due to the fact that the virus is attacking developing instead of fully formed tissues.

The virus exercises an injurious influence on the fœtus, which in many cases dies during the early months of intra-uterine life, so that miscarriage results, and this may take place in repeated pregnancies, the date at which the miscarriage occurs becoming later as the virus in the mother becomes attenuated. Eventually a child is carried to full term, and it may be still-born, or, if born alive, may suffer from syphilitic manifestations. It is difficult to explain such vagaries of syphilitic inheritance as the infection of one twin and the escape of the other.

Clinical Features.—We are not here concerned with the severe forms of the disease which prove fatal, but with the milder forms in which the infant is apparently healthy when born, but after from two to six weeks begins to show evidence of the syphilitic taint.

The usual phenomena are that the child ceases to thrive, becomes thin and sallow, and suffers from eruptions on the skin and mucous membranes. There is frequently a condition known as snuffles, in which the nasal passages are obstructed by an accumulation of thin muco-purulent discharge which causes the breathing to be noisy. It usually begins within a month after birth and before the eruptions on the skin appear. When long continued it is liable to interfere with the development of the nasal bones, so that when the child grows up there results a condition known as the “saddle-nose” deformity (Figs. 43 and 44).

Affections of the Skin.—Although all types of skin affection are met with in the inherited disease, the most important is a papular eruption, the papules being of large size, with a smooth shining top and of a reddish-brown colour. It affects chiefly the buttocks and thighs, the genitals, and other parts which are constantly moist. It is necessary to distinguish this specific eruption from a form of eczema which occurs in these situations in non-syphilitic children, the points that characterise the syphilitic condition being the infiltration of the skin and the coppery colour of the eruption. At the anus the papules acquire the characters of condylomata, also at the angles of the mouth, where they often ulcerate and leave radiating scars.

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

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