infections and susceptibility to other conditions are transmitted from
parent to offspring is one which admits of no dispute. The explanation,
however, is almost as remote from us today as it ever was. But the
recognition of the fact is of the greatest importance to all practising
surgeons. That bacteria frequently enter through wounds and bruises
is self-evident, but we all know that such wounds are more likely
to suppurate in some than in others, and the causes of infection in
some are, to a certain extent, connected with the hereditary habit of
tissues. The same causes influence not merely liability to infection,
but its severity and character. There are undoubtedly also local as
well as general variations, and it is very certain that among these
the results of bruising or contusion are by far the most prominent.
There is also undoubted experimental evidence that under certain
circumstances bacteria produce only local lesions, whereas under others
they produce general and even fatal infection.
4. =Local Predisposition.=--Local predisposition is a factor of almost
equal importance. Once given a distinct infection, and hyperemia
is sometimes a contributing cause of inflammation. _Per contra_,
anemia of tissues seems to be also a favoring condition. In parts
involved in chronic congestion the blood flows more slowly, while
the vessels are dilated and apparently susceptibility is increased.
Infection here produces a type of disease mentioned as _hypostatic
inflammation_. Conspicuous exception as to the occasional value of
an artificial passive hyperemia is seen, however, in the so-called
congestion treatment (Bier’s) of tuberculous joints, where the more
or less constant flooding of the tissues with venous blood seems to
render them uninhabitable for living bacilli, which apparently die
and disappear (by phagocytosis), thus permitting a slow return to the
normal condition. General anemia, again, is a predisposing cause, while
toxemias, including diabetes, etc., are still more so. The liability
of diabetic patients to suppurative and even gangrenous infection
is proverbial. The presence of foreign bodies has much to do also,
and, infection once having occurred along with its introduction, the
presence of a foreign body will nearly always excite suppuration;
otherwise it will ordinarily remain inert. The withdrawal of trophic
nerve influences also apparently permits infection, as is instanced by
the ease with which bed-sores form in paralytic patients. Obstruction
to the circulation or to escape of secretions more easily permits
infection; for example, in the appendix, in the kidney, in the
gall-bladder, the salivary glands, etc. Furthermore, one may formulate
a quite comprehensive statement and say that all such lesions as
solutions of continuity, hemorrhages, degenerations, vascular stasis
produced by strangulation, etc., and all perforations, increase more or
less the liability to infection.
5. =Pre-existing Disease.=--Here are reckoned, first, _previous and
long existent toxemias_, _e. g._, syphilis, diabetes, scurvy, etc.
Other conditions, like lithemia, cholemia, acetonemia, and the various
conditions represented by oxaluria, or in which acetone, peptone, and
excess of uric acid are found in the urine, also come under this head.
One need never be surprised to find suppuration occurring in those
cases in spite of due observance of all ordinary precautions, since by
their existence immunity is destroyed and vulnerability increased. (See
chapter on Auto-infections.)
_Recent toxemias_ also have important bearing in this same respect.
For instance, after typhoid fever and other acute wasting diseases,
including the exanthemas, surgical operations are sometimes followed
by failure, and should always be postponed until complete recovery,
except in cases of emergency. The condition to be hereafter described
as _enterosepsis_, and which has previously been known under many
different names, as fecal anemia, stercoremia, etc., is one which
makes the performance of all operations dangerous, and which certainly
predisposes to septic disturbances of all kinds. The postpuerperal
state is also one in which operations are to be avoided if possible.
Certain _anatomical changes peculiar to the various ages_ also belong
in this category. Old age, with its accompanying arterial sclerosis,
its cardiac debility, and other well-known tissue alterations, favors
sluggishness of wound repair and leads not infrequently to sloughing or
to bed-sores. Amyloid changes betoken impaired vitality. Children are
much more liable to acute osteomyelitis than adults. Nursing infants
are apparently exempt from many of the infectious diseases, but possess
relatively small power of vital resistance to surgical operations.
General anemia and impaired nutrition of the body predispose to most
infections and to acute starvation.
6. =Personal Habits and Environment.=--_Diet_ has much to do with
tissue resistance. Rats fed on bread are more susceptible to anthrax
than those fed on meat. Hunger makes pigeons highly susceptible to
the same disease, and artificial immunity induced in various animals
is quickly destroyed by starvation. Prolonged thirst seems to have
the same result. Excessive fatigue generally reduces immunity, as
already mentioned. The various drugs which destroy red corpuscles
impair immunity, and even by injection of water into the circulation
the bactericidal power of the blood is reduced. White mice fed
with phloridzin, which produces artificial diabetes, become highly
susceptible to glanders, from which they are ordinarily exempt. In this
connection may also be mentioned the various toxemias alluded to under
the previous heading, which may proceed from the intestine, from the
genito-urinary tract, and probably also from other sources. Climate
has more or less to do, as also extremes of weather, with power to
resist infection or to survive serious operations. Dark habitations,
poorly ventilated, constitute surroundings which manifestly predispose
to infection of all kinds. Rabbits inoculated with tuberculosis and
confined within a dark cell, badly ventilated, become rapidly diseased,
while others similarly inoculated, but allowed to roam at large,
present but slight evidences of the affection. Certain occupations
predispose to certain diseases. This is pre-eminently the case, for
example, with workers in mother-of-pearl, who are exceedingly liable to
a particular form of osteomyelitis; and with those who make phosphorus
matches, who are prone to suffer from a peculiar necrosis of the lower
jaw. Prolonged suppuration may produce such changes in the blood and
tissues that vital processes of repair, cell resistance, and chemotaxis
may be so far interfered with as to facilitate subsequent infection.
Finally, the _influence of local injury to tissues_, particularly of
contusions which cause tissues to lose their vitality, is strenuously
insisted upon by all, and is spoken of repeatedly in other places in
this work. Many tissues will succumb to inoculation after bruising,
ligature _en masse_, etc., which before such injury are not in the
least disturbed.
7. =Fetal Infection.=--It is only in a very limited class of cases
that infection can be transmitted from mother to fetus, but there are
instances of this kind in which the surgeon is deeply concerned. As
Welch has stated, syphilis is the only infection capable of direct
transmission through the ovum or spermatozoön; but intra-uterine
infection may occur in many ways, and many diseases may be thus
transmitted. The placenta is usually regarded as a perfect filter;
nevertheless, it is occasionally passable to microörganisms. These may
be caused by preëxisting lesions in the placenta or by the virulence
and activity of bacteria. It is known that in animals the bacilli
of chicken cholera (inoculated into the mammalia), of symptomatic
anthrax, and the pyogenic cocci, frequently traverse this barrier.
In mankind infection _in utero_ has been observed in smallpox,
measles, scarlatina, relapsing fever, syphilis, tuberculosis, croupous
pneumonia, typhoid fever, anthrax, and surgical sepsis.
SOURCES OF INFECTION.
That the effects of bacterial invasion may be anticipated and guarded
against most effectually it is necessary that the practitioner should
be thoroughly familiar with the sources from which they come, and the
localities in and about the body which they most commonly inhabit or
where they are met with in largest numbers.
=Skin and Mucous Membranes.=--Of all possible sources of infection,
the skin itself is probably the most fertile. It is exposed to
contamination by air and by everything which may come in contact with
the body, and there is perhaps no organism met with in disease which
may not be found upon its surface or within its recesses. In fact,
these recesses, such as the crevices beneath the nails, the spaces
between the toes, and the various pockets like the tonsils, the axillæ,
etc., are those most commonly inhabited by microörganisms.
Bacteria may penetrate the skin by means of three different routes,
namely, the sweat glands, the hair follicles, and the sebaceous glands,
by means of their regular openings. The hairy appendages of the skin
are even greater sources of danger than the skin itself, since a
direct path of infection into the depths of the skin is afforded by
their follicles. Experimentally it has been shown that when bacteria
are rubbed into the skin where there are no follicles, there is
freedom from infection, whereas the reverse is equally true, and it
is clinically generally recognized that furuncles and carbuncles form
almost exclusively in those parts provided with hair and sebaceous
glands.
The mucous membranes are in constant contact with microörganisms
and furnish conditions in many respects favorable for their rapid
development. Nevertheless, the latter is interfered with and often
inhibited by certain mechanical and chemical influences which afford
protection. The conjunctiva is an extremely exposed membrane, which
harbors, however, but a relatively small number of bacteria under
ordinary circumstances. The tears before escaping from the conjunctival
sac are sterile, and are probably saline enough to act as an antiseptic
bath for the cornea. Moreover, by free escape of secretion through
the nasal duct the conjunctival sac is kept constantly irrigated, to
which is mainly due its ordinary healthy condition, as it is well
known how commonly lesions follow obstruction to the lacrymal duct.
The horrible results of Egyptian ophthalmia, _i. e._, the pyogenic
form of conjunctivitis, are familiar to travellers in Egypt. Howe and
others have shown that this disturbance is due to flies, which are
carriers of infection, and are attracted toward the eyes of infants,
while the superstitious notions of the parents restrain their children
from instinctive protection of the eyes when thus irritated. There
is probably no greater common carrier of pyogenic infection than the
common house-fly, and nowhere is this agency more demonstrated than in
the hot climates of the Orient.
[Illustration: PLATE III
FIG. 1
Artificial Dental Caries in Cross-section. Tubules Filled with
Bacteria. (Miller.)
FIG. 2
Putrid Tooth Pulp. Infection of Dental Tissue. × 1000. (Miller.)
FIG. 3
Dental Caries. Disappearance of Dental Tissues as Result of Presence of
Bacteria. (Miller.)
FIG. 4
Dental Caries. Tubule Filled with Cocci. (Miller.)
FIG. 5
Dental Caries. × 500. (Miller.)
FIG. 6
Dental Caries. Tubules Plugged with Cocci. × 500. (Miller.)]
=Upper Respiratory Tract.=--The oral cavity and pharynx are seldom
free from bacteria. Miller has studied over one hundred species that
he has found under various circumstances in the human mouth. Some of
these are pathogenic; others are apparently absolutely innocent. Many
of the forms which grow in saliva will not grow in ordinary media.
(See Plate III, illustrating infection of the teeth.) Miller has
also shown that many forms of dental caries are but expressions of
bacterial invasion even of those apparently most solid structures,
the teeth; and of late we have been taught more fully that such
invasion may extend far beyond the confines of the teeth alone, and may
spread to various, even to distant parts, and produce possibly fatal
mischief. Abscesses in the brain and extensive septic infections have
been traced to invasion along the line of the dental tubules. One of
the most virulent of all the common inhabitants of the mouth is the
pneumococcus of Fränkel, known also as the micrococcus lanceolatus of
Stebernrg. In virulence it is a variable organism, but it is present in
a virulent state in only 12 or 15 per cent. of cases of infection due
to it. This is the organism which is the cause of lobar pneumonia, and
frequently of bronchopneumonia, as well as of numerous phlegmons and
other inflammations of the throat, and which, getting into the general
circulation through the tonsils or other possible ports of entry about
the mouth, causes serious septic and inflammatory disturbances in
widely distant regions. Aside from dental caries, a widely opened port
of entry is often afforded by those ulcerations around the margins of
the gums which are produced by accumulations of tartar. Disease in the
antrum of Highmore, for instance, and many other local destructions,
are frequently caused in this way.
The next most common port of entry is the _tonsils_, faucial, lingual,
and pharyngeal, which contain a variety of crypts which are often
filled with secretions or retentions loaded with bacteria. One of the
most common sources of an involvement of the cervical lymph nodes in
tuberculous disease is an infection springing first from the tonsils or
the teeth.
In spite of the fact that myriads of bacteria are swept into the
nasal cavities with the air we breathe, few are seen in the nose.
A peculiar capsule bacillus, closely allied to that described by
Friedländer, has been found in a number of cases of ozena, while the
pneumococcus of Fränkel is also often found there, and is known to
produce abscesses of the brain. One specific organism--namely, that of
_rhinoscleroma_--concerns the nose almost solely, its first ravages
being met with in this location.
=Alimentary Canal.=--Probably more microörganisms enter the alimentary
canal than gain access in any other way, these coming both from food
and drink as well as air. Once within its confines, few of them are
capable of prolonged existence. Welch states that the meconium of
newborn infants is sterile, but that within twenty-four hours it
usually contains abundant bacteria. That bacterial infection through
this passage-way is a fertile source of non-surgical lesions is well
known. The possibility of surgical infections being produced in
the same way is both more remote and less demonstrable. Naturally,
anaërobic organisms find here more favorable conditions, and even
extremely acid or extremely alkaline conditions do not serve to destroy
all such life. Pyogenic cocci are often present and are frequently
found in peritoneal exudates. In the intestines of herbivorous animals
the tetanus bacilli and those of malignant edema are regularly found.
The fungus of actinomycosis also finds its way into the bowel along
with ingested food. Under ordinary conditions the bile in its natural
reservoirs is free from bacteria, but the colon bacilli and pyogenic
cocci often invade these precincts.
=Genito-urinary Tract.=--Even the healthy urethra may contain bacteria.
While these may wander upward to an indefinite extent, it is believed
that the urine contained within the bladder in a condition of perfect
health is free from bacteria, and that if such gain entrance they do
not long remain. The same is true of the female bladder and urethra.
The vagina contains organisms of many species, some of which do not
grow on ordinary culture media, but are to be recognized by the
microscope. While it is generally acknowledged that the vaginal
secretion is, as a rule, possessed of bactericidal properties, there is
as yet no satisfactory nor comprehensive explanation of this fact, its
normal acidity not being sufficient to account for the fact.
=The Milk in the Lacteal Ducts.=--In a condition of perfect health milk
secreted from the ideal mammary gland is sterile, but may easily become
contaminated upon its exit from the nipple. Conversely, under many
favoring conditions organisms may travel into the lacteal ducts from
the skin without, and thus contaminate the milk. In all probability
the breast corresponds in behavior to other glands whose ducts open
upon the surface, and, while such openings invite entrance of bacteria,
their migrations do not extend far from the surface unless some of the
other conditions already mentioned predispose to further infection or
extension.
In summarizing the general topic of possible _sources_ and _paths of
infection_ bacteria may enter and exert deleterious action:
A. _From within the system_; and
B. _From without_.
A. _From within_ they may enter the tissues either through the
inspired air, through food and drink, _i. e._, ingesta, or by means
of more direct inoculation, _e. g._, by foreign bodies or by venereal
contact. The danger through infection by inspired air is very small,
and concerns probably a limited number of organisms, of which the
tubercle bacillus is the most important. Foul air and air which
emanates from sewers, cesspools, etc., while most unpleasant to breathe
and deleterious in many other ways, do not necessarily contain any
microörganisms which can be injurious. This fact, in opposition to
general belief, is, nevertheless, proved by recent investigations. The
ingesta furnish the most fertile source of contagion from within, but
the diseases thereby produced fall for the most part into the domain of
medicine rather than that of surgery.
B. _Infection from without_ the body may come by actual contact with
previous skin or mucous lesions, and particularly from noxious insects
and certain parasites. Among surgeons the principal sources of contact
infection to be enumerated and guarded against are:
1. Skin and hair;
2. Instruments;
3. Sponges or their substitutes;
4. Suture materials;
5. The hands of the surgeon and his assistants;
6. Drainage materials;
7. Dressing materials;
8. From miscellaneous sources, _e. g._, drops of perspiration,
unclean irrigator nozzle, a contaminated nail-brush, the clothing of
the operator, etc.
While insisting here upon the recognition of these sources of danger,
the precautions to be taken against them are to be considered under
another heading, to which the reader is referred.
One of the greatest sources of possible infection has of late been
shown to be the presence of flies and other noxious insects, which act
as carriers of infection. The Egyptian ophthalmia, which ruins the
sight of 30 per cent. of the inhabitants of Egypt, has been shown by
Howe and others to be due to infection by this mechanism; and a simple
bacteriological experiment will suffice to show that the foot-tracks
of a single fly across a wound furnish abundant opportunities for
infection with organisms which are presumably virulent. In fact, the
danger of carriage of infection by this means is greater than from
almost all other sources, except the use of improper materials during
surgical operations.
CLASSIFICATION OF INFECTIONS.
We speak of infections as _primary_, _secondary_, and _mixed_; and it
is necessary, for purposes of accuracy at least, to make a reasonably
clear distinction between them.
=Primary Infection.=--By primary infection is meant infection with a
single form of organism whose effects are prompt and speedy. Of this,
erysipelas or syphilis may serve as illustrations. Most of the acute
infections belong to the primary type.
=Secondary Infection.=--Secondary infection means that after certain
disturbances due to a primary infection, _i. e._, one of a given
type, there occurs at some later period and from a distinct source
another infection whose results may be more or less disastrous, and
cause the case, at least for the time being, to assume a different
aspect. We have an illustration of this in the case, for example, of
primary tuberculosis with distinct infection of a number of lymph
nodes, which, acting as filters, have caught in their tissue net a
large number of tubercle bacilli that, lodging there, have produced
the usual well-known results and have practically converted the
infected nodes into granulomata. In these infected masses well-known
changes, such as those which follow tuberculous infection--atrophy,
caseation, calcification, etc.--may be occurring, when suddenly
there comes infection of a _pyogenic_ type from another source, and
suppuration of the granuloma is the result. It is possible even to have
a _tertiary infection_, of which the following may be a hypothetical
instance: Primary infection with scarlatina or measles, by which vital
susceptibility is in some instances lowered; as the result of this,
secondary tuberculous infection in an individual previously resistant;
and, third, a suppurative infection, as above described.
In contradistinction to these distinct events, separated by an
appreciable, sometimes a considerable, length of time, we recognize
a _mixed infection_, where two or more organisms are implanted at
or about the same time. An illustration of this is seen in most
cases of gonorrhea in which there is a synchronous attack made by
the gonococcus, which is a specific microörganism, accompanied by
staphylococci or streptococci, whose effect will complicate the
case and make it assume a less particulate type of infection. Mixed
infections may often occur in other ways, as syphilis and chancroid,
chancroid and gonorrhea, etc. Most cases of mixed infection belong
rather to surgery than to general medicine, and constitute an apparent
violation of the rule to which physicians often point--that two
distinct infectious diseases are seldom communicated or acquired at the
same time. Nevertheless, the facts remain as above.
=Terminal Infections.=--Terminal infections constitute an apparent
paradox, perhaps oftener in medical than in surgical cases. Few people,
as Osler has shown, die of the diseases from which they suffer.
The final exitus is due to a more or less rapid infection which
terminates life. These terminal infections are mainly due to a few
well-known microbes, such as the streptococcus, staphylococcus aureus,
pneumococcus, bacillus proteus, gonococcus, bacillus pyocyaneus, and
the gas bacillus. In surgery such infections are, perhaps, most often
seen in malignant lymphoma, diabetes, tuberculosis, syphilis, cancer,
and in the so-called surgical kidney.
BACTERIA OF PUS FORMATION.
Bacteria which act as agents in the formation of pus are collectively
known as pyogenic organisms. These are divided into two groups:
A. _The Obligate_; and
B. _The Facultative._
_Obligate_ pyogenic organisms are those whose activity is manifested
in the direction of pus formation, which seem to produce it if they
produce any unpleasant action whatever. On the other hand, the
_facultative_ organisms are those which are known occasionally to be
active in this direction, and yet which are not always nor necessarily
so. The members of group A are fairly well known and catalogued, and
are not numerous. On the other hand, there is reason to believe that
many organisms may have the occasional effect of producing pus, as
it were, by accident or at least in a way not absolutely natural or
peculiar to themselves, but still are frequently found when there is no
pus present. A suitable list of the facultative organisms, therefore,
can hardly be made, and will not be here attempted, the effort being
only to mention the more common organisms which play this facultative
role. It may be mentioned also that even the adjectives “obligate” and
“facultative” are to be accepted with some mental reservation, since
staphylococci, for instance, may be met with even in the absence of
pus, although nearly all that we know about these organisms implies
that pus would be the result of their presence. Furthermore, there are
certain other organisms, not, strictly speaking, bacteria, which also
have the power of producing either pus or pyoid material. These also
will be mentioned in their place. Some of them belong not only to the
vegetable, but also to the animal kingdom.
=Obligate Pyogenic Organisms.=
A. =The Staphylococcus Pyogenes Aureus, Albus, Citreus, the
Staphylococcus Epidermidis, etc.=--One of the characteristics of the
staphylococci as a group is the powerful peptonizing action which they
exert. Moreover, the chemical products of their life changes seem
to be more potent in a local than a general way, leading to greater
destruction of tissue in their immediate vicinity, with greater
inhibition of the chemotactic powers of the leukocytes; that is, with
more interference with phagocytosis, by which their progress would
be interfered with. Their presence is recognized by a peculiar odor,
as of sour paste, which should lead to a prompt change of dressings
and disinfection of the wound (by irrigation, spraying with hydrogen
dioxide, etc.).
B. =Streptococcus Pyogenes and Streptococcus Erysipelatis.=--These two
organisms do not differ in morphology nor characteristics, and, while
for some time considered as distinct from each other, are now by most
observers regarded as identical. The streptococci grow in chains of
variable length, and individual cocci vary in size. They grow with
and without oxygen, in all media, at ordinary temperatures, do not
liquefy gelatin, stain readily, sometimes but not invariably coagulate
milk, and vary in longevity. They differ extraordinarily in virulence
according to their sources.
[Illustration: FIG. 4
Staphylococci in pus. × 1000. (Fränkel and Pfeiffer.)]
[Illustration: FIG. 5
Streptococci in pus. × 1000. (Fränkel and Pfeiffer.)]
There are many streptococci not included under the above head which
are indistinguishable morphologically and in other respects, and yet
which are partly or entirely free from pathogenic activity in man. A
biological study reveals remarkable and unexplainable transformation
between the different members of this species, a part of which may be
referable to conditions pertaining to the organisms infected, but part
of which apparently pertains to the bacteria. It is held by some that
scarlatina is an invasion by certain organisms of this class; this,
however, is not yet definitely established. When found in the stools
of children with summer diarrheas they are regarded as indicating
ulceration of the intestinal mucosa.
In contradistinction to the staphylococci, the streptococci manifest
a predilection for lymph vessels and lymph spaces, along which they
extend with great rapidity. They have less peptonizing power than the
staphylococci (except in the absence of oxygen); hence streptococcus
infection assumes usually the type of widespread infiltration rather
than of circumscribed and distinct edema. One sees remarkable instances
of this in cases of phlegmonous erysipelas. It is suggested also that
the peculiar manner of growth of the streptococci, in long chains which
may coil up and entangle blood corpuscles, has much to do with the
formation of fat emboli and with pyemic disturbances.
Both these bacterial forms have the power of producing lactic
fermentation in milk; and lactic-acid formation sometimes takes place
with suppuration in the human tissues, causing acidity of discharge,
sour odor, and watery pus. It appears also that these two pyogenic
forms have less power of ptomain or toxin formation than many others,
and, consequently, that the pyrexia attending suppuration or purulent
infiltration is not always to be ascribed to this cause alone, for
fever may in some measure be due to tissue metabolism attending their
growth, the metabolic products being pyretic. This is in a measure
substantiated by the fever attending trichinosis, where the question of
ptomain poisoning has not yet been raised.
C. =Micrococcus Lanceolatus.=--Micrococcus lanceolatus is also known
as the _diplococcus pneumoniæ_ or the pneumococcus of Fränkel and
Weichselbaum, and as the _micrococcus of sputum septicemia_ of Pasteur
and of Sternberg. It is of interest to surgeons because it causes many
localized inflammations and is a frequent factor in causing septicemia;
it is often present in the mouths of healthy individuals. It may
produce the various forms of exudates as the result of congestion set
up by its presence; also otitis media, meningitis, osteomyelitis, and
suppurative disturbance in the periosteum, the salivary glands, the
thyroid, the kidney, the endocardium, etc.
[Illustration: FIG. 6
Diplococcus pneumoniæ of Fränkel. (Karg and Schmorl.)]
D. =The Micrococcus Tetragenus.=--Suppurations produced by these
organisms are prolonged, mild in character, not painful, but
accompanied by much brawny induration of tissues.
E. =The Micrococcus GonorrhϾ.=--The micrococcus gonorrhϾ, or
_gonococcus_, is found constantly in the pus of true gonorrhea, in
many cases the pus being a pure culture of this organism. These cocci
are generally seen in pairs (biscuit-shaped), while their inclusion
within the leukocytes or their attachment in or to epithelial cells
is characteristic. Unlike other pyogenic cocci, they do not stain
by Gram’s method, being decolorized by iodine, by which fact they
may be distinguished. They are cultivated with difficulty, and are
known rather by their clinical effects than by their laboratory
characteristics; are human parasites, other animals, so far as known,
being practically immune. The gonococcus may also produce abscesses,
and may be carried to distant parts of the body, where its effects are
commonly noted as pyarthrosis, although endocarditis, pericarditis,
pleurisy, etc., are known to be due to it, and fatal pyemia has been
produced in consequence. In some way it is probably the explanation
of the post _gonorrheal arthritis_, wrongly spoken of as gonorrheal
rheumatism.
F. =The Bacillus Coli Communis or Colon Bacillus.=--This is an
inhabitant of the intestinal canal; varies extremely in virulence
and somewhat in morphological appearances; coagulates milk; is often
associated with other organisms; migrates easily both along the
alimentary canal and from it into the surrounding tissues or channels.
It is a disturbing element in the production of kidney and hepatic
disease, also in the production of appendicitis and peritonitis.
Ordinarily its pyogenic properties are not virulent; occasionally,
however, it becomes extremely virulent.
G. =The Bacillus Pyocyaneus.=--The bacillus pyocyaneus, a widely
distributed organism, often observed in the skin and outside of the
body; a motile, liquefying bacillus, growing at ordinary temperatures,
seldom seen alone, but occasionally producing pus without association
with other organisms; it stains the discharges and dressings a
bluish-green and imparts sometimes an offensive odor. Suppuration
caused by this bacillus is usually prolonged, but characterized by
little constitutional disturbance.
=Facultative Pyogenic Organisms=--_i. e._, those which have the power
of provoking suppuration, but which have other and more distinct
pathogenic activities as well.
A. =Bacillus Typhi Abdominalis.=--This is found in many pus foci,
developing during or after typhoid fever. It is occasionally met with
alone, though most of these abscesses are really mixed infections.
It is generally found in the bone or beneath the periosteum. Such
abscesses are frequently seen in the ribs, and may not be noticed until
months after convalescence from the fever. The pus contained within
them is not always typical in appearance, but may be unduly thin or
unduly thick.
B. =Bacillus Proteus.=--Under this name are included three distinct
forms, which were originally described by Hauser as distinct species,
but which are now regarded as pleomorphic forms of the same organism.
It is a motile bacillus, met with in decomposing animal and vegetable
material, and occasionally found in the alimentary canal. It has been
known to produce pus, especially in the peritoneal cavity and about the
appendix. It may even cause general infection and peritonitis.
C. =Bacillus Diphtheriæ.=--A non-motile bacillus, varying considerably
in size and shape, changing the reaction in sweet bouillon from acid
to alkaline; produces a dangerous infective inflammation of exposed
surfaces, with tenacious exudate amounting to a distinct membrane. As
a part of its life history it also produces a toxalbumin, which is one
of the most powerful cell poisons known, the disintegration of the
cell constituents due to its action being rapid and pronounced. This
accounts for the heart failures which are often reported in connection
with the disease.
D. =Bacillus Tetani.=--More will be said about this organism when
considering tetanus, and to that subject the reader is referred. The
tetanus bacillus is occasionally found in pus which comes from the area
through which the original infection was produced. But these bacilli do
not travel to any distance in the human body, and are seldom found away
from the area involved. Under most circumstances the pus is the product
of a mixed infection.
E. =Bacillus Œdematis Maligni.=--This organism will be more fully
considered under a different heading. (See Malignant Edema.) It is a
long, anaërobic bacillus, widely distributed in the soil and the feces
of animals. It is believed that this, like the tetanus bacillus, may
occasionally lead to formation of pus.
F. =Bacillus Tuberculosis.=--This organism likewise will receive fuller
description in an ensuing chapter. (See Tuberculosis.) The pus of old
cold abscesses in which the more obligate pyogenic organisms have long
since died usually contains this organism in mildly virulent form.
On the other hand, fresh suppurations occurring in connection with
tuberculous disease are mixed infections. There is reason to believe,
however, that this organism is capable of producing pus even when
none of these are present; for example, in that form of acute miliary
tuberculosis which is occasionally met with as bone abscess it may be
found.
G. =Bacillus Anthracis.=--This is one of the most malignant and
resistant organisms known, being in the highest degree poisonous
for the smaller animals, man being less susceptible. One of its
characteristic lesions in the human body is a form of pustule commonly
known as _malignant pustule_, the pus in which is usually a pure
culture of this organism. (See Anthrax.)
H. =Bacillus Mallei.=--This is the organism which produces glanders in
the lower animals and in man. That form of the disease known as farcy,
in which the infected nodules rapidly break down, is likely to contain
pus which will be more or less a pure culture of this organism.
I. =Bacillus Lepræ.=--This is the microörganism which produces
leprosy, closely resembling the tubercle bacillus. It is constantly
and exclusively present in the lesions of leprosy, which are often of
the suppurative type, the bacilli being enclosed within pus cells; it
is also found in the fluid surrounding them. Although suppuration in
these cases may be in a large measure due to secondary infection, it is
positive that the leprous bacilli deserve to be grouped in this place.
J. =The Bacillus Pneumoniæ of Friedlander.=--The bacillus pneumoniæ
of Friedländer was at one time regarded as the cause of croupous
pneumonia, which is now known to be due to the micrococcus lanceolatus.
The Friedländer bacillus, however, is capable of producing
bronchopneumonia, and is occasionally met with in empyema, suppurative
meningitis, and inflammations about the nasopharyngeal cavity, of which
it is known to be an occasional inhabitant.
K. =The Bacillus of Rhinoscleroma.=--A distinctive organism has been
described for this disease and given this name. It has such wide
morphological differences, however, that it is possible that it is only
the bacillus of Friedländer above mentioned. At all events, an organism
of this general character is constantly found in this disease in the
thickened tissues from the nose (Fig. 8).
L. =The Bacillus of Bubonic Plague.=--This was recently discovered
by Kitasato, and, in view of the recent ravages of the disease in
the Orient, has assumed considerable importance. It grows upon most
media, and is found in the blood, in buboes, and in all internal
organs of patients suffering from this disease. The smaller animals
are susceptible upon inoculation. Animals fed with inoculated foods
die also, showing the possibility of infection through the intestine.
When exposed to direct sunlight for a few hours the bacillus dies. The
general symptoms of the disease are those of hemorrhagic septicemia and
its consequences.
M. =The Bacillus of Rauschbrand.=--This is seldom, if ever, seen
in this country. It is known in England as “the black-leg” or
“quarter-evil.” It is an anaërobic organism, frequently met with in
cattle, which causes a peculiar emphysema of subcutaneous tissue,
spreads deeply, and is followed by a copious exudate of dark serum with
gas formation. The smaller animals are not ordinarily inoculable; but
if to the culture material there is added 20 per cent. of lactic acid,
their insusceptibility is overcome and they succumb to the disease.
So, also, as in the case of the tetanus bacillus, by addition of the
bacillus prodigiosus or of proteus vulgaris the disease may be produced
in otherwise insusceptible animals.
N. =The Bacillus Aerogenes Capsulatus.=--The bacillus aërogenes
capsulatus seems capable sometimes of causing pyogenic and even fatal
infection. Its presence is associated with gas formation. It grows as
an anaërobe.
O. =The Bacillus of Chancroid.=--The bacillus of chancroid identified
by Ducrey, and briefly described in the chapter on that subject.
[Illustration: FIG. 7
Rhinoscleroma: infiltration of tissues about the nose. (Case reported
by Dr. Wende, Buffalo.)]
[Illustration: FIG. 8
Bacilli of rhinoscleroma. × 1000. (Fränkel and Pfeiffer.)]
YEASTS.
Busse was the first to call attention of clinicians and pathologists
to the role played by yeasts in certain infections. Since the original
observations of Busse in a case in which the organism produced a
general infection, the lesions of which were a combination of tumor
and abscess formation, various observers have noted the presence of
pathogenic yeasts, usually in skin lesions. Gilchrist and Stokes were
the first in this country to determine the nature of these organisms,
and their observations have been followed by the detection of a large
number of similar cases. In the skin lesions the organisms are found
in minute abscesses; in the subcutaneous tissue and in the infections
similar to those of Busse large abscesses surrounded by extensive
masses of granulation tissue characterize the infection. The organisms
can be detected in the pus by means of an examination of the fresh
unstained fluid (Fig. 9).
FUNGI.
Besides the micro-organisms everywhere grouped as bacteria, there are
other minute organisms which have also the power of engendering pus.
One of these is the ray fungus, known as the _actinomycis_, which
causes the disease known as lumpy jaw or actinomycosis. Suppuration
is always a concomitant of the advanced lesions of this disease,
and, while it may be in many instances a mixed infection, it is not
necessarily so. Moreover, the pus produced under these circumstances
contains minute calcareous particles which are pathognomonic, by which
a diagnosis can sometimes be made off-hand.
Besides these fungi, others, belonging rather to the class of vegetable
molds, which are yet pathogenic for human beings, may be occasionally
met with under these circumstances--_e. g._, _the fungus of Madura
foot_, the _leptothrix_, and other molds from the mouth, while the
different varieties of _aspergillus_ may be found in pus about the ear
or even in that from the brain.
PROTOZOA.
The protozoa have the power of producing, if not absolute ideal pus,
something so nearly resembling it that we may include them among the
facultative pyogenic organisms. The best known of these protozoa
are the _amebæ_, which are met with in the intestinal canal in some
countries, occasionally in the United States, especially as the
exciting causes of a peculiar type of dysentery often accompanied by
abscess of the liver. In these abscesses the amebæ are found, and no
other organisms. Another group of the protozoa, known to biologists
as the _coccidia_, are also capable of causing pus formation, more
particularly in some of the lower animals. Numerous other parasites,
belonging higher in the animal kingdom, are undoubted exciters of pus
formation, though it is not necessary to lengthen the list beyond those
already mentioned.
[Illustration: FIG. 9
Blastomycetic pus (fresh). × 1000. (Gaylord.)]
Protozoa have recently been established as the active agents in the
production of smallpox and probably also of scarlatina. They have been
seen so generally in and around cancer cells as to make it extremely
probable that cancer is a protozoan infection. In syphilis also they
are found as the _spirochetæ_, now regarded as its cause.
Protozoa are as ubiquitous as bacteria, but their recognition is as yet
more difficult, as but little is known of them. The numerous stages
through which they pass in completing their life cycles only complicate
the subject, while the difficulties encountered in cultivating them are
still to be overcome. As we become more familiar with them we shall
more frequently find them to be pathogenic organisms.
CLINICAL CHARACTERISTICS OF PUS FROM DIFFERENT AGENCIES.
_Staphylococcus._--Dirty white, moderately thick, with sour-paste odor.
_Streptococcus._--Thin, white, often with shreds of tissue.
_Colon Bacillus._--Thick, brownish, with fetid odor, or thin, dirty
white, with thicker masses.
_Micrococcus Lanceolatus._--Thin, watery, greenish, often copious.
_Bacillus Pyocyaneus._--Distinctly green or blue in tint.
_Bacillus Tuberculosis._--Thick, curdy, white paste, or thin, greenish,
with small, cheesy lumps or even with bone spicules.
_Actinomycis._--Thick, brownish white, with small, firm, gritty or
chalky nodules of yellow color.
_Ameba Coli._--Thick, brownish red.
BACTERIAL DETERMINATION AS AN INDICATION IN TREATMENT.
There is a practical side of great importance pertaining to the
recognition of the nature of the infectious organism in many cases
of suppuration and abscess. For instance, pus which is due to
streptococcus invasion indicates a collection which should be freely
evacuated and carefully drained. This is also true in essential
respects of staphylococcus pus, particularly that due to the
streptococcus aureus. Putrid pus from any source requires disinfection
and free drainage, the former preferably perhaps by hydrogen dioxide.
Pus which is due to the colon bacillus is not often extremely virulent,
which accounts for so many cases of appendicitis recovering with or
without operation. A collection of this pus needs little more than
mere drainage and opportunity for escape. Pus from a recognizable
tuberculous source may still contain living tubercle bacilli. This
means either that the cavity whence it came should be completely
destroyed and eradicated, or else that the margins of the incision
or opening through which it has escaped should be so cauterized that
infection of a fresh surface is impossible. The same is true of
abscesses due to glanders bacilli and to certain cases of suppurating
bubo following chancroid, where the whole course of events shows the
virulent character of the organisms at fault.
SUPPURATION.
Although it may be possible to produce in certain laboratory
experiments metamorphosed material which very closely simulates pus,
or, in fact, by injection of chemical irritants, to sometimes imitate
the suppurative processes, nevertheless, the student should be brought
face to face with the statement, to which for surgical purposes there
is no practical exception, that suppuration, _i. e._, _formation of
pus, is due to the presence in the tissues of the specific irritants
already catalogued and described, and of the peculiar peptonizing or
other biochemical changes which bacteria exert upon living animal
cells_.
=Coagulation Necrosis.=--Coagulation necrosis is the term applied
to the characteristic changes occurring in the tissue cells when
thus attacked, which may be summarized as a fading away of cell
outlines, diminution in reaction to reagents, and a merging of cells
and intercellular substance. Coagulation necrosis is not the only
result of bacterial activity, but may be produced by other causes.
Nevertheless, pyogenic bacteria do not exert their deleterious action
upon the tissues without occasioning changes included under this
term. In an area thus infected, as already described, leukocytes, _i.
e._, phagocytes, are present in increased number for purposes already
mentioned. As we approach the centre of activity phagocytes are more
numerous than cells, and intercellular barriers completely break
down. When bacteria are found in greatest number, there also occurs
the greatest phagocytic activity, and there also will be found the
evidence of suppuration, _i. e._, _pus_. As already indicated, the
_polynuclear leukocytes_ are most active in the process of defence.
Where coagulation necrosis is most marked there has been the greatest
activity of conflict with the greatest death of cells. Around these
areas bacteria and cells are found in indiscriminate arrangement.
Tissue vitality is impaired by intoxication of the cells by the
excretory products of the bacteria, _i. e._, the so-called ptomains,
toxins, etc., and their power of resistance is thus weakened. From the
mechanical results of pressure tension around the centre of activity is
increased, by which tension vitality is still more impaired and more
rapid tissue death occurs. Thus there occurs migration or burrowing of
pus; or, to state it more clearly, the tissues break down in front of
the advancing destruction, and in the direction of least resistance.
This is known as the _pointing of pus_, which brings it many times to
the surface, and often in other and less desirable directions.
=Abscess.=--An abscess is a _circumscribed collection of pus_. The term
is used in contradistinction to _purulent infiltration_, in which the
collection is not circumscribed, but is exceedingly diffuse and extends
itself in various directions, the amount at any spot being almost
inappreciable. Purulent infiltration is regarded as the more serious
of the two conditions, as it is more difficult for pus to escape under
these circumstances than when it can be evacuated through a single
opening. The term _phlegmon_ is one now generally used to indicate
a suppurative process, usually of the general character of purulent
infiltration rather than of abrupt abscess, but generally employed to
include both conditions. The adjective _phlegmonous_ is coupled with
the names of other surgical infectious diseases to indicate that it
is complicated by suppuration, _e. g._, phlegmonous erysipelas. _Pus_
is a product of bacterial activity usually formed rapidly rather than
otherwise, and abscess formation or phlegmonous activity of any kind is
a question of but a few days. _Empyema_ means a collection of pus in a
preëxisting cavity.
The significance of this condition is well described in the story of
inflammation and suppuration, to paraphrase Sutton, read zoölogically,
as though it were the story of a battle: The leukocytes (phagocytes)
are the defending army, the vessels its lines of communication, the
leukocytes being, in effect, the standing army maintained by every
composite organism. When this body is invaded by bacteria or other
irritants, information of the invasion is telegraphed by means
of the vasomotor nerves, and leukocytes are pushed to the front,
reinforcements being rapidly furnished, so that the standing army of
white corpuscles may be increased to thirty or forty times the normal
standard. In this conflict cells die, and often are eaten by their
companions. Frequently the slaughter is so great that the tissues
become burdened by the dead bodies of the soldiers in the form of
pus, the activity of the cells being proved by the fact that their
protoplasm often contains bacilli in various stages of destruction.
These dead cells, like the corpses of soldiers who fall in battle,
later become hurtful to the organism which, during their lives, it was
their duty to protect, for they are fertile sources of septicemia and
pyemia. This illustration may seem romantic, but is warranted by the
facts.
Around the margin of the site of an acute abscess a barrier is formed
by condensation and cell infiltration of the surrounding tissues. This
is not a distinct wall nor membrane, yet, nevertheless, serves as a
sanitary cordon to confine the mimic conflict within reasonable bounds.
This is the zone of real inflammation; within it there are tissue
destruction and coagulation necrosis. By virtue of the peptonizing
power of the pyogenic organisms the parts involved in this necrosis
gradually liquefy the intercellular substance dissolving first. It is
this which in the main forms the fluid portion of the pus. Various
tissues show widely differing resistance to this softening process. In
true glands the interlobular septa seem to break down first, and in
this way suppuration extends around the acini or gland lobules, and
thus pus may contain masses of easily recognizable size. These masses
are ordinarily known as _sloughs_.
It is by virtue of the so-called lymphoid cells, which are those
principally involved in producing the barrier or boundary of the
acute abscess as above described, that granulation tissue is formed,
which takes up the effort of repair as soon as pus is evacuated. This
boundary has no sharp limit, but shades off into healthy surrounding
tissues.
Under the term “abscess” is meant that which is described as _acute
abscess_. Under certain circumstances, especially when they are
produced by the facultative pyogenic organisms rather than the
obligate, abscesses form more slowly, and may be spoken of as
_subacute_. These are terms used in contradistinction to the so-called
_cold abscesses_, which, although clinically bearing a certain
resemblance to the acute, are in almost every pathological respect
different from it. Cold abscesses will be considered under the head of
Tuberculosis. It is possible to have an acute pyogenic infection of a
cold abscess; in such case we have acute manifestations. _Gravitation
abscesses_ are those where pus forming in one part tends to migrate,
usually in the direction in which gravity would take it, extending
into portions deeper or lower. Perhaps the best illustration of
this is the pointing of a psoas abscess below Poupart’s ligament.
_Metastatic abscesses_ are those which are formed as the result of
embolic processes, each one being in miniature a repetition of a lesion
which has occurred at some other part of the body. The underlying
fact concerning metastatic abscesses is that the primary process
has occurred in some other portion of the body, whence it has been
distributed as above. These will be considered in the chapter treating
of Pyemia.
The product of all acute suppurative lesions is _pus_. This is an
opaque fluid of creamy consistence and whitish or grayish appearance,
varying in density, met with in amounts from a minute drop to half a
gallon or more. Under ordinary circumstances it is odorless, and its
reaction, either acid or alkaline, is very faint. It is, like the
blood, composed of a fluid and a solid portion. The solid portion
consists of so-called _pus corpuscles_ and other debris of tissue,
which vary with the site of the disease and the parts involved. The
source of the pus corpuscles has been cited and the statement made that
they are in effect the bodies of phagocytes which have perished in
the biochemical fight for existence of the parent organism. Cocci or
bacilli are found in pus corpuscles and also in the surrounding fluid.
Pus should be without odor, but under certain circumstances it
possesses an odor which will vary in character according to the source
of the pus or the nature of its principal bacterial excitant. Pus from
the upper end of the alimentary canal frequently has the sour smell
of gastric contents; that from the neighborhood of the lower end,
the fetid odor which is for the most part due to the action of the
colon bacillus. Inasmuch as colon bacilli are found in widely distant
parts of the body, they may also give an unpleasant odor to pus even
from a brain abscess. When the pus has become contaminated with the
ordinary saprophytic organisms, it may smell like any other decomposing
material. The older writers called it _ichorous pus_, while _sanious
pus_ was supposed to be that more or less mixed with blood, undergoing
ammoniacal decomposition or else strongly acid. Pus sometimes has a
well-marked _blue_ or _bluish-green tint_. This is due to the presence
of the _bacillus pyocyaneus_, already described. An orange tint is
sometimes given by the presence of hematoidin crystals, due to the
original hemorrhagic character of the infected exudate. The former
appearance indicates usually a slow course to the suppurative lesion,
while the latter has been regarded by some as affording an unfavorable
prognosis. Distinctly red pus, whose tint is due to the presence of a
bacillus giving bright-red cultures on blood serum, has been noted in
other instances. This can readily be distinguished from blood, because
upon dressings it does not change color.
Pus may form superficially, when it is called subcutaneous suppuration,
in which case there is a minimum of pain, because tension is not
great and the distance to the surface is short. Collections which
form beneath the fasciæ, especially the deeper fasciæ of the limbs
and trunk, give rise to much more extensive disturbance, both locally
and generally, and frequently do not point for many days; or, instead
of pointing, burrow deeply and find their outlet at some undesirable
point. These are known as _subfascial_ collections. _Subperiosteal_
abscesses give rise to still more pain, because of the unyielding
character of their limiting structures, and the symptoms caused by them
are acute and distressing.
An illustration of the pain which may follow deep suppuration may also
be seen in the ordinary panaritium, or bone felon, where the path of
infection is from without, but the destructive lesion is confined
within absolutely unyielding tissues, at least at first. Along certain
tissues infection spreads with rapidity. This is particularly true of
the delicate areolar tissue seen between tendons and tendon sheaths,
and the infectious process may follow this tissue wherever it shall
lead, even along complex courses.
The question often arises, _Can pus be resorbed?_ There is no question
but that small amounts of pus are disposed of by phagocytic activity,
and the disappearance of purulent infiltration, under the influence of
favoring remedies, or even when let alone, is not infrequently noted.
True pus resorption is a question of phagocytic possibilities, and
can occur only in very limited degree, as a result upon which it is
not safe to count, and which is capable of encouragement only up to a
certain point.
One inevitable law seems to govern collections of pus, that when
they _advance_ or migrate in any direction it is in that of _least
resistance_. This causes them to take peculiar and sometimes disastrous
courses, but it is a law which is never violated. It leads to the
bursting of abscesses into the brain, into the pleural cavity, into the
peritoneal cavity, the bowel, and elsewhere; it leads to a condition
where pus may travel along a path even a foot or more in length,
rather than come to the surface, a distance of perhaps an inch, and
affords one of the best reasons for early operative interference so
that the disastrous effects of burrowing may be obviated. When the
pus is limited to a drop or fraction thereof the abscess is called a
_furuncle_, especially when in the skin. The average “boil” of the
layman is a subcutaneous or subfascial abscess. When the infiltration
is pronounced, and when there has been more or less extensive
destruction of tissue, with perhaps formation of numerous outlets for
the escape of pus and detritus, it is known as a _carbuncle_. (See
Chapter XXVI.) In certain conditions small superficial furuncles or
boils form, sometimes in great number and almost synchronously, or, as
it were, in crops. This condition is known as _general furunculosis_.
=Signs and Symptoms of Abscesses.=--The appearances by which pus may
be suspected or detected are those of congestion and hyperemia, more
or less abruptly circumscribed and markedly accentuated. Along with
these there is more or less edema or edematous infiltration of the skin
and overlying tissue, which permits of that peculiar appearance known
as “pitting on pressure.” Often, too, there is a distinctly edematous
swelling of the parts, especially around the margin, with brawny
infiltration of the centre of the infected area. Numerous vesicles
occasionally are noted upon the skin, which may be filled with reddish
serum. When softening and pus formation occur, there is a condition
which to the palpating fingers gives the characteristic sensation known
as _fluctuation_. Fluctuation simply points out the presence of fluid
beneath; but when in an area marked as thus described fluctuation is
noted, it means the presence of pus. It is detected by manipulating in
a direction parallel to and concentric with the axis of the limb or
part. The pain is also in most instances significant; patients speak
of it as having an intense and throbbing character. With these local
signs occur symptoms indicating some degree of septic intoxication, _i.
e._, pyrexia, chills, malaise, sweats, etc., which are corroborative
indications, their intensity being a reasonably correct index of the
severity and gravity of the local infection.
When a deep-seated abscess is suspected a careful blood count will
often permit a diagnosis to be made. This is conspicuously true of
cases of appendicitis. If leukocytosis is established there should be
immediate operation. (See Chapter II.)
It is seldom that a superficial collection of pus can be mistaken for
anything else. In small and superficial abscesses (boils, furuncles)
as pus approaches the superficial layer (epidermis) of the skin it
may be discovered through its thin covering. In deep lesions there is
often a doubt, even on the part of the most experienced. The measure
now usually resorted to for purposes of diagnosis and exact recognition
is the exploring or aspirating needle. The old exploring needle was
one of good size, having a groove along which, after introduction, pus
might pass. Since the almost universal use of the hypodermic syringe, a
small aspirating needle attached to the ordinary syringe is the measure
commonly adopted. Such a needle may be introduced into the brain, into
the liver, or into almost any and every soft tissue without danger, and
if properly manipulated is almost sure to facilitate detection of pus.
Exploration done with either of these means and for this purpose should
always be conducted as an aseptic, even if a minor operation, in order
that no extra infection may be added from without. The skin should be
carefully washed, the needle sterilized, etc.
It is good surgery to resort to the knife either for the above purpose
or in order that by a longer incision or by opening the cavity deep
exploration may be made. Such explorations are of benefit even though
a circumscribed collection of pus is not found, since by relief of
tension and local abstraction of blood they act in a revulsive way and
do much good. Acting upon the same principle the trephine or the bone
chisel may be used for the purpose of opening the cranium and exploring
for pus, or of opening into the medullary canal of the long bones and
hunting there for that which is suspected.
=Treatment.=--As soon as suppuration threatens speedy measures should
be adopted, either for the purpose of bringing about resorption, or of
favoring and hastening suppuration. In theory antiseptic applications
are demanded; in practice they are sometimes of benefit. These may
consist of mere soothing applications, as a lead and opium wash, or
some other wet or dry astringent applied upon the surface; or they
may consist of cold applications, which by their astringent action
will limit the amount of exudate and prevent its further infection.
Or advantage may be taken of the properties of moist heat, and the
application of hot poultices or fomentations may encourage exudation,
but particularly quicken superficial breaking down, and thus hasten
the time when the phlegmon shall point, or come sufficiently close
to the surface to show that its contents are pus and permit of
evacuation. Such local applications, therefore, give relief from pain
and hasten favorably the suppurative process. In cases of phlegmonous
infiltration, the application of an ointment composed of resorcin 5,
ichthyol 10, mercurial ointment 35, and lanolin 50 parts, or else the
Credé silver ointment, is beneficial. Under the influence of these
antiseptic and sorbefacient preparations, and of moist heat, many
phlegmonous infiltrations assume a kindlier type, and may secure the
actual resorption of pus.
Finally in almost every case pus must be evacuated. Here the universal
rule may be applied, to which there are practically no exceptions,
and which should be stamped on the mind of every student and young
practitioner. It is--that _pus left to itself will do more harm than
will the knife of the surgeon if judiciously used for its evacuation_.
Action taken in accordance with this rule may be considered wise and
timely. The operation of evacuation may at one time be a mere puncture,
or possibly the aspirating needle alone will be enough; at other
times it requires extensive and careful dissection and entails no
little responsibility. This is particularly true in such deep-seated
suppurations as those around the appendix and in the brain, while in
the deep-seated bone lesions of this character the use of the bone
chisel or the cutting forceps may be of use. But the rule holds good,
no matter where the pus may be, and as long as good judgment is shown
in the operative procedure nothing but good can come from recognition
of this law. After the evacuation of pus the cavity should be cleansed
and disinfected with hydrogen dioxide, perhaps even with caustic
pyrozone, or, if these are not at hand, with other suitable antiseptic
solutions.
Ordinary judgment should be exercised in evacuating every abscess, in
order that opening be made at that point which in the common position
of the body shall be most favorable to drainage by mere gravity alone.
If circumstances compel opening when advantage cannot be taken of
gravity, then one or more _counteropenings_ should be made at points
selected where drainage may be best effected, and where anatomical
conditions do not make it injudicious to incise. Drainage should be
favored by the introduction of a drainage tube or of other aids, such
as gauze, strands of catgut, bundles of horse-hair, etc. Finally, a
dressing should be applied which is both protective and absorbent, and
in quantity sufficient to make compression of the walls of the abscess
cavity--not sufficient to obstruct drainage, but enough to favor prompt
adhesion of surfaces, which by speedy granulation shall ensure prompt
healing.
Abscesses are found in proximity to large vessels or dangerous
anatomical regions, when care must be exercised in opening them. Here
careful dissection should be made under an anesthetic. This is true of
abscesses in the neck and of those around the appendix, for example,
where the general peritoneal cavity is shut off only by more or less
delicate adhesions, and where the surgeon must literally feel his
way with great precaution lest adhesions be torn and the previously
protected cavity infected. At other times, especially in abdominal
abscesses, it is necessary to pack sponges or absorbent gauze in and
about the parts, so that any fluid which may escape may be absorbed by
these dressings.
=Accompanying Disturbances.=--The disturbance of function which
accompanies all congestion and exudation, whether provoked by specific
irritants or not, has been alluded to; but in cases of surgical
infections, especially those which produce local suppuration,
disturbance of function is much greater, while there are other
disturbances which sometimes constitute the worst feature of these
cases. The _presence of pus_ is often indicated, especially when
deeply seated, by one or more _chills_, and the occurrence of a chill
is always marked to varying degree by _pyrexia_. It is conceded that
the chill is an expression of a general septic disturbance; but it
is necessary also not to forget that general septic disturbance is a
frequent accompaniment of pus which is not evacuated as soon as formed.
Moreover in certain cases suppuration and septic infection seem to
occur synchronously, one being local, the other general.
Pus may also be suspected beneath a surface which is red, tender,
swollen, edematous, and pitting on pressure. When fluctuation is added
to these indications any element of doubt is thereby dissipated.
Other indications of the presence of pus are a well-marked
leukocytosis, coupled with the iodine reaction indicating the existence
of glycogen in the blood, the presence of indican in the urine, and
the positive results frequently obtained by making cultures from the
blood. When pyogenic bacteria are found in the blood the inference
is very plain, and both treatment and prognosis are influenced. In
such a case the introduction into the blood of an antiseptic such as
Credé’s soluble metallic silver or of the antistreptococcus serum,
is plainly indicated. The absence of bacteria from the blood, under
these circumstances, does not disprove the presence of pus, but their
presence gives a very serious character to the disease, and should lead
to a most guarded prognosis. Invasion of the blood by staphylococci is
nearly twice as serious as when streptococci gain entrance. Suppuration
of the bones and of the tendon sheaths is liable to produce such
invasion.
The other disturbance with which suppuration is so often complicated
is _septic infection_. In fact it may be questioned whether pyrexia is
not an expression of this condition. Any collection of pus, no matter
how small, may show signs of septic infection; and, on the other hand,
large collections may be formed without serious septic symptoms--in
other words, suppuration and expressions of septic infection may be
blended in almost every conceivable way. Sepsis as a distinct condition
will be described in another chapter.
It is important to summarize what may become of pus when once it has
formed and is not promptly evacuated. Pus when long present may be--
A. _Absorbed_;
B. _Encapsulated_; and
C. _Undergo various degenerations or chemical alterations_.
A. _The possibility of the absorption of pus_, or, what is equivalent
to it, its spontaneous disappearance, has been mentioned. While it
does not usually take this course, it may thus disappear; as, for
instance, in the anterior chamber of the eye in cases of _hypopyon_, or
in various other localities, particularly when present only in small
amounts. The absorption of pus is purely a matter, as far as we know,
of phagocytic activity plus the power of the tissues to take up various
fluids.
B. _Encapsulation._--This occurs only when pus has been present for
some time and when the virulence of the pyogenic organisms is not
intense. We may get encapsulation of pus in any part of the body, the
most typical illustration naturally being within the bones. Around
the purulent focus, as around any other irritating foreign body, the
capsule is formed by condensation of surrounding tissue. This is the
way in which most cold abscesses with their limiting membranes are
produced, those produced by tubercle bacilli having slight irritating
properties. Inasmuch, then, as the biological activity in such a focus
is small, there is time for such encapsulation; while by the membrane
thus formed, or the sanitary cordon, already referred to, protection
is afforded to the surrounding tissues. In such a collection fresh
infection may incite acute disturbances again, and many abscesses
which thus lie latent for a considerable length of time are fanned, as
it were, into a conflagration, when a new and acute inflammation is
produced.
C. _Of the various metamorphoses and chemical changes_ that occur in
that which was originally pus, the caseous and the calcific are the
most common. These also are connected largely with the tuberculous
process, although calcareous particles are found in the pus of
actinomycosis. Under their respective heads these degenerations will be
more particularly described.
Certain names have been given to collections of pus in different
localities or under peculiar circumstances. A collection of pus in
the anterior chamber of the eye is known as _hypopyon_; when in any
preëxisting cavity, it is known as _empyema_ of that cavity, the
_distinction between empyema and abscess_ being that “abscess” means a
circumscribed collection where previously there was no cavity, while
“empyema” implies a normal cavity, without respect to size or location,
filled with this abnormal fluid. The term _empyema_, when not used
in connection with some particular cavity, is understood to refer
to a collection of pus in the pleural cavity. Other names also are
used which are particulate and distinctive; in these the prefix _pyo_
is used while the suffix indicates the part involved; thus we have
_pyothorax_, _pyopericardium_, _pyarthrosis_, etc.
SINUS AND FISTULA.
These are terms applied to more or less _tubular channels abnormally
connecting various parts of the body, or connecting some cavity
with the surface of the body in a way anatomically quite abnormal_.
Or they may be regarded as _tubular ulcers_, or ulcerated tunnels,
connecting as above. A more exact distinction between the two terms
would imply that a _sinus_ connects the surface with some deeper
portion where a cavity is not normally present--_i. e._, with a focus
of disease--whereas a _fistula_ properly refers to a tubular passage
connecting natural or preëxisting cavities in an abnormal manner. Thus
we speak of buccal, rectal, vesicovaginal fistulas, etc., whereas
a passage leading down to an old abscess or to a focus of disease
in bone, for instance, is properly referred to as a sinus. It is
possible for the margins of a fistula to become more or less cicatrized
and cease to be ulcerous, whereas the entire track of a sinus is
practically a continuous ulcer, only tubular in arrangement.
=Causes.= A. =Congenital.=--There are numerous points about the
body where, as the result of arrest of development or failure to
grow, fistulous passages which are comprised within the normal fetal
arrangements, but which should close later, either before or at birth,
fail to do so. Thus we have congenital fistulas of the neck, persistent
urachus, persistent omphalomesenteric duct, etc. These are in no
sense primarily connected with diseased conditions, but may become so
secondarily.
B. =Pre-existing Abscess with Unhealed Channel of Escape=--_e. g._,
rectal, fecal, and other fistulas and sinuses which connect with
tuberculous foci in any part of the body.
C. =Previous Traumatic or other Destruction of Normal Tissues=--_e.
g._, vesicovaginal fistulas due to tissue death from pressure, buccal
fistulas from gangrene of the cheek, as in noma.
D. =Foreign Bodies=--bullets, ligatures, etc.--which prove irritating
or infectious enough to prevent absolute healing. More or less tortuous
sinuses will generally be found leading down to the irritating material.
E. =The Presence of Necrosed or Necrotic Material=--_e. g._, a
sequestrum in bone, which is usually evidenced by the presence of one
or more sinuses.
=Treatment.=--If the determining cause is still acting, the treatment
is to remove the cause. Consequently, when the sinus leads down to
diseased bone or other dead or dying tissue, the complete evacuation of
the cavity is necessary before the sinus may heal. If the cause is a
foreign body, its removal should be at once insisted upon.
An excellent suggestion is to stain all fistulous tracks with
methylene-blue; the blue trail after doing this may be followed, no
matter how irregular its course (Fergusson). If the color is mixed
with a little hydrogen dioxide, and this forced into a sinus mouth or
a fistulous opening, it will carry the dye to all parts of the cavity.
This may be used even in dealing with fecal fistulas or those extending
deeply into the interior of the body or among the viscera.
Fistulas of congenital origin and those which connect two normal
cavities of the human body are usually due to a cause which has ceased
to act. Consequently we should endeavor solely to atone for the result.
The direction and the course of a sinus may be learned by the use of
a probe curved to suit and manipulated by a gentle hand, force never
being required. Or sometimes, when the silver instrument fails to
pass, a flexible bougie or catheter may be introduced. The character
of the passage can be judged for the most part by the appearance of
the discharges. With sinuses of recent origin leading down to recent
suppurative foci it may be sufficient to enlarge the opening and to
wash the cavity thoroughly. If a particle of gauze, tube, or sponge has
been left therein, its removal is necessary to secure prompt healing.
In cases of long standing antiseptic and stimulating substances should
be injected or the interior should be cauterized with strong solutions
of zinc chloride or silver nitrate, or with these melted upon the end
of a probe. The _chronic_ sinus, as well as the chronic rectal fistula,
is usually an expression of _local tuberculous disease_. Accordingly
these passages may be found lined with the same dense, fungating
membrane which lines a cold abscess cavity--the membrane, protective in
its purpose, to which I have given the name _pyophylactic_. Whenever
such tissue and such membrane are met with they should both be
extirpated thoroughly, since in this way only can absolute eradication
of the tuberculous infection be relied upon. After such complete
excision--which means usually laying open the entire sinus--the parts
may be brought together with sutures (this, at least, is usually
possible about the rectum) to secure primary union; otherwise, the
whole sinus, as well as the cavity to which it has led, must heal by
the granulating process, both being kept packed with gauze or some
other desirable foreign body acting as an irritant, thereby provoking
more rapid formation of granulation tissue. When it is necessary
thus to pack a cavity, or when it is desired to keep its upper exit
open lest it heal before the lower part, ordinary white beeswax, as
suggested by Gunn, makes a serviceable material. This can be molded in
hot water to fit the cavity; can be tunnelled or bored for drainage;
can be diminished in size as the cavity heals, and is absolutely
non-absorbent.
Finally there are numerous plastic methods which have been resorted
to in various parts of the body, most of which are made to comprise,
first, the absolute eradication of the diseased tract, and, later, the
closure of the wound thus made by transplantation or sliding of flaps,
or any other plastic expedient which may be considered best. These, as
well as the special treatment made necessary for particular forms of
sinus and fistula, will be dealt with under their proper headings.
CHAPTER IV.
ULCER AND ULCERATION.
The term _ulcer_ pertains to surfaces, and should be defined as a
_surface which is or ought to be granulating_, _i. e._, _healing_.
While an ulcer may be the result of ulceration, it is not necessarily
so, the term _ulceration_ being one of very loose significance and
applied to many different processes. The idea underlying ulceration is
_infection_, and, when limited to its proper significance, the term
should never be used for a process in which infection and consequent
breaking down of tissue do not virtually comprise the whole process.
Therefore, it is to be distinguished from certain disappearances of
tissue alluded to under the head of Atrophy or Interstitial Absorption.
It is not correct to say that the sternum ulcerates away, making room
for a growing aortic aneurysm, the question of infection here not
being raised. These distinctions should be accurately maintained and
constantly borne in mind.
ULCERS.
The causes of ulcers may be--
A. _Traumatic_;
B. _Local_; or,
C. _Constitutional_.
A. =Traumatic.=--This includes all surfaces which are granulating
and healing more or less rapidly, or are displaying a disposition
toward healing, and which may have been produced by _wounds_, _burns_,
_frostbites_, etc. These include also ulcers due to _pressure_, as from
splints, bandages, orthopedic apparatus, or from _external friction_.
Ulcers which form around _foreign bodies_ may also be included under
this head, their essential cause being traumatic. It should include
also destruction of the surface by various _chemical agencies_, such
as strong caustics, and the consequences of intense _heat_ or _cold_,
including burns and frostbites.
B. =Local.=--1. Among local causes may be mentioned _local infections_,
with tissue death in consequence, such as occur in tuberculous,
cancerous, leprous, syphilitic, and other specific manifestations where
surfaces are involved.
2. _Tumors_, either benign or malignant, whose blood supply is cut off
and whose surface is thereby predisposed to infection.
3. _Perverted surface nutrition_, for example, in connection with
varicose veins of the extremities, where, aside from any perverted
trophoneurotic influence, there is stagnation of blood, saturation of
tissues with serum, and final leakage of the same, even to the surface.
Varicose veins of the leg which lie near or underlie ulcerating
surfaces become thrombosed and obliterated, so that such ulcers rarely
bleed. On the other hand, a passive hyperemia here leads to edema,
perversion of nutrition, failure to repair trifling surface injury, and
a surface is left which of itself rarely, if ever, heals.
4. So-called _pressure sores_ or _bed-sores_, which in some cases may
be regarded as having a traumatic origin, but which, nevertheless,
would not occur from purely traumatic influences without predisposing
tissue changes. The bed-sore is probably the best illustration of this.
Simple ulcer is known as bed-sore, while a sloughing ulcer of this kind
is frequently alluded to as _decubitus_. Such ulcers are usually found
over those regions of the body made most prominent by bony projections,
upon which undue pressure is made when debilitated patients have lain
for a long time in bed.
5. Ulcer is the frequent result of numerous _skin diseases_, into whose
etiology as yet bacteria have not been introduced--_e. g._, pemphigus,
eczema, etc.
6. Ulcer is the occasional result of _embolic_ or other _disturbance_
of the principal artery of the part, by which nutrition is cut off and
tissue death results.
7. _Bites of insects_ or other _parasites_ or of noxious animals
frequently lead to ulceration.
8. Certain more specific forms of ulcer are described by some writers,
apparently with more or less reason, among them being _chancroid_,
_perforating ulcer of the foot_, etc. (Chancroid is described in
Chapter X.) Trophic ulcers of the fingers or hand are also seen,
particularly after injury to or division of nerve trunks in the arm
or forearm. Perforating ulcer of the foot is a circumscribed circular
ulcer with thickened edges, often nearly concealed by overhanging skin.
It may be found in any part of the sole of the foot, but is most common
near the first joint of the great toe. The borders of the ulcer are
usually anesthetic. It is frequently seen in diabetics. By some it is
associated with trophic nerve disturbance; by others it is regarded as
having a specific etiology of its own. The probability, however, is
that it is simply a subvariety of pressure sore.
9. Since the introduction of the _Röntgen_ or _x-rays_ into surgical
therapeutics a new local cause of painful and intractable ulcers should
be enumerated. A too prolonged or injudicious exposure of a part to
this peculiar influence induces first a dermatitis, which is not always
immediate, but may be tardy in appearance, and which may be followed
by desquamation or exfoliation that may proceed to absolute surface
destruction and sloughing. These lesions are popularly spoken of as
_x-ray burns_. The superficial ulcers thus produced may be extensive
and are nearly always excessively sensitive and painful. The very
structure of the surface vessels is affected and they undergo a species
of sclerosis. A strong preparation of _radium_ has been known to
produce a similar effect.
C. =Constitutional.=--1. Ulcers are frequently met with in certain
constitutional conditions which are characterized by tendency to
local manifestation at points of least resistance. Among these may be
mentioned _scurvy_.
2. There are ulcers of apparently distinctive _trophoneurotic_ origin,
of which that mentioned above as B, 8--perforating ulcer of the
foot--may possibly be one. These accompany certain nervous disorders of
central origin, prominent among which are locomotor ataxia and tabetic
disease of all forms.
3. Ulcers are produced sometimes as the result of _specific_ or
selective _action of certain drugs_, among them mercury and phosphorus
being the most prominent. These manifestations are usually perceived
in the mouth, and may be regarded as infections at points of least
resistance. Nevertheless, they are commonly associated with the
tendency of these drugs.
4. There are many constitutional conditions in which vitality is so
lowered that a special liability to ulcer--_i. e._, infection and
production of ulcer at many points--is noted. It is well, however, to
mention that the common diseases in which this tendency is most often
noted are typhoid, diphtheria, diabetes, and syphilis.
With this summary of the common causes of ulcer it is again stated
that ulcers may be due to direct consequence of traumatic loss of
substance or to the process of ulceration--_i. e._, as a consequence of
previous infection, or as permitted by trophoneurotic disturbance and
ischemia. Ulceration is a process of _molecular death_, in which cells
die successively and more slowly, as _distinguished from gangrene_, in
which there is simultaneous death of large aggregations of cells, by
which a slough or its equivalent is produced.
Ulcers are referred to as _healthy_ when the process of granulation
is proceeding with average rapidity; _indolent_, when the reverse
prevails; _sloughing_, when there is actual visible tissue death
in connection with the ulcerative process; _phagedenic_, when the
gangrenous tendency is well marked and the process exceedingly rapid;
_irritable_ or _erethistic_, when the surface is exquisitely sensitive;
_hemorrhagic_, when bleeding easily; _fungous_ or _fungoid_, when the
granulations have risen above the surface and are increasing at too
rapid a rate. There is a peculiar form of ulcer, seen mostly upon the
face, to which the name _rodent ulcer_ (also lupus exedens) has been
given. This is now known to be a slowly growing form of epithelioma,
and is described in Chapter XXV.
The best examples of the indolent ulcer are seen in connection with
varicose veins of the extremities; of the phagedenic ulcer, in certain
cases of chancroid; of the irritable ulcer, in ulceration of the
cornea, when the pain and photophobia are intense; or in fissured ulcer
of the anus, where the pain and sphincter spasm are sometimes agonizing.
Ulcers are described according to their _shape_ as _regular_ or
_irregular_; as _fissured_, when they extend more or less deeply and
abruptly into the surface involved; as _fistulous_ when they have a
tubular arrangement; as _rodent_, when they spare nothing in their
course.
The _borders_ of ulcers are described as _healthy_, _indurated_,
_tumid_, _edematous_, _undermined_, _livid_, _inflamed_, etc., these
adjectives explaining themselves.
The _surfaces_ of ulcers are described as _healthy_ when they have
normal color and appearance, _inflamed_, _excavated_, _covered with
sloughs_, _callous_, etc. The _callous_ ulcer is one which exhibits
little change from month to month; its surface is dirty, and its
secretion thin and mucopurulent. It is usually sunk considerably below
the surrounding level, while its border is firm and nodular. The best
examples of this form are those accompanying varicose veins.
In size or area ulcers may vary from the slightest local destruction of
tissue to an area covering an entire limb or a large part of the trunk.
In depth they vary within lesser limits; while an external ulcer may
connect with some deep lesion by means of a tubular passage or _sinus_.
It thus appears that the term ulcer may be applied to the result of
a natural effort to repair loss of substance without introducing
the element of disease, or that it may be the consequence of local
infection with local tissue disaster.
The character of the material discharged from an ulcer will vary
according to the category in which it belongs. The healthy, healing, or
granulating surface, often spoken of as ulcer, discharges a material
in gross appearance much resembling pus from an acute abscess; in
consistency, color, and other appearances it is the same. Nevertheless,
its origin is essentially distinct. This material represents simply the
waste of reparative material, sent up to the surface for the purpose
of hurrying the process. Its fluid, like that of pus, comes from the
serum of the blood; its corpuscular elements, like those of pus, are
leukocytes or wandering tissue cells, which have been furnished in
great numbers--in fact, in excess. As it comes to the surface--or
as, rather, it is rejected from the surface, being superfluous in
amount--it is likely to become contaminated with bacteria by contact
infection, and consequently may be seen under the microscope to
contain various microörganisms. This contamination, however, has been
final, accidental, and irrelevant. This material is _not pus_; has no
infectious properties, except those which may accidentally be conveyed
to it; represents no warfare of cells, only excess of supply or
overdemand; and should be spoken of as _pyoid_ or _puruloid_ material,
and never confused with pus. In amount it will vary according to the
activity of the reparative endeavor, and somewhat according to the
amount of irritation of the surface by dressings which may be applied.
If a granulating surface is absolutely protected from possibility of
contact infection, it will never contain microörganisms; while this
_pyoid_, if allowed to remain too long, especially when infection is
permitted, may decompose and become irritating, and is a material to be
gently dislodged by a spray or an irrigating stream with each dressing,
which dressing should be made once in twenty-four to sixty hours.
PROCESSES OF REPAIR.
An ulcer having been defined as a surface which is or ought to be
granulating, it becomes necessary to define the granulation process
and to show how healing is thereby achieved. _Granulation tissue_
is a name applied to a new and temporary tissue of embryonic type,
which acts as a scaffolding or temporary structure, permitting the
construction of more permanent tissue. It is produced entirely by the
activity of cells, which are the mononuclear and polynuclear leukocytes
and the wandering cells already mentioned. They are frequently known
as _embryonal cells_ when performing this function; sometimes as
_formative cells_. They have a distinct nucleus, which stains readily,
and, having this resemblance to epithelial cells, they are often
referred to as _epithelioid cells_--sometimes as _fibroblasts_, because
they may later assume the dignity of connective-tissue cells. They
assume a multitude of shapes. Between these cells as they are drawn
toward the point at which they are most needed, perhaps by chemotactic
activity, there is an _intercellular substance_ which later becomes
fibrillated. As these fibers develop the remaining cells become
entangled between them, and in this way a new connective tissue is
formed of cells of originally mesoblastic origin. Of such tissue the
solid part of granulation tissue is built. This tissue is essentially
different from the epithelium which it is expected will subsequently
cover it. If a normal granulating surface is scanned with a magnifying
glass of small magnifying power, it will be seen to consist of
numerous minute projections, each of which is known as a granulation,
consisting of the tissue above described, formed as a minute eminence
around a budding capillary bloodvessel, from which a projection has
arisen upon the exposed surface. This capillary bud is the result of
karyokinetic activity on the part of the endothelium--namely, the
hypoblastic cells of which it is essentially composed. In each of these
cells, under certain circumstances, the karyokinetic threads already
mentioned develop and become loosely coiled, while the chromatin in the
nucleus increases in amount and the nucleolus disappears. The chromatin
threads become thicker, arrange themselves equatorially around the
poles of the nucleus, and gradually turn so as to point toward it,
while a new membrane forms around each separate coil, and two nuclei
are thus made out of one. While this is taking place within the
nucleus the cell protoplasm undergoes active rotary motion, is finally
segmented, and by the time the nucleus is divided is nearly ready
for complete division of the cell. While nuclear division is usually
bipolar, it may be multipolar; if a rearrangement of the protoplasm
is delayed, the result becomes a multinuclear cell, known as a _giant
cell_.
The consequence of this endothelial activity is new cell formation and
the construction of a projection from the capillary which soon attains
the dignity of its parent vessel, and, as connective-tissue cells form
around it, soon becomes a granulation by itself, each granulation being
marked by a capillary loop of its own. Healing by granulation or the
granulation process, no matter how set up or caused, is essentially
the formation of hundreds or thousands of these tiny structures, a
new one being formed on top of those which precede it, while those
first formed and deeper down undergo condensation and metamorphosis
of tissues, by which they are converted into something higher in
the tissue scale. Under ideal conditions true granulation building
proceeds _pari passu_ with epithelial reproduction around the margin
of the granulating surface, so that by the time granulation tissue
has completely filled the defect, no matter how caused, epithelial
covering has been completely constructed and the healing process thus
completed. These two processes, however, do not necessarily keep pace
with each other. Should surface repair take place relatively early,
we may have a depressed scar; while, on the other hand, should it not
proceed rapidly enough, or, to state it in another way, should the
granulating process be too rapid, we have such excess of granulations
as shall rise considerably above the surrounding level, and may, under
certain circumstances, become so exuberant that nutritive material
cannot be formed rapidly enough, and those granulations farthest away
from the centre of supply may die. Such exuberant granulation is often
spoken of as _fungoid_, and constitutes that great bugbear in the eyes
of the laity which is termed by them _proud flesh_. It has no further
significance than that the supply has exceeded the demand and that the
granulating process has been overdone. Such luxuriant granulations may
be cut away with scissors or knife, may be burned away with caustic
agents or the actual cautery, or may be disposed of in any other manner
without harm and only with benefit; in fact, it is often necessary to
suppress this exuberant tendency by caustics and pressure, in order
that the desired epithelial covering may be properly formed.
Epithelium, being an epiblastic structure and capable of no other
origin save from its kind, can only be supplied from those regions
where it has preëxisted. Consequently, ulcers involving the external
surface of the body demand a lively epithelial reproduction in order
that they may have a normal covering. Epithelial activity sometimes
becomes retarded, and is much slower toward the termination of the
healing process than at the beginning. The epithelial covering of a
healing ulcer is always marked by a delicate whitish or pinkish film,
which proceeds from the periphery as well as from any little island
of original epithelial structure left. It is well known that after a
certain amount of this repair the process sometimes comes to a complete
halt, and the various expedients for stimulating and promoting it, as
sponge grafting and the different methods of skin grafting, have been
devised solely to atone for such sluggishness or inability.
Ulcers of small size, which are more or less exposed to the air in
healthy individuals, while also exposed to possibility of infection,
nevertheless seem to escape it, owing to the defensive power of the
blood serum and the active cells. Such discharge as naturally comes
from them, when not excessive, undergoes evaporation until a point
is reached where a _dry crust_ or _scab_ is formed. Under this scab
granulation proceeds to a point where the pressure of the scab itself,
presumably on the level of the surrounding parts, checks its activity,
while at the same time epithelial reproduction goes on until it has
been completed. Then the scab, being no longer of use, drops off or is
detached by slight friction.
_Such is granulation tissue_: at first a mere trelliswork of
temporary and delicate cell structure, traced in a certain amount of
intercellular, homogeneous substance, into which the budding vessels
project, the whole mounting, nearer and nearer to the surface, day by
day, with variable rapidity, diminishing in this regard as the days go
by, so that frequently the granulation process comes to an apparent
halt before enough new tissue has been formed. While the superficial
granulations preserve the characteristics above noted, those deeper
down undergo firmer and more complete organization, and the delicate
embryonic structures show the same tendency which they do in the
growing embryo, by virtue of what Virchow has called _metaplasia_,
to become converted into something higher and more dignified in the
tissue scale. These cells do not specialize themselves to the extent
of permitting complete repair of organs of special sense. Thus, while
a wound in the cornea or retina may be completely healed, it heals
by cicatricial tissue, and not by repair of the special structures
involved. On the other hand, tissues of more common connective
type--fibrous, bone, cartilage, etc.--are capable of regeneration;
and it seems to be a part of the privilege of these new granulations
to merge themselves into that kind of tissue necessary for filling
the gap. Nevertheless the most _common result of granulation is its
metablastic conversion_ into fibrous tissue, which has the special
characteristic of contractility without elasticity. As a result the
_scars contract_, in consequence of which disfiguring results are
sometimes the almost inevitable consequence of healing of extensive
losses of substance. In certain instances it is possible by constant
effort to overcome the unpleasant effect of this cicatricial
contraction. For example, after extensive burn of the anterior part of
the arm, the forearm will be gradually and permanently flexed upon the
arm by virtue of contraction of the scar in front of the elbow unless
some forcible means is practised for maintaining extension of the limb
for at least a part of the time. So with many other injuries and the
various mechanical or other expedients required to prevent the untoward
result. Nowhere are the after-effects more disfiguring or serious than
about the face, where the eyelids are drawn out of shape, the contour
of the mouth altered, and where, sometimes, there are other extensive
manifestations (Figs. 10 and 11).
[Illustration: FIG. 10
Cicatricial deformity following burn. (Original.)]
[Illustration: FIG. 11
Cicatricial deformity following burn: side view of same case.]
[Illustration: FIG. 12
Epitheliomatous degeneration of chronic ulcer, necessitating
amputation. (Original.)]
As a result of healing of the granulating surface there is what is
known as a _cicatrix_ or _scar_. This is composed of fibrous tissue,
probably more or less distorted by virtue of its contractility, and
of epithelial covering furnished from the margin of the original
ulcer, constituting a thin, glistening membrane, applied closely to
the scar tissue beneath, without intervening fat or tissue which
permits of the play of the one upon the other. When this epithelial
surface is abraded it is repaired with difficulty, and a raw or
ulcerating scar is difficult to heal. Manifestation of perverted
epithelial outgrowth is frequently provoked at these points by the
action of continuous irritation. In consequence there is what is
generally recognized as the _transformation of a chronic ulcer_,
or the site of one, _into an epithelioma_, or possibly, by similar
irritation of the connective-tissue elements, into a sarcoma. This is
the so-called cancerous degeneration of previous ulcers, and is noted
occasionally. The lesion is one which often requires disfiguring,
or even mutilating operations in order to get rid of the malignant
disease (Fig. 12.) All the scars thus resulting are liable to undergo a
fibrous and degenerative change to which is given the name _cicatricial
keloid_. It is marked by increase in size and density, by reddening
which denotes increased vascularity, and extension into surrounding
previously healthy tissue. By these changes a given scar is made much
more prominent and disfiguring. It cannot be prevented by any ordinary
treatment, and is often the _bête noir_ of surgeons. (See also under
Fibroma, and chapter on Diseases of the Skin.)
The surface of a superficial scar while thus covered with epithelium
shows a complete lack of all the other skin elements. No hair grows
upon such a surface, because the original hair follicles are destroyed;
neither is it moistened by perspiration nor anointed by sebaceous
material, because the secretory glands have also disappeared. It is a
surface which often needs more or less protection, especially when in
exposed situations.
=Treatment.=--Here, as in all other instances, the first effort of the
surgeon should be to remove the cause. This may be done by _local_, or
may require _constitutional_ measures. If a definite local cause can be
established, its removal may be a slight or may entail a more or less
serious surgical operation. Aside from this disposal of the exciting
agent, treatment should be divided into the general and the local.
General treatment is scarcely called for when dealing with healthy
ulcers; but in all those instances where the constitutional condition
of the patient is below par, or where there is a general poisoning
or infection underlying the ulcer itself, prompt and energetic
constitutional treatment should be at once instituted. In scurvy, for
instance, the diet and hygienic surroundings of the patient should
be rectified immediately. In syphilis no lasting nor deep impression
can be made on local manifestations without general constitutional
treatment. In tuberculosis and the other surgical infections much will
be accomplished by internal medication, by proper hygiene, as well as
by local applications or operation. The importance of these general
measures is likely to be underestimated, and many fail to realize the
advantage of combining suitable internal and external therapeutic
measures.
=Local Treatment.=--First of all may be mentioned the insistence upon
repose which induces _physiological rest_. The ulcer may then show a
tendency to heal. This may necessitate wearing a splint or restraining
apparatus, or confinement in bed, depending upon the location of the
ulcer. Physiological rest will be enforced sometimes by stretching a
sphincter in order to temporarily paralyze it in cases of irritable
rectal ulcer, where the principal pain is produced by the reflex spasm
of its fibers. Again, the eye with irritable ulcer of the cornea is
sometimes kept so tightly closed by the same kind of spasm there that
it may be necessary to divide the lids, or the orbicularis muscle at
the angle of the lids, in order to make access to the part. This is
carrying out the principle of physiological rest, because it permits
proper exposure and treatment.
The healthy and healing ulcer needs no treatment except protection.
Epithelial covering will probably keep pace with filling of the
depression by granulations, and all that is necessary to do is to
prevent external irritation. Should there be excess of discharge, the
simplest absorbent dressing, with enough antiseptic material to prevent
putrefaction by contamination with the bacteria of the surrounding
air, should be employed. The ulcer which is becoming tardy in its
repair may be stimulated by silver nitrate, zinc chloride, or other
caustic applications, which act as a spur to the sluggish granulations,
destroying those with which it comes in contact, but stimulating those
below to do their duty more promptly.
The conventional applications to ulcers fall usually under two
categories--the _watery solutions_ and the _unguents_.
[Illustration: FIG. 13
Cicatricial deformity following specific ulcer. (Original.)]
Investigations in the laboratory have led to the employment of
peptonized preparations, among which are peptonized cod-liver oil and
some of the partially or predigested foods, such as _bovinine_, etc.
These appear to have the power of digesting sloughs and of causing a
speedy separation or disposal of everything necessary in the endeavor
to secure a healthy condition of the ulcerating surface and give most
satisfactory results. When sloughs are present it is an advantage to
dust over them papoid, caroid, etc., which have the power of catalytic
disposition of decomposing material without reference to the action of
bacteria. Under their use there seems to be a solution and disposition
of these dead products. With a foul ulcer--one from which the discharge
is more or less offensive, due usually to decomposition of sloughing
masses, not yet separated--the method of _continuous immersion in hot
water_, when it can be performed, is always valuable. But nothing
seems to equal _brewers’ yeast_ for this purpose. It may be applied on
absorbent cotton (which should be soaked in it) and covered with oiled
silk. Its curative property may be ascribed to the nuclein which it
contains in a nascent state. It will, when fresh, clean off a sloughing
surface better than anything I ever used.
Many ulcers are surrounded with such firm, indurated borders that it
seems impossible that any active regenerative process can arise from
such source. Hence, incisions have been practised for centuries. These
have been made radially from the centre or have been made parallel to
the margin of the ulcer, or sometimes the firm, dense tissues have
been minced or chopped by a series of cross-cut stabs or incisions;
as the result of which renewed activity has arisen, and an impetus
given to the healing process. These methods, however, have yielded
to that alluded to above. The ulcer in which granulation has come to
a standstill is often treated with the _sharp spoon_ or _curette_.
The result of this has been to provoke again a speedy renewal of
granulation efforts, and treatment by curetting is standard and
often useful. Actual cauterization of the ulcer with a view to such
complete destruction of its covering and border as shall lead to their
separation by the sloughing process is occasionally practised. This
is perhaps best performed with the actual cautery. It lacks, however,
the valuable features of the operative method, to be described below.
Modern methods have made it plain that it is often an absolute waste
of valuable time to resort to the older expedients of stimulation,
incising the edges, etc., and that one can accomplish by an operation
in perhaps three weeks what ten times that length of time would fail
to do by older methods. The _most effective method_, therefore, in
dealing _with old and chronic ulcers_ is to anesthetize the patient, to
_excise the entire affected area_--_i. e._, the surface which ought to
be granulating and the firm border and tissue in its neighborhood--and
then to cover the surface either with _skin grafts_, pared off with a
razor according to the Thiersch method, or with a strip of skin whose
full thickness is raised, which is taken from surrounding parts by
some autoplastic or heteroplastic method. This line of treatment is so
far preferable to all others that, except in case of refusal of the
patient to submit to it, it is the one which must hereafter commend
itself. It may afford opportunity for extensive plastic operations or
for the exercise of the best discretion and knowledge of experienced
men; yet cases are rare in which it cannot be successfully performed.
These methods of skin grafting have so far supplanted the older method
of sponge grafting that the latter is now seldom practised. It may
possibly have a sphere of usefulness in certain ulcerated cavities, but
under all other circumstances it must take a position far below the
plastic methods in practical value.
Finally, ulcers of specific type--syphilitic, tuberculous, leprous,
glanderous, etc.--need methods in which the first effort should be not
so much to arrange for healing as to dispose of infectious material.
The knife, the scissors, the sharp spoon come first into use here,
the surgeon bearing in mind that almost all this material is more or
less infectious, and that inoculation of his own hands is possible as
the result of carelessness. After taking away with instruments all
the granulation tissue, with its surroundings, which seems to expose
to danger, it is well to cauterize the part with the actual cautery,
nitric acid, bromine, or zinc chloride.
The markedly _hemorrhagic ulcer_, whose surface bleeds on the
slightest contact or disturbance, is often a cancerous ulcer, though
not necessarily so. This ready bleeding is usually the effect of
the fragility of the walls of the new-formed bloodvessels. In many
instances it is sufficient to scrape until harder or more resisting
tissue is encountered. Hemorrhage may be profuse for the moment, but it
is easily controlled. Caustics may then be applied or not, according to
the judgment of the surgeon.
Another method is to treat such a surface with the actual cautery.
Another is to operate, even in the presence of incurable disease, in
order to check a tendency to fatal hemorrhage before the disease has
expended itself. In a general way, in regard to small, ulcerating,
cancerous surfaces, it may be said that if they bleed excessively or
are unduly irritable, it is preferable to attack them by operative
measures in spite of the impossibility of effecting a cure.
There are other methods of treating ulcers, but they have mainly been
abandoned for those mentioned.
CHAPTER V.
GANGRENE.
Gangrene is known also as _necrosis_, although this term is usually
limited to gangrene of bone. It is known also as _mortification_, and
to the older writers, especially when soft parts die and separate in
sloughs, as _sphacelus_. _Gangrene means death of tissue in visible and
more or less circumscribed masses._ It is distinguished from ulceration
not on account of molecular disintegration, particle by particle,
but because of death _in toto and synchronously_ of a large, perhaps
innumerable, number of cells. Gangrene is described as due to causes
which may be:
A. =Traumatic=, including the so-called thermal causes as essentially
mechanical injuries. Under this head are included cases where _injury_
is the primary cause, whether this injury is the crushing of a limb,
the separation or occlusion of its main bloodvessels, the division of
its main nerves, or the crushing or pulpefying of its entire structure
by machinery or accident; also those so-called _thermal_ cases which
are due to intense heat or intense cold. To these might be added the
_chemical_ causes, comprising injuries by powerful caustics, alkalies,
or acids, which are known to cause speedy death of every living tissue
with which they come in contact.
Gangrene from _frostbite_ is often of the moist type. There is scarcely
a limit to its extent, either in area or depth. It is due primarily to
thrombosis, which is followed by a purplish color of the skin, by loss
of local warmth, and numbness. Naturally it involves the ears, nose,
fingers, and toes. But after alcoholism and exposure one or more entire
limbs may be involved. With moist gangrene there is danger of septic
infection (_q. v._). After formation of a line of demarcation the line
of amputation may be made to follow it closely, but the best results
are obtained by higher division, at points of election, where tissues
are less sensitive and less infiltrated.
B. =Local Causes.=--These are largely connected with _ischemia_.
_Gangrene from edema_--itself the result of passive hyperemia and
exudation--is not infrequent, the most common expression of this
condition being seen perhaps in the external genitals of the male.
_Embolism_ due to valvular heart disease, _thrombosis_ due usually to
a preceding phlebitis, but possibly to marasmic origin, especially
met with after confinement, with disturbance in the uterine sinuses,
shutting off the circulation by endarteritis, which thus assumes the
form _obliterans_, are some of the local causes which concern the
bloodvessels alone. In fact, the majority of cases of spontaneous
gangrene are probably due to changes in the vessels, endarteritis
being the cause of a condition known as atheroma of vessels, in which
fungoid outgrowths, or, rather, ingrowths into the vessel lumen, are
common. Any one of these, if detached, may serve as an embolus. The
degenerative excavations in the thickened walls of the bloodvessels,
which discharge more or less cholesterin and other debris, and which
have been known as _atheromatous abscesses_ (misnomer), are frequently
the precursors of the disease under consideration. As the result of
these changes alone, without reference to formation of emboli, vessels
may become completely occluded, especially when slightly injured.[2]
[2] Intermittent claudication, when recognized, may be regarded as a
precursor of that arteriosclerosis which may proceed to gangrene. The
term implies temporary anemia of one or more of the extremities, with
numbness, burning, or prickling sensations in the skin, occasional
cramps in the muscles, with loss of power, tenderness of the nerve
trunks, weakening or loss of pulse in the affected part. When these
symptoms occur in the feet they are not infrequently followed by
terminal gangrene or other evidences of angioneurotic necrosis,
including even those forms known as erythromelalgia and Raynaud’s
disease. Its treatment, of course, is relaxation of vasomotor
spasm, best accomplished by the use of the nitrites, among which
nitroglycerin is perhaps most valuable.
_Extravasation_ of blood is another cause connected with the
bloodvessels, this coming usually from traumatic rupture, possibly from
idiopathic causes. At any rate, the tension in the part may threaten
its life because of the pressure which overcomes the circulation of
blood. _Ligation_ of the main trunk of an artery is sometimes followed
by gangrene, no matter how carefully done, collateral circulation
being insufficient to sustain the nourishment of the part. In certain
fractures, simple as well as compound, the blood supply of a part is
rudely broken off by injury to a bloodvessel in such a way as to cause
local or general death, either of a bone or of the entire limb. Flaps
made for plastic purposes, arranged without sufficient regard to their
proper blood supply, or so dressed after operation as to sustain undue
pressure, are often so shut off from the heart as to die for want
of blood. Finally, gangrene may be the result of _pressure_ either
from splints, bandages, etc., or from _tumors_ increasing in size, or
possibly, as in certain pressure sores, etc., from the mere weight of
the body. Here, too, _chemical agents_ must be mentioned, referring
now to the peculiar action of certain _foods or drugs_, particularly
ergot. Thus antiseptic solutions, particularly carbolic acid, may be
made strong enough to destroy the vitality of certain tissues. Carbolic
gangrene (Warren) is a possibility not to be forgotten.
Extravasation of urine, unless promptly recognized and appropriately
treated, or especially as occurring when the urine is peculiarly toxic
(ammoniacal) and the patient’s vitality reduced, as in confirmed
alcoholics, is almost sure to produce gangrene which may easily
terminate fatally.
[Illustration: FIG. 14
Raynaud’s disease: digiti mortui. (Original.)]
[Illustration: FIG. 15
Raynaud’s disease: perforating ulcer of foot. (Original.)]
C. =Constitutional Causes.=--Among these are to be mentioned
particularly that symptom-complex ordinarily known as _diabetes_ or
_glycosuria_. This means a depraved condition of the system in which
gangrene is threatened or permitted under circumstances which otherwise
would have little or no disastrous effect. Thus _diabetic gangrene_
has come to be one of the recognized manifestations of the general
disease. That the trophic nerves have a more or less pronounced effect
in determining gangrene in certain cases seems to be now quite well
established. It is well known how quickly _bed-sores_ form after
injuries to the spine, while in certain nervous affections a minimum of
friction of the skin may determine its death, particularly about the
labia or scrotum. It is said that the insane, when made to sleep by
chloral, may develop decubitus from pressure in a single night. There
is also a well-known form of _symmetrical gangrene_, known sometimes
as _Raynaud’s disease_, which is characterized by symmetry of lesions
and absence of definite pathological changes (Figs. 14 and 15). The
so-called _digiti mortui_, or _dead fingers_, and _erythromelalgia_ are
examples of this character. A condition almost leading up to gangrene,
but perhaps not absolutely terminating in such a way, has been known
as _local asphyxia_, which seems to be a condition of arterial spasm
with venous congestion and slight edema. While the aged will often
recover from a legitimate surgical operation without disturbance, it
is, nevertheless, true that senile gangrene commencing in the toes has
for its cause some very trifling injury or lesion, such, _e. g._, as
paring of a corn, or the like. This shows a weakened local and general
resistance, as well as the wisdom of redoubling aseptic precautions in
operations upon such patients.
As constitutional causes also should be included the deleterious
effects of certain drugs, particularly ergot, mercury, and phosphorus.
D. =Infectious Causes.=--In the instances already mentioned reference
to the infectious microörganisms has been avoided. There remain
to be considered types of gangrene due to the activity of certain
microörganisms--_hospital gangrene_, _phlegmonous erysipelas_,
_malignant edema_, _gangrenous emphysema_, _noma_, _ainhum_, etc.
Gangrene as the result of infectious processes is seen in phlegmonous
erysipelas, where death of tissue seems to be due to the combined
influence of the invading organisms and of mechanical agencies--_i.
e._, tension produced by stasis and exudation, with such stretching
of tissues or overcrowding with inflammatory products as to virtually
strangle them, in consequence of all of which they die. Gangrene of an
entire hand may thus result, or, more commonly, the gangrene is limited
in extent to the more superficial parts, so that sloughs separate. A
specific form of gangrenous inflammation known as _malignant edema_,
due to a peculiar anaërobic bacillus, will be treated of separately
under a distinct heading. Quite like it in several respects is the
gangrenous emphysema of certain writers, known also as the fulminating
form, or, as the French call it, the “_gangrène foudroyante_.” More
or less emphysematous condition may accompany malignant edema; yet
that we do have gaseous forms of gangrene without the specific
bacillus of malignant edema is established. At least sixteen cases of
so-called gaseous gangrene due to infection by the _bacillus aërogenes
capsulatus_ are on record, of which twelve were fatal. Most of them
followed surgical injuries--_e. g._, compound fracture.
[Illustration: FIG. 16
Noma. (Original.)]
_Hospital gangrene_, so called, has been in years past the terror
of military surgeons and camp hospitals. As a type it has almost
completely disappeared from observation, and, in its old manifestations
at least, is now practically never seen.
_Noma_, known also as _gangrenous stomatitis_, _cancrum oris_, and
_gangræna oris_, is a term applied to a form of tissue necrosis
affecting the cheeks or parts about the face of young children,
occurring frequently as a complication of the exanthemata. A similar
condition occasionally involves the external genitals. From the fact
that it seldom passes across the middle line, it has been regarded
by some as of neurotic origin. Naturally bacteria are always found
in the decomposing tissues; but whether there as cause or as result
is not yet established. The probability is, however, that we have
to deal with a specific form of infection. The loss of substance is
usually so great as to determine complete perforation of the cheek, so
that the jaw bones may be laid bare. The gums and alveolar processes
also frequently share in the process, and the teeth occasionally drop
out. Death of tissue is rapid, and septic infection may accompany
it to such an extent as to cause the death of the patient in a few
days. While most vigorous measures are necessary for combating it,
the patients are often so reduced as to preclude the possibility of
doing much, and death is the termination of noma. Free incision, even
complete excision, is called for, perhaps with combined resort to
the actual cautery or such remedies as bromine (strong or diluted).
Antistreptococcic serum has also been used with success. Obviously it
must be used early if success is expected. Should patients recover,
there is extensive deformity as the result of cicatricial contraction.
Along the coast of Africa and in the West Indies there occurs among the
negroes a peculiar gangrenous affection of the toes known as _ainhum_.
This may assume either the moist or the dry type of gangrene, but the
result is gradual separation of the part, usually by the dry process,
as if it had been strangulated by a ligature. The disease is slow and
may extend over ten years. The cause is unknown.
Finally, gangrene is the termination of the infectious process in
several other zymotic diseases, among the best illustrations being that
afforded by _diphtheria_. The formation of diphtheritic ulcers in the
mouth and the vulva, about the eyes and elsewhere, as the result of
separation of sloughs, is too frequent to pass unnoticed, yet at the
same time does not essentially differ from the separation of sloughs
due to any other specific cause. All these acute zymotic diseases,
therefore, need to be regarded as among the possible causes of gangrene
by infection of tissues.
The _symmetrical gangrene_, often paroxysmal, affecting the fingers
and toes, described by Raynaud and often called by his name, is due
to vasomotor spasm, and is accompanied by neuralgia and sensory
disturbances, with coldness of the part and discoloration suggestive of
impending gangrene. (See above.)
Billroth and others have also described a _spontaneous_ or
_angioneurotic gangrene_ of the extremities, occurring during youth,
in abrupt distinction to senile gangrene, whose course is tedious
and painful, which will usually necessitate amputation. The cause of
this condition has been found to be a well-marked arteriosclerosis
and thrombosis, both in the arteries and veins. This form of gangrene
occurs most often in the frigid zone--_e. g._, in Northern Russia.
There are also forms of _visceral gangrene_, traumatic and
non-traumatic, which often constitute fatal maladies. The latter are
mainly due to thrombotic or embolic lesions, for example, the gangrene
of the mesentery, already alluded to when discussing thrombosis (_q.
v._), clinically described under Surgical Diseases of the Mesentery.
=Gross Appearances.=--In a general way tissue death, known as
_gangrene_, assumes two opposite types--_the moist_ and _the dry_.
In _moist gangrene_, aside from those appearances which indicate
commencing putrefaction of tissues, and the loss of heat due to
stoppage of the blood supply, one of the most characteristic features
is the formation of a so-called _line of demarcation_, _i. e._, a
line which separates the dead from the living tissues. While this is
usually plainly indicated by a red line which abruptly separates the
discolored, usually dark, dead portion from the bright red, congested
appearance of the living tissues, it is noted that this area of redness
shades out into a more and more natural appearance as we pass upward,
while below the line is seen a surface, usually covered with blisters,
from which exudes a foul-smelling, altered serum, while the gangrenous
portion assumes a dark, finally an almost black appearance, retaining
only the crude outlines of its original shape. Along with this the
objective evidences of putrefaction are unmistakable, appearances
and odor being characteristic. With all there are more or less
constitutional disturbances, and a recognizable, often a profound,
condition of septic infection, due to the fact that along the line
of demarcation absorbents are still active and that the poisonous
products of putrefaction are being absorbed into the general system.
Consequently _collapse_, _profuse perspiration_, _septic diarrhea_,
etc., are noted. In gangrene from frostbite the process is slower than
in the traumatic forms. In _gangrene from extravasation of urine_ the
separation of sloughs is extensive, and sloughing of the scrotum with
exposure of the testicles is a frequent result. In _decubitus_, or
_bed-sore_, the process is still more slow, but always of the moist
type. After a variable length of time there is separation of slough and
a resulting large, often foul, ulcer.
_Dry_ or _senile gangrene_ presents a very distinct contrast to
the moist type. It occurs generally in patients over fifty, often
as the result of causes which are slow of action. As a result of
the shrinking and corrugation of the tissues, with the dryness of
the same by evaporation, there is a peculiar appearance known as
_mummification_, the foot, for instance--the feet are usually first
involved--resembling the foot of a person who has been embalmed, except
that it is discolored. It is possible sometimes to have a combination
of moist and senile gangrene, especially when there has been infection
by which putrefaction is permitted. When from the outset putrefactive
processes are prevented, the gangrene of this type is almost invariably
dry. In practically all of the cases of this character there will be
found evidences of vascular disease, usually in the femoral artery
and its branches. Gangrene of the foot alone is most commonly due to
endarteritis, while gangrene of the foot and leg together are usually
due to embolism or thrombosis.
While disease of the vessel walls is usually of the type either of
endarteritis or arterial sclerosis, peculiar to the closing years of
life, and commonly affecting the lower extremities, gangrene due to
embolism of arteries or thrombosis, or both, may occur in the young,
and in the upper extremities as well, in the latter case the emboli
being detached from the heart, while thrombosis may be caused by a
tight splint or bandage, or even the use of crutches. I have repeatedly
amputated the arm as well as the leg for gangrene of this type.