NATIONAL LIBRARY OF MEDICINE NLM DD5bD3D5 M SURGEON GENERAL'S OFFICE LIBRARY. Section, JVo.. lknsz o. 9 3—16c NLM005603054 r LECTURES UPON THE Principles of Surgery DELIVERED AT THE UNIVERSITY OF MICHIGAN CHAS. B.^NANCREDE, A.M., M.D., LL.D. Professor of Surgery and of GWfiical Surgery ; Emeritus Professor of General and Orthopedic Surgery, Philadelphia Polyclinic ; Senior Vice-President of the American Surgical Association; Corresponding Member of the Royal Academy of Medicine of Rome; Member of the American Academy of Medicine; Late Major and Chief Surgeon, U. S. V., etc. APPENDIX CONTAINING A RESUME OF THE PRINCIPAL VIEWS HELD CONCERNING INFLAMMATION BY WM. A. SPITZLEY, A. B., M. D. Senior Assistant in Surgery, University of Michigan ILLUSTRATE! PHILADELPHIA W. B. SAUNdLb_&£_ 925 Walnut Street. 1899 LIBRARY SURSt-ON G(; |£RftL*S OFFICE / &7 33 0. Ylo N171 ^OU» Copyright, 1899, By W. B. SAUNDERS. ELECTROTYPED BY WESTCOTT & THOMSON. PHILADA. PRESS OF W. B. SAUNDERS, PHILADA. TO PHINEAS SANBORN CONNER, M.D., LL.D. Professor of Surgery in the Medical College of Ohio and in Dartmouth Medical College THAT EMINENT SURGEON AND ELOQUENT TEACHER OF SURGERY BY WHOSE KINDNESS THE AUTHOR WAS AFFORDED AN OP- PORTUNITY OF TEACHING THOSE PRINCIPLES OF HIS ART WHICH HE HAS STRIVEN TO ELUCIDATE IN THESE LECTURES THIS WORK is GRATEFULLY DEDICATED BY HIS FRIEND THE AUTHOR PREFACE. Although many excellent works have been written treating of the Principles of Surgery, the attempt to render them too comprehensive has marred their useful- ness for the undergraduate, or undue prominence has been given to the author's special methods of applying principles to practice. It must be manifest that it is impossible in the compass of a few hundreds of pages to give adequately all the essentials of surgical path- ology, bacteriology, and the more or less obsolete teach- ings of the past, when each of these subjects requires a larger volume than any work extant on the Principles of Surgery ; yet this has been attempted by many writers. Modern specialism in the teaching of medical science has recognized the necessity of, and has provided for, specific instruction in pathology, bacteriology, etc., so that anything beyond a mere reference to the peculiar- ities of form and growth of various germs, or the changes undergone during diverse pathological proc- esses, would be a useless repetition, occupying time more properly belonging to new studies. In the hope that some of these objections have been met, the author submits these lectures, trusting that they may be of assistance to students and, in some measure, to teachers of surgery. The author has reluct- antly bowed to the steadily increasing custom of drop- ping the hyphen in many compound words and altering the spelling of familiar terms. All illustrations, unless otherwise indicated, are the product of the skilful pencil of his assistant, Dr. Spitzley. 11 CONTENTS. LECTURE I. PAGE The Necessity of a Knowledge of the Principles of Surgery for Successful Practice of the Art; Hyperemia. ... 17 LECTURE II. Hyperemia (continued); Microscopic Appearances; Exudates; Results ; Treatment of Hyperemia........... 25 LECTURE III. Hyperemia (concluded) ; Process of Repair......... 39 LECTURE IV. Regeneration of Tissue................... 52, LECTURE V. Inflammation a True Microbic Process........... 65 LECTURE VI. Inflammation (continued) ; Diapedesis of White Cells, etc. . . 77 LECTURE VII. Inflammation (continued) ; Predisposing Causes of Inflamma- 86 LECTURE VIII. Inflammation (continued); Primary and Secondary Infection; the Avenues by which Germs gain access to the Tis- sues ; Causation of Symptoms ; Fever, etc......... 97 LECTURE IX. The Treatment of Inflammation..............106 13 14 CONTENTS. LECTURE X. PAGE Treatment of Inflammation (continued)...........Il6 LECTURE XI. Changes in Blood; Leukocytosis; Diminution of Hemoglobin; Thrombosis no LECTURE XII. Thrombophlebitis; Thrombo-arteritis; Embolism; Metastatic Processes; Fat- and Air-embolism...........139 LECTURE XIII. Surgical Fevers; Sapremia; Septicemia; Pyemia.......15° LECTURE XIV. Surgical Fevers (continued); Septicemia...........i58 LECTURE XV. Pyemia...........................x^5 LECTURE XVI. Toxemic Conditions Produced by Drugs; Differential Diag- nosis Between Sapremia, Septicemia, and Pyemia; Auto- intoxication .....................174 LECTURE XVII. Auto-intoxication (continued)................183 LECTURE XVIII. Suppuration; Abscess; Sinus; Fistula............189 LECTURE XIX. Gangrene, Moist and Dry; Raynaud's Disease; Spreading Traumatic Gangrene; Malignant Edema; Perforating Ulcer.........................197 LECTURE XX. Ulceration; Ulcers . . :.................208 CONTENTS. 15 LECTURE XXI. PAGE Erysipelas; Tetanus; Tetany.................217 LECTURE XXII. Treatment of Tetanus; Hydrophobia............228 LECTURE XXIII. Glanders ; Farcy ; Anthrax, or Malignant Pustule.....239 LECTURE XXIV. Actinomycosis; Tubercle; Cold Abscess ... .......248 LECTURE XXV. Tuberculosis (continued); Methods of Infection; Destructive Processes ; Treatment.................259 LECTURE XXVI.' Hemorrhage: Symptoms, General and Local; Natural Hemo- stasis; Artificial Arrest of Hemorrhage.......268 LECTURE XXVII. Hemostasis (continued) ; Ligature; Acupressure; Hemophilia. 281 LECTURE XXVIII. Treatment of Wounds; Antisepsis; Asepsis..........291 LECTURE XXIX. Sterilization of Field of Operation ; Sterilization of Special Regions; Antiseptic Surgery..............299 LECTURE XXX. Sterilization of Instruments, Ligatures, Sponges, and Dress- ings ..........................309 LECTURE XXXI. Treatment of Wounds; Varieties of Wounds........319 16 CONTENTS. LECTURE XXXII. PAGE Shock; Collapse; Treatment of Shock and Collapse; Saline Transfusion . . ....................327 LECTURE XXXIII. Traumatic Delirium; Delirium Tremens; Traumatic Hysteria; Traumatic Insanity..................335 LECTURE XXXIV. Anesthesia and Anesthetics; Causes of Death; Preparation of Patient ; Accidents during Anesthesia ; Late Acci- dents ........................342 LECTURE XXXV. Anesthesia Effected by Ether, Chloroform, and Nitrous Oxid Gas; Treatment of Accidents during Anesthesia; Treatment of Sequelae................351 LECTURE XXXVI. Local Anesthesia ; Administration of General Anesthetics ; Points Requiring Especial Attention during the In- duction of Anesthesia with (i) Ether and (2) Chloro- form .........................360 APPENDIX. Containing a Resume of the Principal Views held Concern- ing Inflammation................... LECTURE I. THE NECESSITY OF A KNOWLEDGE OF THE PRIN- CIPLES OF SURGERY FOR SUCCESSFUL PRACTICE OF THE ART; HYPEREMIA. The principles of surgery are those laws formulated from the combined results of experience and experiment, which when applied to special cases are found to explain the phenomena of disease and indicate the general meas- ures best calculated to combat morbid conditions. Because certain of the principles or laws tend to nullify one another the resultant phenomena actually observed when the former are operative seem so totally dissimilar from what should logically be expected, that they ap- parently disprove the truth of the alleged principles until closely scrutinized, when, if two laws are concerned, a third principle will be clearly distinguishable, which, like the resultant of two physical forces, is the diagonal —a mean as it were—between the two. When the appli- cation of many apparently conflicting principles is clearly demanded for the explanation of a pathologic condition or to warrant the enunciation of a therapeutic law, the ultimate principle may be difficult of detection. Still, the truth of every composite law can be demonstrated by careful study, because the resultant principle applicable to any given case will be found either logically, experi- mentally, or clinically, or often by all three methods combined, to be the result of the mutual modifications effected by the conflicting laws, and the final composite law would be incapable of proof by any of the methods applicable if any of the laws of which it is the result were false. In the present state of science our knowledge 2 w 18 PRINCIPLES OF SURGERY. is only partial ; hence from time to time surgical princi- ples require revision, as advances reveal the imperfection of the data upon which they are founded. Although this might seem the most appropriate place to give an illustration of the method of reconciling scientific principles with their apparent contradictions by one another, or by the results of their attempted practical application so that both science and practice would profit, yet as this presupposes information not yet given, and would entail later repetition, any illustration must be reserved for the chapter on the Therapeusis of Inflamma- tion. The skill of the practitioner—i. e., he who applies principles to practice—consists in justly appreciating the modifying influences one pathologic law must or may exert upon another in individual cases, and the general therapeutic principles best calculated to remove all the morbid conditions. If this be impossible, as is the rule, he must strive to recognize which is the most serious of the morbid conditions and endeavor to eliminate that. When neither of these desiderata is attainable, he must single out that one, or those which are under the control of his art and remove it or them, for much that is de- sirable in theory is not feasible in practice. For example, take a moderate-sized carbuncle. Before the overlying skin has either lost its vitality or become seriously infected, after preliminary freezing to render the diseased tissues friable, an incision can be made, all the diseased tissues be curetted or dissected away, disinfection be effected, and the skin being sutured over a drainage-tube, the cure will progress in many cases as if only an aseptic wound with loss of substance was concerned, because all the morbid conditions have been removed—viz., the germs, their products, and the com- pletely or partially devitalized and infected tissues. In an acute abscess, however, all the morbid conditions cannot be directly removed by art. The virulent infec- tion ends in death of the cells at the focus and their con- version into pus, and the intense surrounding hyperemia PRINCIPLES OF SURGERY. 19 results in such an outpouring of exudates that the still living tissues have their nutriment mechanically dimin- ished, producing a lowering of vitality which renders them an easy prey to the multiplying germs. The pressure under which the pus exists forces into the surrounding tissues toxic substances destructive to the cells or so lowering their vitality that fresh soil for new crops of micro-organisms is prepared. Clearly, then, evacuation of the pus will remove only a portion of the germs and their toxic products, but the relief from pressure also effected will prevent the dissemination of toxins, and will relieve the strangulation of the tissues which pre- vents proper nutrition, thus enabling them to cope with the germs left behind. Thus, although the germs in the still living tissues—i. e., the chief morbid condition—can- not directly be attacked, the evacuation of many of the germs contained in the pus with their toxic products and the relief of tension will remove many of their worst effects, and enable the tissues not only to protect them- selves against further invasion, but also to destroy those germs already present. Inflammation is the topic usually first considered when lecturing upon the principles of surgery, because it is the most common foe the surgeon has to contend against in some form and at some stage of the majority of the ail- ments for which he is consulted. Moreover, inflammation may complicate any wound, operative or accidental, and frustrate the best directed efforts of operative skill. I shall not pursue the usual plan because I believe that inflammation, in any true sense, is not a necessary process occurring during the repair of injuries. I believe and trust that I shall demonstrate that there is only one process of repair, which, when progressing undisturbed, has been mistermed "aseptic inflammation." When mi- crobic invasion has been successful, certain modifications of the processes of repair occur owing to interference with the normal processes, which modifications all con- fess to be inflammatory and are essentially destructive. 20 PRINCIPLES OF SURGERY. The withdrawal of the perturbing influences, whether this be effected by an actual physical removal of the germs, an acquired immunity to them and their toxic products, or a vital obstacle, formed by the erection of a barrier of sound granulations, prevent their entrance into the tissues matters not. When the disturbance is removed, the original reparative processes are promptly resumed just where they were interrupted, and they proceed in all essentials exactly as if nothing abnor- mal had occurred. Hence there is no longer room for such terms as "aseptic" and "infective inflammation," but only for "repair" and "inflammation," because the latter is always due to the action of germs or their products. While it is true that in the laboratory certain aseptic irritant substances may, under specially favorable circumstances, cause the production of a pyoid fluid, this is not true pus, either microscopically or clinically, and can with impunity be injected into other animals without producing any of the results following the injection of pus, provided the injected material either contains none of the original irritant, or this in a much diluted form. Still further, clinically such conditions never confront the surgeon as are possible to the laboratory experi- menter. The position that I assume is, I contend, the only logi- cal as well as scientific one—viz., that inflammation is never anything but an infective process, yet pyogenic germs do not necessarily mean pus. What is seen during normal repair should not be termed inflammation, and while at certain stages presenting clinical and histological phenomena similar to those seen in inflammation, they are not identical processes due to the same cause. Up to a certain point some of the phenomena are indeed due to the same conditions brought about by analogous causes. Others are similar conditions brought about by different causes, and because the conditions are the same the blunder of assigning them one causation has led to much confusion. I, in common with many other teachers HYPEREMIA. 21 have felt that our theories and statements did not hang together ; but the trammels of custom and the dif- ficulty of overcoming the dead weight of authority have hitherto prevented us from stating certain facts frankly. If the microbic causation of inflammation be true, many of the statements usually made are irreconcilable with this theory, and the germ theory is in fact ex- ploded, and should be abandoned. If it is a fact, not a theory, that microbes are the real cause of inflammation, let us be consistent in our teachings and honestly true to our theory in all—not a few—of its details. Hyperemia.—Before beginning to study the proc- esses of repair I must pass rapidly in review certain facts relative to "hyperemia" or "congestion." A study of the phenomena of both acute and chronic hyperemia will demonstrate that, by direct or indirect lowering of the vitality of the tissues, these conditions predispose to the localization and efficient action of pathogenic organisms. Close scrutiny will show that these conditions are predisposing, never efficient, causes of inflammation. It will become possible next to recon- cile the conflicting statements that germs are the sole cause of inflammation, and the demonstrable fact that conditions resulting in marked permanent tissue-changes exist, closely resembling many of those seen during or after genuine—i. e., microbic—inflammations, which yet are not due to microbic action. Again, the otherwise inexplicable fact that certain so-called chronic inflam- mations will persist for years, producing mere "hyper- plasia '' of some of the tissue-elements, while other cases apparently identical in nature will rather suddenly term- inate in suppuration, are readily explainable by a study of the phenomena of the two conditions mentioned, when viewed in the light of modern bacteriologic knowl- edge. This study of hyperemia is an imperative duty, if for no other reason than because the reaction of tissues to injury during the processes of repair and the primary 22 PRINCIPLES OF SURGERY. symptoms of microbic action present, for a time, the same appearances. The arrangement of the vasomotor system of nerves must first be passed in review. Starting from the center located near the calamus scriptorius two courses are pursued by the nerve-fibers. The majority leave the spinal nerves with the rami communicantes, passing up- ward and downward to merge with the sympathetic or splanchnic nerves. Some branches return from the sympathetic to the spinal nerves by the communicating branches, to supply the skin, muscles, and bones. A minority of the filaments form an integral part of the spinal nerves without any connection with the sympa- thetic system of nerves, forming the direct vasomotor supply, while the first set of nerves constitute the indi- rect vasomotor nerves, as they may be termed. Certain experimental facts, for the details of which physiological text-books must be consulted, prove that branches pass- ing out with the sensory (posterior) roots of the spinal nerves, when irritated, cause vascular dilatation, either by their direct action or by an inhibitory action on the pe- ripheral vasomotor apparatus. The remaining branches are vasoconstrictors. The existence of a peripheral vasomotor apparatus cannot be ignored, that is to say, the presence of perivascular ganglia with a communi- cating plexus of nerve-fibrils. The vasoconstrictor nerves and the perivascular mech- anism are believed to be "continuous in action," while the dilators act "exceptionally." A restatement of the facts just related, in a different order and manner, will enable us to draw certain conclu- sions which will explain important clinical facts often imperfectly understood. If the vasodilators pass out from the spinal cord through the sensory roots of the spinal nerves, by irritation of the dilator nerves a hyper- emia should result, which would produce pain in the area supplied by the spinal nerve having its origin in the irritated root or roots, while stimulation of the HYPEREMIA. 23 periphery of the sensory nerve should produce dilata- tion of the vessels in the area supplied by this nerve. What is the clinical answer to this theoretical conclu- sion ? Quite often in trifacial neuralgias—the result of hyperemic conditions of the sensory root—a congested conjunctiva, lacrimation, salivation, edema, even des- quamation of the epithelium has been noted. A still better illustration is that form of herpes zoster resulting from congestion of the posterior spinal nerve-roots or their ganglia, where pain thus produced is followed by nutritional changes in the skin, reaching even vesica- tion. In turn, the early pain of inflammation is in part due to the congestion of the posterior nerve-roots result- ing from the peripheral irritation of the sensory nerve. With a vasomotor apparatus as described, irritation of a sensory nerve of sufficient intensity to reach the nerve- center should be capable of propagation to other centers, exciting their action so that the circulation of a more or less distant part shall be modified. What have experiment and clinical observation to say for or against this deduction? Lombard and Brown- Sequard have demonstrated that irritation of the skin- nerves by pricking with a pin causes elevation of tem- perature on the side of irritation, while the temperature is lowered upon the opposite side of the body. Again, immersion of one hand in cold water will produce low- ering of the temperature of the other hand. Clinically this reflex vasomotor action is made use of because demonstrably efficient when the moderate cold of an ice- bag to the head produces diminution of the smaller vessels within the cranium, when enlarged during intra- cranial inflammation. I know well that the presence of vasomotor nerves to the cerebral vessels has been denied, but G. C. Huber's experiments unquestionably prove their existence, as I have personally seen under the microscope. Every resort to the common expedient of applying cold to the nape of the neck or over the fore- head to arrest nose-bleed is founded, unconsciously 24 PRINCIPLES OF SURGERY. usually, upon the existence of this reflex action produced by an impression upon a sensory nerve. What phenomena should manifest themselves in vaso- motor paralysis, including perhaps also the suspension of the activity of the perivascular ganglia? The arte- rioles and capillaries should dilate to the maximum extent so that arterial blood, or at least the cardiac impulse, will probably reach the veins. After division of the sciatic nerve in the dog, increased tension can be demonstrated to exist in the correspond- ing femoral vein, which, if tied, shows a pseudo-arterial pulsation ; the smallest arterioles, if compressed, can also be felt to pulsate, while the veins contain blood of an arterial hue. Microscopically, dilatation of the capillaries is manifest. Clinically, all of these phe- nomena are observable after the application of an Es- march bandage, or an irritating, not destructive lesion of a nerve of an extremity. Finally, should the part be cut off from the vasomotor center, leaving the peri- vascular apparatus intact, wrould it not be reasonable to expect that after an inevitable temporary dilatation of the vessels, a more or less perfect readjustment would take place, in virtue of the increased power acquired in the course of time by the perivascular apparatus, pro- vided no extraneous influences intervened ? Assuredly ; and this is seen in the course of time in the transplanted flaps of a plastic operation after division of their pedicles, and in the rabbit's ear after section of the cervical sym- pathetic. Clinically it is well known that in a limb whose main nerves have been divided, or in the area supplied by a divided nerve, although the local vaso- motor apparatus is equal eventually to the regulation of the circulation under favorable circumstances, the most trivial changes in temperature may produce the most intense hyperemia, leading perhaps to vesication, so that immersion in cold water causes a neuroparalytic conges- tion resulting in almost identical appearances with those of a scald severe enough to produce isolated vesication. LECTURE II. HYPEREMIA (CONTINUED); MICROSCOPIC APPEAR- ANCES; EXUDATES; RESULTS; TREATMENT OF HYPEREMIA. Regarded from the clinical standpoint, hyperemia or congestion means excess of blood in a part. If this results from a too free access of arterial blood to the parts the resultant hyperemia is termed "active hyper- emia." When the exit of venous blood is interfered with, the congestion which follows is appropriately called "passive hyperemia." The element of the time con- sumed before the phenomena reach their acme also partly determines the application of these terms. Thus, in an acute hyperemia all the phenomena rapidly supervene, the process soon presenting a sharply defined condi- tion, each contributing element promptly reaching the highest point attainable, from which retrocession must follow, or a different set of phenomena must result. Acute hyperemias are usually excited by decided "me- chanical disturbances," and the essential causative fac- tors must be, directly or indirectly, an increased vis-a- tergo of the circulation and such an altered condition of the part as will permit the accommodation of an increased bulk of blood. On the other hand, chronic hyperemias are of slower development and commonly result from persistent, slight irritations, aided nearly always by mechanical inter- ference with the exit of venous blood, although this latter condition is not always easy of detection. Ischemia is another term the significance of which should be understood. It means an abnormally small amount of 25 26 PRINCIPLES OF SURGERY. blood in a part, or a reduced supply to a part, while sometimes it is incorrectly made to include the idea that whatever blood is present in, or supplied to, the part is abnormal in quality. From what has been said, active hyperemia results from disturbances of balance of the vasomotor system of nerves and may be "neuroparalytic" from paral- ysis of the vasoconstrictor fibers, as in blushing, after division of the cervical sympathetic, injury of a nerve, as its partial division, or the pressure of an Esmarch bandage. While sometimes otherwise explainable, the congestions following the rapid removal of fluid by tap- ping the pleural or abdominal cavities, or the sudden withdrawal of urine from an overdistended bladder —this last sometimes producing death from the conse- quent congestion of the kidneys, causing suppression of urine—are "neuroparalytic," and the recognition of the mechanism of these congestions teaches us their thera- peusis—viz., the avoidance of the removal of pressure from vessels whose constrictor nerves have been long unaccustomed to maintain, unaided, their normal caliber. This is one of the best illustrations of the advantages accruing from an acquaintance with minute, and ap- parently trivial, scientific facts. But the usual vaso- motor balance existing by virtue of the equal action of the vasodilators and vasoconstrictors may be disturbed by irritation of the dilator fibers, the same excess of blood in the part—i. e., congestion—resulting, not from paralysis but from active dilatation, a " neurotonic" congestion is induced. These hyperemias are more comprehensible, if it is remembered that they must be essentially reflex__ i. e., an afferent impression causing an efferent impulse. These reflex hyperemias are nearly always preceded by pain. This is due either to irritation of the peripheral branches of a sensory nerve, or more often to hyperemia of the sensory spinal roots caused by the action of the reflexly excited vasodilators. If the causes of a hyper- emia are temporary, the effects are equally so ; but HYPEREMIA. 27 when the former are persistent, certain more permanent changes take place. The smaller arteries and arterioles may at first show acceleration of their current; but this condition is soon reversed, the blood moves more slowly, and upon purely physical principles the intravascular pressure is increased, this abnormal pressure being ex- erted upon vessel-walls thinned by distention, and less capable of restraining the escape of their contents, which normally pass out, though in less quantity, during the processes of nutrition. In consequence, the watery con- Fig. 1.—Showing diapedesis of a white blood-cell from a capillary. Observa- tions at intervals of eight minutes. stituents escape freely, producing an increase in bulk from the edema, as it is termed. When a cavity is con- cerned, such as a joint, this collection of serum is called an effusion, and is occasionally seen in an articulation after irritation or injury of one of the main nerve-trunks of a limb. The hyperemia persisting, the organized elements of the blood, such as the white corpuscles, begin to pass out by diapedesis through the walls of the venules and capillaries, still further increasing the bulk of the parts ; even the red cells may also pass out into the tissues by either diapedesis or rhexis. The student should note well these symptoms, which are, of course, accompanied with heat and, as has been said, with pain, 28 PRINCIPLES OF SURGERY. for here are, as will be mentioned later again, the '' calor,'' "rubor," "dolor," "tumor," and not uncommonly, as in the joint-effusion just described, the " functio laesa " —i. e., the same symptoms which mark true (microbic) inflammation. In marked contradistinction to this acute hyperemia is passive hyperemia, resulting from mechanical obstacles to the exit of blood, a diminished vis-a-tergo from feeble heart-action with or without loss of elasticity of the arte- rial walls, or a combination of both these factors. When obstruction of the main or only vein of a part is the cause of the hyperemia, serious consequences may follow, as gangrene. In passive hyperemia the parts instead of being too warm are colder than normal, of a bluish, cyanotic tint ; marked serous transudation takes place, with escape later of liquor sanguinis and the corpuscular blood-elements. When the process has been of long duration, the repeated escape of red cells into the tissues and the subsequent changes undergone by the hemo- globin produce marked discolorations—i. e., pigmenta- tion of the integument or other deeper parts. The results of hyperemia vary according to the ex- tent and duration of the hyperemia. Thus, in the acute form it may promptly disappear when the cause is removed, as a foreign body from the eye ; this corresponds, in many instances, to the "delitescence" of the older writers. Persisting longer it produces an increase in the bulk of the parts due to effusion of serum into the interstices of the tissues—i. e., edema occurs—or where a cavity is concerned, the fluid accumulating in this forms an effu- sion. If it lasts still longer, the corpuscular elements escape and the tissue-cells are stimulated to division, until a considerable cellular exudate is formed, which if vascularized will develop into a permanent tissue—viz. scar-tissue. As only fluid exudate can be quickly re- moved by the lymphatics or by absorption by the blood- vessels, if many cells be present, a much more complex and longer set of processes is requisite than the former HYPEREMIA. 29 which chiefly entails the return of the vessels to a normal caliber. A term indicating a change preceding absorption has long been employed—viz., resolution (re-solulio). Although this process may, and often does, occur in its more marked forms after a mild infective process, yet many cases of resolution of inflammation really mean a subsidence of an acute hyperemia which has resulted in considerable cell-exudate. The sudden accumulation of blood, fluid exudate, and such cells as may migrate, resulting from a rapidly developed hyperemia in parts whose blood-supply is damaged, especially if it normally be poor, will so re- duce the remaining blood-supply that cellular or more massive death of the tissues often occurs, that is to say, gangrene results. This is because the veins and lym- phatics cannot drain away the exudates which compress the plasma-channels by which nutriment reaches the cells, or still further, compresses the veins, interfering with the return circulation so that stasis occurs, pre- venting all access of arterial blood ; hence the death of the tissues. The active forms of hyperemia more often cause ulceration or sloughing than what is termed o-an- grene, but the essential processes are the same in both. Passive hyperemia is a more common cause of the massive death we call gangrene and for the following reasons. Death of the cells composing a part means death of the part. Death of a cell must result either from physical disintegration, chemical change, or starva- tion. Death of cells, or small masses of them may, and often does, follow from cutting off of nutriment by mechanical pressure, from what is called "strangula- tion" of tissue ; but in "passive hyperemia" the exit of venous blood being in a great measure prevented, the arterial supply is first diminished, then more or less completely arrested by a combination of pressure in the venous system and exudation into and increased soli- darity of the tissues, until death of all the cells of a whole limb follows from starvation of cells, aided per- 30 PRINCIPLES OF SURGERY. haps by the effects of substances elaborated by the cells and retained in them, the venous blood, or the exudates. Pressure-sores, although often ascribed solely to passive hyperemia more often are due to a primary ischemia of the part, followed by a passive hyperemia from vascular paresis. Thus the cells are first directly starved by mechanical pressure preventing access of nutrition, and later, indirectly, by the exclusion of arterial blood by the venous congestion. Infection is promptly super- added, being here the essential cause of tissue-destruc- tion. If the hyperemia persist—i. e., becomes chronic hyper- nutrition—hypertrophy will result, that is to say, in- crease in bulk from numerical increase of cells with, perhaps, increase in size of the individual elements. The presence in the tissues of migrated white blood- cells doubtless adds somewhat to the bulk of the part. It is rarely true that the enlargement results from an equal numerical increase of all the cells of a part, more often those of the connective tissue being chiefly multi- plied. From the subsequent contraction of the neo- plastic connective tissue the true tissue-elements have their nutrition so diminished that many disappear—i. e., atrophy results, although the physical bulk of the part may remain increased in these "chronic indurations," miscalled "hypertrophies." Sometimes, with no mani- fest connective-tissue hyperplasia, diminution in bulk— atrophy — seems directly to follow from nutritional changes induced by a prolonged hyperemia. It may be well to call attention to the fact that hypernutrition and a consequent form of hypertrophy may result from inter- ference with the exit of lymph from a part. Exudates.—The meaning of certain terms already employed or yet to be used can best be explained now. An "exudate" is the material, chiefly fluid which passes out from the vessels either during hyperemia or inflammation, mingled with the products of cell-prolifer- ation. Exudates receive names either from their ana- HYPEREMIA. 3* tomical relations or on account of some special, dis- tinguishing quality. Thus, a "free" exudate is one poured out upon a surface or into a cavity, the latter often being termed a '' dropsy." An " interstitial'' exu- date is one located between the layers of the tissues. A "parenchymatous" exudate is one located in the es- sential, functionating part of an organ, such as the secreting portion of a gland. An exudate composed only of the serum of the blood is called "serous;" when pus-cells are present in sufficient numbers to render the fluid opaque, it is now a " seropurulent" exudate. If mucus is the predominating element, it is called "mucous" or "catarrhal;" but if pus be mingled with the mucus, "mucopurulent" is now the proper term ; while if red blood-cells are sufficiently numerous to color the exudate, it is called "sangui- nolent" or "hemorrhagic." Serous exudates, poor in fibrin-forming elements and showing flocculi of coagu- lated fibrin, are classed as "serofibrinous." A "fibrin- ous exudate" is one which, containing large amounts of fibrin-forming elements, promptly coagulates in the inter- stices of the tissue or upon the surface of a membrane, usually a mucous one—in which latter event it is called a "croupous" exudate. Although micro-organisms prob- ably have much to do with this croupous coagulation, it does occur in their absence. The term "diphtheritic" should be restricted to a microbic coagulation-necrosis which involves the epithelium, basement membrane, and other structures of the mucous membrane, even extending to the submucous tissues. In addition, some true fibrinous exudate is often present. When this ap- parent membrane is torn away, the true nature of the process is revealed, showing an actual loss of substance, not the removal of a surface addition to the part, as is a "membrane." The "results" or "terminations" of hyperemia have thus been shown to be a rapid increase in bulk, following acute congestion ; a slower increase from multiplication 32 PRINCIPLES OF SURGERY, of some of the tissue-elements, resulting from a chronic hyperemia; death of a part—i. e., gangrene—the result of a passive hyperemia, although the primary process may be acute, the stagnation of the venous current phys- ically preventing the entrance of arterial blood, and maintaining poisonous substances in contact with the cells ; and certain nutritional changes which must now be considered. Hyperplasia—i. e., a numerical increase of cells—is what produces true hypertrophy, if all tissue-elements be concerned. If only the cells of one of the tissues of a part or organ are increased, then only hyperplasia of that tissue has taken place, although this is often incorrectly called hypertrophy. With the numerical increase of the cells there may be a greater bulk attained by the cell- elements themselves. True hypertrophy may result from increase of function or from increase of nutrition. Thus, the heart-muscle compelled to overcome undue resistance grows thicker and stronger ; the set of muscles constantly employed to perform certain movements become abnormally developed, and the fibula, grafted upon the remains of a tibia whose shaft has been removed, having to sustain the whole weight of the body, markedly increases in thickness. While it is true that the exercise of function—in the case of muscle, contraction—neces- sarily attracts more blood, and hence increased nutrition of the part results, yet in the absence of all functional action, such manipulations as will bring more blood to the tissues—^. g., massage—will retard the wasting of paralyzed muscles or restore power to those of a lono- disused limb, because an increased amount of pabulum is available. Both these forms of increase of bulk are physiological and probably include an increase in num- ber and size of all the cell-elements of the limb, those of bone and blood-vessels as well as muscles. Congenital excesses of blood-supply cause the congenital hyper- trophies, such as those of the female breast ; although others, as gigantism of a limb or segment of a limb are HYPEREMIA. 33 often as much due to interference with the exit of lymph as to the excessive vascular supply. Indeed, such condi- tions as macrocheilia are purely lymphangiectases, or result from obstruction to the exit of lymph. The hypertrophies of pathologic origin result, for the most part, from so-called "chronic inflammation," which really means a chronic hyperemia initiated by traumatism and maintained by mechanical or chemical irritants, such as uric acid, altered nerve-influence, etc. All these act in one and the same way, maintaining a constant excess of pabulum in contact with the tissue-cells. Of these, the connective-tissue cells are most readily incited to proliferation, in consequence of which there results, not a true hypertrophy, but a hyperplasia of the con- nective tissue. All such young connective tissue tends to occupy less space as it develops—i. e., contraction occurs—the cells diminishing in numbers, and fibrilla- tion taking place, until the tissue-elements, as those of a gland, are compressed, and their nutrition so interfered with that they numerically decrease. The bulk of the organ or part may, instead of being diminished, be actually increased, although its functioning power is markedly decreased. This tendency of hyperplastic con- nective tissue must always be borne in mind as the most disastrous effect of chronic hyperemia. On the other hand, this property is made use of in the treatment of certain diseased conditions, as will be mentioned later. Perversions of nutrition resulting in the undue main- tenance or increase of certain elements of an organ occur in advanced years, such as the senile hypertrophy of the prostate gland. From a diminished blood-supply, which is equivalent to diminished pabulum for the tissues, results the reverse of hypertrophy—that is to say, atrophy. This may fol- low from disuse, as seen in the thin-walled, light, and fragile long bones of a paralyzed limb, or those of an extremity with a chronically diseased joint, although the muscles and fat are the tissues which suffer most. Partly 34 PRINCIPLES OF SURGERY. from the diminished vis-a-tergo of a weak heart, but more from the lessened dilatability and elasticity of the arteries in old age, senile atrophy of the muscles occurs despite their functional activity, while the hair-follicles undergo similar changes. Under this head writers, such as Park, have considered another form of diminution in bulk, which is effected not by lack of pabulum, but results from the actual removal of tissue by phagocytic action. This is best seen around a pus-focus, or better still, physiologically in Howship's lacunae of bone, the result of resorption effected by osteoclasts—i. e., phago- cytic cells. This view seems incorrect, the process not being atrophy as commonly understood, although this process cannot be ignored, because it is the method by which the excess of osseous bone-callus, for instance, is removed, and the manner in which room is made both in this and in softer tissues for the proliferating tissue-cells needed for repair. In contradistinction to this is true atrophy, which causes a permanent diminution in the num- ber, or in both the number and size of the cells of a part, which reaching a certain point ceases to progress, and the future nutrition merely maintains the tissues where the atrophying process left them ; or this process may be slowly progressive during the life of the individual. The diminution in bulk following diminished blood-supply is best seen around rapidly growing non-infiltrating tumors, notably cysts, or the muscles near a joint over which an elastic bandage has been long worn, or the atrophied line where the woman's tight garter presses. Certain atrophies, such as those following disease of an important articulation, are due to a complexus of causes. Disuse and the absence of the normal reflex dilatations of the muscle-vessels, resulting from the im- pressions made upon the articular branches by move- ments, account for the muscular atrophy following joint- affections. The removal of restraining pressure upon the end of a bone, together with the absence of stimulus to the growth of the muscles from lack of use and ten- HYPEREMIA. 35 sion, with the persistent, though not fully normal growth of the bone, accounts for the so-called "atrophic elongation'' of the bones. What are the general indications, the laws of thera- peusis, the '' principles'' applicable to the treatment of hypertrophy and atrophy ? For hypertrophy the blood- supply, particularly the arterial, must be diminished, while for atrophy, the circulation must be increased. How this should be effected belongs rather to the Prac- tice of Surgery than to the Principles of Surgery, but will be touched upon when considering the treatment of inflammation. The symptoms of hyperemia or congestion are, as we have seen, redness {rubor), due to the excess of arte- rial blood and possibly minute hemorrhages ; heat icalor), resulting from the excess of blood ; swelling {tumor), due to collection of fluid and leukocytes in the tissues, and slightly to excess of blood ; pain {dolor), from the pressure exercised by the exudates upon, and stretching of the nerves by separation of the various layers of tissue through which they pass. The pain of congestion may, like that of inflammation, not be felt at the actual point of hyperemia, but is often referred to the terminal distribution of the nerve, or to other branches of the same nerve, or even other branches of the plexus from which the irritated nerve arises, or, reaching the cord, the irritation may be apparently felt upon the opposite side of the body. Thus, the pain produced by the dying nerve-pulp of a tooth may be referred to another tooth or to all the teeth ; the pain complained of in all the branches of the brachial plexus when only one nerve is actually diseased, and the refer- ence of pain to the right kidney when there is a renal calculus in the left kidney are additional examples. Throbbing pain rarely occurs in mere hyperemia ; but, if it does, can only be explained by the hypersensitive nerves recognizing the slightly increased pressure pro- duced by the pulsation in the much enlarged arteries. 36 PRINCIPLES OF SURGERY. Park's explanation is that it is caused by "the added heart-pressure of systole upon sensitive nerves." While this is true, it is not the whole truth. The pressure would not be recognizable if the vessels were of normal caliber, and that which I have taught for many years is, I think, preferable—viz., that the congested, hypersen- sitive nerves recognize the increased pressure induced by the pulsation of the enlarged vessels, when the car- diac impulse would remain unnoticed in normal-sized vessels. The impaired function {functio Icesd) results from the pain following the hyperemia of the nerves ; besides this, in the instances quoted the serous transuda- tion into the cavity of the joint interferes with its mobility, the increased secretion of tears and mucus from hyperemia of the conjunctiva embarrasses vision, or the abnormal sensibility to light, resulting from con- gestion of the retinal and choroidal vessels produced by excessive use of myopic eyes, prevents their use. These symptoms are the classical ones given by Celsus nearly two thousand years ago as indubitable proof of inflammation. While they are more marked in a genu- ine (microbic) inflammation, they are, as we have seen, all present in pure hyperemia; in fact, during the earlier stages of inflammation (microbic) the phenomena are identical, and in many traumatisms are due to the same causes, the microbes later interfering with the reparative processes and undoing the good effected by the circulatory changes which are a necessary prelude to repair. I will ask you to take upon faith some of the succeed- ing statements, promising explanation and demonstra- tion later. All the phenomena of hyperemia are, at the outset, conservative. The increased rapidity of the blood-cur- rent serves to remove tissue-waste and brings abundant pabulum and numerous phagocytes. To employ a simile often used, the women and children and the sick are sent away from the besieged city, stores of provisions HYPEREMIA. 37 are accumulated, and the number of the defenders is increased. Why then interfere? Because the hyperemia may really be owing to slight infection, or this will be favored if germs subsequently reach the congested area from a distant infection-atrium. This is because uncon- trolled hyperemia is followed by slowing of the blood- current, thus favoring the dropping out and accumula- tion of germs in such numbers that the tissues cannot cope with them. The excess of pabulum favors their growth, while the exudates mechanically interfere with the nutrition of the tissue-cells and with the excretion of the results of their metabolic activity, producing a lowered vitality—i. e., diminished tissue-resistance. Treatment of Hyperemia.—What are the general indications, the suggestions resulting from this study as to treatment—i. e., the removal of the conditions—in other words the Principles of Surgical Therapeutics involved? In acute hyperemia, the access of arterial blood should be diminished, the return of venous blood and lymph should be favored. To do this, the caliber of the arteries must be lessened, which upon purely physical principles will increase the rapidity of the cur- rent, thus sweeping out the accumulated, cohering leukocytes, preventing mural implantation of germs if any be present, and favoring reabsorption of effused products. The conditions of the intra- and extra-vas- cular pressure will be reversed, which will aid in the removal of exudates and metabolic products—not inter- fere with this as they did before—and hence increase the resistance of the tissues and their power of destroy- ing germs, thus preventing any serious hindrance to the reparative processes. In chronic hyperemia, the access of arterial blood should be increased and the exit of venous blood and lymph favored. How this can best be effected in any given instance belongs to the Practice of Surgery. I have striven to demonstrate thus far that the reaction of tissues after injury leads to hyperemia, 38 PRINCIPLES OF SURGERY. which is conservative and a necessary prelude to repair. It is productive of many of the conditions caused at the outset, by the action of microbes, even to the migration of leukocytes (due to chemotaxis, a term later ex- plained), tissue-cell proliferation, and the clinical signs of swelling, redness, pain, heat, and disturbed function. LECTURE III. HYPEREMIA (CONCLUDED) ; PROCESSES OF REPAIR. If the tendencies are toward repair after every trau- matism, whether infection has occurred or not; if without infection repair would always succeed, unless prevented by purely physical disturbances ; if infection produces merely a temporary interruption of these proc- esses, repair being resumed at essentially the point where arrested just as soon as infection ceases to be operative, then the best way to understand the modify- ing influence exerted upon the normal processes by microbic (true) inflammation, its evil tendencies, how these are operative, and the best way to remove or pre- vent their efficient action, will be to study the normal reparative processes in the various tissues. Let me start with the positive statement that repair is effected by the same processes in the hard and the soft, the vascular and the avascular tissues, any apparent dif- ferences being temporary, non-essential, and chiefly de- pendent upon physical conditions. Thus the physical obstacle presented by the mineral salts in bone tem- porarily prevents the rapid accumulation of reparative cells ; but the same changes are effected as in the softest cellular tissue, though more slowly. Two forms of repair have been erroneously described, because in reality there is only one process of repair, that attended by suppuration being merely a modification, the resultant of perturbing influences; when the perturba- tions cease, repair at once tends to proceed as at its in- 39 40 PRINCIPLES OF SURGERY. ception, any variations of type observed being accidental and non-essential. In normal repair the processes commence as soon as the physical disturbance of the parts ceases and the bleed- ing is checked. When the divided tissues can be accu- rately apposed, the wound heals with the minimum expenditure of material by what used to be called the "first intention," by "simple adhesion," or, incorrectly as I contend, by "aseptic inflammation." Such healing is only possible in the absence of infection, mark you, not the absence of germs, because as we shall learn, microbes may be present, but unable to multiply and interfere with the normal processes, for reasons which will be studied later. When, however, the normal processes are interfered with by infection—i. e., germs in such numbers that they can overpower the vital resistance of the cells, and which do multiply—repair is temporarily thwarted, resulting in vast loss of reparative material, tissue-destruction, and the formation of an excess of germinal tissue which, after conversion into scar-tissue, too often exerts most perni- cious, atrophying pressure on the parenchyma of glandu- lar organs, etc. So soon as the tissue-cells gain the upper hand of the microbes, a reversion to the normal reparative processes commences, which finally proceed, in essence, as if no disturbance had occurred. I have said "in essence," because there is great excess of material needed for the repair, producing at first sight some real differences ; but after the destruction of tissue by either ulceration or sloughing, repair is effected by the same processes which produce healing in an aseptic wound with loss of substance—viz., by the formation and organization of granulation-tissue, or, employing the old term, by the "second intention." Finally, in any method of healing, whether by immediate union or by the "second intention," this takes place by the formation and organization of granulation-tissue. In one, only a microscopic amount is formed ; in the other it is readily PROCESSES OF REPAIR. 41 seen by the unaided eye, but the end-processes are the same. If two aseptic granulation-covered surfaces are held in contact, they will fuse, and healing will occur, as it is sometimes called in the older books, by the "third intention." It is useful to know both the meaning of these terms and the minute processes involved to understand the older authors. It is interesting to notice how the older authors recognized that however diverse the phenomena presented after traumatism, all evinced an "intention" to effect repair, and that their first choice is what we elect, because it is pure repair, while when this is im- possible we avail ourselves of the second method, often thus being able to utilize the third, and in all—provided suppuration is avoided—in the end securing really the same kind of repair. Healing of Incised Wounds.—Let us now examine the minute processes observed during the healing of an incised wound. Hemostasis is effected by the formation of thrombi in the blood- and lymph-vessels. The small amount of blood between the closely apposed wound-sur- faces, together with leukocytes from the lymph-spaces and the fibrin-forming sustances contained in the effused liquor sanguinis, forms a clot, which extending into the interstices of the tissues forms a mechanical bond uniting the divided surfaces; this is the " coagulable lymph" which the older authors regarded as the chief agent in the union of wounds. Wandering cells soon crowd the wound-borders, whence the leukocytes migrate into the fibrinosangineous coagulum, until by the third day this has about disappeared, here and there remains of clots alone being detectable, the bulk consisting of a mass of leukocytes. By the sixth day large epithelioid cells, descendants of the fixed connective-tissue cells and the endothelial cells of the small vessels—i. e., the so- called " formative cells" or "fibroblasts"—invade and gradually replace the leukocytes, which are consumed as food by the former cells, although some leuko- 42 PRINCIPLES OF SURGERY. cytes doubtless wander back into the lymph-spaces or possibly into the blood-vessels. Some authorities con- tend that the cells resembling leukocytes, seen during this and the next stages of healing, really serve as formative cells or provide the endothelium for the new lymph- spaces. The fibroblasts promptly assume various shapes, becoming clubbed, spindle-shaped or multipolar and branched, the processes of contiguous cells anastomosing. As development proceeds, a portion of the protoplasm with the intercellular substance becomes fibrillated, leaving little beyond the original nucleus and a small portion of the protoplasm, forming fixed connective-tissue cells embedded in a fibrillated structure, which later assumes all the characteristics of fibrous tissue. Rendering pos- sible this development, special provision for abundant pabulum is made. At first the cells, being nourished through the medium of the plasma-channels, obtain just sufficient pabulum to maintain their vitality and to stimulate them to multiplication, but not enough to admit of their development into a permanent tissue. About the fifth to the sixth day new vessels are formed from the pre-existing vessels at the borders of the wound, which gradually grow into the mass of cells, supplying them with such ample nutriment, that the development into fiber-cells passing across from one side of the wound to the other is very rapid, so that as early as the sixth day a vital bond of union, replacing the mechanical one, is well advanced in vascular structures, such as those of the face. The first steps in new-vessel formation consist in an accumulation of granular protoplasm on the exterior of a pre-existing capillary loop, which gradually forms a solid, nucleated filament. This may be simple or branched, and fuses with another vessel, with another bud from a neighboring capillary loop ; or, again, the filament may arch back and become connected with the vessel from which it sprang. The young connective- tissue cells (fibroblasts) near the vascular outgrowths PROCESSES OF REPAIR. 43 arrange themselves alongside them, or as bundles form solid continuations ; again, they are said to form channels which later communicate with the lumen of some capil- lary. Occasionally a protoplasmic vascular filament will join a process of one of the branched formative cells. These solid protoplasmic processes liquefy in their centers, a lumen forming continuous with that of the parent vessel. Fig. 2.—Showing various ways in which new capillaries are formed in organ- izing granulation-tissue. The protoplasmic outgrowths may also be from the out- set hollow, admitting blood; but even then they termi- nate by filamentous prolongations, and develop after one of the methods already described. Although at first the new capillaries possess only homogeneous walls, later they display the ordinary appearances. Let me call your attention to the fact that " healing by a blood-clot," as it is termed, is merely an extension of the process just studied. Instead of a minute linear 44 PRINCIPLES OF SURGERY. space to be bridged by cells, there is a gap requiring a scaffolding to enable the cells to reach across from one side to the other and one which must remain in situ until vascularized—i. e., until they have developed into granulation-tissue. The leukocytes penetrate and chan- Fig. 3.—Showing organization of thrombus in femoral artery: A, vessel- wall ; B, remnants of blood of thrombus; C, epithelioid cells; D, recently developed connective-tissue fibers. nel the clot in various directions, preparing pathways for the formative cells, which follow along these tracks, until all clot disappears and vascularization is effected. Wherein does this differ from the manner in which the physical bond between the wound-surfaces, composed of blood- and fibrin-clot is substituted by a vascularized cellular mass? Not one iota. The only difference is that of degree and not of kind, again illustrating what I am contending for, that there is, in essence, but one kind of healing, modified by physical conditions. This PROCESSES OF REPAIR. 45 however, is not always the fate of blood-clots, for they may disappear by the ingrowth of processes of already vascularized masses containing formative cells—viz., granulations, the constituents of the clot disappearing by absorption effected by the phagocytic cells. This illustrates how, when a physical obstacle interferes with the filling in of a gap by granulations, this physical obstacle is removed, whether it be the compact tissue of bone, an ivory peg, a fragment of devitalized soft tissue, or a blood-clot, which last, for some reason, acts as a physical obstacle, not as a useful scaffolding. The term " filling up of a wound by granulations " is a misnomer. The actual depth of a layer of healing granulations is slight. The deeper layers—those nearest to the blood-supply—are rendered capable of develop- ment into adult tissue, which " contracting," as it is termed, draws down the margins of the wound, pulls in the surrounding tissues, somewhat elevates its base, and markedly diminishes its superficial area, so that the defect is largely effaced ; but it is not done by the "organization" of cubic inches of granulation-tissue, which would often be requisite if a defect was really "filled in by granulations." What is this granulation-tissue which has been so frequently mentioned? Superficially it consists of nu- merous multi- and mono-nucleated leukocytes, with many delicate blood-vessels running more or less verti- cally to the surface. Deeper, epithelioid cells abound, and, still deeper, spindle-cells arranged in bundles can be seen. In this layer, in old wounds the majority of cells become converted into fibrous tissue, with the blood-vessels forming a horizontal network. The class- ical capillary loops capped with cells, which are said to account for the granular forms of the granulations, do not exist, parallel vessels, ascending more or less verti- cally, as has just been said, being alone detected in the superficial granular layer of the granulations. All the essential facts concerning the aseptic forma- 46 PRINCIPLES OF SURGERY. tion of granulations, by which healing is effected in every tissue, have been already stated, although in cer- tain highly specialized ones, such as spinal nerves, re- generation of nerve-tubules takes place. If there has been loss of substance, either mechanically produced or from sloughing in an aseptic wound, the healing will be by granulation in the ordinary acceptation of the term, although it has been shown that even primary union is effected by the formation and organization of vascular- ized formative cellular masses—viz., granulations. The chief reason why rapid repair is possible in aseptic wounds when compared with infected ones is not any difference in the processes, but because no peptonizing ferment is present, as is the case during infection, which, dissolving the intercellular cement, disassociates the cells one from another, thus mechanically prevent- ing them from receiving the pabulum necessary for development into a permanent tissue. Unquestionably the vitality of the cells is impaired or absolutely de- stroyed by other toxic products of germ-growth ; but were the cells absolutely normal, they could not develop when separated from one another and floating free in the wound-fluids. In the same way, aseptic separation of a slough and infective separation of a slough are identical processes. In the former, at the border where the dead and living tissues are in contact, as in the processes of repair, leukocytes and then formative cells accumulate, until nothing but a layer of cohering, vascularized cells holds the two together. Those cells farthest from the blood- supply—viz., those in contact with the dead parts—lose their vitality, their intercellular cement is dissolved, and the "slough separates"— i. e., the layer of granulation- cells between it and the better nourished granulations in contact with the living tissue becomes liquefied ; hence separation ensues. Precisely the same is effected much more rapidly by the peptonizing ferments of microbic origin. In the aseptic separation of a slough the mini- PROCESSES OF REPAIR. 47 mum conversion of the border-line between the dead and living tissues into granulation-tissue occurs, and the minimum liquefaction of cells to permit separation is requisite, only a small amount of cloudy serum or lymph being produced, repair being secured with the least pos- sible waste of material and development of scar-tissue. Infection of an incised wound, for instance, promptly causes solution of any mechanical bond of union and disintegration of all coagula ; hence any scaffolding en- abling formative cells to bridge gaps is destroyed. Ex- tensive conversion of the wound-margins into granula- tion-tissue occurs, and much of these densely infiltrated tissues perishes from destruction and separation of the component cells. Many living cells are washed away by the freely exuded wound-fluids, although far too many remain to develop into a dense, dangerously con- tractile scar. Sloughing in an infected wound is well known clinically to produce worse cicatrices than even prolonged suppuration. This is because the prolonged presence of the dead, intensely irritating, infected slough excites the most lively proliferations of the cells in the depths of the tissue too far removed to be destructible by the microbic ferments and toxins, thus leaving more cells than mere suppuration does to develop into scar- tissue. The longer maintained and more intense hyperemia following true inflammation (microbic) enables the much larger number of cells resulting from this condition to form a denser and thicker cicatrix, but the same end- processes take place as in aseptic healing. Epidermization.—Although everything has been de- scribed pertaining to all healing in the depths of a wound, the method by which the superficial layers of organized granulations are covered in by epithelium has not been described. The process is the same whether the minute line between the edges of an incised wound heal- ing by primary union is concerned, or the wider area left where loss of substance has occurred. Epidermization, 48 PRINCIPLES OF SURGERY. or the final covering in of the surface-granulations by the formation of epidermic cells, results from multiplication of the deeper layers of the rete Malpighii. When the whole thickness of the skin has not been destroyed, regeneration of the epithelium takes place in part, by multiplication of the epithelial elements of the remnants of the sebaceous and sweat glands, and those of the hair- follicles, little islets of new epithelium being seen scat- tered over the granulating surface. To secure this development of the young epithelial cells they must be retained sufficiently long in contact with the older cells to undergo some corneous change. Toward the end of every variety of cicatrization, the drying of the exudate over the last part to heal forms a "scab"—i. e., desic- cation of the more superficial layers of cells retains the deeper layer of young epithelial cells mechanically in position, until the necessary developmental changes can take place. This healing under a scab sometimes occurs upon a larger scale, and can often be successfully imitated in aseptic wounds, by means of an artificial scab formed by the application of shreds of absorbent cotton, which becoming soaked with the blood or serum dries. The use of nitrate of silver, lightly applied around the margins of a granulating surface, acts in the same way; the layer of coagulated albumin and cells retains the deeper epidemic cells in contact with the wound-margins, enabling the corneous change to occur. Comparatively few epithelial cells are requisite to cover in defects that were originally very large, because, as has been said, the superficial area of a wound is very much diminished by contraction of the original granulations. Union by Adhesion of Two Granulating Surfaces.— Two aseptic surfaces if maintained in contact will fuse, as has already been stated, and definitive heal- ing will take little if any longer time than if the wound had been primarily coaptated. This is be- cause the most superficial formative cells are as cap- able of development as those formed in a perfectly PROCESSES OF REPAIR. 49 coaptated wound, or those of the deepest layers of an infected granulating wound, and for the same reasons—viz., their vitality is unimpaired since no germ-products can reach them in either case, and no accumulation of fluids occurs effecting mechanical sepa- ration. Upon this fact depends the success of '' secondary suturing," when, for instance, tamponade of a wound becomes requisite for the arrest of hemorrhage. Here the passage of sutures five or more days after the infliction of a wound will often secure prompt union. This is because all the same preliminary changes must first be effected in the coaptated as well as the uncoaptated wound ; but if physical fusion of the two layers of cells is then produced by pressure, the development of fiber- cells takes place, uniting the wound-surfaces just about as quickly as if the bond had been originally formed of one mass of cells. The vitality of a severed part, as the tip of a nose or finger, or skin (not epidermic) -grafts, is maintained according to Thiersch and Tillmanns, by communications formed between the vessels of the granulations and those of the graft or severed part, through the medium of the intercellular plasma-channels. Later, all the phenomena described as pertaining to union by primary adhesion occur. The detached part is passive until after the third day, when it commences to be vascularized by outgrowths from the vessels of the surface of the wound. Despite the two or three days' interruption of the direct blood-supply in the case of a skin-graft, only the epidermal layer, a portion of the rete Malpighii, and most of the vessels perish, the last by atrophy preceded by hyaline degenera- tion. In from three to four days the epithelial cells of the sebaceous and glandular follicles proliferate and penetrate the mass of newly-formed cells infiltrating the wound-surface and contiguous portions of the graft, and in two weeks, according to Garre, the conversion of the granulations into connective tissue is completed. The mechanism of the contraction of scars requires 50 PRINCIPLES OF SURGERY. explanation, because, as commonly understood, there is a vague idea that an active process is concerned, analo- gous to the shortening produced by contraction of mus- cular tissue. The primary mass of soft succulent granu- lation-tissue composed of innumerable cells, in the structure, with few nuclei; the vessels are almost completely obliterated by the condensation of the scar-tissue. process of organization into a permanent tissue, undergoes a species of condensation. Many cells disintegrate from lack of pabulum, and the detritus is absorbed. The greater part of the protoplasm of those which remain undergoes fibrillation—/, e., becomes converted into a dense, interwoven mass of fibers containing but little fluid. As this physical condensation progresses, the ap- proximating fibrous bundles so compress many of the capillaries that they atrophy and disappear, still further lessening the bulk of the cicatrix. The diminution of PROCESSES OF REPAIR. 51 the blood-supply leads to the atrophy of many more cells, until the previously succulent, bulky, cellular mass is now composed of very few vessels and cells, and consists almost solely of desiccated fibers with a few nuclei, all occupying a comparatively small space. A comprehension of these processes explains the long continued, progres- sive character of this " contraction of a scar," the dura- tion of the contracting period being in proportion to the number of cells maintaining their vitality. Repair of Non-vascular Tissues.—Only a few words need be devoted to a description of the modifications of the ordinary processes of repair observed in non-vascular tissues, such as cornea and cartilage. In the former its anastomosing intercellular plasma-channels readily ad- mit wandering cells coining from the vessels of the related vascular structures (sclera and conjunctiva), and, later, proliferation of the fixed cells and their vasculari- zation occurs. It has been recently alleged that some of the cells seen in corneal wounds are corneal cells squeezed out by the elastic laminae from the edges of the wound which slip down, as it were, into and aid in filling up the wound. In a similar manner wandering cells pass along the plasma-channels of the cartilage, the fixed cells of which later proliferate, the blood-supply reaching them by outgrowths from the vessels of the surrounding vas- cular tissues. The cicatrix in cartilage after aseptic heal- ing remains long, if not always, fibrous; "if a severe inflammatory (microbic) reaction takes place, the cica- trix will rapidly become hyaline, like normal hyaline cartilage.'' LECTURE IV. REGENERATION OF TISSUES. Do tissues actually become regenerated ? In only a few tissues does repair progress beyond the formation of scar- tissue. Where regeneration is possible its perfection will be in proportion to the apposition effected and the asepsis secured. Surface epithelium and all connective- tissue structures, such as fascia, bone, or tendons, can be completely regenerated. I shall briefly describe the extent of regeneration and the special modifications of the typical processes of re- pair observed in the various tissues or organs, recapitu- lating in part what has already been said. Epidermis.—The epidermis, including the epithe- lium of the gastro-intestinal tract and of other mucous membranes, is completely re-formed, the new cells being descendants of the old epithelial cells of the margins of the wound, or, after partial destruction of the skin, as has been already explained, originating by division of the epithelium of the various cutaneous structures whose extremities lie in the deeper portions of the skin, or actually in the cellular tissue beneath. The same is also true for the remains of glandular epithelial struct- ures after partial destruction of mucous membrane. Skin.—The fibrous portion is completely regenerated, although the arrangement of the bundles is more irregular, and it is long before elastic tissue is developed in the scar ; but the hair, sebaceous and sweat follicles, with the true rete Malpighii, are not re-formed. Lymphatics are also absent, and an old scar is so much less vascular than normal skin—from obliteration of most of its vessels REGENERATION OF TISSUES. 53 effected as described when explaining the contraction of a scar—that the cicatrix is liable to break down from slight causes. This avascularity of scars is a matter of common observation. At first redder than the surround- ing parts from excess of blood-vessels, as the scar con- denses most of these atrophy, rendering the scar in time whiter than the environing structures. Fasciae, tendon-sheaths, and tendons are practi- cally regenerated. After division of a tendon the proximal end retracts, and the method of repair varies somewhat according to whether a blood-clot is or is not present. In the rabbit, when but little blood is effused, emigration of leukocytes occurs, followed in from two to three days by rapid proliferation of the cells of the sheath. Many of the cells of the tendon-stumps rapidly degenerate, but about the fourth or fifth day some take part in the formation of the granulation-tissue. The exudate extends some distance above and below the extremities of the softened, succulent, and freshly vascu- larized tendon-ends. Warren contends that when the sheath is filled with blood, the clot is removed by in- growths of vascular granulation-tissue springing from the sheath without a primary infiltration with leuko- cytes ; other observers deny this, and probably both are right at times. The grayish cellular mass becomes pink from vascularization (fifth day, Paget; tenth to four- teenth day, Warren), the new vessels in the granulations joining those of the tendon-ends. Thus a spindle- shaped cellular bond of union usually fills the gap by the fifth day. If no blood-clot be present, the sheath col- lapses and becomes adherent to the tendon-stumps, regeneration being effected by proliferation of the cells of the sheath and of the cut tendon. The new tissue gradually approximates that of normal tendon until microscopically no difference can be observed. The sheath usually remains slightly adherent at the point of section. Muscular Tissue.—Defects in muscular tissue are 54 PRINCIPLES OF SURGERY. only repaired by scar-tissue formed from the granula- tion-tissue produced by the connective-tissue elements. Regeneration is observed to a limited extent after slight injuries or contusions, and even near a cicatrix, com- mencing by enlargement and proliferation of the mus- cular nuclei, resulting in the formation of large mono- and poly-nucleated cells, occupying the place of the destroyed fibers. These develop into spindle-cells lying side by side, which promptly become longitudinally . 5.—Showing, in upper half of cut, longitudinal and cross-sections of generating muscle-fibers; in lower half, normal muscle-fibers. fibrillated and during the third week show commencing transverse striation. Another view is that granulation- tissue forms among and around the necrosed muscle- fragments. The extremities of the injured muscle-cells split up into spindle-shaped fragments, which fattilv degenerate and are absorbed. The nuclei of the living REGENERATION OF TISSUES. 55 muscle-cells around the injured area form bundles of muscular fibrils which totally disappear by the third week. The disappearing fibers are replaced by bundles of longitudinally striated fibers and spindle-cells formed by splitting up of the living muscle-fibers and prolifera- tion of the nuclei. Growth of new muscle-fibers into the granulation-tissue and disappearing mass of mus- cular debris, commences about the sixth day by small, multinucleated protoplasmic fibers, springing from the stumps of non-degenerated fibers or from those longitud- inally split. These outgrowths may be bifurcate, with club-shaped or fusiform extremities which contain many nuclei. Longitudinal striation occurs early, transverse striation at the close of the second week. The new muscular filaments interlace, lateral budding being not uncommon. Many of the fibers fail to develop, fattily degenerate, and are absorbed. Those which persist, in- crease in bulk, acquire transverse striation, interlacing with others from the opposite side of the gap, until the connective-tissue scar may, in very slight wounds, prac- tically disappear. Some irregularity always remains, but the interlacement of the fibers is to a great extent gradually replaced by a more normal arrangement. Blood-vessels.—Vascular repair depends upon the formation and "organization of thrombi." Injury to or destruction of the vascular endothelium, and partial or complete arrest of the blood-current are necessary for the production of thrombi. A thrombus in a living vessel materially differs from a mere blood-clot, owing to the part played by blood-plaques and white cells. Vascular thrombi are indeed often entirely white, although ante- or post-mortem accretions of genuine clot may occur. Unless only a portion of the circum- ference of a vessel is injured, the thrombus usually extends in time to the collateral branch above, or much farther if a vein be concerned. A small parietal wound may become blocked by a thrombus limited to the wound and its immediate neighborhood, which may 56 PRINCIPLES OF SURGERY. organize, leaving only a localized thickening. This is quite common in veins, but may also occur in arteries of any caliber. The thrombus when once formed must either become organized, soften, disappear by absorption in whole or in part, or calcify. The minute processes are exactly the same seen when "healing by a clot" occurs, if the including vessel-walls are understood to take the place of the surfaces of the wound (see Fig. 3, p. 44, showing organization of thrombus). The vascular walls—like the wound-surfaces—first become infiltrated by leuko- cytes, next the thrombus is invaded, penetration taking place along many routes, thus breaking it up into nu- merous isolated masses. The endothelium proliferates where injured, and the thrombus gradually becomes re- placed by the "formative cells" thence derived, which penetrate along the tracks prepared by the previous invasion of leukocytes (Ballance and Edmunds). Vas- cularization of the germinal tissue is effected here as elsewhere, all traces of the thrombus—the superseded scaffolding—gradually being removed. As the forma- tive cells can enter only through the portions of throm- bus in contact with the vascular wall, organization of a thrombus which does not entirely occlude a vessel is a slower process than where complete blocking has oc- curred. One or more of the new vessels may persist or even enlarge, restoring in a measure the continuity of the vascular lumen, but usually the occluded segment of the vessel is converted into a fibrous cord. Sinus- degeneration and other rare changes in thrombi do not concern us here. Occasionally, where tense surround- ing tissue interferes with the egress of blood, a small wound of a large artery may become occluded by a clot commencing outside the coats of the vessel, extending thence through the gap in the wall and causing an intravascular thrombus limited to the immediate vicinity of the wound, leaving a portion of the lumen free. Granulation-tissue grows into and replaces the portion of thrombus occupying the vascular wound, and a con- REGENERATION OF TISSUES. 57 nective-tissue—i. e., an inelastic—scar results. Intra- vascular pressure causes yielding of this scar, an aneur- ysm forming, or perhaps the cicatrix suddenly ruptures giving rise to an arterial hematoma. Repair after liga- ture of a vessel proceeds upon the same lines. To sum- marize, a protective thrombus forms, proliferation of intimal and connective-tissue cells takes place, substitu- tion of the clot by these formative cells occurs, to be followed by vascularization of this germinal tissue, its development into scar-tissue, and the conversion of the vessel up to the next collateral branch into a fibrous cord. Warren insists that at the site of ligature the vessel- walls become, as we have seen, converted into a mass of granulation-tissue, but that later the vessel-ends separate, expand, and the granulations freely penetrate the throm- bus carrying in new vessels. Between the irregular masses of granulations spaces are left, which after absorption of the clot form blood-spaces, opening on one side into the lumen of the vessel, on the other communicating with the capillaries of the granulation-tissue external to the vessel. Eventually a regeneration of the vessel-walls is effected, the cicatrix being lined internally with intima, unstriped muscular tissue forming the new middle coat, and most externally is fibrous tissue. The frequent per- sistence of a small central vessel opening into the lumen above and communicating "with the capillaries sur- rounding the arterial stumps" is also described. As I have elsewhere said, while Warren's observations stand alone with regard to the formation of a muscular scar, they are deserving of further investigation, as explaining —if confirmed—why aneurysmal dilatations so rarely result from the scar of a ligation in continuity. Nerves.—Under favorable circumstances repair is here so complete that the peripheral end of one sensorimotor nerve has been united with the central end of another, with restoration of peripheral function. The alleged "immediate union" of nerves with restoration of their conducting power, no degeneration of the peripheral one 58 PRINCIPLES OF SURGERY. occurring, appears to have been established clinically. The vast bulk of both clinical and experimental results de- monstrating the apparent impossibility of this method of union, the accuracy of the observations as to cases of supposed immediate union are to be viewed with grave doubt. Anastomoses between nerves—not always those mentioned in the anatomical text-books—which are subject to wide variation, supplemental or vicarious sensibility, and individual differences in the distribution of a given nerve probably explain the supposed "pri- mary union." Degeneration of the whole of the distal segment with a portion of the proximal is the rule, a downward growth of embryonic fibers from the proximal end taking the chief part in the repair ; these originate from pre-existing fibers. The embryonic fibers penetrate the granulation-tissue by means of which the physical union of the nerve-trunk is effected. From Howell and Huber's experiments we learn that in the dog, four days after section of the nerve, segmentation of the myelin- sheath and fragmentation of the axis-cylinder takes place in the peripheral portion of the nerve. Active nuclear proliferation in the neurilemma is distinct by the seventh day, with migration of the new cells, several often oc- cupying one internodal space. During the following week the segmented myelin and fragmented axis-cylinder disappear by absorption, complete removal being effected in fourteen days. Next, the nuclei acquire an invest- ment of protoplasm, which increases until "a single solid protoplasmic fiber with embedded nuclei occupies the old sheath." When physical union is effected with the central end this is the rule, but if union is not made one or more fibers may arise within an old sheath by lon- gitudinal cleavage (Howell and Huber). These amyelinic "embryonic fibers" later acquire a myelin sheath, the old sheath probably becoming, according to these authors, part of the endoneural connective tissue. In the dog, return of function commences as early as the twenty-first day and is complete in eighty days, a much REGENERATION OF TISSUES. 59 shorter time probably than is occupied in the restorative processes in man. Nerve-impulses can be conveyed in the embryonic-fiber stage when the newly-formed fibers are united with normal fibers of the central end. Immediate suture gives the best results, even an hour's delay producing a recognizable difference. Experiment corroborates clinical experience that although complete degeneration of the peripheral end apparently always occurs, yet regeneration is more rapid when immediate suture is done. Because granulation-tissue opposes a physical obstacle to the penetration of the newly-formed nerve-fibers, pyogenic infection, which invariably pro- duces an excess of this tissue, is to be avoided, aseptic healing with the formation of the minimum of granula- tion-tissue affording the most perfect results. The greater the length of the distal portion, the longer will be the time requisite for cure. The same remarks are true as to the time and perfection of result if a segment of a nerve is actually removed. Arrest at the "em- bryonic stage" occurs where suture is not done, a bul- bous enlargement usually forming on the proximal end, composed chiefly of fibrous tissue ; exceptionally the dis- tal end undergoes the same changes. The statements I have made, embodying as they do the results of modern research, must be accepted as true, however much they may invalidate some of the earlier, cruder observations. Bone.—Union may take place by the same processes seen in primary union of soft parts, or it may be sec- ondary—i. e., by granulation-tissue—the bond usually being genuine osseous tissue. When a long bone is fractured, considerable blood will be effused from the ruptured medullary and Haversian vessels, as well as from those of the periosteum and contiguous lacerated soft parts. Even in the rare event of the periosteum remain- ing untorn, it is more or less stripped off the broken ex- tremities. The injured tissues infiltrated with blood are soon invaded by leukocytes and effused blood-plasma, and, fibrinous coagulation taking place, the extremities 6o PRINCIPLES OF SURGERY. of the broken bone lie embedded in a dense, ill-defined mass of firm cellular exudate, involving periosteum, con- nective tissue, and possibly contiguous muscle. In from fourteen to twenty-one days the blood is completely absorbed, leaving a firm, dense, cellular, vascularized, partially organized mass. This " callus," as it is called, is most abundant in and beneath the periosteum and ex- tends between the ends of the fragments ; it is sometimes even at this stage partly cartilaginous. In from seven to fourteen days—i. e., during the fourth or fifth week— ossification occurs in the callus, which forms a spindle- shaped ferrule of porous bone around the extremities of the broken bone, provided these are not much displaced, in which latter event the reparative tissue is more irregu- larly disposed. Meanwhile, similar changes have also been taking place in the medullary tissue ; the blood-clot with the contiguous soft parts of the medulla has become infiltrated with leukocytes. The blood is next absorbed, the fat disappears as the connective tissue and endothelial cells proliferate, and granulation-tissue forms from both bone-fragments, which soon fuses and develops into porous bone blocking the medullary canal. Owing to the physical obstacle presented by the dense osseous tissue, the proliferation of the connective and vas- cular tissues occupying the Haversian canals in the com- pact tissue contiguous to the fracture progresses but slowly, the lime salts gradually disappearing, so that it is com- paratively late before the granulation-tissue thus pro- duced ossifies, definitely uniting the fragments. When union has been finally completed, the excess of "exter- nal" and "internal" callus is absorbed, the medullary canal in the course of years becomes restored, and in time the site of the fracture may be hard to detect if the reduction has been perfect. The restoration of the medullary canal as well as the re- moval of excess of callus results from the phagocytic action of certain cells—"osteoclasts"—which in the former proc- ess accumulate in the small spaces of the comparatively REGENERATION OF TISSUES. 6l spongy callus, enlarging these until the bone becomes can- cellous, the partitions between cancelli disappear, large rarified spaces form, these finally coalescing, until the medullary canal is re-formed. If overlapping of the Fig. 6.—Showing action of osteoclasts causing absorption of dense cortical bone and callus. fragments persists, the open ends of the medullary canal become closed off by bone, and its lumen is usually only imperfectly restored by a gradual conversion of the over- lapping and fused portions of cortical bone into cancel- lous bone. (Fig. 6.) To impress upon your minds the identity of the re- 62 PRINCIPLES OF SURGERY. parative processes in bone as well as in the softest of tissues, let me briefly rehearse the various steps. The lacerated periosteum, muscles, etc., and blood-clot are infiltrated by leukocytes ; the cells of the soft parts of the bone, especially those of the deeper, osteogenetic layer of the periosteum some little distance from the fracture begin to proliferate, numerous angular and stellate cells—osteoblasts—appearing, which originate chiefly from the deeper periosteal cells. As time prog- resses all the osseous soft parts—i. e., the periosteum, bone-cells, medullary tissue and contents of the Haver- sian canals, which are all continuous structures—under- go similar changes. The dense bone opposes a tempo- rary, physical obstacle to cell-proliferation, because the. earthy salts and matrix can be only gradually removed ; but this is only a question of time, being exactly what is seen in the soft parts where the phagocytic cells re- move the tissue-cells, as the granulation-tissue appears. The osteoblasts, probably formed by division of the fixed connective-tissue and endothelial cells of the bony soft parts, as well as from the deep periosteal cells, are sepa- rated by a finely striated intercellular substance, each surrounded by a halo somewhat like that seen around cartilage-cells, the more highly differentiated portions forming interlacing trabecular, here and there infiltrated with lime salts. This is osteoid tissue. The more cen- tral portions of callus show less striation of the inter- cellular material, later assuming the hyaline appearance of true cartilage, of which tissue a large part of the internal portions of the provisional callus often consists during the early period of consolidation. Direct ossi- fication of the osteoid tissue may take place, the cells growing smaller and some becoming branched, occupy- ing spaces in the calcareous matrix—i. e., they are now bone-corpuscles. Trabecular of bone soon form by the deposition of the lime salts at numerous points. This commences in from ten to fourteen days, while newly formed blood-vessels spring from those in neighboring REGENERATION OF TISSUES. 63 Haversian canals. These ramify between the bone-plates, and run at right angles to those of the old bone. Ossification of the external callus usually commences in the angles formed between the separated periosteum and bone, and extending thence, the two buttresses meet and fuse at the middle of the spindle-shaped mass of provisional callus. This bony callus is composed of a network of bony trabecular, the interstices of which are filled by masses of young cells that have not yet ossified ; the periphery of these masses is steadily con- verted, layer by layer into bone. Although most of the cartilage sometimes found in callus disappears before advancing vascular ingrowths containing osteoblasts, some is converted directly into bone by deposition of lime salts in the matrix, a portion of the cells remaining as bone-corpuscles. In the medullary canal similar changes are effected, the osteoid tissue commencing to form at the periphery of the canal, whence it spreads concentrically until it is occluded. Hyaline cartilage is rarely seen in this "internal callus." Finally, the Haversian canals of the compact tissue of the ends of the fragments become choked with a round-celled infiltrate ; the lime salts are dissolved and removed with the ground substance, the resultant large cancellous-like spaces be- coming filled with osteogenetic cells. The germinal tissue thus formed between the ends of the fragments fuses with the contiguous portions of the cellular mass forming the "internal" and "external callus," and union of the cortical bone takes place by ossification of this "definitive callus." From this description it is clearly seen that callus passes through a stage resembling the formation of fibrous tissue and that where cartilage is developed it is often immature fibrocartilage ; hence, "fibrous union" of bones is often a mere arrest of osseous union at a cer- tain stage of the process. If the disturbing causes can be removed in time—i. e., before development into an adult tissue has taken place—nature (as we know clini- 64 PRINCIPLES OF SURGERY. ' cally she often does) takes up the process where it was left off and completes bony union. This explains the benefits resulting from rubbing the fragments together, blistering over the fracture, and partial use of the limb when fixed by apparatus, sufficient hyperemia being thus induced to lead to further development of the callus and deposition of lime salts, in these cases of delayed union. Healing of bone may thus occur by a process identical in all essentials with primary union of soft tissues ; but it may also take place by the "second intention," by granulations—indeed, must do so in open fractures, where either loss or death of bone has occurred. Where bone has been primarily lost, the periosteum having usually been destroyed over the osseous defect, proliferation of the fixed and endothelial cells of all the surrounding soft tissues, including those of the subjacent bone, takes place, the granulation-tissue thus formed becoming converted into bone by one or more of the methods described, as the superficial soft parts close over and cicatrize. When death (necrosis of bone) occurs, at the border- line between the dead and living parts, lively prolifera- tion of the cells of the periosteum, medulla, and Haver- sian canals produces a mass of germinal tissue, some of whose constituent cells (osteoclasts) cause absorption of the bone-substance, until the continuity of the dead and living bone is interrupted by a layer of cells. The bacterial peptonizing ferments, in suppurating wounds, with their other toxic products dissolve the intercellular cement and destroy the vitality of many of the cells, reducing them to a fluid tissue—pus—thus detaching the dead fragment. In aseptic wounds the same results follow from a more gradual loss of vitality, solution of cement and cells producing disintegration of the cellu- lar bond of union. When the dead bone is removed the remaining granulations go on to cicatrization—i. e., ossification. I need hardly point out how exactly alike are this "sloughing of bone" and the sloughing off of a piece of dead cellular tissue. LECTURE V. INFLAMMATION A TRUE MICROBIC PROCESS. I have now put you in possession of all the facts requisite for a clear understanding of the phenomena of inflammation, which may be defined to be the series of results caused by microbic interference with the nor- mal processes of repair in injured, living tissues. These results usually for a time lead to the destruction of tissue, but are ultimately conservative in their tendencies, the end-results being the removal or neutralization of the microbic cause. Microbes produce their injurious effects indirectly ; first by bacterial proteids, possibly liberated from the germs only during their degeneration ; and second, the presence of these proteids leads to the production of toxic substances—toxalbumins, etc., in the tissues them- selves from perverted metabolism, hence the presence of germs themselves is not essential for the evolution of inflammatory phenomena, but substances containing ptomains, toxalbumins, etc., will produce all these, until the toxic substances have exhausted their power to harm, when the processes will cease, unlike what is seen where living germs are present, which continually produce new supplies of toxic substances. It is far too generally accepted as the teaching of mod- ern science that the presence of germs invariably means inflammation, or the disease which the microbe is the cause of, for instance, tubercle. This misapprehension is the foundation of much of the confusion existing in the minds of students in their comprehension of path- ologic phenomena and methods of wound-treatment, 5 65 66 PRINCIPLES OF SURGER Y. and must be abandoned at the outset of the study of inflammation. To produce their characteristic effects germs must be present in sufficient numbers to overcome the vital re- sistance of the tissue. Immunity.—The relations borne by micro-organisms to the production of inflammation can be best ascertained by first studying how the tissues safeguard themselves under ordinary and extraordinary circumstances, in other words how they dispose of germs or render them inert. Only a few words can be devoted to the question of im- munity, as it bears upon tissue-immunity and resistance. Hankin's definition, aided by a few illustrations, will suffice for our purposes. "Immunity, whether natural or acquired, is due to the presence of substances which are formed by the metabolism of the animal rather than that of the microbe, and which have the power of destroying the microbes against which immunity is possible, or the products on which their pathogenic action depends." Observers have extracted certain substances—"defensive proteids " —from the livers and spleens of animals, capable of de- stroying bacteria. These are never found in normal blood ; but when the febrile state has supervened, these substances, in an active state, are detectable in the circu- lating fluid. Blood-serum is well known to be germicidal in virtue of the nucleinic acid it contains, dissolved out of, or resulting from the disintegration of the phagocytic leukocytes. The reaction of tissues to germs is never exactly the same in any two individuals. The differences clinically observed are probably explainable as follows: From the analogies presented by the differing vulner- ability of the lower animals to certain infections, and our knowledge of the relative immunity present in certain peoples to some forms of disease, we may certainly infer that there is such a thing as inherited racial immunity. It is also a matter of common observation that some in- INFLAMMA TION. 67 dividuals, although frequently exposed to an infection, escape again and again, but finally do succumb. Prob- ably in such cases the individual's tissues, having tri- umphed over previous slight infections, continue to produce substances inimical to the growth of the same germs if again implanted in large numbers—?', e., an antitoxin or antidote to the toxins produced by the germs is formed. This power may gradually cease in time or may suddenly be destroyed. Thus, among the lower ani- mals the adult white rat is naturally immune to anthrax. Change, however, the conditions of cell-nutrition in the same rat, by inducing extreme fatigue, and the blood becomes overloaded with the products of retrograde tissue-change which so depress cell-vitality either by directly poisoning the cells, or by interfering with physiological metabolism, that the normal defensive proteids are no longer formed and the animal can now acquire anthrax. This is frequently paralleled in the human subject. It is a matter of common remark how troops resist disease in the earlier stages of a campaign when later, after the extreme physical exertions of forced marches, etc., they readily yield to an infective exposure which is comparatively slight. Lowering of tissue- resistance may then be brought about first, by deficiency in the amount of pabulum available for the cells, so that sufficient defensive proteids are not formed ; and second, by the presence of substances in the blood, in the tissues, or in both, which are capable either of actually destroy- ing the cells or so altering metabolism that their products, far from supplying defensive materials against germs and toxic substances, rather add new poisons to those already present. Certain tissues are normally deficient in pabulum from their poor blood-supply, and hence are peculiarly vulner- able to infection. Anatomical structure sometimes favors infection. The almost sinus-like arrangement of the blood-vessels of the epiphyses of growing bones favors the accumulation of germs, because the velocity of the 68 PRINCIPLES OF SURGERY. current is lessened. This explains the frequency with which such portions of the bones are attacked in acute infectious and tubercular osteomyelitis. In contrast with the lack of resistance shown by normally avascular tissues is the well-known resistance offered to severe infection by very vascular parts, such as those of the face. The tissues then can only maintain their normal resistance by having an abundant blood-supply ; but this must move at a normal rate, in vessels of a certain caliber—although these conditions may vary within somewhat wide limits —otherwise germs will, for purely physical reasons, accumulate in overwhelming numbers. Still further, if this blood does not move at a proper rate it will not promptly carry away the poisonous products of cell- metabolism, which will otherwise directly injure the cells. Again, this poison-laden, because sluggishly moving blood may incite the tissue-cells to abnormal metabolism productive of toxic substances, even in the absence of germs, which when absorbed will produce most serious constitutional effects. Although when the tissue-cells, the hemopoietic organs, the blood, and excretory organs do their whole duty, complete tissue-immunity is secured under ordi- nary circumstances, are there no reinforcements which they can call upon in an emergency ? Yes. Some of the leukocytes, which, as we have seen, soon crowd into any injured part, the mono- and poly-nucleated ones, are capable and eagerly embrace the opportunity of encapsulat- ing dead or dying cells, detritus of the same, and germs or spores. The phagocytes, as they are called, are often unable to cope with the adult germs, dying in their efforts, but can encapsulate, destroy, and digest, or mechanically remove spores by virtue of their ameboid power. The wandering tissue-cells and the tissue-cells themselves also exert this phagocytic action, especially the descendents of the fixed connective-tissue cells (the fibroblasts), and the endothelia of blood- and lymph- vessels, the latter being less active. This accounts-for INFLAMMA TION. 69 the mural implantation of germs seen during infection from germs circulating with the blood, which, although unfortunate, is a protective effort upon the part of the vessel-cells. The degree to which the tissue-cells can exert this protective power depends upon the degree of perfection of the nutrition of the cells themselves. It is believed that phagocytes exercise a selective power as to the forms of organism they attack. Thus the polynuclear cells will take up and digest streptococci and gonococci, neither of which are attacked by the mononuclear forms (Park). Chemotaxis.—Why do phagocytic cells accumulate in a part attacked, rushing like soldiers summoned to beat off an assault ? Because of chemotaxis. What then is chemotaxis ? It is the mutual attraction or repulsion possessed by animal or vegetable cells for one an- other, or of an animal cell for a vegetable one. When two cells tend to approach one another, or one immobile cell causes a mobile cell to move toward it, "positive chemotaxis'' is said to exist; when a mobile cell is repulsed—i. e., moves away from another cell or sub- stance—"negative chemotaxis" is said to have been operative. Thus the vegetable cell, the bacterium, attracts an animal cell, a leukocyte. Mobile bacteria move toward pabulum, and phagocytes are peculiarly attracted by the albuminous material composing or set free from bacteria. The disintegration of tissue follow- ing aseptic wounds or other traumatisms sets free pro- teids which attract phagocytes. These remove the detritus as well as effect the solution of living tissues where reparative cellular exudate is forming. I must here again impress upon you the possible disadvantages of the hyperemia of repair if exces- sive, and explain how it may be possible to prevent the successful secondary implantation of germs when such hyperemia exists, thus converting what would inevitablv become an inflammatory into a purely reparative process. This is an appropriate place to JO PRINCIPLES OF SURGERY. introduce in advance certain statements, because the therapeusis of inflammation depends largely upon a rec- ognition and application of similar facts, and also because hyperemia is just as much a part of inflamma- tion as it is of repair. Although hyperemia, however excited, at first serves to remove detritus, poisonous metabolic products, and to bring phagocytes, thus im- proving tissue-nutrition, eventually a slowing of the blood-current must ensue, and any germs reaching the circulation through some distant infection-atrium will tend to drop out. The exudate supplies abundant pabulum for the germs while it compresses the plasma-channels, thus interfering with the nutrition of the cells ; moreover, metabolic products are now retained in the part. In chronic hyperemia even varicosity of the vessels has been observed, than which no better trap could be devised for germs. If we can secure diminution of the caliber of the blood-vessels and thus increase the rapid- ity of the current, germs will not be so able to collect, those present will be swept away, exudate will be re- moved, and tissue-resistance increased from the improved nutrition. You will recall that when considering hyperemia, the minute processes were first described and then the clini- cal symptoms. I shall reverse this plan and consider first the clinical signs presented by inflammation of a superficial part, and later explain the variations observed in the minute processes of repair, produced by the injurious action of germs and their products. In the first place never forget that, just as repair is effected by the same processes in every tissue, so is inflammation the same in the hardest as well as in the softest tissue—that most vascular and that without any direct blood-supply. Symptoms of Inflammation.—The first symptom of inflammation of a superficial part usually recognized is redness {rubor). This is at first uniform in tint, disap- INFLAMMA TION. n pears upon pressure, and fades out into the hue of that of the surrounding tissues. Later it is darker at spots— i. e., it is mottled—these darker spots not disappearing upon pressure. Surrounding the periphery of the in- flammatory focus there is an area of the tissues which steady pressure by the finger-tip will indent; they "pit" from edema as it is called. What causes the uniform redness? Hyperemia—i. e., the blood-vessels are dilated and contain more blood than normal. How is the mottling to be explained ? By the escape of red cells into the tissues by rhexis from the capillaries, or by the rupture of some of the vessels. Why do the sur- rounding tissues pit upon pressure? Because of the early, free escape of serum from the distended blood- vessels and later of liquor sanguinis. The lymph-nodes through which lymphatics draining the inflamed area pass are enlarged and tender, while the lymph-vessels, if cut, give exit to a much larger amount of fluid than can be obtained from those of a corresponding normal part. Do these phenomena vary in kind from those observed during the hyperemia of repair ? Not in any important particular. It is true that escape of red cells is infrequent in hyperemia, and that any edema noticed is rather from the escape of blood-serum than liquor sanguinis ; but all this can and does occur, the differ- ence being only in degree and not in kind, every phe- nomenon reaching its maximum in inflammation. Both to the hand and to the thermometer an inflamed part is warmer than normal {calor), but it is never hotter than the blood in the left ventricle of the patient, in fact is not so high. Owing to the increased registering power of the nerves, the sensation of heat as experienced by the patient is far in excess of the actual elevation of the temperature. This increased heat results not from any chemical changes in the part, but from the rapid flow of blood through the dilated vessels bringing caloric more rapidly than it can be dissipated by radiation. The bulk of the part is.increased, and swelling {tumor) 72 PRINCIPLES OF SURGERY, has taken place. This is due in a slight degree to excess of blood, but in the main to escape of fluids from the blood into the tissues and the migration of the corpus- cular elements during the earlier stages, while, later, proliferation of tissue-cells adds another increment. This accumulation of materials separates the different tissue-layers, thus stretching the nerves, which are also compressed by the exudate, so that pain {dolor) becomes a prominent symptom. The pain is doubtless increased by the chemical irritation of the toxic substances pro- duced by the germs, and the exalted sensibility of the nerves themselves, which are also hyperemic—i. e., rendered abnormally capable of recognizing impressions, which in this case means pain. These physical alterations of the tissues, or organs composed of them, of necessity interferes with the easy performance of the functions of the parts or actually arrests them {functio l&sa). Again, except in degree, has anything yet been men- tioned which cannot be matched by the hyperemia of repair ? Assuredly not; and up to this point the two processes are identical, whether excited by efforts at repair or by agents destructive of the tissues. From this point the two processes diverge and the phenomena peculiar to inflammation supervene—i. e., those which interfere with and thwart nature's reparative efforts. Microscopic Changes.—A few words can be profit- ably devoted to a consideration of the microscopic changes involved in the production of the coarse phe- nomena just detailed, because I wish to emphasize again the folly of the artificial distinction made between "the hyperemia of repair" and that of "inflammation." Thus, when inflammation is excited there is first ac- celeration of the blood-flow, then slowing of this ; the leukocytes drop out of the axial current, roll lazily along, collecting until a peripheral layer of leukocytes forms in the venules and capillaries. Leukocytes crowd into the tissues, serum and liquor sanguinis also escap- INFLAMMA TION. y^ ing, and finally stasis occurs with coagulation of the exudate, including the blood in the vessels where circu- lation has been arrested. In the aseptic healing of a wound where none claim the presence of germs, have I not described all this, especially the crowding of the wound-margins, clots, and dead tissue with leukocytes, and even coagulation of the exudate? Because it is impossible to follow these minute processes continuously by the microscope for many days, an artificial inflamma- Fig. 7.—Showing normal capillary circulation in mesentery of frog. tion can be observed only for a few hours at most. Despite what has been seen when examinations have been made at intervals of hours and days, it is still insisted upon by some, that as similar appearances are presented during infective processes, both should be con- sidered inflammation, although one is purely conserva- tive, the other destructive. Still further, because during 74 PRINCIPLES OF SURGERY. the earlier stages of experiments where eventually true (infective) inflammation does occur, leukocytes migrate into the tissues, it is contended that leukocytes only escape from the vessels during true (infective) inflamma- tion ; this is entire forgetfulness of the laws of chemo- taxis, and an ignoring of the conditions actually seen during the aseptic healing of a wound in which these Fig. 8.—-Showing acute hyperemia, induced by mechanical irritation, in mesentery of frog. Stage of dilatation of vessels, retardation of blood-current, and exudation with diapedesis of white cells. same observers declare no germs are present. Moreover, the simple expedient of securing perfect asepsis, dam- aging a tissue, thus inducing hyperemia, seeing the white cells migrate into the surrounding tissues, and proving that no germs were present by culture experi- ments, has been entirely neglected, until at my sugges- tion Dr. Spitzley recently did all this. All this iteration and reiteration in my judgment is demanded, because a INFLAMMA TION. 75 clear comprehension of my position can alone reconcile the confusing statements of many of our books and teachers, which when carefully sifted amount to this : germs are the sole excitants of inflammation ; migration of leukocytes is seen only during true inflammation, which has just been declared to be a germ-process ; yet wounds are said to heal by aseptic (non-microbic) in- Fig. 9.—Showing inflammation (infective) in mesentery of frog. Stage of stasis with exudation and diapedesis of both red and white cells. flammation, and further it is insisted upon that the migration of leukocytes with all the processes seen in a microbic inflammation, except the destructive ones, do occur in the aseptic repair of wounds. Migration of white cells then does occur, nay must occur during the hyperemia of repair; but owing to the immensely greater chemotactic power of bacterial proteids over those of dead or dying tissues, this phenomenon is much 76 PRINCIPLES OF SURGERY. more marked in genuine (microbic) inflammation, while the later destructive processes really constitute the true essence of inflammation. The pseudo-neoplastic growths induced by the tubercle bacillus, the poison of syphilis, etc., said to be the products of "inflammation," need not be considered here, since I am now only contending for the truth of the proposition that aseptic wound- repair should not be called "inflammation," and that the essence of microbic inflammation is the interference exerted by it upon the processes of repair. LECTURE VI. INFLAMMATION (CONTINUED): DIAPEDESIS OF WHITE CELLS, ETC. LET us partially retrace our steps and recapitulate the causes of the phenomena of so-called " aseptic inflamma- tion " and "aseptic fever," the former of which I have shown you is not inflammation but repair, so that we may better understand the resemblances presented by the two processes and the point where divergence commences. I will take for illustration the tissues of a sprained joint, where no question of microbic action can be dreamt of, and shall consider only those details essential for the comprehension of certain results which have not yet been dealt with. Thus, while the stasis does not neces- sarily terminate in thrombosis of the vessels unless the stasis is maintained for some time, yet thrombosis with coagulation of the exudates in the tissues will occur unless the circulation recommences. The effused serum and liquor sanguinis are drained away by the lymphatic vessels, which pass through lymph-nodes. These latter almost never become enlarged, as in microbic processes, and never suppurate, but may in rare instances be tender. The nucleins and tissue-detritus removed by the lymphatics and poured into the venous blood produce elevation of temperature and some increased frequency of pulse—"aseptic fever;" but these symptoms are usually onlv detectable because sought for, the tongue being not dry, often but slightly furred, and the secre- tions of the skin, intestines, and kidneys not diminished in quantity or materially altered in quality, none of which can be affirmed of them in true inflammation. The extent to which temperature and pulse are increased 78 PRINCIPLES OF SURGERY. is dependent upon the quantity of aseptic pyrogenous substances that are absorbed, hence cannot be pronounced after a slight injury, require a considerable surface for their absorption, and the symptoms commence just as soon as any shock present passes off. A "restitutio ad integram " is brought about in the areas around the lesion which is being repaired ; the so-called inflammation " terminates " in one of two ways. When the stasis is very recent and of limited extent all the circulatory and parenchymatous changes are reversed, the central mass of red cells begins to oscillate, the range of oscillation increases, the current recommences, the peripherally located white cells mingle with the central column of red cells, the migrated cells wander into the lymph-spaces (possibly into the blood-vessels) or become disintegrated and are absorbed together with the excess of fluids, leaving the part normal. When very rapidly effected this was what was formerly called "delites- cence," because all the induration rapidly melted away, as it were. When, however, extensive removal of tissue by phagocytosis, with its substitution by numerous young formative cells, must of necessity follow thrombosis of the vessels with coagulation of the exudate in the tissue, the removal of the excess of cells, with the development of those which remain into permanent tissue, is a much slower process, requiring disintegration of the cells—a re-solution of the exudate; this termination of inflamma- tion is appropriately called "resolution." Resolution may be perfect or imperfect, in which latter event the tissues are rendered denser, by the development of some of the cellular exudate into young connective tissue— i. e., scar-tissue. Induration, inflammatory thickening, cirrhosis, according to the stage of the process or the organ attacked, is now said to have followed the inflam- mation, or as I should say, the excessive and prolonged hyperemia of repair. No doubt, under the term "reso- lution," there is often included not only conditions where, with temporary stasis, there has formed too much INFLAMMA TION. 79 cellular exudate for the majority of the cells to migrate and most have to be slowly disintegrated, but also in some instances, where mild genuine (microbic) inflamma- tion has been present, the tissues so quickly gaining the upper hand that the processes of repair are promptly in- stituted. I shall once more explain the minute processes taking place in the depths of the tissues during "resolution," because it may seem that something different takes place from that which is seen upon the surface ; but in future my statements about repair must be taken without ex- planation. The stasis becomes permanent, the blood coagulates in the vessels, and thrombosis follows. The fibrin-form- ing constituents present in the effused liquor sanguinis and cellular exudate combine, coagulation occurring, rendering a return to the normal impossible after the manner of delitescence. The cells of the involved area, from the original injury, plugging of the vessels, and accumulation of fluid and cellular exudate, are deprived of their vitality or starved, so that they perish, and their solid detritus is removed by the phagocytes, leaving, instead of the tissue, a mass of densely packed formative cells, descendants of the connective tissue, endothelial cells, and perhaps some of the later appearing leuko- cytes. Vascularization is next effected as has been de- scribed for surface-wounds, and now we have '' granula- tion-tissue " in the depths of an organ, for the granulation form is not the essence of granulation-tissue but an accident, granulation-tissue really meaning a mass of vascularized, young, formative cells, which if undis- turbed will inevitably develop into cicatricial tissue. If disseminated fibroid thickening results, and if this occurs at one spot only, a subcutaneous scar is formed, capable of all the untoward consequences already described as following the contraction of a surface-scar. No difference then exists between what is seen during normal repair and infection up to the point we have 8o PRINCIPLES OF SURGERY. reached ; but if pyogenic infection has caused the changes, or if this now occurs, all the processes are rapidly completed; peptonizing ferments are formed which dissolve the inter- cellular cement, separating the cells one from another, thus preventing nutrition reaching them. Other toxic substances aid in destroying the cells, or coagulation- necrosis occurs in many instances, fatty degeneration and other retrograde changes follow, and what remains of the exudate, reinforced by dead phagocytes with a few living leukocytes, forms a fluid mass—i. e., pus. The physical change from a mutual relation of the cells to their separation one from another, prevents their vascu- larization ; but even could this be effected, the dead and dying cells could not avail themselves of the pabulum. The destructive processes manifest themselves by certain clinical phenomena to be described later. '' Infective inflammation '' has been the term employed of late years to express the conditions resulting from the presence in the tissues of germs—or their products—in overwhelming amounts, but I have shown you two facts —viz., that when these are both absent after traumatism, repair and not inflammation results, and that, even if present, they must be in sufficient numbers to overcome the vital resistance of the tissue-cells. It is true, as I have said before, that the introduction into the tissues of a number of germ-free, irritant substances may be fol- lowed by the collection of a puruloid fluid ; but this is not pus, as proven by its injection into an animal, neither general infection nor any of the destructive effects of true pus following. This fluid consists of an accumulation of leukocytes and phagocytes resulting from chemotactic action. Moreover, even if pus could thus be produced, the laboratory conditions requisite for success are never present clinically. Do not forget that what really causes the destruction during inflammation are the germ-products, not the germs1 themselves. The presence of these substances, although the germs pro- 1 Pyogenic organisms are alone referred to. INFLAMMA TION. 81 ducing them are absent, will initiate the phenomena of inflammation. Stings of insects, bites of venomous rep- tiles, etc., may later present all the evidences of true inflammation from the effects of toxic alkaloids, ptomains, etc., analogous to those formed by germs, from the simul- taneous inoculation with pathogenic germs, or from secondary infection ; but at the outset the conditions are often identical with those resulting from the presence of aseptic turpentine in the tissues. Although this would seem to be an appropriate place in which to describe the varieties of germs, their culture methods, and the means of distinguishing between them, yet since most of those who will read these pages have been carefully instructed in bacteriology, it will be un- necessary. Moreover, in these lectures upon the Princi- ples of Surgery, I can deal only with the general laws governing the action of germs, mentioning special in- stances for illustrative purposes only. The characteristic effects of germ-products upon the cells of the exudate and those of the tissues are the pre- vention of the former from undergoing conversion into permanent tissue of a higher grade, and the destruction of the latter. This is true of the effects of the tubercle ba- cillus as well as of those of pyogenic organisms. In the former, coagulation-necrosis, fatty degeneration, caseation, followed perhaps by liquefaction into a puruloid fluid, take place ; in the latter, disassociation of cells by peptonizing ferments occurs—often preceded by a coagulation-necro- sis, fatty and retrograde changes in the cells take place, and true pus is formed. These changes affect the ma- jority of the cells, although some remain immature for long periods, but later they develop into scar-tissue. Although the most common result of pyogenic infection is suppuration, yet from what is sometimes observed clini- cally, it would seem possible that very small quantities of pus may be formed as the result of a limited infection, the germs be removed by phagocytes or destroyed by nucleins, and the dead cells be absorbed. This would be 6 82 PRINCIPLES OF SURGERY. difficult of proof, but it is directly in line with some of the facts I have just related. Pus consists first of a liquid portion (liquor puris), com- posed of the liquefied cells, intercellular cement and liquid exudate, and second, of pus-cells—i. e., dead or dying leukocytes and germinal cells—which have perished in attacks upon the germs or have been killed by the germ- products. Suppuration occurring on a free surface, with loss of substance, is called ulceration ; when occurring in the depths of a tissue, and circumscribed, it forms a "purulent collection," or "abscess." The acuteness of an "inflammation"—i. e., the rapidity with which the pathological processes reach their acme—depends upon three things—viz., the charac- ter of the germs, the number of germs present, and the resistance of the tissues. Thus, the micro-organisms of suppuration—aptly termed pyogenic—rapidly induce the formation of pus. The inoculation of the micro- organism of glanders results in a subacute process—pos- sibly a chronic one—while the bacillus of tuberculosis usually sets up chronic changes. Approaching the defensive power of the tissues from another standpoint, we shall see that the portion of the old view which maintained that a form—the so-called " healthy inflammation "—was conservative, an effort to cast out or destroy something injurious, was correct. Premising that the stages of inflammation are arbitrary divisions, it must be admitted that the early hyperemia of a pyogenic inflammation, with the increased quantity and rapidity of the blood-flow, must tend to sweep out accumu- lating germs and prevent their implantation ; hence the good results which follow, at this stage only, the use of those therapeutic agents which increase the rapidity of the blood-current. During this period the result is in doubt, for the tissues may, unaided, conquer, and when intelligently assisted, not thwarted, often do triumph over the germs. The second stage, during which the multiplying germs overcome the enfeebled resistance of INFLAMMA TION. 83 the tissues, terminates in destruction of the central cells with peripheral extension of the cellular infiltration and conversion of the tissues into embryonal tissue, until the exciting cause ceases to be operative. The lack of resistance of the embryonal cells is characteristic of immature tissue, because they must develop and also form protective proteids—a double task which the most trivial physical or vital disturbance renders impossible. An increasing number of phagocytes now crowd into the peripheral zone; the uninterrupted and abundant vascular supply here present enables some of the cells to progress toward development, and vital resistance is thus gradually increased, until the growth of germs is so inhibited and their toxins so neutralized that repair commences. Of course, evacuation of a purulent collection loaded with micro-organisms is one of the most important means of arresting pyogenic processes ; but even after this has been done, the germs and their products in the tissues at the periphery must be disposed of, and they are dealt with after the manner just described. The cells around the pus-focus, having thus maintained their vitality and being properly supplied with blood, form a boundary layer of granulation-tissue ready for repair. During the final (third) stage of "inflammation," the microbes having been entirely disposed of, or being in process of removal by phagocytes, all toxic substances being now rendered inert by the exalted resistance of the tissues, repair is rapidly effected, a superabundance of nutriment uninterruptedly reaching the cells from the many newly formed vessels." In certain chronic infective processes, as in tubercle, under favorable circumstances this tendency toward repair is so strong, that when retro- grade degenerative processes are prevented, the tubercular granulation-tissue in whole or in part becomes converted into scar-tissue. Severe injuries do not tend to produce localization of germs present in the circulation, owing to the large num- ber of the phagocytic leukocytes which collect in the 84 PRINCIPLES OF SURGERY. injured part, and the amount of nucleins present. In bone-tubercle or acute infectious osteomyelitis, in both of which ailments the germs unquestionably reach the osseous tissue solely by way of the circulation, a slight blow or wrench, by lowering the vitality of a few cells, and the slight hyperemia following thrombosis of a few minute blood-vessels which have been ruptured, will enable the microbes to drop out and multiply in this locus minoris resistentiae. This is because the hyperemia is too limited to admit of the prompt arrival and accumulation of phagocytes. Mark the difference in the case of an exten- sive infected wound. Here multitudes of germs are im- planted, and despite the intense hyperemia induced, phagocytes in sufficient numbers cannot accumulate in time ; it requires the lapse of days or weeks before the defenders can even prevent the further increase of their foes, much less overwhelm and destroy them. Chronic infective inflammations, such as those produced by tuber- cle and syphilis, by preparing a favorable soil—i. e., a low grade granulation-tissue—predispose to the im- plantation of pyogenic organisms, which secondary infection accounts for much of what is ignorantly set down to the uncomplicated effects of those diseases. As yet, little beyond the local defensive power of the cells has been considered. In a general way the germi- cidal power of the blood-serum and the phagocytic blood- leukocytes has been mentioned ; but it must not be thought that many, much less all, the germs reaching the blood-current are thus disposed of. Large numbers of pyogenic organisms when introduced into the circula- tion promptly disappear therefrom, lodging in such organs as the liver, spleen, and kidneys, where some are destroyed, by methods already described, and others are eliminated with the urine, probably with the bile, and certainly from the intestinal tract. Whether the germs eliminated in the intestinal discharges are directly ex- creted by the intestines themselves, or escape with the bile and pancreatic secretions, is at present in doubt. INFLAMMA TION. 85 The allegation that microbes are excreted by the sweat and salivary glands, while likely to be true, would seem hardly susceptible of proof, because pyogenic organisms are so constantly present in health between the super- ficial layers of the epithelium of the skin and upon the surface of mucous membranes. Unquestionably the toxic materials formed by germs can be eliminated by the kid- neys, skin, and intestines, and possibly by other emunc- tories. This emphasizes what I have been contending for during the last twenty-five years—viz., that during infective processes much may be done by stimulation of these various emunctories, death of the patient often resulting because these organs cannot be made equal to the double task of excreting toxic substances as well as the products of tissue-metamorphosis. Too often the practitioner fails to recall the advice of his much scorned "old-time" predecessors, to " clear out the primse viae, to stimulate the emunctories, and to maintain their secre- tions free," the scientific basis of which advice is now freely conceded. LECTURE VII. INFLAMMATION (CONTINUED): PREDISPOSING CAUSES OF INFLAMMATION. If my previous statements have been founded upon facts, not theories, as I have contended, inflammation can only terminate by either suppuration, ulceration or resolution ; gangrene, or mortification, as will later be shown, being not a "termination," but an accidental consequence or result of inflammation. The essential cause of the abnormal penetrability of the vascular walls by fluids and cells probably is a molecular change effected in the vessel-walls by the products of germ-growth. Have I yet put you in possession of all the preliminary knowledge requisite for an intelligent study of the treat- ment of inflammation ? Certainly not. Why is it that of two men who have each suffered from a similar injury one recovers without any unpleasant consequences, and the other has an abscess form ? Still better, study the effects of contusion of a bone before and after an attack of typhoid fever, pyogenic organisms being acci- dentally present in the blood on both occasions. Before the fever nothing beyond a temporary soreness follows even a severe contusion ; after the fever, an osteomyelitis results, which has no relation to the typhoid bacillus. Clearly, if pyogenic organisms were the causative factors in the second instance, and they were equally present on both occasions, why, when the local impairment of nutrition was greater because of the severe bruising, did no localization of germs follow? Something else besides micro-organisms, and something which was present before the traumatism which co-operated with and re- 86 INFLAMMA TION. 87 inforced the effect of the germs, is requisite to explain the results. Certain conditions which favor the implantation and development of germs are called "predisposing causes of inflammation." In the supposed instance the tissues were incapable of normal metabolism and the formation of defensive proteids, from having been supplied with blood containing the toxins of typhoid fever. Even when these ceased to be formed, the amount of the nutriment in the blood was deficient ; hence malnutrition of the cells resulted, and finally this poor blood was propelled by a feeble heart, so that any- thing favoring local hyperemia would become effective in favoring or causing such a slowing of the circulation as would render certain the accumulation of pyogenic microbes. A slight blow which would be incapable of ex- erting any such effects in health will be quite sufficient to initiate stasis aided by such predisposing causes as have just been detailed. Let this illustration suffice, for in future I must confine myself to general statements with regard to the modus operandi of "predisposing causes." In order then to treat inflammation properly, it is absolutely requi- site not only to understand that any interference with ac- cess of the ultimate nutriment to the cells diminishes the resistance of the tissues to germs, but that general con- ditions influence the distribution of the pabulum which the blood contains to the cells, and also that the quality of the food influences these conditions. Therefore we cannot ignore the general state of the patient and address ourselves solely to improving the local conditions, be- cause this may either be impossible, or all may have been secured that can be effected by local measures, while the local nutrition can yet be modified by changes in the force of the current and bulk of the blood sup- plied to a part, and by the quality of that blood. Predisposing causes may, for convenience of descrip- tion, be classed under two heads, although there is no sharply dividing line. 88 PRINCIPLES OF SURGERY. i. Deficiency in Quantity of the Blood.—This results from causes which physically induce such a dilatation of the blood-vessels as will favor a slowing of the cur- rent, less blood passing during a given time through the part; hence its nutrition suffers, and with this the re- sistance to germs. This slowing of the current permits the accumulation in the damaged part of any germs which may be circulating in the blood, just as mud is deposited by the rapid mountain torrent when it reaches the valley and forms a broad, languidly moving stream. Deficiency in the quantity of blood reaching a tissue results from a vis-a-tergo which is below the normal— i. e., the rate and quantity of blood passing through the tissues are diminished. This results from weakness of the heart which may follow hemorrhage, lack of general nutrition, disease of the organ, or senile changes, the last of which, together with diminished elasticity of the vessels, account for the greater part of the bad repute of age, as predisposing to slow repair, inflammation, and gangrene. Sometimes loss of elasticity of the vessels from atheroma or calcification is the sole or chief cause ; sometimes it is a fibroid heart, though more often both coincide ; but if neither condition is present, advanced years do not produce malnutrition of the cells, hence do not predispose to inflammation, while in comparatively young individuals, when these conditions exist, the tissues are ill-nourished and incapable of resisting the attacks of germs. It is a most important point to keep constantly in mind that it is certain conditions, usually obtaining in old age, which produce imperfect nutrition of the tissues, not the mere years numbered by the patient and that similar changes can occur during comparative youth. Thus, one of the best marked examples of atheroma and calcification of the vessels I have ever seen, was in a man of thirty-nine years of age whose tissues, in consequence, resembled those of an aged man. Other conditions favor poor nutrition in the aged, nota- bly imperfect digestion ; but I must insist that age, per INFLAMMA TION. 89 se, does not necessarily mean imperfect tissue-nutrition. The importance of recognizing the role played by a lessened vis-a-tergo is that this condition is capable of betterment by the administration of food, stimulants, etc. Defects in the quality of the pabulum are due to insuffi- cient or improper food, to anemia however induced, and to the presence of toxic materials. Thus the laborer who, owing to a strike, for instance, actually has too little food, and the individual who has enough food, but of a kind that his digestive organs cannot convert and appropriate, both have their tissue-cells insufficiently nourished, because the blood does not contain the requi- site amount of pabulum. In both also, the heart- muscle, in common with other organs, is so weakened that the normal vis-a-tergo is diminished, and thus, in addition, a deficient supply of blood to the tissues re- sults. Again, fatty foods may be indicated, as for in- stance, cod-liver oil in tubercular affections, to increase the assimilability of albuminous foods and supply hydro- carbons, thus improving nutrition ; yet this remedy often arrests digestion and, causing diarrhea, instead of improving the patient's condition, institutes a new drain upon him. To illustrate the importance of recog- nizing such causes of imperfect tissue-nutrition, let me tell you that an occasional dose of calomel will render it possible to administer the oil, or, if,. failing by this method, inunction is employed, suppuration will dimin- ish or cease, because the cell-nutrition has been in- creased, which is the same thing as saying that resist- ance to germs has been increased. The injurious effect upon the tissues of retained excrementitious substances, which have either been imperfectly elaborated or are in excess, although possibly normally present in the blood, is seen in the deposits of sodium urate so common in o-out. In like manner the tendency to inflammation so often seen in serous membranes as an end-result of chronic renal—or even cardiac—affections, equally de- 9° PRINCIPLES OF SURGERY. monstrates the unseen, but tangible evil effects upon cell-nutrition of retained excreta. The presence of certain chemical substances in the cir- culating fluids creates conditions unfavorable for tissue- nutrition, hence plumbism, mercurialism, and phosphorus poisoning are well-known predisposing causes of inflam- mation. Reasoning by the analogy presented by diabetes, a disease in which pyogenic infection is so common, we may infer that the presence of certain substances renders the pabulum more suitable for germs, as has been demon- strated for some species by showing how much more luxuriant the growth of pyogenic organisms is after the addition of diabetic sugar to the culture medium. Trophic changes, which are alleged to be capable of initiating inflammation by themselves, are really pri- marily alterations of the vascular tonus through the medium of perverted nerve-influence, or as the result of the withdrawal of all nerve-influence. This prepares the tissues in such a way for the implantation of germs, that infection so readily occurs that the process seems almost the spontaneous resultant of altered nerve-influence. Very little scrutiny, however, is necessary to show that vasomotor changes, insensibility to pain, and pyogenic infection, account for bed-sores, etc. The sluggishly propelled blood in a paralyzed part is readily expressed by the pressure it is subjected to, which is possible because, no pain being felt, the patient is content to per- mit injurious pressure to continue indefinitely. When this is now removed, any vascular tonus which previously existed, or would be instituted by the perivascular gan- glia, will be found to have been destroyed by the press- ure, hence partial or complete stasis, thrombosis, gan- grene, at least malnourished tissue results, which readily succumbs to even the feebly infective germs normally resident in the skin-epithelium, or to the more virulent ones accidentally present. I must here devote a few words to the purely mechani- cal effects of acute hyperemia, which, although already INFLAMMA TION. 91 mentioned, have not been emphasized as I wish. Although conservative at the outset because tending to sweep out germs, prevent their accumulation, remove metabolic and microbic toxins, and bring phagocytes and abundant nutriment, yet all these advantages of hyperemia are soon reversed by the inevitable changes which follow. As the circulation becomes retarded, the increased amount of blood with the exudates compresses the plasma-channels, preventing the proper access of pabulum to the cells ; the blood becomes surcharged with metabolic and microbic toxins, which means that the pabulum which does reach the cells is actually harm- ful to them, while the failure to remove the injurious metabolic products of cell-activity is a physical result of the saturation of the tissue-fluids and the blood. This, combined with the diminished or actually arrested cur- rent, interferes with osmosis. All these conditions, consequent upon a -persisting hyperemia, mechanically result in a concentration of microbic and metabolic poisons in direct contact with the cells, instead of di- minishing this as the hyperemia at first did. Chronic hyperemia can never be said to be conserva- tive, but is obnoxious to similar charges, as has been already particularly pointed out. Although it has been more than once explicitly stated that all the alleged " exciting causes " of inflammation were only " predisposing causes," favoring inflammation by either locally or generally depressing cell-vitality, or producing vascular conditions favorable to microbic lodgement, accumulation, and multiplication, yet the importance of the fact that germs alone can excite genuine inflammation needs iteration and reiteration. If this belief does not become second nature, slovenly practice and incalculable evils will follow. All predis- posing and exciting (germ) causes can in theory, and in most instances in practice, be removed or avoided. Exciting Causes of Inflammation.—Bacteria.— While the sole exciting causes of inflammation are path- 92 PRINCIPLES OF SURGERY. ogenic organisms or their products, yet it will be profit- able to study how the different classes act, and how non-pathogenic organisms can reinforce the action of pathogenic ones, thus explaining many clinical facts which seem to be stumbling-blocks in the path not only of beginners, but also of those who should know better. Nearly all the bacteria of putrefaction are non-pathogenic, but they are of grave interest to the surgeon, because they predispose to the multiplication of pathogenic germs by preparing the soil. This preparation of the soil is brought about by the prejudicial action on cell-vitality of the chemical products of the non-pathogenic germs. Moreover, by preventing coagulation of the wound-fluids and dissolving coagula, the lymph-spaces are kept patent, thus permitting the free and rapid introduction into the circulation of large amounts of the toxic materials. These produce a chemical, systemic, and often fatal form of poisoning, termed sapremia or septic intoxica- tion, which will be studied later in its appropriate place. This is not the place to teach bacteriology, but I must emphasize certain general facts to show their bearing upon our own special studies. Again I wish to impress upon you that the local conditions cannot alone furnish a complete explanation of germ activity. First, a few words as to germs themselves. All are not pathogenic, as you must have already learned from my previous remarks ; yet it must not be thought that even the non- pathogenic organisms are always harmless, because some of them cause the putrefactive changes mentioned, while others become actually pathogenic if the local conditions, the general conditions, or both combined predispose to their multiplication. Again, one variety of germs may produce substances which either enhance the virulence of action of another species, or so alter the cell-resistance or metabolism that the true pathogenic organisms can usurp full sway over the tissues. Thus the Bacillus prodigiosus increases the effect of the toxins produced by the streptococcus of erysipelas. Still further, the growth INFLAMMA TION. 93 of one form of micro-organism may originate an un- favorable environment for a most virulent germ, thus attenuating its effects, as does the erysipelas coccus when inoculated at the same time with the micro-organism of anthrax. Certain temporary and often controllable cir- cumstances which diminish natural or acquired immunity have been already described, but others must also be mentioned as pertinent to the point we have now reached in the study of the causation of inflammation. The decided effects of altered diet, the absence of fresh air and sunshine, and the humidity of the atmosphere are most potent as depressing influences. Surely, if feeding a rat upon bread will destroy its immunity against anthrax, the matter of diet is worthy of a careful study in man. Again, when we know that a relatively short exposure of tubercle bacilli to direct sunshine will kill them, and that moisture favors the growth of all micro-organisms, the importance of a proper environment for the maintenance of healthy tissue-resistance, and the destruction of tubercle germs at least, becomes at once apparent. Improper or wet clothing, because permitting or causing sudden alterations of the surface temperature of the body, as well as actual pertubations of the atmos- pheric temperature, favor the production of internal con- gestions, and should be included here as predisposing causes of germ-growth. Innumerable germs are to be found upon or in the skin and mucous membranes, ready to penetrate so as to reach the circulation by any avenue accidentally opened to them ; hence the enforcement of cleanliness of the cutaneous and mucous surfaces, proper changes of clothing, etc., etc., are not only not beneath the notice of the practical surgeon, but it becomes his duty to see that the importance of all these things is recognized. The surgeon who expresses exaggerated fears of the evil effects of various drugs, of germs, of bad hygienic surroundings, etc., will often not appreciate how preju- dicial to cell-nutrition are retained excreta, and so fails 94 PRINCIPLES OF SURGERY. to gain the advantages secured by the old-time doctor who got rid of these by stimulating the secretions of the skin, liver, kidneys, and intestines. Others fully under- stand the importance of all these and even the effects of diabetes, cholemia, lithemia, chronic renal disease, and scurvy, yet they fail to recognize how dangerous is that malassimilation evidenced by the presence of free uric acid, oxalates, and lactates in the urine. The conditions induced by recent attacks of certain diseases, such as typhoid fever and the exanthemata, should be well understood, because clinical experience has long demonstrated that after these affections, bone and joint tuberculosis, acute infectious osteomyelitis, etc., are not infrequent. This is partly because of the lowered tissue-nutrition produced by the prolonged pres- ence of poisons in the blood and tissues, partly because of the impoverishment of the blood, reducing both its capacity for nutrition and its germicidal properties, and partly because unexcreted toxins or a few remaining specific germs reinforce the action of pyogenic or other microbes which have accidentally gained access to the circulation. The possibility of the fetus becoming infected (other than by syphilis) through the placenta, by microbes cir- culating in the maternal blood, has been proved, result- ing in various forms of sepsis. Although some local predisposing conditions have already been lightly touched upon, they require more extended notice. Thus, while the normally sluggish circulation of the epiphyseal regions of growing bones has been spoken of as accounting for the ready localiza- tion of germs at these points, yet the large, slightly collapsible, and therefore patent, veins of adult bones, in which large hemostatic thrombi must form, have not been mentioned as explanatory of the readiness with which pyogenic infection occurs after open osseous traumatisms. Granulations also have been stated to be a protective barrier against the entrance of microbes ; but the reason INFLAMMA TION. 95 for this has not been distinctly pointed out—viz., the presence in them of large numbers of phagocytic cells, in the more superficial layers. This protective barrier may be weakened or destroyed by its chemical disinte- gration by caustic germ-products, or mechanically by rough handling, or the unrest of a part. This is not a new observation, because many years ago Billroth showed that putrid meat-infusion, which when injected into the cellular tissue promptly caused the death of the animal from sepsis, was innocuous when maintained in contact with healthy granulations. Moreover when, actuated by the knowledge of this fact, he put up his open fractures in a fixed dressing, he was rewarded by having to contend with markedly fewer evidences of either local or general infection. Therefore carefully avoid all injury to this protective layer of granulations when opening abscesses and handling granulating wounds, although this rule has some notable, apparent exceptions, which will be found stated elsewhere, espe- cially when treating of the Practice of Surgery. One more fact of general importance and we shall be ready to consider another division of our subject. Septic germs—i. e., those which induce putrefaction and pro- duce alkaloidal poisons—can flourish only in dead or dying tissues, while the true infective micro-organisms can multiply in the living tissues, wherever found being capable of producing their characteristic poisons. This is a matter of prime importance, because septic micro- organisms can form their dangerous alkaloids only in the wound, which must be large enough to permit both the manufacture and absorption of enough poison to cause symptoms. Once this laboratory is destroyed by efficient disinfection or by physical removal, further danger ceases, and recovery ensues, if a fatal dose has not been already absorbed. But of what avail is it to remove a limb, the original source of true infection, if every organ of the body, including the blood, be swarming with eerms which continue to produce, wherever present, 96 PRINCIPLES OF SURGERY. their poisons in ever-increasing amounts? The impor- tance, the applications, and the exceptions to these facts will become more apparent as we proceed. Other low forms of vegetable life which are not microbes initiate pathogenic processes in man, as the ray- fungi, the actinomycetes, producing " madura-foot," etc., although their destructive lesions are chiefly due to sec- ondary pyogenic infection. The Amoeba coli also pro- duces grave lesions in the intestinal tract, liver, etc. LECTURE VIII. INFLAMMATION (CONTINUED): PRIMARY AND SEC- ONDARY INFECTION; THE AVENUES BY WHICH GERMS GAIN ACCESS TO THE TISSUES; CAUSA- TION OF SYMPTOMS; FEVER, ETC. Certain terms which have been unavoidably em- ployed must now be defined. " Primary infection" refers to the implantation of a single variety of microbe, or to the inoculation of that form which came first in order, if later other species were introduced. "Secondary infection" means that in the soil pre- pared by one kind of germs another variety is sown which flourishes, often to the destruction of its prede- cessors, as the pyogenic cocci which cause the rapid breaking down of a caseated tubercular focus. This, however, is not an example of destruction of the first germs by those coming later. A " mixed infection " occurs when two or more varie- ties, or species, of germs are implanted at the same time, the stock illustrations being the pyogenic and tetanus germs, the gonococcus and pus-organisms. Avenues of Infection.—The avenue whereby the germs gain access to the circulation or a part, the "in- fection atrium " as it is often called, is usually a "locus minoris resistentiae," a point of diminished resistance, the result of normally or abnormally defective nutrition, or a trauma. Thus a blow upon a bone, which ruptures minute vessels, producing collateral hyperemia, inevit- ably causes such slowing of the circulation that germs there present will collect at the injured part in numbers sufficient to overwhelm the tissue-resistance. Juxta- epiphyseal strain, adding hyperemia to the normally 98 PRINCIPLES OF SURGER Y. sluggish current and damaging a few tissue-cells, often determines an osteomyelitis. The proof of these state- ments has been demonstrated by introducing into the circulation large numbers of the pyogenic cocci causa- tive of osteomyelitis, whence they quickly disappear by means such as have been already, or will be later, ex- plained. Repeat the inoculation, however, and then contuse or fracture a bone, and promptly the microbes will be located, and osteomyelitis will develop. The time during which a given number of germs re- main in contact with the tissues also determines whether they will conquer cell-resistance or the cells conquer them. This is because their toxic products require time to reduce the tissue-vitality by means which have been frequently mentioned, thus creating a " locus minoris resistentise" where none previously existed. Wegner and Grawitz have shown that the same number of germs, which when introduced into the peritoneal cavity will cause no trouble, because quickly removed by ab- sorption, will produce a septic peritonitis if sterilized water be added to the pure culture. This so increases the bulk that a longer time is requisite for absorption, and hence a longer time is provided for the toxins to act locally ; moreover, the inflammation usually starts at the point of original trauma—i. e., the hypodermic needle puncture, the " locus minoris resistentiae." If no "locus minoris resistentiae" exists, the germs are disposed of by the mononuclear and polynuclear leu- kocytes and the nucleins of the blood-serum, while some are excreted by the kidneys, others by the liver, the in- testinal tract, and it is even alleged, by the saliva, and certainly microbes do pass out by the mammary secre- tion ; the young endothelial cells of the blood- and lymph-vessels also act as phagocytes. These protec- tive cells accumulate where the germs are, by virtue of the chemotactic attraction exercised by the bacillary proteids. The most common sites of "infection atria" are the INFLAMMA TION. 99 mouth, the respiratory passages, the intestinal tract, and the skin, because microbes are always found in these localities. A carious tooth, the lesions inflicted upon the gums by the tooth-brush or tooth-pick, burns, scalds, and damages of the buccal mucous membrane caused by the teeth, lesions of the nasal passages, and recently healed wounds, may any of them be the entrance point of micro-organisms productive even of fatal pyemia. Clinical Signs of Inflammation.—We have now reached a point where the clinical signs of inflammation can be profitably considered. These are local and con- stitutional. The former are in their earlier stages pre- cisely those which have been described when considering hyperemia, although all the symptoms are present only in typical cases occurring in parts accessible to the eye. One or more symptoms may be detected without inflam- mation being present, as pain, redness, and even swell- ing, the last induced by edema, observed in certain severe neuralgias ; swelling alone, as seen in hygromata of bursae. Redness and heat may mean only vasomotor disturbance, as seen after injuries to the cervical sym- pathetic in the rabbit or man; while loss of function with pain on movement is well exemplified by an hysterical joint. Redness.—The tint of redness varies in intensity, being bright in acute and dull in chronic inflammation. It is generally livid when suppuration is imminent in a superficial part. It is at first, of course, absent in non- vascular tissues, although the hyperemia is present in the nearest vascular area, as in the conjunctiva or sclera around an inflamed cornea. When the inflammation is deep-seated, the redness cannot be recognized. The redness of inflammation fades somewhat after death. The temperature of an inflamed part, like that of a hyper- emic one, is never higher, indeed is usually lower than that of the blood in the left ventricle of the patient, although this fluid is of course hotter than normal, dur- ing an inflammation causing constitutional symptoms. IOO PRINCIPLES OF SURGERY. The sensations of the patient commonly indicate a much higher temperature than the thermometer reveals. Pain.—The pain of inflammation is increased by press- ure and by the dependent position, the latter of which increases the blood-pressure in the part, and by mechani- cally interfering with the return blood- and lymph-cir- culation increases the compression of the sensory nerves. This is a matter of common observation and gives an excellent hint as to the necessity of position in the treatment of inflammation. The character of the pain is apt to vary with the tissue inflamed. Thus, it is stabbing, "stitch-like," when a serous membrane is concerned. Burning is the adjective employed to describe the pain of inflamed skin, while aching or boring pain is usually complained of during inflammation of bone. Although "throbbing pain" is commonly noted during suppuration, this is not invariably present. The pain of inflammation is most intense when the exudate is situated beneath unyielding fibrous structures, such as the sclerotic coat of the eye, the palmar fascia, and within the tunica albuginea testis. The converse is equally true, for the pain even of suppuration, when situated in such regions as the axilla, eyelids, or scrotum, is comparatively trivial. The nerves of special sense when themselves irritated by inflammation of their own structures or of contiguous parts, of course cannot express this by pain. When the optic nerve is concerned, sparks, flashes of light or colored rings are seen ; abnormal sounds, such as tinnitus, indicate auditory-nerve involvement ; dis- agreeable odors are often perceived when the olfactory nerve is the sufferer ; while perversion of the gustatory sense is shown by the apparent perception of unpleasant substances, such as a "metallic taste," when the nerve of taste is irritated. Pain is of much clinical importance as a means of diagnosis, as I shall endeavor to show. What is termed "reflected" or "radiated pain" may greatly mislead if INFLAMMA TION. IOI certain facts are not remembered. Thus, the irritation of one branch of a sensory nerve may be referred to another branch of the same trunk, or to all the terminal branches of the irritated nerve-trunk. Again, the im- pression reaching the nerve-center may cause congestion of the gray matter of neighboring nerve-fibers which form part of a nerve of the same plexus, and the irrita- tion thus induced may be incorrectly recognized as due to trouble in the area supplied by the latter nerve, instead of the one actually irritated. The pain pro- duced by a stone in the pelvis of one kidney may be referred to the other kidney, still further illustrating the last condition cited, because here the irritation causes congestion of the gray matter across the cord, so that the nerves on the opposite side of the body seem to be the irritated ones. Radiated pain is well illustrated by the dying nerve-pulp of a tooth in the upper jaw. This may cause pain apparently located in one of the lower jaw teeth, or in all the teeth of both jaws. In like manner the pain of an inflamed appendix is often at first referred to the whole abdomen. Irritation of the ciliary nerves, as during iritis, is often noticed by the patient as severe pain in the side of the nose—?', c., the nasal branch of the ophthalmic branch of the fifth nerve : or again, the entire distribution of the fifth nerve may recognize by pain the irritation of the ciliary nerves. Irritation of the trunk of a nerve high up, as by the pressure of a rapidly forming abscess, may be felt as a peripheral neuralgia ; hence this fact often proves of great value in the diagnosis of certain deep-seated ail- ments. For instance, perinephric abscess will, by press- ure upon branches of the nearly related lumbar plexus, give rise to pain in the distribution of the genito-crural, ilio-hypogastric, ilio-inguinal, or anterior crural nerves— sometimes in all of these. Swelling varies in amount and rapidity of development with the distensibility of the tissue. It is slow and limited in extent in bone and tendon, while it is exten- 102 PRINCIPLES OF SURGERY. sive and rapidly supervenes in the eyelids, scrotum, and vulva. Disturbance of function may be the first symptom noted by the patient ; for instance, inability to retain urine in the bladder for a proper length of time, or the distress produced by light (photophobia) upon an in- flamed eye. Constitutional Symptoms.—Fever.—Having now sufficiently considered the local symptoms of inflamma- tion, those by which the circulatory, nervous, and diges- tive systems, and the secretory organs recognize its presence remain for study—i. e., the constitutional symptoms of inflammation—in other words fever, with its complications must now be considered. While the conditions produced by the absorption of nucleins cause some rise of temperature with increased rapidity of the pulse, it will elsewhere be shown that this "aseptic fever " materially differs from the fever of true inflamma- tion. Thus, after the lapse of many hours, usually forty-eight or more, the rise of temperature in true fever is usually preceded by malaise, chilliness, or rigor. The pulse becomes increased in frequency, the secretions of the skin, stomach, intestines, and kidneys are modified or arrested, whence follows the dry skin, furred tongue, anorexia, constipation, and scanty high-colored—i. e., concentrated urine. Pains in the back and limbs and a general feeling of soreness are complained of. The sensorium may become so malnourished or poisoned by the impure blood circulating through it that sleepless- ness, restlessness, or delirium may result. The degree of fever usually is in proportion to the extent and severity of the inflammation ; but this is not always the case, as for instance in a septic peritonitis where there may be none, or an insignificant rise of temperature, although in such a case the pulse usually runs high. In sharp contrast to these symptoms is the constitu- tional condition presented by patients during the aseptic repair of injuries, or wounds, or after operations. In about INFLAMMA TION. 103 one-third an absolutely normal temperature prevails throughout the whole course of treatment, in another third there is a slight rise of temperature, while in the remainder quite a rise, even to 1030 F. or 1050 F. occurs. But this "aseptic fever" represents many distinctive peculiarities when contrasted with the description just given of true fever. To enumerate them, after the (perhaps) subnormal temperature following the injury, operation, or the nausea of anesthesia, the temperature at once commences to rise, without previous chill or malaise, and the pain of injury or operation after reach- ing its acme, in a few hours in a typical case steadily diminishes, as does the tenderness upon pressure. The neighboring lymph-nodes are neither swollen nor tender ; the individual complains of no general discomfort, head- ache, loss of appetite, nor (usually) of any sensation of increased heat ; the skin is only moderately or not at all dry, the tongue is moist and often not even furred, the urine is not diminished in quantity nor loaded with solids, and the same can be said of the intestinal secre- tions, hence the absence of constipation. Finally the pulse is only slightly increased in frequency. Except in those with the highest temperature, unless the ther- mometer be used no suspicion is excited of any elevation of temperature, while in a large proportion of the cases absolutely nothing abnormal can be detected beyond the increased temperature. The duration of aseptic fever is from one to five days, but Volkmann has reported one case which lasted six- teen days. It is caused by the absorption of fibrin- ferment, nucleins, and the pyrogenous substances result- ing from the retrograde products of tissue-necrosis. Whether these stimulate heat-production, or diminish heat-elimination or both, does not concern us now. All other varieties of fever are due to the absorption of chemical pyrogenous substances (ptomains, toxins, or toxalbumins) in addition to the ordinary aseptic pyrog- enous substances which cause aseptic fever ; in other ic>4 PRINCIPLES OF SURGER Y. words, true surgical fever follows infection. The clinical combination of aseptic and septic fevers has been long observed and was explained thus : fever always followed wounds or injuries and was called traumatic, inflammatory, or symptomatic fever; these terms were employed because constitutional symptoms invariably followed any con- siderable trauma, but it ordinarily ceased by the fifth day at the latest. When this favorable termination did not occur, it was said to have merged into surgical or septic traumatic fever ; which if it in turn did not disappear in the course of about a week longer—i. e., shortly after suppuration was fully established—was taught to be the commencement of septicemia ; or at least it was sup- posed that there were good grounds for fearing the existence of this dread condition. Now we know that a rise of temperature, etc., can commence as soon as the shock is past, from the absorption of aseptic substances long before infective germs could produce enough toxins to cause constitutional symptoms ; but that if slight infection has occurred at the time of accident or opera- tion, it will begin to show its effects somewhere from the third to the fifth day, true (septic) fever being en- grafted upon and superseding the disappearing pyrexia due to the absorption of aseptic substances. This sequence of events might have been inferred from your laboratory studies which show that it requires two to three days to develop such an abundant crop of pyogenic organisms as will be able to manufacture enough poisons to produce systemic effects. The systemic intoxication leading to fever is nearly always preceded by increasing local changes in the wound indicative of disturbances of the healing process ; the part becomes tender, then painful, the redness ex- tends in area and deepens in hue, the wound becomes swollen with pouting edges, a purulent discharge forces its way between the margins, and breaking down of all repair, causing gaping of the wound, follows unless the mechanical restraint of stitches maintains apposition. INFLAMMA TION. J05 The lymph-nodes are enlarged and tender. Fever con- tinues until the wound either ceases to be septic (I do not say, ceases to suppurate) or at least until it no longer permits absorption of toxins. As the fevers following surgical injuries and wounds present either temporarily or throughout their course certain types, for convenience of description I shall describe them under certain heads. Be it remembered, however, that this is an artificial division and that the distinctions cannot always be sharply drawn. LECTURE IX. THE TREATMENT OF INFLAMMATION. IF germs alone cause inflammations and other surgical affections, what is the use of considering the therapeutics of inflammation ? Why not merely state what preven- tive measures can be most successfully employed, and when these either fail or cannot be adopted, say that of course the surgeon is at the end of his resources and must abandon any attempts to control or guide the in- flammatory process? This is the question actually asked by some who should know better, and when not put in words is really the principle governing others. Although I have already explained much in essence, or specifically, that should demonstrate to you the folly of such views, yet I will restate the main points, thus leaving no room for misunderstanding. None will deny that if we can modify the hyperemia at the periphery of the focus of inflammation, we can either prevent or at least limit microbic lodgement and multiplication. In many instances the germs are so few in number at the outset, that the tissues can gain the mastery if fresh hordes of microbes are prevented from arriving and being detained. If in addition, some of those present can be removed, the chances of victory for the tissue-cells are still further improved. If all local conditions unfavorable to cell-nutrition can be amelio- rated or removed, everything which is demanded both by theory and in practice will have been effected, and all or most of this can often be achieved. The time during which the germs are arrested in the tissues, as shown by the experiments of Grawitz just 106 TREA TMENT OF INFLAMMA TION. 107 quoted, is of prime importance and emphasizes the neces- sity of instituting effective measures against hyperemia due to infection at the earliest possible moment. The gen- eral measures which at the outset are effective at the focus are useful later on at the periphery. A word of caution, however, is requisite here. Although cold, for instance, will tend to diminish the caliber of the enlarged vessels in the peripheral hyperemic area, thus obviating the dangers of a slowed circulation, yet it exerts a depressing in- fluence upon the vitality of the cells, and somewhat con- denses the tissues. It thus lessens the size of the plasma- channels, and certainly diminishes the ameboid powers of the leukocytes, both inside and outside the circulation, hence favoring stasis and thrombosis of the vessels, with gorging of the tissues by cellular exudate at the focus of inflammation. Judgment is therefore requisite to decide whether the evil at the focus will not outweigh the good exerted at the periphery. This question will be considered again later. The various means by which the lodgement, multi- plication, and damaging effects of germs on the tissues can be modified or checked are manifestly to be exerted though the medium of the vascular system. They will be treated of under certain heads as most conducive to a clear understanding of the matter. First, those will be considered which influence the circulation chiefly upon the proximal side. The indications are clearly then to lessen sufficiently the amount of, and force with which, the blood enters an inflamed part, that the veins may carry it away just as it arrives, otherwise the tendency to slowing of the circula- tion and stasis and exudation, interfering with nutrition and determining the accumulation of germs, must all remain unchecked ; in other words, the vis-a-tergo, if excessive, must be diminished. The measures adapted to secure this end are those which act upon the heart itself. The one always safe to employ and of far greater power than is generally sup- io8 PRINCIPLES OF SURGERY. posed, is the interdiction of all muscular action, secured by rest in bed. This will materially reduce the number of heart-beats, and thus the amount of blood passing through an inflamed part in a given time. Guy showed that there was upon the average 15 beats more per min- ute in the upright posture as compared with the recum- bent one, and that this was caused almost entirely by the muscular effort required to maintain the upright position. Nitrogenous food is the most permanent of all heart- stimulants, maintaining the force of the heart's action better than any drug. Herein lay whatever of good belonged to the employment of the so-called "anti- phlogistic diet," a fact which unfortunately many prac- titioners ignore who reject the small, but important truth with the mass of error. Unquestionably restric- tion of the amount of nitrogenous animal food, or its total withdrawal, will often favorably influence an inflam- mation by reducing the force and frequency of the heart- action. The use of such drugs as aconite, etc., which depress the power of the heart may at times do good, but they must be used with caution and only when the excess of vis-a-tergo is so pronounced as to require more prompt and decided results than can be secured by re- cumbency and the restriction of animal food. Venesection is of very doubtful value in any surgical affection and I cannot countenance it, although I am a firm believer in local blood-letting, which will be mentioned in its ap- propriate place. The same tendency to all the unfavorable conditions mentioned may be produced by the exact reverse of a too powerful action of the heart—viz., by a weak heart- action. The measures best calculated to combat this are those drugs which increase the force of the heart-beat, and by rendering its contractions more efficient, as well as in other ways, decrease the number of contractions per minute. Strychnin, digitalis, nitrogenous food, alcohol, ammonia, etc., are the remedies usually employed. TREA TMENT OF INFLAMMA TION. 109 Again, the caliber of the arteries which supply an inflamed area, as well as that of the arteries in the part, can be influenced. For instance, if their caliber be les- sened, the rapidity of the current must be increased, ensuring the favorable results upon tissue-nutrition as well as those detrimental to germ-development, which have been so often mentioned. The measures commonly employed, involving the use of remedies which belong to the class of drugs called astringents, are of doubtful value even at the outset of an inflammation, but they are still used for inflam- mations of the skin and mucous membranes. I gravely question whether the real benefit which sometimes accrues from their use is not rather due to the germicidal action of many of them, as for instance nitrate of silver, than to any narrowing of the vessels produced. In any event they can be of benefit only at the outset, before stasis has commenced, or in the later stages, when the reparative processes are hampered by the sluggish cir- culation incident to passive hyperemia. Cold, however, is a most potent remedy when judiciously employed, yet it must not be so intense as to act on the vessels directly through the medium of the overlying tissues, but by im- pressing the cutaneous nerves and reflexly causing con- traction of the vessels. For instance, no amount of cold which could be endured would directly influence the intracranial circulation, hence a moderate degree of cold is all that is requisite. Cold so applied as directly to abstract enough caloric to influence deep-seated vessels, or those at the center of a more superficial inflammation, would lower the. cell-vitality of the part, favor the co- hesion of the leukocytes, and diminish ameboid activity. It should therefore always be employed with caution in parts whose vascularity is normally poor and where decided strangulation of tissue has resulted from exten- sive and rapid exudation, lest stasis be precipitated and gangrene result. When employed in proper cases, cold relieves pain by reducing the hyperemia of the nerves no PRINCIPLES OF SURGERY. and thus their increased registering power. The highest degree of heat compatible with the safety of the tissues will also produce contraction of the vessels, but it is rarely applicable except where very superficial parts are inflamed. The vascular contraction induced by heat is well seen when hot water is used to check oozing after the removal of the Esmarch bandage applied for oper- ative purposes. Increase in the caliber of the vessels may occasionally prove directly beneficial in the treatment of inflammation, when the vis-a-tergo is deficient, by serving to clear out the vascular areas which have become engorged with slowly moving blood, especially if the force of the heart can at the same time be increased. The increased rate of the circulation removes pressure from the cells by favoring absorption of the fluid exudates and debris, brings numerous phagocytes, and hurries away those which have seized upon germs. The means available to increase the caliber of the vessels also render the tissues more distensible, again removing pressure upon the tissue-elements and widening the narrowed plasma-chan- nels. In addition, the veins are dilated, thus emptying the part of blood, which again favors all the conservative changes just described. The only means which will produce this local increase in size of the veins is heat, and a moderate degree of this, such as can be comfortably endured. Pain is also relieved by heat when the favorable changes I have mentioned take place. Inflammation being chiefly a vascular process can be starved, as it were, by interfering with the access of arterial blood by means of position—i. e., elevation— which while lessening pressure from the cardiac side, will favor the return of the venous blood and lymph, thus aiding in the re-establishment of the circulation through the part, and at the same time improving the nutrition of the tissues and unfavorably affecting the environment of the germs. Ligation of the main artery TREA TMENT OF INFLAMMA TION. 111 of a limb for secondary hemorrhage has so often favor- ably influenced septic processes that this procedure has been warmly advocated to starve the inflammation. While this may have been permissible in the past when antisepsis was unknown, it is merely mentioned here to impress upon you how much effect can be produced upon inflammation by diminishing the access of arterial blood to an inflamed part. Compression of the carotids has been also advocated and asserted to modify favorably acute traumatic intracranial inflammation. This I cannot but think is somewhat doubtful, yet it may possibly prove beneficial. But inflammation should be capable of modification by measures which influence the circulation upon the dis- tal—the venous—side of the inflammatory area, and this can be done, as will be shown. If the freedom and rapidity of the venous current can be increased, impending stasis with engorgement of the tissues, and interference with their nutrition will be prevented. Prompt removal of injurious substances and germs will be favored even at the focus, much more at the periphery—i. e., the spread- ing margin of the inflammatory area. To favor the exit of venous blood the size of the vessels must be increased, but at the same time the blood-flow must be rendered more rapid. To secure these results first, warmth may be employed to increase the caliber of the vessels, and second, the velocity of the current can be accelerated by calling in the aid of gravity, by elevating a dependent part. Where it is possible directly to reach the vein, or its radicals, leading from the inflamed part, local blood- letting will often be of benefit, employed preferably before stasis has commenced, certainly before thrombosis has occurred. Gennsmer and I have both demonstrated the utility of local blood-letting in relieving an experi- mentally induced hyperemia, and clinically I have seen the same many times. A moment's reflection upon the anatomy of the encephalon will show that in inflam- mation of this organ venous blood can be directly ab- 112 PRINCIPLES OF SURGERY. stracted from its vessels, hence the proved utility of leeching and cupping in its ailments. The free com- munication of the superficial veins of the back of the neck with the large veins communicating with the lateral and superior longitudinal sinuses enables us to understand the effects of abstraction of blood from this region. The pain of an otitis media, which morphin hardly influences, is often relievable by removing blood by means of a leech from the external auditory meatus, and with the relief from pain, the hyperemia caused by irritation of sensory nerves in the area they supply will be sensibly abated. The relief of tension by incisions, position, and by supporting pressure are all important adjuvants to the therapeusis of inflammation. Pain—i. e., irritation of the sensory nerves—as we have just stated, induces congestion, hence this must be relieved to reduce the hyperemia, or at least prevent its extension. Rest to be effective must be physiological. Of what value would it be to confine a patient to bed with an in- flamed eye, if this be exposed to the irritation of light? Yet an injured joint is too often in like manner not benefited, as it should be, because rest in bed or the em- ployment of crutches is not supplemented by means calculated to prevent all motion of the joint—i. e., physiological rest has not been secured. As the exercise of function always means an increased flow of blood to and through an organ—a temporary hyperemia—in the event of a previous slight infection this physiological congestion often proves most disastrous. Still further, the mechanical advantage of rest, by preventing the inoculation of fresh surfaces with germs or their products, is well exemplified by the experiments of Billroth, quoted during a previous lecture. The bodily temperature, when excessive, often proves exhausting to the heart directly, or by increasing the frequency of its contractions. Again, heat is sometimes TREA TMENT OF INFLAMMA TION. 113 directly productive of restlessness, delirium, etc. For any or all of these reasons the temperature must be reduced in hyperpyrexia. Antipyretic drugs are very rarely to be employed, cold, in the form of baths, spong- ing with cold water, etc., being both safer and more easily regulated. The elimination of bacteria and bacterial products, together with the poisonous metabolic products of tissue- metamorphosis by the bowels, kidneys, liver, and skin, directly improves the condition of the tissues, besides often averting the death of the patient from toxemia. I have now given the general '' indications'' for the therapeusis of inflammation, with a few illustrations of the manner in which some can be carried out. It now remains for me to show what are the various ways by which these ends can be reached—i. e., how these " indi- cations can be fulfilled," as it was wont to be said. I shall now briefly indicate the methods of employing the various classes of remedial agents already considered. Cold may be used either dry or moist; each form possesses its advantages and disadvantages, but both must be continuous in action to prevent " reaction," as it is vaguely termed, meaning either a paretic dilatation of the vessels, which usually follows only the direct appli- cation of too intense a degree of cold, or, more commonly, the return of the vessels to their original hyperemic caliber, an interval of time existing during which they may still further dilate. Moist cold is often preferable, especially when there is much discharge, because germicidal agents can be com- bined with the fluid. The danger from absorption in poisonous amounts of such drugs as carbolic acid or cor- rosive sublimate, following the prolonged use of irrigating fluids containing these agents, must never be forgotten. Moist cold is also more generally applicable, because more attainable, since water even at ordinary tempera- tures, if allowed to evaporate rapidly, will abstract much caloric. Other more rapidly evaporating fluids can also 8 ii4 PRINCIPLES OF SURGER Y. be employed, as alcohol and water, or mixtures can be made of various chemicals in solution which are actually frigorific. Evaporation is, however, the main reliance, hence the folly of applying bulky wet dressings and covering them up closely, when endeavoring to utilize the therapeutic powers possessed by cold. Moist cold can be most simply employed by cloths, constantly changed, wrung out of water or some frigorific mixture, by com- presses frequently changed, which are kept lying upon a piece of ice, or by irrigation in some one of its many forms. The simplest method of irrigation is to place under the part a piece of oil-cloth or rubber-cloth so dis- posed on the bed and hanging over its edge as to form a gutter which will empty the fluid into a receptacle placed upon the floor. This arrangement is as requisite for the most elaborate irrigating apparatus as for the simplest. Next hang above the part any vessel capable of contain- ing enough fluid. The ends of several lengths of plain wicking, or long narrow pieces of any cotton material should be dropped into the vessel, while the other ends rest upon a single or double layer of absorbent material smoothly covering the part to be irrigated. By capil- larity a constant flow will be maintained, the fluid of the receptacle being kept at any temperature desired or securable, evaporation from the wetted covering of the inflamed part enhancing the refrigorating effect. A large bottle with the bottom broken out and whose neck has been fitted with a cork perforated by a quill may be sus- pended above the bed, and will allow a constant drip of fluid to fall on any given spot. There should always be at least one layer of absorbent dressing interposed be- tween the inflamed part and the falling water, to pre- vent pain from the impact. This latter method is more difficult to arrange and not a whit more efficient than the one first described. The disadvantages of moist cold are that it is more depressing to both local and general vitality ; it is diffi- cult to manage so as not to wet the patient's clothing or TREA TMENT OF INFLAMMA TION. 115 bedding ; it macerates the skin, sometimes making it painful for the part to rest even upon a pillow, and it favors the development of pressure-sores (decubitus). Dry cold possesses none of these disadvantages and is therefore more generally applicable, especially when a very limited area is to be treated. As before said, cold is an agent which should act only reflexly upon the cir- culation, hence some non-conductor of heat must be interposed between an ice-bag and the subjacent parts. Dry cold can be applied by means of ice-bags, blad- ders, Leiter's block-tin coils, or by several yards of small rubber-tubing coiled and secured in proper shape by interweaving three or four pieces of wire, or sewing the turns upon a properly shaped piece of thin flan- nel. Through these tubes, water at any temperature can be passed from a vessel above into a receptacle below. Any of these devices will cause deposition of moisture upon their surfaces, necessitating care lest the clothing become wetted ; indeed, the nurse often insists that the bag or bladder must leak. Special emphasis must now be laid upon certain indications and contra- indications, despite their mention on a previous occasion. Cold acts best before stasis has occurred by preventing such dilatation of vessels as will favor this ; but later, cold will do the same at the periphery, and, as has already been pointed out, the surgeon must decide whether the good done here will be outbalanced by the possible harm done at the focus. Cold in any form is distinctly contraindicated in the later stages of inflam- mation, especially where there is much strangulation of tissue, because it may determine gangrene, diminishing the already feeble arterial pressure through a lessening of the volume of blood carried in the afferent vessels by narrowing their caliber. LECTURE X. TREATMENT OF INFLAMMATION (CONTINUED). Heat is to be used either as moist heat or dry heat. Moist heat is usually applied in the form of fomentations or poultices, either of which may be medicated by the addition of opium, morphin, or antiseptics. Hot fomen- tations consist in the application and frequent renewal of flannels or cloths wrung out of as hot water as can be borne by the patient, these then being covered by dry flannel or cloths. A poultice consists essentially in the constant appli- cation of heat and moisture. The supposed virtues of hops, bread, or bread and milk, for poultices are purely imaginary, while the two last soon undergo fermentation and become positively irritating. Sometimes the mate- rial of which a poultice is composed is a matter of moment. When it is desirable to maintain a degree of heat in the applications higher than that of the part itself, it will require far less frequent changes of poultices if corn meal be used as the material, because this substance retains its temperature longer than anything else that can be used. It must be sewn up in bags, otherwise it will crumble as soon as it begins to dry. The best mate- rial for poultices in general is ground flaxseed, since it can be made thin and light and requires changing less frequently because it coheres, and, containing much oily matter, does not dry readily. The practice of pouring oil or melting lard over the surface of a poultice, or covering this with a piece of gauze to prevent it sticking to an irregular surface, making it hard to cleanse, is no 116 TREA TMENT OF INFLAMMA TION. 11J longer necessary, because it is impossible with poultices to maintain effective asepsis, and they are no longer employed for open wounds. For the same reason, carrot poultices and the ferment- ing poultice, useful as they were in the past, should no longer be employed. An exception may possibly be made in favor of the charcoal poultice, especially for such a con- dition as gangraena oris, where it is practically impossible to secure anything beyond relative asepsis. A thick layer of recently sterilized, powdered charcoal should be spread over a moderately thick flaxseed-meal poultice, which has been sterilized by heat, as can readily be done by keeping the vessel in which it is mixed over the fire for a few minutes, after mixing the meal with boiling water, as should always be done when making any flax- seed poultice. No poultice is properly applied unless it is covered in with some substance relatively impermeable to heat and moisture, and which extends some distance in all directions beyond the margins of the poultice, otherwise it will soon first become cold, then dry. Unless high temperature be indicated, so long as a poultice thus covered remains moist it need not be renewed. Wet absorbent cotton, gauze, moss, etc., when thus covered constitute a poultice. Stout paper, well-greased paper, paraffin or waxed paper, oiled silk or calico, mackintosh or thin oil-cloth are suit- able materials to place outside a poultice. Never employ anything but a wet aseptic or, better, antiseptic dressing —i. e., an antiseptic poultice—for any open wound, or even for an abscess, after it has been opened. Before an abscess has been incised or has ruptured spontaneously, it is both permissible and often advisable to use any material suitable for a poultice which is available ; but when spontaneous rupture is possible, an antiseptic poultice should always be substituted, lest the abscess unexpectedly evacuate itself into a non-sterilized dress- ing, such as a poultice almost necessarily must be. Dry heat can be employed by the use of Leiter's tubes, Ii8 PRINCIPLES OF SURGERY. coils of rubber tubing, hot-water bags, hot sand- or salt-. bags, hot stove-lids, irons, etc., which never should actually touch the bare skin of a patient, a flannel cloth, • or if nothing else is securable, several thickness of paper intervening lest accidental burning of the integument take place. Heat in extreme form is indicated during the very earliest stages of inflammation, as was explained when speaking of the use of cold in the dry form and also hot fomentations. Later, especially when there is much engorgement producing strangulation of the tissues, moist heat in the form of warm poultices is better than dry heat; it relaxes the tissues more, and favors ameboid movement of the cells, which, if suppuration be avoid- able, hastens the departure of phagocytes which have incorporated germs into their substances, brings more leukocytes to the defence of the tissues, and favors the clearing away of excessive cellular exudate. If sup- puration is inevitable, the same processes favor the rapid accumulation of cells at the inflammatory focus, resulting in the most rapid disposition of all germs which can be destroyed by phagocytes, the promptest breaking down of tissue at this point, and the erection of an efficient barrier of phagocytic cells outside the focus, which will prevent undue spread of the infective process. When the inflammation is somewhat deeply seated, derivation of blood to the skin and more superficial tissues is pro- duced by a poultice, as can easily be proved by seeing the exact outline of the poultice indicated upon the skin by a reddened area ; this derivative action may possibly favorably influence the peripheral hyperemia of the in- flammation. By some or all of these means the inflam- mation is limited and brought to a focus, and the abscess "points," if suppurative inflammation be the condition present, thus giving the explanation of the well-known good effects of moist heat noted in practice. Heat is usually contraindicated in the earlier stages of inflammation, cold being generally preferable. Certain TREA TMENT OF INFLAMMA TION. 119 exceptions to this rule have been already mentioned in a previous lecture. Starvation of an inflammation by the temporary or permanent arrest of the arterial supply to the part is rarely, if ever, considered nowadays ; but it is somewhat of a question in my mind whether in very rare instances, when a septic process involves the leg and knee-joint, a ligation of the femoral artery low down might not be properly attempted before amputation is resorted to. The temporary arrest of arterial circulation could often under similar conditions be harmlessly employed by digital compression of the main vessel or the application of a horseshoe tourniquet for a number of hours. Diminution of the contents of the veins may be effected by means of leeches or wet-cups, always remem- bering that to be useful the blood must be drawn from the vein—or the radicals thereof—which drains the in- flamed area, the instance cited before of drawing blood from the mastoid region being sufficient. Multiple, small incisions or punctures may also be beneficial by virtue of the blood withdrawn, but probably prove more useful by the relief of tension afforded. Relief of tension is a most potent means of diminish- ing the hyperemia and other phenomena of inflammation for the following reasons. Extravascular pressure will, as has been experimentally shown, increase the rapidity or actually determine the absorption of poisonous alka- loids. Tension also produces compression of the plasma- channels and the cells, thus mechanically interfering with nutrition and reducing tissue-resistance. The means employed to relieve tension, notably incisions, besides permitting stretching of the tense skin and fascia, ab- stract blood from the vessels, and the bulk of their con- tents is thereby reduced. The improved circulation fol- lowing this increases tissue-resistance. Exit is also given to numerous germs and bacterial products, their withdrawal reducing the stock available for absorption, 120 PRINCIPLES OF SURGERY. and altering the osmotic conditions upon which their former rapid absorption depended. When I state that a small card can be so cut as to form a ring capable of en- circling the waist of an adult, it will be admitted that the manner of making the incisions for the relief of tension Fig. io.—Showing how marked relief of tension can be secured by numerous small incisions, if properly planned. is a matter of moment, in order to secure the maximum of extensibility with the minimum damage to the tissues. The method shown in the illustration is the best, the incisions extending through the deep fascia. Elevation of a limb also reduces tension by favoring the return of venous blood and lymph, and also by rendering the en- trance of arterial blood more difficult. Control of Pain.—Pain is controllable by many of the measures already advocated, such as cold, heat, and position. Certain drugs, which except in children had better be given hypodermatically, such as opium, mor- phin, and codein, often prove most useful, sometimes in- dispensable. Codein seems not to be of much value as an analgesic except for abdominal pain, when, from its non-constipating effect it is often preferable to opium. Whether opium directly causes contraction of the periph- eral vessels or does so by reducing the registering power of the sensory nerves, certainly its administration during inflammation, when pain is a prominent symptom, does diminish the hyperemia, as witness the prompt healing of the congested, so-called painful ulcer of the leg under TREA TMENT OF INFLAMMA TION. 121 the administration of full doses of opium when everything else has failed. Under very exceptional circumstances, in an exceedingly plethoric individual, phlebotomy, when everything else has failed, will sometimes relieve pain in a wonderful way. For instance, I have known of a case of vesical stone, where, after a long journey such intense inflammation of the bladder was excited that mor- phin in large doses hypodermatically utterly failed to give relief, the patient being forced to attempt to void urine every few minutes. Finally, the patient was bled from a large vein by a large orifice in the standing posture, until he was very faint, thus securing the most marked effect on the circulation with the minimum loss of blood. Immediately after this, the patient slept for a number of hours and had no return of his excessive dysuria. This is an exceptional case, but it is also worth remembering because it demonstrates that a marked diminution in the force of the vis-a-tergo will powerfully affect the hyper- emia of inflammation. Rest.—I cannot refrain from returning to the subject of rest during inflammation—rest complete and physi- ological, especially where a wound is concerned. Rest sometimes means restraint by a splint, at others restraint of a function, as by the exclusion of light from an in- flamed eye by a bandage, permanent drainage of an in- flamed bladder preventing its recurring distention and contraction. Drainage is often the most potent means for securing rest, for how can a wound be at rest if alter- nately filling with fluid, and, when the distention becomes sufficient to separate its edges, collapsing, to refill again ? Position, making the drainage-opening dependent, com- presses and other dressings so applied as to efface cavities, that separation of wound-surfaces by accumulation of fluids is impossible, are important means for securing rest. The infrequent dressings rendered possible by modern methods of wound-treatment likewise secure the same end. Removal of a foreign body may, by relieving irritation, diminish hyperemia and the secretion incident 122 PRINCIPLES OF SURGERY. to its presence, hence the "unrest" produced by this cause. The foreign body may be really something introduced from without, or a piece of dead bone or other tissue, which sometimes also acts prejudicially by blocking the exit of discharge. Affording free exit for extravasated urine and collections of pus would perhaps come equally under the head of relief of tension, but the physiological rest thus afforded to the parts requires emphasis here. Lowering of the general temperature in a surgical case can rarely be done by immersing the whole body in a bath. By placing a rubber sheet, a piece of mackin- tosh, or oil-cloth beneath the patient and elevating the edges, bathing with cold water, ice water, or rubbing with ice can be done, freely exposing the wetted surfaces during the bath to ensure the refrigerating effect of evaporation. Such measures will prove more efficient than would be conceded at first sight by those insisting that the cold bath is the only really efficient method of lowering temperature. These measures are those only which are available in country practice, and with an army in the field. The attempt to eliminate bacterial and metabolic products, although long out of fashion, is now estab- lished upon a firm scientific basis of facts. Increasing the secretions of the intestines, kidneys, and skin are the means employed to secure this result. Whatever good "revulsion "—i. e., the temporary accumulation of blood in one part to its relative exclusion in another—can effect, is likewise probably secured when we reflect upon the many square feet of intestinal mucous membrane which must be congested after the exhibition of a hydra- gogue cathartic. Again, the increased evaporation from the skin-surface produced by free diaphoresis will lower temperature, revulse and also cause excretion of consider- able amounts of solids. The steam bath is especially effective in securing free secretion from the skin and probably by revulsion aids in the re-establishment of the TREATMENT OF INFLAMMATION. 123 renal secretion when this is partially or completely sup- pressed. A steam bath is always possible in any place where hot water and a few bottles, ears of corn, or corn- cobs are obtainable. Thus, lay the patient upon a blanket and cover him with another supported by barrel hoops, or any other device which will secure an air-space around the patient. Now place inside, carefully avoiding laying them in contact with the patient's skin, six or eight large bottles or preserve jars filled with hot water, some of which are wrapped in towels loosely wrung out of hot water. If ears of corn or corn-cobs be used, boil a dozen or more of these for a sufficient time and place them as directed for the bottles, except that no wet towels will be requisite, sufficient moisture being contained in the porous cobs. Diuretics increase the number of germs excreted by the kidneys as well as eliminate large amounts of toxic products. The special drugs to be employed to produce catharsis, diuresis, or diaphoresis need not be specified, because they must vary with the case, and you have elsewhere been taught the varieties and properties each of the remedies belonging to these classes of drugs. Special remedies, such as colchicum, salicylate of sodium, mercury, etc., are of benefit because preventing the formation, directly or indirectly, of the injurious substances produced in gouty, rheumatic, or syphilitic subjects, or aiding in their elimination. Iron and cod- liver oil, by improving general nutrition are occasionally useful, while iodin often proves beneficial in tubercular and other conditions, as well as in syphilis. Pain exhausts the old and the young, hence increases the frequency of the contractions of the heart while its force is decreased ; this is largely the result of loss of sleep and inability to take enough nourishment. For all these reasons sleep must be secured, oftentimes by the use of such drugs as sulphonal, chloral combined with bromid of potassium, codein and opium. When dealing with an 124 PRINCIPLES OF SURGERY. individual addicted to the use of alcohol in any form—I do not say one who frequently, but even one who never has, been intoxicated—regard restlessness or sleeplessness with grave suspicion, lest delirium tremens be imminent, and to avoid any possibility of this secure a proper amount of sleep and the ingestion of sufficient nourish- ment. The sudden withdrawal of all stimulants in men accustomed to their use is sometimes most prejudicial in its effects, precipitating an attack of delirium tremens. I have more than once seen a few good-sized doses of whiskey, administered at intervals of a couple of hours, put a case of delirium tremens promptly to sleep, when very large doses of opium had completely failed to pro- duce even drowsiness. Elsewhere this subject will be more thoroughly considered, and the limitations of the exhibition of alcohol will be discussed. If, despite all efforts scientifically directed toward the removal of all the microbic and those secondary causes which so often maintain inflammation, the conditions do not improve ; or when it is manifest that the causes cannot possibly*be removed or their effects restrained within safe limits, the aim must then be to prevent molecular death or the death of the patient, even at the cost of destruction of the part, as by using the hot iron in a case of gangraena oris or amputating a limb for a hopelessly destructive septic process. While devoting a proper amount of attention to all that has been mentioned, the practitioner must remem- ber that he is dealing with a patient not a machine, and see that proper food in adequate amounts be not only supplied but ingested ; that bed-sores are not permitted to occur; that the bladder does not become distended, because never entirely emptied at each act of micturition, or because no urine can be passed in the recumbent posture by many individuals ; that proper sleep is secured, and that in a drunkard delirium tremens is thus warded off; and finally, that elimination is properly carried out by at- tention to the secretions of the skin, bowels, and kidneys. TREATMENT OF INFLAMMATION. 125 Treatment of Chronic Hyperemia.—Because chronic hyperemia is so often incorrectly considered to be "chronic inflammation," the general principles governing its treatment will here be considered. The congestion being a passive one, either directly or indirectly due to difficulties presented to the free egress of venous blood, this determines a constant escape of leukocytes and liquid pabulum into the tissues ; still further, the retention of an excess of venous blood in a part prevents the access of a proper amount of arterial blood. The objects to be attained are the bringing more arterial blood to the tissues, thereby increasing the vis-a- tergo, improving nutrition, and hastening the return of the venous blood. As secondary objects the removal of fluid exudate and the disintegration and absorption of the low-grade, neoplastic, fibroid tissue are to be earnestly striven for. The sluggish circulation in the part itself results from the dilatation of the vessels from causes which are often no longer operative. Under these cir- cumstances, when accessible to the action of such agents, astringents are unquestionably of value. So-called counterirritants, such as tincture of iodin, sometimes do good, but not, as usually believed, by effecting revulsion. As commonly applied—viz., directly over the diseased area—they produce not only hyperemia of the skin but of the deeper parts—i. e., direct irritation, not revulsion, occurs. Nevertheless, from dilatation of the vessels of the hyperemic area more arterial blood reaches the part, hence, when this is a desideratum, good follows irritants thus applied. The shape of a blister over the thorax will be outlined upon the pleura by a hyperemic area. Fur- neaux-Jordan long ago insisted that when iodin, the actual cautery, and blisters were applied over a super- ficial joint, direct irritation of the joint-tissues resulted instead of a lessening in the amount of blood contained in the hyperemic articulation. Counterirritation can then only be effected when congestion of vascular areas near by, but not continuous with those of the diseased 126 PRINCIPLES OF SURGERY. part, is produced, as the vascular areas above and below a joint. These are the results which must of necessity follow if the fact that irritation of a sensory nerve pro- duces congestion in the area supplied by it be true, and this has experimentally been proven. Elevation of a dependent hyperemic part is our most potent means of draining off the excess of venous blood. The indirect measures which bring more arterial blood and hasten the return of the venous blood and lymph also aid in the disintegration and removal of cellular exudate. Supporting pressure by means of an ordinary bandage, applied over an elastic substance such as cotton or oakum, as well as elastic bandages or stockings, act by compressing and narrowing the veins and also the other vessels to a lesser extent, thus increasing the velocity of the blood-current. Pressure also interferes with the access of pabulum to the neoplastic connective tissue, producing degeneration and absorption of this. Massage is of benefit when applicable, because it breaks down exudate and diffuses it over a wider and often healthier area for its absorption, empties the part of lymph and venous blood, and brings more arterial blood to the tis- sues. Electricity is also sometimes useful, because capable of producing the favorable vascular changes which I have stated are indicated. Constitutional Treatment.—The pertinent question now arises, is there any such thing as a "constitutional treatment" for inflammation? Is there any special remedy or remedies that should be exhibited because the patient has an inflammatory process involving, for in- stance, the cellular tissue of a limb, which will directly influence the inflammation ? Certainly not. Treatment must be guided by the indications present, and a purgative is not to be given because the patient has a cellulitis of a limb, but because the bowels are confined, or the elimi- native powers of the intestines must be called into play, to tide the patient over a critical period induced by a toxemia, perhaps an enterosepsis. Patients who have been TREATMENT OF INFLAMMATION. 127 eating too much or indulging in an excess of one kind of food, as meat, especially those who have led a sedentary life, should have their diet restricted, not because of any antiphlogistic effect upon the inflammation by restriction of the diet, but because the eliminative organs will have all they can do to get rid of toxins and the results of metabolism and must not be required to excrete large amounts of nitrogen, carbon, etc., which have been un- necessarily ingested. Moreover, if fever be present, fer- mentative changes in the food are apt to occur, which re- sult in the production of poisonous substances, whose absorption will either directly cause grave symptoms, or being eliminated by certain organs will prevent them from performing their depurative duties, thus allowing the accumulation of bacillary proteids and tissue-waste in the blood. Patients whose habits are known, or who present the appearance of those who eat and drink too much, in whom the intestinal digestion and evacuations are imperfect, where, as used to be said, there '' is con- gestion of all the chylopoietic viscera," are often bene- fited by laxatives, notably calomel. This drug acts well because acceptable to an often irritable stomach and because it is an intestinal antiseptic. In addition, re- striction of—not always total abstinence from—certain articles of food and drink must be insisted upon. The intestines being freed from retained contents and stimulated to proper action, cease to be a source whence such large amounts of poisons of intestinal origin can be absorbed as will embarrass the liver when it is required to do extra eliminative work, as is often the case during a serious inflammation. Copious draughts of water will often be advantageous because of the free flushing out of the kidneys produced. Remember, however, never to alter the patient's habits radically, without a distinct indication. Get the histories of your patients, find out what they eat and how much. If underfed—and this is sometimes difficult to ascertain, owing to false pride on their part— 128 PRINCIPLES OF SURGERY. feed them up ; if anemic, strive to ascertain the probable cause and remedy this if possible. When alcohol has been used, ascertain the form, quantity, etc.—for whis- key will not do for a beer drinker—and get along with as little as is safe of the variety habitually imbibed, lest delirium tremens result from a too sudden withdrawal of the accustomed stimulant. If practising where mala- ria is prevalent, or when the patient has recently come from such a locality, quinin may be used as a precau- tionary measure, but is better exhibited after an exami- nation of the blood has shown the certain or probable presence of malarial organisms. In young vigorous patients, at the outset, it is wise to restrict the quantity somewhat and to be careful as to the quality of the food, for the reasons already given. If the patient be either old or young with a poor circulation and indifferently nour- ished, do not restrict the quantity, but see to it that the food is easily digestible. If the patient at any age be asthenic, give as large amounts of easily digestible food as is compatible with comfortable assimilation and the ability of the excretory organs. Meat-broths, oysters, scraped raw beef, eggs, and milk alone or in combination with eggs should be given, in measured amounts, and at as regular intervals as possible. From 2 to 6 pints of liquid food is about as much as the average patient can assimilate ; some can manage much less. In ex- ceptional instances semi-solid food agrees better than liquid. Water is rarely necessary when liquid diet is employed ; but if for any reason indicated, and it dis- tresses the patient when taken by the mouth, it may be administered in the form of rectal enemata—4 to 8 ounces every four, six, or eight hours. Farinaceous food may be given to supplement the liquid diet, and later, as the patient's digestion permits, vegetables and meats may be added. Great judgment is sometimes demanded to hit the happy mean between the administration of insufficient nourishment and overtaxing the digestive and eliminative organs, a pernicious blunder which is not uncommonly TREATMENT OF INFLAMMATION. 129 made and is perhaps worse for the patient than a some- what scanty diet. In certain rare cases of head-injuries if the patient be vigorous, albumen-water, barley-water or even plain water may alone be given during the first twenty-four to even forty-eight hours, and despite all theory, these patients suffer less from headache, mental confusion, and dizziness than when placed upon a more generous diet. When, at any stage of an inflammation, the patient seems to be losing strength, more food, if it can be appro- priated, strychnin, digitalis, alcohol, etc., should be exhibited, the choice or combination depending upon the condition of the digestive organs, and the deficiency or normal amount and character of the renal secre- tion. It is better to determine by auscultation of the heart when to commence the administration of stimu- lants, rather than to be directed solely by the condition of the pulse. A heart whose first sound is prolonged and strong is not in need of assistance, while if the first sound approaches in time and strength the second sound, then the organ is in urgent need of stimulation. Quite often the pulse seems fairly good when auscultation sug- gests a different idea, and vice versa. Finally, keep track of the condition of the kidneys and intestines by frequent personal observations, to ascertain whether they are eliminating properly. Abnormally offensive stools indicate a degree of intestinal fermenta- tion which may prove serious, and intestinal antiseptics, purgatives, or both are indicated. Deficiency in the quantity of urine and the solids contained demonstrate the necessity of increasing these if possible, and if this be impossible, of calling in the assistance of the skin and intestines. 9 LECTURE XI. CHANGES IN BLOOD; LEUKOCYTOSIS; DIMINUTION OF HEMOGLOBIN; THROMBOSIS. At this stage of our study of the Principles of Surgery it becomes necessary to consider certain facts relative to the blood, which have recently been shown to be im- portant in the diagnosis and treatment of several surgi- cal affections. While there are many other problems of interest, I desire at present to confine my remarks chiefly to leukocytosis, because of the increase of the white cells of the blood during acute, especially suppurative inflam- mation. Leukocytosis means a temporary increase of the white cells of the blood as contradistinguished from their permanent increase in leukemia. The increased number and disintegration of these cells and the conse- quent presence of an excess of fibrin-ferment and of paraglobulin in the blood accounts for the well-known increased liability to thrombosis of the vessels during true (infective) inflammation. The different forms of cells detected and the proportion of each present, at times serve a useful purpose in the differential diagnosis of certain surgical affections. Neither increase in the number of blood-plaques nor deficiency of the leukocytes has yet been proved to be of any certain pathological significance, hence these points will not be referred to further. The varieties of leuko- cytes and the proportion of each in normal blood will now receive brief notice. Taking 5,000,000 red cells per cubic mm., for men and 4,500,000 for women, 7000 to 7500 would represent the number of white cells, of all forms, present in normal blood. 130 CHANGES IN BLOOD. 131 The following forms are recognizable : Lymphocytes, small leukocytes with a single rounded nucleus and but little protoplasm ; these compose some- what over 20 per cent, of all leukocytes. Large mononucleated cells, with a greater amount of protoplasm than the former possess, present only in the proportion of 2 to 3 per cent. Certain cells, forming about 2 to 4 per cent, of the total, with rounded, often lobed, but somewhat irregular nuclei, in whose protoplasm are granules staining only with acid anilin dyes, refusing to take the basic ones : from the readiness with which these stain with eosin they are called " eosinophile" leukocytes. About 70 per cent, of all leukocytes are either actually polynucleated, or the main portions of their nuclei are united by such delicate prolongations that they appear to be two or more separate bodies. The nuclei stain readily, but the granular protoplasm feebly, unless a mixture of acid and basic anilin stains be employed, hence these cells are called " neutrophile cells." Certain transitional forms are found, which, being of no special importance, will receive no further notice. Although the proportions of these cells may vary slightly in health, they remain fairly constant, so that decided changes, amounting to an increase of one-sixth or more, are often of great diagnostic import. Thus, some general septic conditions closely simulate typhoid fever. Again appendicitis may, from systemic infection, put on the guise of typhoid fever with exceptionally severe ulceration, hence peritoneal symptoms in the iliocecal region. In typhoid fever, however, unless there be some complication, such as pneumonia, or local or general sepsis, leukocytosis is absent. Leukocytosis is either absent or very slightly marked in non-sup- purative (so-called "catarrhal") appendicitis. An ex- ceedingly limited suppurative inflammation will cause a distinct leukocytosis, as I often observed as long as twenty years ago. Some surgeons, as Cabot, rely so 132 PRINCIPLES OF SURGERY. much upon the absence or presence of leukocytosis as to decline to undress an open fracture, even when general symptoms would suggest the propriety of this, if no leukocytosis exists. While unwilling to go so far as this, for some time I have placed almost implicit reli- ance upon leukocytosis as proving the existence of an infective inflammation, probably of a suppurative type. Leukocytosis is absent in uncomplicated tuberculosis, while in malignant disease, especially in rapidly growing sarcomata, it is very common. Suppurative inflammations of mucous surfaces, such as cystitis and endometritis, where free exit for all dis- charges exists, do not give rise to leukocytosis. On the other hand, pocketing of pus in suppurating wounds will generally give rise to it. Infective osteomyelitis shows marked leukocytosis, this symptom being thus of great value in suspected cases where a deep-seated bone is con- cerned, enabling the surgeon to insist upon early opera- tion. The application of the fact that leukocytosis is an early symptom of infective and suppurative inflammation is of wide applicability, and needs no further illustration. The red cells are chiefly of interest to the surgeon because a scarcity in their numbers indicates a deficiency of the oxygen-carriers, and hence the necessity of avoid- ing all unnecessary loss of blood during an operation. Yet sometimes when the number of cells is not seriously lessened, the material upon which their power of carry- ing oxygen depends may be diminished out of all pro- portion to their lessened number. I recently operated upon a patient whose red cells were reduced less than one-sixth, yet whose blood contained only 50 per cent. of hemoglobin. Probably hemoglobin rarely equals 100 per cent., 95 per cent, being fully up to the average for men, with 3 to 4 per cent, less for women. Reduction of hemoglobin to less than 20 per cent, probably always means death by collapse, and just in proportion as the deficiency of hemoglobin approaches this point so is the danger. The CHANGES IN BLOOD. J33 chance of eventual recovery can often be quite accu- rately determined by the rate at which the hemoglobin is regenerated. According to Osier mere regeneration of the number of cells may take place at the rate of 50,000 per c.mm. per day ; but as before mentioned, this does not always mean that the total hemoglobin of the blood is proportionately increased. Rapidity of the pulse is often explainable by deficiency in the number of red cells or the amount of hemoglobin they contain, because fewer cells having to carry the oxygen they must complete the round of the circulation oftener, doing double or treble duty, as it were ; this accounts largely for the increased frequency of the pulse noticed after severe losses of blood. In my service at the University Hospital I have found that the hemoglobin is always markedly diminished in rapidly developing sarcomata ; in carcinomata the same probably holds good, but the change is not so marked. After removal of large sarcomata (and probably this is always more or less true for carcinomata) the hemo- globin increases, my experience in this respect confirm- ing that of Park and others who state that a very decided, early, and persistent increase of hemoglobin indicates that complete removal has been effected ; while if this does not obtain at all, or the increase of hemoglobin is not maintained, a radical operation has not been done or visceral metastases have taken place. The results of changes in the blood-vessel walls must now be studied, as well as certain abnormal elements which accidentally reach the blood-stream. This neces- sity arises because such knowledge is an essential pre- liminary to the study of the pathology and treatment of many wound-complications. Thus, the conservative efforts whereby natural hemostasis is secured unfortu- nately lay the best possible foundation for the develop- ment of pyemia if infection occurs, and hence explain why infection is especially dangerous in tissues, such as bone, where, anatomically, extensive hemostatic throm- 134 PRINCIPLES OF SURGERY. bosis must occur. Some vascular changes are diag- nostic ; moreover, the vessels are the avenues by which germs, toxic materials, and accidentally present patho- genic substances, such as fat, are disseminated through- out the organism. Thrombosis first deserves consideration. This means the ante-mortem formation of a clot in the heart or blood-vessels. Although there are other co-operating favoring circumstances, damage to, or loss of vitality of, the vascular endothelium seems a prerequisite. This may be physical, by a cut, a tear, the compression—i. e., laceration—produced by a ligature, or the chemical action of bacterial products. The bearing on thrombosis of the presence in the blood of increased numbers of polynucleated leukocytes during inflammation demands a brief study. Since all the fibrin-ferment and most of the paraglobulin are con- tained in the leukocytes, so long as there is no undue disintegration of these cells there can be no increased tendency of the blood to clot. As a matter of fact this tendency is present during inflammation. Let me make a few more statements, and the explanation of the well- known clinical fact that thrombosis is very liable to occur during inflammation can be made clear. Generations ago it was experimentally shown that the coagulation of the blood contained between two liga- tures applied to a living vein was retarded for long periods, while this same blood withdrawn from the vessel soon coagulated. Again, although the blood may be maintained at complete rest in an aneurysmal sac, coagulation often fails, but when there is little or no such rest of the contents, coagulation may be started by, and this may rapidly extend from, even a slight point of dam- age to the endothelium, as Macewen has shown. This damage causes first the accumulation of blood-plaques and later of leukocytes. It is then by virtue of some prop- erty exercised by the healthy vascular endothelium that coagulation does not occur, either because disintegration CHANGES IN BLOOD. 135 of the leukocytes is prevented, or any fibrin-ferment accidentally present is rendered inoperative ; this latter action has apparently been experimentally proved. If healthy endothelium can so act in health, so it will in disease ; but if there is present a large amount of mate- rial, ready to provide an excess of fibrin-forming mate- rials, but little damage to the endothelium will be requisite; hence the presence in the circulation of bacterial proteids resulting from inflammation may either directly damage the endothelium sufficiently, or its nutrition may be so altered as to deprive it of the power of preventing coagulation. Among the predisposing causes of thrombosis, one indeed which takes first rank, is "slowing" or arrest of the circulation. The causes of this "slowing" may be central or local or both, the former being a weak heart, however produced, which is the chief factor in the production of the so-called "marasmic thrombosis," although blood-changes, notably leukocytosis, probably assist. Local predisposition arises from obstruction to the exit of venous blood, often aided by the diminished vis-a-tergo due to loss of elasticity of the arteries in- duced by calcareous or atheromatous changes. The pressure of a tumor will at times likewise so interfere with the exit of venous blood as to produce the "slow- ing '' necessary for a rapid vascular thrombosis. Com- plete arrest of the blood-current, resulting in thrombosis, may be produced by the pressure of a tumor upon a vein, or by partial or complete division or rupture of an artery or vein. Again, embolism of an artery, even if complete blocking of the lumen is not at first induced, will soon lead to this by extension of the clotting process. Ligation of an artery will, of course, produce thrombosis of the vessel at the point tied ; but it may so reduce the force of the return venous circulation as to lead to thrombosis of the vein, especially when pressure, as of an aneurysm is exerted upon the latter vessel. Foreign bodies, such as detached fragments of tumors, 136 PRINCIPLES OF SURGERY. vegetations from the heart valves, etc., by multiplying the points around which leukocytes will gather, provide abundance of fibrin-ferment and paraglobulin for the rapid formation of fibrin. Infective micro-organisms lodging in the vessels of a part act both as foreign bodies multiplying the points of contact, and as a source of chemical injury of the endothelium. Another cause productive of the necessary changes in the endothelium is aseptic death of the tissues surround- ing a vessel, resulting in aseptic thrombosis, because the endothelium also dies from lack of nutriment. Bacterial products formed by the germs causing a pri- mary tissue-infection will produce nutritive changes in the endothelium, usually by setting up a pyophlebitis, or by killing the tissues, a '' primary infective throm- bosis" resulting. An extension of the primary hemo- static thrombi of a wound often follows secondary infec- tion, this form being termed "secondary infective thrombosis.'' Any chronic arterial disease altering the physical or vital condition of the endothelium predisposes to throm- bosis such as endarteritis in any of its forms, the athe- roma so commonly following this with its calcareous changes, and notably the roughening caused by the rupture and evacuation of softened atheromatous areas— the so-called " atheromatous ulcers " of the older writers. Thrombi then are primary—i. e., of local origin—and therefore usually limited to the locality where the cause is operative; and "propagated" or "spreading," start- ing indeed locally, but extending beyond the point where the primary cause is operative, or even originating at a distance, as the result of secondary influences. Parietal, annular, partial, and obstructive or complete, as applied to thrombi, are terms which explain them- selves. Although the first three conditions may remain so throughout, it is vastly more common for any one of the forms of partial thrombosis to become complete. Through late secondary changes, a complete thrombosis CHANGES IN BLOOD. *37 sometimes presents apparent indications that it was originally only parietal, or annular. Thrombi are more prone to form in the veins than in the arteries, because the conditions are normally more favorable. The thrombus once formed, in the case of an artery usually extends only to the next collateral branch above ; but it may reach farther upward, and possibly extend a little downward. In veins the thrombus passes far beyond the primary focus, sometimes extend- ing as far as the vena cava when originating in the veins of the lower extremity. The possibility that the veins of any organ may become thus blocked, especially the sinuses of the brain and the superior mesenteric vein, must never be forgotten, because arrest of the circulation in these localities is pro- ductive of such serious and often anomalous symptoms. The majority of thrombi which fill small wounds of the vascular walls are at first composed of blood-plaques and then leukocytes. These sometimes undergo organization, repairing the injured wall ; but later, from partial or complete arrest of the blood-current by the extension of the parietal thrombus, accretions of ordinary red clot may occur. When from any cause an ordinary blood-clot causes partial blocking of a vessel, the accretions consist chiefly of blood-plaques and white cells, because deposited from circulating blood. Thrombi are classed as fibrinous, hematoblastic, leu- kocytic, red, hemostatic, etc., because composed princi- pally of one or other constituent of the blood, but every thrombus contains all of the constituents in varying pro- portions. From the gradual manner in which thrombi are usually formed by deposition of fresh layers upon their exteriors, they present a laminated structure, and, owing to the different proportions of red cells present in the different layers, this lamellar structure is often readily distinguishable by the eye. Changes must occur in every thrombus. While the first detectable by the eye is decolorization, invasion by leuko- 138 PRINCIPLES OF SURGERY, cytes and the changes mentioned on pages 56 and 57 have previously taken place. Calcification is not very uncom- mon, giving rise to the bodies called phleboliths. The alteration most to be dreaded is softening, which even when not due to infection may give rise to embolism, pro- ducing serious consequences if the fragments are swept away and lodged in an important organ. Softening, leading to such untoward results, is very rare, except when infection is the cause. The liquefied clot is red- dish, pulpy, oily, grayish, or puriform in appearance, according to the number of red cells present, and, especially when a white one—i. e., one composed chiefly of leukocytes—is concerned, macroscopically the mate- rial closely resembles pus, although the microscope at once corrects this erroneous impression. Later, when micro-organisms have actually penetrated the thrombus, or have originally been present, genuine pus does form as the thrombus with the vessel and the other environing tissues breaks down and forms an abscess. LECTURE XII. THROMBOPHLEBITIS ; THROMBO-ARTERITIS ; EMBOL- ISM ; METASTATIC PROCESSES; FAT- AND AIR- EMBOLISM. Thrombophlebitis or thrombo-arteritis—i. e., a spreading infective inflammation of the vessels, accom- panied by an advancing thrombosis—is the usual cause of these infective softening processes, and is a most fatal malady, as witness the spread of thrombophlebitis from the middle ear to the cerebral sinuses and to the brain itself. Embolism, a process already incidentally mentioned, demands thoughtful consideration by the surgeon. Em- bolism is the process by which blood- or lymph-vessels are occluded by substances—emboli—brought to their points of arrest by the blood- or lymph-stream. The embolus or plug may completely occlude the lumen of the vessel where it lodges, or at first it may only partially block this, later additions nearly always taking place which render the obstruction complete. The material composing these plugs is most often fragments of thrombi or blood-clots, although vegetations torn away from the heart valves, portions of degenerated intima of the heart or blood-vessels, masses of micro-organisms, fat globules, myeloplaxes or liver cells, after traumatisms of or hemor- rhages into the medulla of bone or the liver, aggregations of pigment, even air may form them. These emboli are dislodged from the site of their formation by movements of the part, by traumatism, or by the force of the blood-current increased by a more powerful action of the heart, whether this be induced 139 140 PRINCIPLES OF SURGERY. by exertion, mental emotion, or otherwise. While it is possible thus to dislodge a part or the whole of an unaltered thrombus, it is extremely unlikely unless precedent softening has occurred, which rarely takes place to any dangerous degree unless infection has taken place. Emboli having their origin from a thrombus located within the pulmonary circulation are most apt to lodge in the lungs, although they may pass the lung-capillaries and reach the systemic circulation. Those originating in the systemic circulation are most often arrested in the vessels of the lungs, brain, spleen, or kidneys. If the thrombus, by fragmentation of which the emboli are formed, be situated in a radicle of the portal vein, the emboli will lodge in the liver, unless very minute, when they may reach the right side of the heart and thence be distributed. It must not be overlooked, however, that these primary emboli may initiate a thrombosis which in turn may give rise to secondary emboli, thus accounting for some of the apparently anomalous or irregular distri- bution of emboli so often observed. The importance of metastatic processes depends chiefly upon the composition of the emboli. If an embolus contains chemically active materials of microbic origin —i. e., is a "septic embolus"—necrobiotic changes of the tissues of the vessel and of those which surround it must ensue. If, in addition to their products, it contains micro-organisms which are capable of multi- plication, the "metastatic infectious embolus" will become a new center of microbic growth, forming a possible fresh center for metastasis. Should the embolus consist of or contain cells capable both of maintaining 1 • • • ^ their vitality and of multiplying, new centers of growth for such malignant neoplasms as sarcoma or carcinoma will be formed. Some benign growths, such as the famous case of chondroma of Paget, under extraordinary circumstances have undergone metastatic dissemination ; THROMBOPHLEBITIS. 141 but such a case is unique, supposedly similar ones having always shown evidences of sarcomatous tissue. The ease with which the vascular metastases are rec- ognized seems to have overshadowed the equally impor- tant fact of lymphatic metastases, which, like those occurring by means of the blood-vessels, usually take place in the direction of the normal current ; yet "retrograde metastasis" may occur in the lymph-circu- lation exactly as in the vascular, from blocking of the normal, direct route. The term "retrograde metastasis" requires explana- tion. It is rendered possible in the peripheral vessels by reversal of the ordinary direction of the current because of obstruction of the direct current through distal blocking of the vessels. Arnold has shown that when artificial emboli are introduced into such large veins as the jugular and femoral, which from their size are unable to enter, much less pass, through the capil- laries, they are '' carried, by a current running in a reverse direction, not into the trunks but into the small- est branches of the veins in the liver, kidneys, heart, extremities, dura and pia mater, and orbits, as well as into the posterior bronchial veins." The result of the lodgement of an aseptic embolus in a vessel of a young person, or in one of those of an older individual with dilatable vessels, is merely a temporary lack of direct blood-supply to the area nourished by the occluded vessel, the collateral circulation soon amply sufficing, unless the vessel be a "terminal" one, when most serious consequences must follow, as will now be explained. Of course, even when the artery is not a "terminal" one, if the collateral vessels do not dilate sufficiently, necrobiotic changes or gangrene of the parts supplied by the blocked vessel must follow. When an artery is "terminal" or nearly so, the tis- sues supplied by it must either undergo simple coagula- tion-necrosis, and subsequent degenerative changes, or coagulation-necrosis followed by hemorrhagic infiltra- 142 PRINCIPLES OF SURGERY. tion ; in other words, "hemorrhagic infarction" is de- termined. By an infarct or infarction is meant the more or less conical altered area of tissue which was formerly sup- plied by the artery occluded by the embolus. If there exists practically no communication with the capillaries of the surrounding tissues, simple coagulation-necrosis and certain later changes take place, including the pos- sible occurrence of moist gangrene from infection of tissues whose vitality has been reduced to a minimum by total deprivation of pabulum. If the vessel which is blocked is not absolutely terminal, but its capillaries have some communication with those of the environing tissues, a reflux of blood takes place, and, as Rindfleisch has pointed out, a higher pressure prevailing in the vessels of the infarct than in the surrounding normal capillaries, it is not surprising that, aided by the coagu- lation-necrosis almost invariably present in the vessels distal to the embolus, vascular rupture should occur, a "hemorrhagic infarct" resulting. When hemorrhagic infiltration does not occur, the parts remain bloodless, an "anemic infarction," as it is termed, resulting. Embolism of the mesenteric artery is second in import- ance only to embolism of the brain, indeed is a far more fatal condition, leading to necrosis of the parts involved. The symptomatology of neither condition can be pur- sued, the occurrence of embolism in these localities having been cited merely to show the importance of the process under consideration. The general indications for the treatment of throm- bosis and embolism are to maintain the life of the part by favoring the development of both the venous and arterial collateral circulation, and securing the freest possible return of the venous blood. Maintenance of the warmth of the part and elevation are means to secure these results when applicable. When tissue-death re- sults, the diseased parts must be removed if accessi- ble, as a gangrenous patch of lung, a mortified limb, FA T-EMBOLISM. 143 necrotic bowel, etc. If the process be a septic one, the measures indicated are those appropriate for the treat- ment of the same local or general conditions induced by infection otherwise produced. Fat-embolism.—By fat-embolism is meant the occlu- sion by minute fat-globules of arterioles and capillaries, chiefly the latter, the embolic material having gained access to the circulation on the venous side. This acci- dent is not uncommon after crushes of bone, espe- cially open ones (except in children, because they have Fig. 11.—Showing fat-emboli (stained with osmic acid) occluding a number of the lung vessels. so little fatty medulla) ; extensive injuries of the pan- niculus adiposus ; traumatism of or hemorrhage into the liver or the medulla of bone ; and acute infectious proc- esses in bone. Park makes the statement, evidently experimentally not clinically determined, "that fat- 144 PRINCIPLES OF SURGERY. embolism may occur when fluid fat has been passed into the heart through the thoracic duct, although more slowly." As the data for this statement are not given, as well as those upon which the allegation is founded that the same accident can occur from absorption of fat from a serous sac, the possibility of fat-embolism thus originating is suggested, not affirmed. It is also be- lieved that fat may enter the opened vessels during an operation. First and chiefly the capillaries of the lungs are blocked, then, if the force of the circulation is com- petent to drive the fat through these vessels, the capil- laries of the brain, spinal cord, choroid, liver, and kidney may one or all become blocked ; of course, the vessels of other organs may also suffer. The fat is most often finally arrested in the liver and kidneys, where it is dis- posed of in non-fatal cases. Oxidation and saponifica- tion effected by the alkaline salts of the blood also aid in getting rid of the fat. Symptoms.—These are often confounded with or com- plicate shock. Opinions vary as to the frequency and importance of fat-embolism, but none deny the serious nature of this accident if extensive capillary areas of important organs remain for any length of time oc- cluded. The symptoms in minor degrees of fat-embol- ism, where the occlusion is only temporary, however pronounced they may be at the outset, are evanescent. The primary dangers from fat-embolism and the earlier symptoms are those of pulmonary embarrassment with edema, deficient oxidation of the blood soon becoming pronounced — i. e., acute asphyxia results. This is shown by restlessness, rapid respiration, increasing dyspnea, pallor, promptly succeeded by more or less decided cyanosis, and a rapid pulse. The later symp- toms result from obstruction of the capillaries of the organs due to the lodgement of such fat-globules as have been forced through the lung-capillaries. In addi- tion to the pulmonary symptoms, mental excitement, somnolence, and coma may succeed. The respiration, FA T-EMBOLISM. H5 rapid from the outset, later becomes stertorous, the pulse irregular and feeble. Pulmonary edema is apt to be- come marked, with expectoration of frothy, blood- stained mucus, or actual hemoptysis occurs. Symptoms indicative of involvement of the spinal cord are at times detectable. The temperature is usually subnormal at first, may remain so, or may become elevated if compli- cations arise. Diagnosis.—The occurrence of fat-embolism may at first be difficult to detect, if pronounced shock also exists. Fat-embolism usually presents symptoms only after any shock which has been present has passed away, or when this was never pronounced. This time-rule is by no means absolute, because cases have been reported where the accident occurred and death resulted inside of twelve hours. Except at the beginning, the pallor so pro- nounced in shock is replaced by cyanosis, and the rapid and, later, stertorous respiration differs materially from the feeble, sighing character of that observed during shock. The pulmonary and renal congestions sometimes following prolonged etherization may be confounded with fat-embolism. If free fat is detected in the urine the diagnosis will be clear, otherwise it must often remain for the time in doubt. Unless the fat comes from an infected source or sepsis supervenes, fat-embolism is unlikely to be confounded with acute septicemia, be- cause of the gradual onset of the symptoms in the lat- ter, with the pronounced temperature rise. Still, sepsis may later complicate fat-embolism. The previous recognition of the existence of fat-embolism, or the detection of fat in the urine should insure a correct opin- ion. The discrimination of fat-embolism from other acute pulmonary affections occurring independently of the former should be possible with ordinary care. The occurrence of acute suppression of urine after a serious injury or operation should always excite a suspicion of the presence of fat-embolism. Cerebral symptoms may, indeed, be due to hemorrhage or ordinary embolism. In 10 146 PRINCIPLES OF SURGERY. fat-embolism they commence gradually with the prece- dent symptoms of fatty lung-embolism, or when of later development the wound-fluids contain much free fat, which can also be detected in the urine. Hemiplegia is usually absent, coma gradually supervening without dis- tinct paralysis, while the detection of fat-globules in the urine will settle the diagnosis. In addition, the history of rapid respiration with dyspnea should suggest a lung- embolism which had escaped detection. Prognosis.—Severe cases are nearly always fatal,while for slight fat-embolisms recovery is the rule. The most dangerous period is the first forty-eight hours; but if this be successfully passed, recovery will probably ensue. Recovery depends upon the ability of the heart to free the occluded capillaries by forcing the fat through them in time to prevent either asphyxia or grave secondary changes in the pulmonary tissues, and the subsequent escape of the brain, spinal cord, etc., from serious in- volvement produced by the lodgement of the fat which has passed beyond the lungs. The possibility of fresh increments of fat entering the circulation must be taken into account. Unless originating from a septic focus or secondary infection occurs, nothing beyond "hemor- rhagic infarcts'' follow. Treatment.—The indications are to increase the vis-a- tergo, to dilate the arterioles and capillaries as much as possible to permit the readier passage of the fatty accu- mulations, and to supply enough oxygen both to main- tain life and aid in the removal of the fat by increased oxidation. The administration of strychnin, ammonia, and alcohol will fulfil the first indication, while bella- donna, and possibly nitrate of amyl cautiously employed, will secure the maximum dilatation of all the peripheral vessels, hence those of the lungs. Although digitalis is usually recommended, it should not be used, because it will increase the contraction of the peripheral vessels. Inhalations of oxygen should be tried. Because fresh amounts of fat may enter the circulation, absolute quiet AIR-EMBOLISM. H7 of the part and of the individual must be secured at any cost, lest movement set free additional fat by rupture of more fat-cells. Experiments having shown that the in- troduction of a laminaria tent into the medulla of a bone is competent to cause fat-embolism, the tension actually forcing the fat into the circulation, free drainage must also be provided for all wound-secretions. Air-embolism.—Although air-embolism has always been one of the rarest of surgical accidents in the past, and should be still more so when general anesthesia is employed, yet the possibility of its occurence demands that the whole subject shall be thoroughly considered. The danger of air-embolism is chiefly due to the impos- sibility of the right heart forcing the air through the lung-capillaries, large areas of these becoming obstructed. This results both from the inherent difficulty of the task, and because the valves are not so readily closed by the pressure which a bloody froth can exert as by that of the fluid blood. The left heart, nearly empty of blood, fails to supply with blood the nerve-centers essential to life and the heart itself, hence the symptoms and death. Quite large quantities of air can be slowly introduced into the circulation of animals without dangerous conse- quences, the air failing to cause the lung- and heart-com- plications, because at no one time is there enough present to block the lung-capillaries, and it passes through them and is found in the capillaries of many organs, being there disposed of. Smaller amounts, if suddenly introduced, will cause death in the human subject. Operations in the axilla, about the base of the neck, and such as involve the cerebral sinuses are those in which this accident is most likely to happen. " Canalization" of veins predisposes to air-embolism—i. e., a condition, normal or acquired, which by converting a vein into a rigid tube prevents it when cut from collapsing. The cerebral sinuses are anatomically incapable of collapsing from atmospheric pressure, and so are some veins in the "dangerous regions" just mentioned, owing to their perforating or 148 PRINCIPLES OF SURGERY. being attached to dense fascise. Inflammatory induration of a vein-wall, or a similar induration of the tissues sur- rounding veins also produce '' canalization.'' Putting the vein upon a stretch just as it is cut will cause temporary "canalization." When any such favoring conditions are present, if a patient be not anesthetized, the sudden, deep inspiration following the holding of the breath induced by the pain of a cut, or while struggling to get free, renders it very likely that air will be drawn into an opened vein emptied of blood by the inspiration. All cases where, after sudden death, air or gas is found in the veins, are not due either to air-embolism or to the entrance of gas formed during putrefactive changes in wound-fluids under pressure. Modern research has shown that this condition sometimes results from the rapid growth in the blood of aerogenetic bacilli. Symptoms.—A hissing noise is heard, and bubbles of air are seen in the wound ; there is sudden heart-failure, with irregular respiration and dilatation of the pupils. A "churning" systolic sound is recognizable on auscul- tation over the heart, convulsions quickly commence, and death soon follows. Treatment.—This should be chiefly prophylactic, because introduced in sufficient amount the time which will elapse before death takes place will not suffice for the adoption of efficient therapeutic measures. Complete anesthesia must be maintained when operating in the " dangerous region." If anesthesia for any reason be impossible, the arms should be confined to the sides and the movements of the thorax be restrained by a firm binder. The head must not be much elevated when operating within the cranium, lest air enter an open sinus.. Structures which may contain large veins should not be put upon the stretch while being incised. Veins had better be tied when possible before division. Should air- bubbles be seen in the wound or a hissing sound be heard, fill the wound with water or blood by a squeeze of a sponge, compress the vein by the finger until it can AIR-EMBOLISM. 149 be clamped with forceps, stop further administration of the anesthetic, institute artificial respiration with lowered head to retain a functioning amount of blood in the brain- centres, give strychnin both as a cardiac and respiratory stimulant, and atropin as a respiratory one and to aid in securing the maximum dilatation of the clogged pul- monary capillaries. In a few cases life will be saved by the prompt employment of such measures. LECTURE XIII. SURGICAL FEVERS : SAPREMIA ; SEPTICEMIA ; PYEMIA. Fever has already been incidentally considered as a symptom of inflammation. Several of the most impor- tant wound-complications are invariably accompanied by fever, indeed their most patent symptoms being febrile, they have often been described as "fevers," practically ignoring the fact that the combination of phenomena we call fever is merely the evidence that some pathological condition exists, and not the essence of that condition. It is of first importance to understand that in all fevers observed during the course of any sur- gical affection the rise of temperature is due more to excess of heat-production than to lack of heat-elimina- tion. Again, because fever is a symptom, all the possible causations of each factor must be studied lest serious practical error result. When the onset is gradual neither chill nor rigor occurs; but when there is a large dose of poisons suddenly thrown into the circulation chill is practically certain to result, unless the vital powers be overwhelmed. But an actual chill, or the statement by the patient that he has felt chilly or has shivered with cold, is not always indicative of the absorp- tion of toxic substances, for no rise of temperature or any other symptom of fever may follow. This variety of chill has been called for lack of a better name, a '' nerv- ous chill." While this does occur, it is only by close and repeated thermometrical observations that we can be sure that this supposed "nervous chill" is not in reality a "septic" one, resulting from a small dose of poison in one with an unusually susceptible nervous 150 SURGICAL FEVERS. 151 system and in whom a repetition of the dose, or a larger one, will occur later, unless the unsuspected source of infection be diligently sought for and, being found, is removed. All the febrile symptoms occurring after any trauma- tism or operation are due to the presence in the blood of some pyrogenous substance usually, but not always, originating in and absorbed from the wound.1 These pyrogenous substances belong to two very different classes—viz., the aseptic and the septic. The aseptic pyrogenous substances are fibrin-ferment, the nucleins of the tissues, and similar proteids, the results of increased metabolism or of tissue-destruction. None of these produce much beyond a higher bodily temperature and a somewhat more rapid pulse ; but the arrest of the secretions and other evidences of the toxemia of true fever are all absent, as described in Lecture VIII. when treating of "aseptic fever." As this "aseptic fever," which lacks most of the characteristics of genu- ine fever, is usually self-limited, subsiding spontaneously when all the original stock of pyrogenous substances has been absorbed from the wound, the question of treatment might seem of no importance; nevertheless, when very marked, it may possibly be just the slight additional depressing influence which will so lower local or somatic vitality that a primary or secondary infection, too slight to become operative in normally resistant tis- sues, will now prove effective. Again, "enterosepsis"2 may complicate true "aseptic fever," and this in turn pave the way for a true septic infection ; therefore, it is sometimes wise to accelerate the disappearance of aseptic fever by cold sponging, laxatives, and free diuresis, induced by drugs or preferably by the ingestion of large amounts of fluids, especially water. These latter may be administered either by the mouth or rectum, or by both avenues. Careful regulation of the diet is also advisable, both as a prophylactic against enterosepsis ' See Autointoxication, page 178. 2 See page 103. 152 PRINCIPLES OF SURGERY. and as relieving the emunctories of all unnecessary labor. Sapremia.—The name sapremia should theoretically be applied only to the constitutional effects produced by the absorption of the chemical products of the growth of saprophytic germs. In addition, however, it is probably true that at times the toxins manufactured by the pyo- genic cocci are taken up in sapremia, adding to the sys- temic poisoning, although the germs themselves, of course, do not gain access to the circulation. The two facts that putrefactive changes are prominent in the class of cases to which the term sapremia was originally applied—viz., puerperal—the discharges in such cases being very offensive, and that just as soon as the putre- fying blood-clot is removed from the uterus, and disin- fection—as shown by the absence of odor—has been secured, the symptoms quickly subside, go far toward proving that the putrefactive organisms manufacture most of the substances producing sapremia. Still fur- ther, the measures which prove efficient in putting a stop to sapremic intoxication would have but little effect in arresting the development of pyogenic organ- isms lodged in the interior of the uterine cavity, or in preventing their effecting a successful lodgement in the uterine tissues. Again, laboratory investigations have taught us that while saprophytic microbes grow with such rapidity that in a few hours they can manufacture poisonous amounts of ptomains, yet pyogenic cocci require a longer time to develop in sufficient numbers to produce toxins in dangerous quantities. This is not a fine theoretical point, but has an important practical bearing upon the therapeusis of septic conditions. Chemical substances are with difficulty absorbed when in contact with a healthy granulating surface, while if in solution in the wound and tissue-fluids of a recent traumatism, or in the peritoneal cavity—i. e., an enor- mous lymph-space—are in direct osmotic relation with the blood and lymph, only the requisite animal mem- SURGICAL FEVERS. J53 brane intervening. A consideration of these latter facts must convince us of two things—first, that sapremia nearly always must commence soon after the traumatism has been inflicted; and second, that given a normal granulating surface throughoutl any operative or acci- dental traumatism—i. e., a number of days must have elapsed since the primary infection occurred—if systemic intoxication now takes place, it must be from germs manufacturing their poisons within the economy, not developing in the wound alone. Sapremia cannot develop from a small point of infec- tion, because there must be sufficient space for the accu- mulation of enough wound-fluids to undergo changes which will supply large amounts of chemical poisons, and also a surface extensive enough for their rapid absorption. It has been estimated that it requires the absorption of from i to 2 ounces of fluids saturated with the chemical products of germ-growth to produce sapre- mia. Sapremia, at one time well termed "septic intoxi- cation," was formerly quite common after intra-abdomi- nal operations, the abdominal cavity being in reality an enormous lymph-space, presenting .unparalleled oppor- tunities for the absorption of unlimited quantities of toxic substances. The rapidity of absorption is so great that the resulting death is even now sometimes, and formerly was frequently, considered to be the result of "shock." To epitomize the conditions most favorable for the development of sapremia, and thus provide data for a differential diagnosis between this and septicemia; sapremia most often follows recent, extensive wounds which are kept neither aseptic nor properly drained ; wounds of serous and synovial membranes which are not kept aseptic and efficiently drained ; abscesses and granulating wounds in which septic discharges are retained under pressure, because free drainage is pre- 1 Of course, destruction of the granulations over any extensive surface by caustic microbic products or mechanically would invalidate this statement. 154 PRINCIPLES OF SURGERY. vented by too small an opening, the pressure mechanic- ally rendering the protective barrier of granulation- tissue ineffective. Post-mortem examination shows, as would be ex- pected from the gastrointestinal and nervous symptoms, congestion of the stomach, intestines, and nervous centers ; the kidneys, through which the poisons are chiefly eliminated, are also hyperemic. Marked dis- integration of the red blood-cells is found, accounting for the staining of the tissues and vessels, the detritus often producing blocking of the vessels, causing their rupture, and hence the petechias more or less generally present throughout the body, but seen more especially beneath the serous membranes. No germs are found in the blood or internal organs, because saprophytic microbes cannot flourish in normally vitalized tissues. Prognosis.—In a typical case, because the poisoning is a chemical one, unless the amount of the poisons ab- sorbed either in one dose or continuously be necessarily fatal, the prevention of the absorption of fresh incre- ments, and the arrest of any further formation of poison- ous alkaloids, should cut short the sapremia. This is often both theoretically and practically possible by affording free drainage and securing efficient disinfection of a wound, by the removal of a limb, etc. Of course, even when all these things have been promptly and effectively done, a fatal dose of poisons may have already been absorbed ; yet sometimes, by securing free action of the emunctories, what would otherwise unquestion- ably prove a lethal dose is recovered from. Unfortunately pyogenic cocci often coexist in the wound with the saprophytic micro-organisms. The former only too frequently gain a firm hold on tissues partially devital- ized by the chemical products of putrefaction, penetrat- ing whence through the lymph-spaces they soon reach the blood, and now germs, capable of living, flourishing, and manufacturing toxins wherever arrested, become located in every part of the organism, true septicemia SURGICAL FEVERS. 155 being now engrafted upon and having been rendered more possible by the previous sapremia. Nevertheless, although a fatal termination is too often the outcome of this aggravated condition, it is theoretically and some- times clinically possible to prevent fatal septicemia by ridding the economy of the poisonous alkaloids, thus enabling the blood and tissues to render inert or destroy a number of germs which otherwise would prove fatal. Symptoms.—General malaise begins soon after shock has passed off, and the attack is often—but far from always—ushered in by a chill or severe rigor, with a sudden elevation of the temperature to 1030 or 1040 F., and with all the other manifestations of fever. Head- ache and nausea, possibly with vomiting, soon appear. Mental disturbance, frequently culminating in delirium, soon shows itself. The pulse becomes rapid and feeble and the tongue dry and coated. If a lethal dose of poi- son has been absorbed or a continuous absorption of ptomains obtains, rapid collapse occurs with subnormal temperature ; coma takes the place of any previous de- lirium, and death ensues. Sometimes an overwhelming dose produces collapse, and death takes place in coma without any of the symptoms first detailed. In contrast with this, after a medium dose of poisons or repeated non-lethal doses, the fever and nausea with occasional vomiting persist, diarrhea or purging appears, and the patient becomes anemic, icteroid, or actually jaundiced. Either death occurs from exhaustion, the tongue becom- ing dry, brown, and fissured, sordes accumulating on the lips and around the teeth, and the pulse becoming frequent and feeble, septicemia or pyemia sometimes terminating life, or recovery takes place gradually. Hectic Fever.—Although not altogether fashionable to speak of "hectic fever" and fully recognizing that the condition so called is only a modified sapremia, yet it is so common a clinical condition as to demand special recognition. It gradually supervenes upon more acute forms of sepsis, the original fever declining in severity 156 PRINCIPLES OF SURGERY. as the system becomes partially habituated to the poisons, these being slowly introduced in smaller amounts, a sufficient daily elimination of toxic sub- stances occurring during the sweating stage to secure a daily apyretic period. Hectic will show itself in any case of chronic suppuration where free exit for the pus cannot be secured, and is a danger-signal to be heeded, for unless its causes can be removed, in a marked case, death will eventually ensue from exhaustion or from amyloid disease of the liver, kidneys, or intestines. Symptoms.—Every afternoon, usually without even chilliness, there is a rapid rise of temperature, the cheeks present a circumscribed flush, the palms of the hands often show similar appearances, the eyes are brilliant, the pupils large, and the pulse rapid and feeble. Dur- ing the evening or night, profuse sweating occurs, usually during sleep. In the morning the temperature is normal ; but the patient is pale and exhausted, the tongue is red and dry at the sides and tip, the pulse is rapid, small, and weak. The appetite steadily de- creases, diarrhea begins, emaciation is rapid and marked, and death results from exhaustion, although with all the tissues so depressed in vitality secondary infection read- ily occurs, so that some hectic cases die rather suddenly of acute infective complications. Treatment of Hectic Fever.—This demands that the source of the infection be radically attacked, and pref- erably by methods which will ensure complete removal of the infecting focus, or if this cannot be done, the most rapid healing possible must be secured, to save further drain ; for instance, amputate a limb rather than resect or erase a diseased joint. Fresh air, sunshine, plenty of good food, stimulants, and tonics are indicated. In all other respects the advice given for sapremia is appli- cable here, modified to meet the altered circumstances. Treatment of Sapremia.—This has been outlined by the explanations already given. Removal of the cause by free drainage and disinfection must be secured by SURGICAL FEVERS. *57 placing the part, when possible, in the continuous warm aseptic or antiseptic bath ; by the cautery even, as in hospital gangrene ; by amputation possibly ; by laying open a suppurating joint ; by amputation of a hopelessly infected puerperal uterus, etc. In the severe cases, secure free watery movements of the bowels by the exhibi- tion of salines preceded by calomel, as is so successfully done for septic peritonitis. Increase the elimination of the kidneys by fluids and drugs, if the renal conges- tion will not thereby be increased, or relieve this and secure a freer secretion of urine by calling in the aid of the vicarious action of the skin, employing to this end hot-air or steam-baths; these last measures will sometimes be followed by free diuresis, when diuretics would only increase the suppression. Wash the economy free of poisons by saline transfusion—hematoclysis. Admin- ister drugs capable of sustaining the power of the heart, such, as strychnin, digitalis, etc. See that sufficient nutritious, easily digestible food is ingested. In the more chronic cases, when the diarrhea seems in excess of the requirements for elimination, endeavor to dimin- ish the frequency of the evacuations by the use of intes- tinal antiseptics and the administration of mineral acids. Secure sleep, if possible, without the use of opium. By some or all of these measures most unpromising cases are occasionally saved, while in those less severe the scale is often turned toward recovery. There can be no question that proper measures will sometimes prevent the conversion of a sapremia into a septicemia, despite the pessimism of some writers. Tonics and nutritious food will prove useful during convalescence. I hardly need to point out that antistreptococcus serum is not only utterly useless, but probably will prove harmful in pure sapremia—a fact which presents an additional rea- son for attempting to distinguish between the various forms of so-called "blood-poisoning." Even delay by a resort to a bacteriological examination of the blood is warranted. LECTURE XIV. SURGICAL FEVERS (CONCLUDED) ; SEPTICEMIA. While fully admitting that sapremia may pave the way for septicemia by favoring the access of micro- organisms into the circulation, yet it is clinically neces- sary to describe two separate diseases, because first, there is a chemical infection entirely controllable by art, and second, if this be controlled or modified, either the genuine infective process may be prevented, or if not actually arrested, may be confined within limits com- patible with final recovery. In sharp contrast with the necessary conditions of a sufficiently large wound and absorbing surface for the production and entrance of enough alkaloids to produce sapremia, uncomplicated primary septicemia often starts from some trivial wound, as, for instance, a slight cut or a needle-puncture received during a post-mortem ex- amination of a body of a patient who has died of septi- cemia, a wound manifestly too small to permit either the accumulation of enough wound-fluids to generate the chemical poisons of sapremia, or even if formed—which is impossible—to admit of their absorption rapidly enough and in sufficient quantity to produce sapremia ; hence, an incubation period of from two to three days must elapse before the germs can become diffused, loca- ted, and multiply sufficiently to form enough toxins to produce the systemic effects of septicemia. Symptoms of Septicemia.—When occurring after a wound or operation there is usually some slight fever, which is first observed soon after reaction has taken place. This may, at the outset, be genuine aseptic fever, or slight 158 SURGICAL FEVERS. *59 chemical intoxication—i. e., sapremia—and it lasts during the incubation period of the septicemia, merging with the symptoms of that disease; or this may suddenly evidence its onset by a chill. If resulting from a small focus of infection, such as a dissecting wound, there are usually no perceptible symptoms until an initial chill announces the onset of some grave malady. The marked prostra- tion preceding any chill, or this symptom if no chill occurs, when present with fever continuing from the time of reaction, or with a fever commencing after the third day, is almost pathognomonic of septicemia. When gradually superseding the non-infective fevers just men- tioned, marked prostration soon develops with gastro- intestinal symptoms, such as anorexia, diarrhea, etc., the fever and general condition rapidly assuming the ty- phoidal type. The fever is a continued one, but usually shows slight morning remissions ; later, the temperature- curve becomes more irregular, the perturbations being sometimes clearly dependent upon changes in the condi- tion of the wound, when there is much local septic dis- turbance. A sudden rise just before death is not very unusual. Slight hematogenous jaundice is usually ob- served, the spleen is enlarged and tender, and the lymph- nodes nearest the lesion, if accessible, will also be found in the same condition. Septic lymphangitis is a variable symptom and is dependent largely upon the character of the wound—i. e., whether the local infection is marked and the infection be single or mixed. It is an error to lay too much stress upon the local conditions found in septicemia, such as sloughing, gangrene, etc., for they really result from inflammatory strangulation, or from the locally destructive effects of bacterial alkaloids or proteids, just as in any other infected wound not causing septice- mia, and are not directly due to the general toxemia. Doubtless the resistance of the wounded tissues to the invasion of germs is seriously impaired by the constitu- tional poisoning as well as by the development of purely saprophytic organisms. It has been too readily assumed 160 PRINCIPLES OF SURGERY. from the small extent of the local lesions often discover- able in diphtheria that in surgical toxemias also much of the poison is manufactured in the wound and its immediate surroundings. The diphtheria bacillus like that of tetanus seems capable of developing specific poisons capable in minute doses of producing tremendous effects, but this is not true for the toxins of the pyogenic cocci. It is not correct to state that septicemia is a " progressive invasion of tissues by continuity," because with a most trivial "infection-atrium," with no local lesion capable of producing appreciable amounts of tox- ins, the most marked constitutional symptoms often develop, and again, marked local infection of the tissues does not necessarily produce septicemia. Still further, the post-mortem findings demonstrate that the toxins are not manufactured in the wound alone but everywhere throughout the economy. Unquestionably, if septicemia attack a patient with a large infected wound, marked local changes spreading far and wide by continuity will almost necessarily occur, especially if saprophytic organ- isms are present. This, however, is an accidental ac- companiment of septicemia, not an essential part of the disease, because some of the most typical instances of septicemia develop in the absence of marked local trouble, proving that the widespread presence and multi- plication of the germs in any and every part of the body form the essence of this disease. As would be expected leukocytosis is marked, and cult- ures made from the blood will often demonstrate the pres- ence of viable pyogenic organisms. The heart early shows the depressing effects of the toxins, becoming weak, frequent, and irregular in action. The skin at first hot and dry, later is leaky, or free sweat- ing may alternate with dryness. Different forms of skin- eruptions are sometimes observed, usually tending to be pustular or purpuric, although erythematous conditions often simulate scarlatina, etc. Hoffa teaches that these eruptions, other than erythematous, are due to capillary SURGICAL FEVERS. 161 thrombosis. He contends that the micro-organisms he has obtained from the skins of patients with such lesions are non-pathogenic, but either mechanically, or through action on the fibrin-forming constituents of the blood stand in a causative relation to the thrombosis. Microbes which are non-pathogenic in health may be pathogenic when the vitality of the individual infected is lowered, and since the blood has an abnormal tendency to coagu- late in septic conditions, even non-pathogenic germs might readily serve at least as mechanical starting-points. The nervous system early shows the action of the poisons by restlessness, delirium succeeded by apathy, stupor, coma and death in this state. The renal secretion is diminished or suppressed, the urine containing albumin in most instances. The distaste for food increases, the earlier diarrhea becomes more pronounced, the evacuations become offen- sive, the icterus deepens, and there are bronchial symp- toms, shown by quickened respiration, cough, etc., the fatal ending resulting from exhaustion and collapse in the less acute cases. Milder cases are observed, where a moderate febrile septic condition may persist for weeks, with nothing very distinctive except a decided enlargement of the spleen. Recovery often occurs in this class of cases, which are unquestionably mild septicemias. Indeed, from the slighter febrile attacks lasting for from seven to ten or more days after operation, formerly called " traumatic" or "septic traumatic" fever, which were either slight sapremias, or sapremias combined with, or followed by, slight septicemias, up to the most malignant septicemia, there are all conceivable grades of severity. Although, as has been explained, there can be no "characteristic changes in the wound" beyond those seen in an infected one in a patient whose vitality has been seriously impaired, undoubtedly in the more malig- nant septicemias there will be marked evidences of local infection, shown by edema and congestion of the wound- 11 162 PRINCIPLES OF SURGERY. margins and surrounding tissues, watery, ichorous, and offensive discharges, possibly sloughing and gangrene, with lymphangitis and local bacterial infiltration; but all this can be said of many infected wounds which may be followed only by slight sapremia if drainage be free, or by septicemia, or pyemia, according to whether certain local conditions do or do not prevail. After death, examination shows the blood to be tarry in consistence, with little power of coagulating, and the various internal organs contain cocci, streptococci being perhaps more common than staphylococci, although both may be found. The pia mater shows extravasations, and punctiform hemorrhages may also be seen in the deeper portions of the nerve-centers. Beyond a brownish discol- oration of the muscles, these present no changes. In the more chronic cases the endocardium is thickened, but any ulcerative lesions of this membrane are rare in pure septicemia. Slight pleural and pericardial effusions are often found. There are evidences of a distinct gastro- intestinal catarrah, especially marked in the duodenum and rectum by punctiform hemorrhages. The spleen and the lymph-nodes, especially those of the mesentery, are enlarged. The kidneys are congested, and the glomeruli are many of them blocked by germs, evidently brought there for excretion. The liver is often "emphysema- tous" from early decomposition, indeed the bodies of those dead of septicemia show a marked tendency to early decomposition. Post-mortem examination of these bodies, when fresh, are especially dangerous; after putre- faction they become less so, because the saprophytic germs supersede and apparently destroy the infective micro-organisms. In and around the wound numerous bacteria will be found, with infected thrombi, originally merely hemostatic, extending some distance along the course of the vessels. A similar condition exists in the lymph-spaces and vessels. Phlebitis and thrombophle- bitis, although vastly more common in wounds giving rise to pyemia, are conditions not incompatible with SURGICAL FEVERS. 163 septicemia. As has been stated many times, while septi- cemia most commonly originates from some surface-lesion, or one which is readily detectable, yet there are many cases whose origin is most obscure. Warren and other writers have pointed out that many of these cases start from infective processes involving the appendix, the nasal cavities, the tonsils, the urethra, rectum, the teeth, or the middle ear. I have seen typical septicopyemia originate from a trivial skin-lesion. Treatment.—It is imperative to adopt energetic and effective local disinfection, because thereby any further sapremic complication can be prevented, and fresh in- crements of germs also may possibly be prevented from reaching the circulation from the wound. Certain forms of wound-infection, which certainly sometimes destroy life by instituting genuine septicemia, seem to be controllable, as hospital gangrene, by destruction of the diseased parts with a zone of the surrounding appar- ently healthy tissues. The actual cautery, because the radiated heat is germicidal far beyond the point of application, and pure bromin—as Goldsmith showed during the Civil War—from the penetration of its vapor into the deepest recesses of the wound are the best when applicable. Pure carbolic and nitric acids are also effic- ient ; potassium permanganate, one dram to the ounce of water, may also be employed. At other times the knife or curette is preferable to any form of caustic, but this is true only when the infected parts can be removed entirely, and through healthy tissue. Sometimes none of these measures can be adopted, when the continuous warm bath or antiseptic irrigation should be tried, re- membering the risk of absorption of poisonous anti- septics. Powdered charcoal mixed with one-third its bulk of sugar containing 5 per cent, of naphthalin is extolled by Park as an application in malodorous cases, and may be tried in default of the possibility or desira- bility of employing the measures already mentioned. Increasing the eliminative action of the emunctories to 164 PRINCIPLES OF SURGERY. get rid of chemical and bacterial poisons, sustaining the circulation by large doses of alcohol and appropriate drugs, and maintaining the nutrition by rectal as well as oral feeding, and the restraint of the temperature within safe bounds by the use of cold, have already been sufficiently dwelt upon when describing the treatment of sapremia or will be considered under Pyemia. The diarrhea, when in excess of any useful purpose in elimi- nating, must be kept within bounds by such intestinal antiseptics as salol, occasional doses of calomel, or mer- cury and chalk, bismuth, beta-naphthol, etc. Intestinal antiseptics also lessen the chances of enterosepsis. When the action of the bowels is irregular and inade- quate, the occasional use of small doses of calomel and soda, followed by a laxative is indicated, mechanically removing much poison : indeed, purgation is sometimes indicated, especially in peritonitis, as the most efficient method of evacuating germ-products. If- the original focus or any suppurative lesion shows a pure streptococ- cus infection, or if this is reasonably probable because of the extensive lymphatic involvement,1 the hypo- dermatic use of Marmorek's antistreptococcus serum will often completely revolutionize the course of the disease. If staphylococci are the sole or the predominating organ- isms, but little if anything can be expected from the use of the serum, which it must be remembered is not with- out danger. 1 Streptococci seem to be peculiarly prone to attack the lymphatic system. LECTURE XV. PYEMIA. Pyemia is a misnomer, the liquefied thrombi having been mistaken for pus-collections occupying the lumen of the vessels. Pyemia is a disease resulting from the lodgement of septic or infective emboli, which are in turn the result of septic or infective thrombophlebitis; possibly it sometimes originates from septic or infective lymph-emboli, due to septic or infective lymphangitis; in rare instances infective emboli have been found in the capillaries which have originated in an infective thrombo- arteritis. Although the presence of pus in the blood is not the cause of pyemia, yet now and then the rupture into a large vein of a quantity of infected pus, or the introduction of the same through the lymphatics, may give rise to infective embolism and hence to pyemia. Let there be no mistake, however ; pyemia thus pro- duced is not due to pus—either cells or liquor puris— but, just as in the case of an embolus of blood-origin, it is due to the contained micro-organisms, which, en- tangled in masses of pus-cells, form emboli exactly as cinnabar, fragments of sterilized pith, or potato will secure the retention of the germs where these masses lodge, damaging the endothelium and rendering im- plantation of the germs a certainty. Thus a postperito- neal abscess has caused pyemia by rupturing into the ascending vena cava, as Schuh has reported. The many ways in which infective emboli can originate require study. The hemostatic thrombi formed in every wound may either become soaked with the ptomains of decom- position, or with bacillary products, or pyogenic cocci may infiltrate them. The same remarks apply to 165 166 PRINCIPLES OF SURGERY. lymph-thrombi. Lodgement of germs in the arteries will set up coagulation-necrosis of the vessel-walls and thrombosis followed by suppuration, just exactly as if an infected embolus had been arrested. Although mycotic endocarditis may be secondary to septicemia and pyemia, it may originate the latter disease ; emboli composed of fibrin loaded with germs, or of practically nothing but masses of micro-organisms being swept away from the heart-valves, lodge in the arteries and set up thrombo- arteritis with coagulation-necrosis and suppuration in the surrounding tissues. The microbes causing the endocarditis enter the circulation at some distant infec- tion-atrium and accumulate upon a previously rough- ened valve, or themselves so damage the endothelium as to gain a permanent lodgement and produce a local thrombosis. The microbes causative of endocarditis, or of infection of the thrombi elsewhere formed which by their disintegration give rise to infective emboli, may indeed come from a wound ; but sometimes an unsus- pected appendicitis, dysenteric ulcer, gonorrhea, nasal catarrh, an ulcerated tooth, slight pyosalpinx, osteo- myelitis, or the mere abrasion from the adhesive plaster employed for extension after fracture of the thigh may be the real cause of the miscalled "spontaneous pyemia." Pyemia has even first shown itself after the wound giving rise to it has healed, as I have seen. A definition of pyemia often accepted is incorrect—viz., "pyemia may be described as septicemia plus thrombotic and embolic accidents which lead to distribution of infectious material to all parts of the body," unless this statement can be shown to be true of all varieties of pyemia, which it cannot. Thus, as is well-known, the disease may originate from a trivial lesion, from a focus in which neither alkaloids nor toxins can be developed in sufficient amount to produce any systemic intoxica- tion, which is conspicuously absent until thrombo- phlebitis occurs or saturation with and softening of a PYEMIA. 167 hemostatic thrombus by chemical poisons takes place, when infective or septic embolism occurring—as it may and often does—then, as every surgeon knows, systemic poisoning promptly shows itself. Instances of this have been already given and could be multiplied indefinitely. Unquestionably many cases of pyemia are preceded by a mild septicemia, the majority of cases observed in prac- tice being really instances of "septicopyemia"; but this condition differs materially from the one pictured to us by the definition, which incorrectly states the causation and pathology. Bearing in mind the statements made concerning metastasis in Lecture XII. it is easy to realize how one infected thrombus may provide numer- ous emboli, which, carried to the lungs, will establish secondary foci of infective disease, each of which in turn may supply dozens of emboli. In the infective form of pyemia, germs are present in the blood, and they can usually be cultivated from this as well as from the other fluids of the body ; but where the disease originates from the distribution of emboli, free from germs though soaked with ptomains and toxins, diligent search fails to detect any. Fatigue and starvation, or an insufficient supply of food, are usually believed to predispose to pyemia, but this is no more than stating that all mycotic processes are favored by anything causing general lowering of the vital powers ; hence, deprivation of food plus overload- ing of the blood with the retrograde products resulting from excessive tissue-waste is a peculiarly prejudicial combination. Children rarely suffer from pyemia, because in them elimination and assimilation are apt to be more perfect than in those of more advanced age. Open wounds of the medulla of long bones, of the diploe of the flat bones of the skull, because large hemo- static thrombi must form in their relatively non-col- lapsible veins ; infections of a puerperal uterus for similar reasons; infective inflammations, such as carbuncle situated on the lips or neck, are especially prone to be i68 PRINCIPLES OF SURGERY. followed by pyemia, as well as many of the so-called phlegmonous inflammations of the cellular tissue. Symptoms.—The germs require quite as long a time as those producing septicemia to multiply into numbers sufficient to infect the hemostatic thrombi in a wound, or to cause thrombophlebitis ; but, in addition, more time must elapse before they can effect such secondary soften- ing of the thrombi as will permit fragments to be washed away by the blood- or lymph-stream ; hence the symp- toms of pyemia rarely appear before the end of ten days after a wound or operation, although precedent sapremia or septicemia may have been in evidence all along. From what has been already said it will also be clear that pyemia may appear much later, indeed at any time when the local conditions are favorable. There are probably two distinct forms of pyemia, although clinically they can be only inferentially distinguished by the relative mildness of the local manifestations and the greater fre- quency of recovery. In one, the thrombi are plainly only soaked with ptomains or bacterial toxins, hence, when the locally destructive effects of these substances are exhausted, unless a geniune infection occurs second- arily, or a fatal septic—mark, not infective—embolism takes origin from the primary embolic centers, recovery may readily ensue, if the necrotic tissues can be success- fully evacuated. In the other, the infective form, the emboli contain infective micro-organisms as well as their poisonous products ; hence, wherever these emboli are arrested, their germs multiply, extending the destruction of tissue continuously, and almost certainly become new centers for the distribution of infective emboli. This is not a nice distinction, but upon the possibility of the occurrence of the first variety depends a more hopeful prognosis, which encourages the surgeon to adopt active measures. Typical cases of pyemia differ from sapremia and septicemia chiefly by the repeated chills followed by abrupt rises of temperature, which are in turn succeeded by profuse sweating, the temperature PYEMIA. 169 rapidly approximating but rarely reaching the normal point. Occasionally even in acute cases the temperature may remain normal for twenty-four hours, possibly longer, but this is very rare. Sometimes no chill pre- cedes the first abrupt temperature rise and sweat, but the rule is that the onset of the disease is marked by a rigor. It is also rare to have more than one chill a day, yet this is possible. The temperature-chart of a case of pyemia indicates an irregular remittent type. When combined with septicemia the irregularities of the temperature- curve are still greater, fluctuating from hour to hour, even in the intervals between the chills. The tempera- ture is lowest toward the close of the colliquative sweat- ing. Although it is generally believed that each recur- rence of chills results from the lodgement of fresh emboli, this is not invariably the case, while one primary embolic focus has been known to give rise to paroxysms of chill, fever, and sweat, recurring with such regularity as to simulate intermittent fever closely, yet recovery ensued without any evidence of other embolic foci.1 Later in the disease sweats occur independently of chills, but pre- ceded by accesses of temperature. When the emboli are sufficiently disseminated throughout the lung and pro- duce distinct edema, or the secondary changes set up by them become pronounced, dyspnea aud cough are notice- able, with or without sputum, the latter possibly dis- colored or even bloody. Small emboli deeply situated, unless very numerous, may give rise to no very definite pulmonary symptoms, but if lodged near the pleural sur- face they will give rise to pleuritic pain; auscultation will then usually reveal a friction-sound or effusion, and evi- dences of basal pneumonia involving one or both lungs may likewise be detected. Too much stress has been laid upon the "hay-like " odor of the breath, described by Braidwood. Tenderness on pressure over the liver or in the epigastrium, soon followed by icterus and pain on deep inspiration, next show that embolism of the liver 1 Personal experience. 170 PRINCIPLES OF SURGERY. has occurred. Embolism of the liver is usually the first symptom of visceral involvement where the infective thrombus has originated in one of the tributaries of the portal vein, but conversely is a late symptom when the primary source of the emboli is located in a systemic ves- sel. Enlargement of the liver can usually be detected by the time liver-tenderness is unquestionable, and may even be present without this. Pain on deep inspiration will be detected only when the emboli are near the peri- toneal covering, or an abscess is extending toward the hepatic surface. Friction-sounds produced by the lymph- roughened surfaces can sometimes be heard on auscul- tation. Small multiple abscesses are the rule in the liver and in the lungs, but in the former occasionally large collections are found resulting from the confluence of several smaller ones lying close together. Owing to the fact that the embolic processes are often confined to small portions of a few organs, the amount of poisons present in the blood at any one time is not so great as in septicemia, where the germs are more widely diffused, hence the nervous symptoms such as delirium, etc., are absent during the early stages of pyemia, unless it is complicated by septicemia. Of course, at any period embolism of the central nervous system may occur, giving rise to symptoms indicative of the part involved. Late in the disease delirium and coma occur. Erythe- matous, papular, pustular, and purpuric skin-lesions are occasionally seen in pyemia. With or without any or all of the visceral lesions, a sudden implication of one or more joints, or the tendon-sheaths around a large articu- lation sometimes occurs. Other joints become involved, those first attacked in a few days improving to relapse, or possibly to go on to permanent recovery. The pain is slight if the parts are kept at rest, but is intense if the joint be moved. There is often neither fluctuation nor red- ness in the early stages. Owing to edema of the soft parts over the joint, the swelling does not assume the charac- teristic form the joint would show if only the synovial PYEMIA. 171 membrane was distended, but is rounded and ill-defined. The improvement seen in most of the joints after the first few days results from the manner of the deposition of the germs. Small embolic masses of micro-organisms are found in the slighter cases lodged in the synovial fringes and the tissues surrounding the articulation. The tissues gain the victory, nothing but a serous effusion being found in the joint-cavity, or at worst one containing many phagocytic cells loaded with microbes, giving the appearance of seropus. The tissues having won the vic- tory, the serous fluid is absorbed, and the phagocytic cells also disintegrate and are absorbed, or they migrate into the lymphatics. A similar explanation holds good for the painful indurations so often seen in the cellular tissue, so many of which are evanescent. The one or more joints which do not improve gradually present the ordinary appearances and symptoms of articulations being destroyed by suppuration, the cartilages becoming eroded and the bones carious. Emaciation is rapid and marked, in this respect decidedly differing from sep- ticemia. Gastro-intestinal disturbances are not marked in pure pyemia, although, later, diarrhea may set in. The tongue is heavily coated at the tip and sides, brown and dry in the middle, and later covered with sordes, as are the teeth, lips, etc. There is a general hyperesthesia. The spleen is not enlarged unless the subject of metastases, presenting in this respect a marked contrast to the almost constant enlargement of this organ observed in septicemia. The pulse is at first fairly strong, although it is quite rapid, later it becomes very feeble, and subsultus tendi- num is common. The blood shows a marked leuko- cytosis with diminution of the number of red cells, while germs can usually be detected, except in the purely septic, non-infective variety. The urine is scanty, high colored, and contains both albumin, peptone, and germs. Prostration now becomes marked in these latter stages of pyemia, presenting in this respect a marked contrast to the early exhaustion characteristic of septicemia. The 172 PRINCIPLES OF SURGERY. duration of pyemia varies according to whether it is acute or chronic, cases of the former rarely lasting more than ten to fifteen days, instances of the latter continuing for many weeks or months before either death or recovery takes place. If there be a wound it will cease to give exit to normal pus, the discharge becoming watery, and if sloughing or gangrene be present, it will be free and malodorous, while any granulations which may have formed will become dry, glazed and will either melt or slough away. It is astonishing to see how rapidly long amputation-flaps will disappear, leaving the bones pro- truding. The surrounding soft parts are swollen, red- dened, and edematous. Evidences of thrombosis of the veins and inflammation of the lymphatics leading from the wound are often detectable. On post-mortem examination, uncomplicated pyemia shows metastatic processes, infarctions, and suppurations in the viscera, joints, parotid gland, and cellular tissue, in one or all, in addition to the conditions usually found in septicemia, except that the spleen is not enlarged, unless it contains emboli. In septicopyemia the spleen is, of course, enlarged as it is in pure septicemia. Germs are to be found in the infective form, which is the only one the surgeon usually has to examine post mortem. Prognosis.—Acute cases of the infective variety are practically always fatal, because the vital organs con- tain numerous emboli, and even if the systemic intoxi- cation does not prove fatal, the destructive effects of the consequent suppuration in organs essential to life will cause death. Where the brunt falls chiefly or entirely upon the joints and cellular tissue, recovery is not very infrequent. Some patients in whom sapremia exists, if this can be relieved, provided the viscera are not seri- ously involved, and especially if the emboli are entirely germ-free—only septic, not infective—may possibly be saved. In a few cases the pus resulting from the lodge- ment of one or more emboli in an accessible organ or an external part may be successfully evacuated, the pros- PYEMIA. 173 pect being more promising if the source of the sapremia can be removed, as by amputation of a limb. While the outlook is always gloomy for any case of pyemia, it is a great mistake to consider the result a foregone conclu- sion and to abandon all serious effort, as is too often done. Cases of chronic pyemia, where the viscera usually escape, recover more frequently than do those attacked by the acute disease. Treatment.—Remove the primary source of the emboli when possible, but if this cannot be done, disin- fect the thrombotic focus. All blood-flow through the thrombosed vein beyond the obstruction should, when feasible, be checked by ligature of the vein. Macewen freely opens the thrombosed lateral sinus, for instance— in cases of middle-ear disease where the infection has spread to the membranes of the brain—scrapes away the clot, packs it full of boric acid and iodoform powder, and plugs with gauze, also tying the jugular vein upon the affected side when considered advisable, low down in the neck. Aspiration or incision of liver-abscesses, opening and draining of joint, parotid, and other meta- static abscesses, the continuous hot bath for appropri- ately located lesions, and the other measures advocated for the treatment of septicemia are to be adopted if possible. For the medicinal and dietetic treatment, what was said under the same head must suffice. LECTURE XVI. TOXEMIC CONDITIONS PRODUCED BY DRUGS; DIF- FERENTIAL DIAGNOSIS BETWEEN SAPREMIA, SEPTICEMIA, AND PYEMIA; AUTO-INTOXICATION. Before considering the differential diagnosis between the various infective and septic diseases and the more innocent wound-complications, certain preliminary in- formation is requisite. The local or constitutional effects of certain drugs may give rise to errors in diagnosis. Thus, iodoform, carbolic acid, and corrosive sublimate sometimes pro- duce a most marked and often puzzling erythema and even dermatitis. The internal use of the iodids, quinin, antipyrin, copaiba, etc., may give rise, some to papular, others to urticarious skin-eruptions ; more rarely, still different drugs give rise to pustular, bullous,-purpuric, or nodular skin-lesions. Eruptions caused by the local action of any drug are either strictly limited to the area to which they have been applied, or spread but a short distance beyond, while those resulting from the internal use of drugs are seen in parts far distant from any traumatism. The erythema and edema, suspected to be due to the local effects of iodoform, may be quickly proved to have this origin by the application of iodo- form to some distant part, closely confining it by the outer dressings, when if the suspicion be well founded, the healthy skin will soon present the same appearance as that around the wound. Although, in a general way, in any given case of suspected sepsis, it can be affirmed that the appearance of skin-lesions which are pustular or hemorrhagic is confirmatory evidence that "derma- 174 DRUG TOXEMIAS. J75 titis medicamentosa" does not exist, this cannot be relied upon if one or more of the drugs mentioned below have been exhibited. If, on the other hand, no such drugs have been administered, and pustular and hemor- rhagic eruptions do appear in a case of suspected sepsis, then they may be considered as almost pathognomonic. Although the prolonged use of drugs is usually neces- sary for the production of pustular or hemorrhagic skin- lesions, this is not always the case, a single dose of 2.5 grains of potassium iodid having produced a fatal pur- puric eruption in an infant. These purpuric eruptions produced by iodin usually appear soon after the first administration of the drug and cease when it is with- drawn, but are often reproduced by even minute doses. Again, the toxins produced by some microbes give rise to scarlatiniform eruptions which may readily be con- founded with drug-erythemas or with genuine scarlatina. Scarlatina was recognized many years ago as apt to appear in young patients who, previously exposed, showed no evidences of succumbing to the ailment until their vital resistance was lowered by a severe operation or injury. The discrimination of "dermatitis medica- mentosa" from septic or scarlatinous eruptions de- pends upon the exaggeration of the features of the dis- ease simulated, the absence of the throat-lesions of scarlet fever, the head- and backache with the fever of small-pox, etc., and the effect of withdrawal of all inter- nal and external drug medication. The stress laid upon the fact that skin-eruptions not uncommonly follow the use of copaiba, quinin, iodin, and bromin seems to have diverted attention from the rarer, but possible, skin- lesions caused by the administration of such common drugs as chloral, opium, and mercury. Skin-eruptions have followed the exhibition of arsenic, antipyrin, bella- donna, atropin, bitter almonds, bromin, borax, cannabis indica, carbolic acid, chloral, copaiba, creasote, cubebs, digitalis, duboisin, hyoscyamus, iodin, iodoform, mer- cury, opium, pilocarpin, phosphoric acid, petroleum, 176 PRINCIPLES OF SURGERY. quinin, resin, salicylic acid, santonin, tar, and turpen- tine. Of course, these eruptions are nearly always the result of idiosyncrasy. The toxemia produced by the absorption of either iodoform or carbolic acid is liable to lead astray the inexperienced, who may continue the local use, or increase the amount of these drugs, hoping thereby to diminish the sepsis apparently indicated by symptoms which in reality are produced by the drugs themselves. Hence, in all cases where instead of sepsis the poisonous effects of these drugs might explain the symptoms, chemical evidence of the presence of carbolic acid or of iodin should be sought for in the urine, even if the use of these remedies has been suspended. It is therefore of the highest importance to be acquainted with the toxic symptoms resulting from the absorption of these drugs. Iodoform poisoning may be preceded for a day or more by general malaise, succeeded in the worst cases by som- nolence deepening into coma, with contracted, immobile pupils. In slighter cases marked restlessness is first noticed, which soon develops into active delirium, the temperature in these two form of poisoning being always normal and the pulse very rapid. In the more severe cases removal of the dressings fails to avert a fatal termi- nation ; indeed, sometimes the evidences of poisoning have not been detected until after the use of iodoform has been suspended. Schede describes five other types of iodoform poisoning from absorption, besides those already mentioned—viz., " 1. High fever, without other phenomena. 2. Fever, with mild gastro-intestinal irri- tation, depression of spirits, and rapid pulse ; recovery almost invariable. 3. Very rapid, soft pulse, 150-180, no fever ; great danger. 4. Very rapid pulse, with high fever ; death almost invariable. 5. After severe opera- tions, rapid collapse and death. A form of poisoning with melancholia, dilated pupils, and hallucinations is also described ;'' recovery from this is slow. A dark- red, roseola-like condition of the skin has been not DRUG TOXEMIAS. 177 uncommon in some cases. Iodin in large amounts is always to be found in the urine. Two forms of carbolic-acid poisoning are said to be recognizable. One, chronic, is evidenced by headache, anorexia, bronchial irritation, severe pain in the renal regions, cutaneous pruritus, and "various paresthesias, and loss of power in the legs." The acute forms show dizziness, delirium, and unconsciousness. The urine is of an olive-green or blackish hue, this usually being detected only after exposure to the air. One of the earliest symptoms of poisoning is declared to be the dis- appearance of the sulphates from the urine. Proper chemical manipulations will show the presence of large amounts of carbolic acid in the urine. After two hours' exposure to the carbolic-acid spray formerly employed during operations, one surgeon reports that he recovered 30 grains of the acid from his urine. Differential Diagnosis.—While freely admitting that many cases commence as sapremia, then are suc- ceeded by septicemia, and later perhaps have engrafted upon them pyemia, so that the condition present in any given instance is often a most complex one, unquestion- ably there are cases where each ailment pursues its course uncomplicated by any other. It is theoretically possible to distinguish between them, and while their therapeusis is practically identical, the prospects of suc- cess depend largely upon which of the three diseases is the sole one, or the chief one to be dealt with. Sapremia follows large recent wounds or incision of a large abscess ; the discharges are offensive ; there is early chill or profound collapse ; prostration occurs early, and recovery follows when the cause is removed and disinfec- tion secured. The symptoms may recur if the condi- tions productive of sapremia are reproduced, to recede again when they are removed. Septicemia occurs later. It may result from an in- significant wound, such as a needle-prick ; it is often engrafted upon a previous wound-fever ; is an irregular 12 178 PRINCIPLES OF SURGERY. remittent fever. It promptly produces exhaustion out of all proportion to the amount of the fever, etc. The spleen is enlarged. Chill, if present, is early and is not repeated. Metastatic processes are not present. Pyemia.—Suppuration is a necessary predecessor and usual accompaniment of pyemia, although it sometimes occurs with very small lesions. The necessary formation of infected thrombi and their softening takes time, hence uncomplicated pyemia commences after the first week or ten days, sometimes much later. Chills, repeated at irregular intervals, followed by a sharp rise of tempera- ture and profuse sweating, always occur. Evidences of visceral or articular metastatic processes are detectable ; the spleen is not distinctly enlarged except when the seat of embolic processes. Although many other minor differences are distinguish- able, they need no repetition, having already been men- tioned when describing the symptoms of the three affec- tions. Auto-intoxication.—Much has been said concerning the chemical poisons which result from bacterial activity in dead or dying tissues and even living tissues ; but are these the only sources of the toxemias observed after accident or operation ? Nearly thirty years ago I had my first clinical lesson, which unmistakably taught me that my predecessors in the art of healing during many cen- turies were right in regarding attention to the condition of the " primse vise," as they quaintly termed the skin, intestines, and kidneys, as of equal importance with diagnostic and operative skill in surgery—nay, as of more importance, because both these might be frustrated by failing to get rid of all "peccant materials" both before and after operation. The scientific explanation and enforcement of the clinical fact so often insisted upon in the past have but recently been given. This fact of the possibility of auto-intoxication has been too often ridiculed until recently, because the old explana- tion was not in accord with modern teaching, therefore A UTO-INTOXICA TION. 179 (strangely enough) the fact could not be admitted. Thanks to Bouchard's forcible teaching we now recog- nize that when we have perfectly appreciated the role played by germs in the causation of disease, we are still far from comprehending all about pathogenic proc- esses, even those in which germs are the real agents. Perhaps more important still, we have learned that often- times no germs could develop, or if multiplying unaided they could not cause death, and that even in their absence from the blood and tissues death may occur from auto-intoxication. Bouchard with a few of his pre- decessors and followers have reconciled modern science and ancient clinical observation. A few words must be devoted to a recapitulation of some facts which are familiar, but are commonly over- looked. Much of what follows will be found in the pages of Bouchard, Vaughan and Novy, and in text-books of physiology. Various alkaloidal substances are normally found in the tissues—the result of metabolism and retro- grade metamorphosis. These are believed by some to be formed as the result of the growth of germs in the intes- tines, whence they are absorbed, being either eliminated or retained ("stored up") in the tissues. Some of them are the predecessors, perhaps necessary steps in the formation of urea, for instance. Thus, adenin and guanin from vital or putrefactive changes give rise to ammonia, and this in turn serves to form urea. All leukomains are probably poisonous when in sufficient amount. The true leukomains probably result only from the metabol- ism of the cells and protoplasm. To what end have these statements been made? To impress the fact that substances elaborated by the cells are injurious to these same cells, " if the products of their activity accumulate about them." To give a few illus- trations of the poisons produced, the hydrocyanic mole- cule is a frequent constituent of leukomains. The peptones and albumoses of digestion, which are actively poisonous, should not reach the circulation, yet there are 180 PRINCIPLES OF SURGERY. evidences that these do, or at least are not retained in an inert form by the leukocytes, as maintained by Hoff- meister, peptonuria and albumosuria evidencing this possibility. Unquestionably all the phenomena of fever do result from the overformation of poisons from pro- longed mental or physical exertion, or from both, pro- ducing chilliness, a rise of i° to 30 F., anorexia, wakeful- ness, an increased frequency of pulse. All this is explained by the conception that the presence in the blood of an excess of leukomains resulting from retro- grade tissue-changes causes disintegration of the leuko- cytes and a setting free of fibrin-ferment and nucleinic acid. "Exhaustion fever," as it is called, is a more severe form of "fatigue fever;" and has actually been mistaken for typhoid fever ; but rest and proper food, the lack of which caused it, will soon clear up the diagnosis. This form of fever is not uncommon among young troops during an active campaign when sufficient food is rarely obtainable, and the men are unaccustomed to the severe, prolonged exertion of marching, trenching, etc. Fever from retention of excreta is more common than either of the preceding forms, especially in those con- fined to bed who have previously lived an active life. Purgation will commonly relieve this fever, because dehydration of the tissues will enable the fluids to take up the poisons which in turn, reaching the blood, are eliminated into the intestines or pass off by the kidneys. The elimination of these substances is also advantageous because it permits the liver to perform its own functions properly instead of being compelled to attempt the transformation of poisonous into inert substances, and their excretion with the bile. For instance, pepsin or trypsin absorbed unchanged are very poisonous. These the liver arrests and transforms. It will be profitable to consider still further "the dangers threatened by the imperfect performance of the functions of the kidneys, liver, intestines, and skin, by which both poisons nor- mal to the economy and also those of extraneous origin A UTO-INTOXICA TION. 181 are evacuated." Only the salient points need mention, because further information can be secured by consulta- tion of any physiological text-book, and the works of Bouchard, and Vaughan and Novy. If time permitted, there are many interesting questions upon which I should like to dwell, but I can mention only those which distinctly bear upon symptomatology and treatment. As has been said, "man escapes intoxi- cation by the intestinal, cutaneous, pulmonary, and renal emunctories," as well as by the arrest and destruc- tion of poisons by the liver.1 Although some of the poisons eliminated by these organs are not preformed, some are, and each has precedent substances, out of which they are formed, that are injurious if not trans- formed and eliminated. The importance of the renal secretion as a means of elimination of poisons has always been appreciated, and we have in modern times learned that it contains convulsive, pyrogenous, and narcotic substances, even in health. When possible, in all sur- gical cases, the quantity of urine must be ascertained, and to what substances its specific gravity is due. Urea, too commonly regarded as a deadly poison, is far from being this, and is, while injurious if accumulated in enormous quantity, a most useful agent whereby the depurative action of the kidneys is increased. It would take sixteen days for a man to form enough urea to kill him, while in the presence of anuria, so-called uremic accidents appear within the first three days. Urea is eliminated fifty times as rapidly as water by the kidneys, being the most powerful diuretic known, and thus these organs are enabled to carry off in solution large quan- tities of other more poisonous materials, for instance the coloring matters, which are infinitely more toxic than urea. The evidences of one or more defective links in the chain of disassimilation as shown by the deficiency of certain normal urinary ingredients and their replace- ment by oxalates, lactates, etc., although the specific 1 Bouchard. 182 PRINCIPLES OF SURGERY. gravity may be normal, should warn the surgeon of possible cellular malnutrition, which may render ef- ficient an otherwise inadequate number of germs, acci- dentally present in the economy ; or, in the absence of germs, auto-infection may be imminent. LECTURE XVII. AUTO-INTOXICATION (CONTINUED). The kidneys may be ready to do their whole duty, while the liver is unable to entirely convert natural, much less excessive amounts of retrograde materials into urea and normal biliary excreta. Thus, while an excess of uric acid probably results from '' a metabolism slightly diverging from that of urea," it is most likely that the " turn to uric acid rather than to urea is given in the liver," although the spleen may play some part. Again, substances which should be converted into nor- mal constituents of the bile or urine remain unchanged, or the bile is reabsorbed, producing poisoning. The coloring matters contained in the bile are ten times more poisonous than the biliary salts usually credited with so much toxicity. A man secretes enough bile in twenty-four hours to kill three men of the same weight as himself. The poisons of the bile are known to be six times more toxic than those of the urine and lead to destruction of the red-cells of the blood and those of other tissues, notably the hepatic cells themselves. There are also many poisonous materials absorbed from the intestines which may fail in the liver to undergo conversion into innocent ones. That such changes do take place in the liver has been proven by the experi- mentally determined greater toxicity of the blood of the portal vein as compared with that of the hepatic vein. Still further, germs normally present in the intestines which aid digestion produce poisons that should be almost entirely excreted by the feces, but which may be absorbed in dangerous amounts under favoring circum- 183 184 PRINCIPLES OF SURGERY. stances, when present in excess. The steady diminu- tion in the amounts of solids excreted in the urine is a serious menace in any surgical condition, but is pecu- liarly so when both the liver and kidney are crippled. As the author so often quoted insists, when the urine has lost the toxicity due to substances either absorbed from the intestines, elaborated by the liver, or excreted by the tissues into the blood, then systemic poisoning is imminent. The sources of this toxemia are disassimila- tion, the substances which should form the solids of the urine and bile, the food, and the products of intestinal putrefaction. Small amounts of the intestinal poisons are constantly being absorbed, but are as constantly excreted by the urine, no harm thus resulting. Any excessive bacterial action which would lead to the for- mation of dangerous amounts of toxins is probably re- strained in health by the hydrochloric acid of the gastric juice. In many, although not all, cases of fever, this acid is reduced in amount, and large quantities of indol, phenol, and cresol are formed, as shown by the increase of such substances in the urine as the "conjugate sul- phates." It is quite possible that leucin is formed in the presence of certain germs from peptones, which (leucin), if absorbed in large amount, it will embarrass the liver to dispose of by conversion into urea, thus inter- fering with the occurrence of the proper metabolism of this organ. The amount of indol detectable in the urine is regarded by many as an index of the amount of intes- tinal putrefaction and absorption. It is asserted that in simple constipation no increase of the indican can be detected, while intestinal obstruction shows the opposite condition. Although the skin does not normally elimi- nate nearly as much excrementitious material as the other emunctories, yet it does enough, or can be made to do enough in disease to make its assistance worth invoking. While the poisons eliminated by the skin seem to be few in number and small in amount, it is believed that much more of the imperfectly metabolized A UTO-IN TOXICA TION. 185 substances out of which the toxic substances are formed are thus got rid of. Treatment of Auto-intoxication.—What can be done in the way of prevention and cure of auto-intoxi- cation ? The importance of the avoidance of excretory strain being put upon damaged or even healthy kidneys, by compelling them to eliminate autopoisons in addition to bacterial ones, must be apparent to all, because congestion may be thereby induced and functional activity be dimin- ished or arrested. The question of general anesthesia, prolongation of the anesthesia, and the anesthetic se- lected should be influenced by such considerations, especially if examinations of the urine reveal lessened solids or solids in abnormal forms. Relieve the liver from all unnecessary labor by diminution in the quan- tity and discrimination as to the quality of the food, which will also lessen the chances of the formation and absorption of intestinal poisons. Disinfect the feces by charcoal for instance, which by fixing the coloring mat- ters and biliary salts reduces the toxicity of the urine from one-half to two-thirds, the amount of dangerous substances in this fluid being a fair index of the quanti- ties of intestinal poisons formed and absorbed. Give calomel, salol, charcoal with bismuth, bismuth, betanaph- thol, etc., to so inhibit germ-growth that less toxic matter will be formed in the intestines. The use of intestinal antiseptics becomes an imperative duty when the dejecta are especially offensive, and proper mechanical removal of the fermenting intestinal contents by laxatives and enemata are equally demanded. Free purgation by dehydrating the tissues, etc., may not only permit the solution and direct removal of leukomains, but also by their removal favor proper cell-metabolism and elimina- tion. Ingestion of fluid by the mouth, rectum, or by hypodermatoclysis, must follow purgation, lest the kid- neys be not provided with enough fluid to enable them to dissolve and eliminate the proper amount of solids. Use judgment in calling upon the skin to remove ex- 186 PRINCIPLES OF SURGERY. creta, lest, as has just been said, the water of the urine being diminished, renal excretion is interfered with ; but when renal congestion exists, causing partial or complete suppression of urine, the revulsion effected by securing free diaphoresis will often relieve the conges- tion of the kidneys and start the secretion of urine. In the presence of deficient renal activity or actual anuria, cold enemata introduced into the colon1 have been successful by contracting the abdominal vessels, thus expelling from the veins of the spleen and those of the chylopoietic viscera a large amount of blood loaded with poisons, while arterial tension is also in- creased. Dilution of the poisons and increased vascular tension, securing increased renal elimination, may be se- cured by venous saline transfusion, or by hypodermato- clysis, these measures sometimes being followed by chill and a decided rise in temperature, both being due to the increased amounts of poisons dissolved out of the tissues and suddenly added to the blood.2 If time permits, before every operation the old-time practice of securing a normally acting skin by baths, friction, and the ingestion of water ; proper regulation of food, sufficient in amount to nourish, yet not to embarrass the action of the liver ; improvement of the hepatic cir- culation by diminishing the work of the liver by the restriction of food, and alcohol, and the employment of mechanical cleansing and chemical intestinal antiseptics (calomel combining both of these requirements in a notable degree), must one and all be attended to. Do not always be satisfied with one mechanical cleansing of the bowels, but administer laxatives upon several successive days in all cases where circumstances seem to indicate the neces- sity of this measure. Determine whether the kidneys are excreting enough solids, and these properly elaborated. If this is not being done, overcome the incompetency by free ingestion of water, and attention to stomachic, 1 Bouchard. 2 Possibly also to disintegration of blood-cells setting free nucleinic acid. A UTO-INTOXICA TION. 187 intestinal, and hepatic digestion. Should it appear probable that the function of the kidneys is likely to be inadequately performed because of lowered vascular tone, employ means to improve the force of the circulation. Insist upon fresh air and sunlight when possible, both before and after operation, securing this by free ventila- tion and by placing the bed where the sun can fall upon the patient for a few hours each day, except during the height of summer. Abaki and others have observed the favorable influence of these agents on the presence of albumin, sugar, and lactic acid in the urine. To sum up for practical purposes—excessive amounts of poisons are produced in the intestinal tract in the relative absence of hydrochloric acid during febrile dis- turbances and other less well understood conditions, which poisons must pass through the liver. Of these, the greater part in health are arrested and re-excreted with the bile, or modified, the residue passing out by the urine. In disease the following are the results: The overtasked liver cannot perform its own metabolism properly, thus adding to the poisons present in the blood ; the kidneys fail to get rid of all that which passes beyond the liver, partly because of sheer inability, partly because of the diminished formation by the liver of the normal diuretic urea ; and finally, either dangerous sys- temic auto-intoxication results, or the auto-intoxication removes the restraint exercised upon the development of germs by normally nourished tissues, thus often rendering fatal an amount of mycotic infection which would other- wise have proved trivial in its effects. Such considerations are of special importance when we reflect how often in hepatic surgery jaundice is present, symptomatic of im- proper liver-metabolism and excretion. Under such cir- cumstances if the kidneys are fully equal to their duty, there is no special danger ; but if they are inadequate, unless the formation of the autopoisons can be checked, death will occur irrespective of mycotic infection. Still i88 PRINCIPLES OF SURGERY. more certainly will this take place if germs are present, although but few in number. Intestinal sepsis being more often mistaken for sapre- mia than for anything else, a few words are still requisite concerning auto-intoxication. Nothing specific has been said concerning diagnosis because it has seemed more important to impress the fact of the possible occurrence of conditions outside of the wound causing serious in- toxications, believing that with this information and a description of the conditions productive of toxemia this would seldom be permitted to arise, and when present would be eliminated by the measures which would nat- urally be taken during the treatment of surgical ail- ments, if the advice given, born of experience, be taken. If the skin, urinary, and intestinal secretions are scanty, and altered as already described, especially if there be no adequate explanation of the systemic condition in the wound, suspect the presence of auto-intoxication, and if the restoration of these secretions to their normal amount and character be followed by a decided change for the better, auto-intoxication may be safely affirmed to have existed. Even in the absence of any apparent deficiency in the alvine and urinary secretion, it is wise to assume that in disease undue amounts of deleterious substances are formed, requiring exceptional freedom of excretion to maintain health, hence an occasional laxa- tive will often be followed by surprisingly large and offensive stools. Free ingestion of water or the exhibi- tion of diuretics will likewise be followed by the passage of large quantities of urine whose specific gravity is not diminished in proportion to the increase in the quantity of fluid, while the systemic intoxication diminishes pari passu with the successful maintenance of this excess of secretion. LECTURE XVIII. SUPPURATION; ABSCESS; SINUS; FISTULA. Suppuration.—The subject of acute abscess and its possible consequences, sinus and fistula, must now be considered. True (microbic) inflammation resulting from infection with pyogenic organisms must result in sup- puration, microscopic or macroscopic. When this occurs in the tissues, not upon a free surface, it presents general characteristics only slightly modified by the anatomical and physical surroundings of each case. In like manner the general principles applicable to the diagnosis and treatment of acute suppuration require in their applica- tion to special cases only the modifications enforced by the anatomical and physical peculiarities of the location. When suppuration is circumscribed, forming a well- defined collection, the environing tissues being rendered more dense and easy to differentiate from the central liquefied portions of the tissue, an "abscess" is said to have formed. When the circumscription is less well defined, the surrounding parts tending to break down into pus, no distinct boundary of normally vitalized and vascularized cells existing, this is often called a "purulent collection." If throughout the tissues in- numerable foci of pus exist, varying in size from micro- scopic collections to large accumulations, with boundaries between the pus and the tissues so ill defined as to defy accurate delimitation, this condition is termed "purulent infiltration." This is clearly a misnomer, tjie pus not originating from some one or more points and thence permeating the tissue; but the germs, located by embolic processes simultaneously at numerous points or spreading 189 190 PRINCIPLES OF SURGERY. through the lymph-spaces to become arrested in greater numbers at certain points, really account for this dissemi- nation. These three conditions are questions of degree merely, depending upon the virulence of the infecting agents and the resistance of the tissues. The central por- tion of any infected focus undergoes coagulation-necrosis, the intercellular cement and many of the cells are dis- solved, others are loaded with bacteria—i. e., they are dead phagocytes—these constituting pus-cells; moreover, the phagocytic action of the leukocytes serves to remove some tissue. The soakage into the tissues of germ- products containing peptonizing agents disassociates the new cellular exudate, mechanically preventing the vas- cularization and conversion of the cells into tissue while also actively attacking their vitality and rendering them an easy prey for the germs. This process continues to extend peripherally until the virulence of the infection is less potent than the resistance of the tissues, or more generally, until nature or art evacuates the pus; hence one of the dangers of delay in giving exit to pus. Symptoms.—The inflammatory process becomes more localized, the pain usually assumes a throbbing charac- ter, and a chill frequently accompanies the formation of pus if the focus be a considerable one. When super- ficial, the circumscription of the inflammatory redness and swelling is readily discernible. Palpation soon reveals central softening which in turn passes into "fluctuation," detectable by pressing alternately with a finger of each hand. The softened area becomes more acuminated— i. e., " pointing'' takes place. The skin overlying the pus, having its return blood-supply through the subjacent parts destroyed, becomes purplish, thinned, glazed by distending pressure, and finally gives way either by the detachment of a small slough or by ulceration, in either case this being usually preceded by the formation of a "bleb" of epithelium elevated by exuded serum. When suppuration is deeply seated, edema of the super- jacent parts, mottling of the skin from an interference SUPPURA TION. 191 with the venous return less marked than in superficial abscess, tenderness upon pressure, a localized induration or sense of increased resistance of the deeper parts, later softening of the previously indurated area, and possibly obscure fluctuation, indicate acute abscess, especially if fever with preceding rigors has occurred. If situated in certain localities, from pressure upon important veins, edema of the distal parts is produced pari passu with the development and spread of the localized tumor. Pains felt in the distribution of a nerve or many branches of a plexus are often significant when conjoined with local tenderness and constitutional symptoms ; this is notably the case in a perinephric abscess. Percussion will often map out a dull mass which palpation may not locate with much certainty. This is, of course, ap- plicable only to regions where normally resonance should be detected, as the loin, abdomen, and thorax. Sweats with irregular temperature are frequently present in deep-seated pyogenic processes ; in other words, a variety of sapremia or possibly true septicemia results. In such cases as would entail operative procedures to reach a supposed focus of deeply-seated pus, when there is such reasonable doubt as cannot otherwise be resolved, unless the anatomical relations forbid, the use of the exploring or aspirating needle should be employed. This must never be done if it be a question of an intra-abdominal abscess, careful incision being not only a much safer, but more certain procedure, because coils of thickened intestine, matted together with lymph, may readily be punctured by the needle, while the pus-cavity may not be struck or the fluid may be too thick to flow through the instrument. Again, if pus be found by the needle, immediate incision should follow lest the exploratory track become infected. In many localities nothing but good can follow a properly executed incision into an infected inflammatory focus, even if no pus be found, but this cannot be averred of the abdomen, liver, pleura, etc.; hence the qualified 192 PRINCIPLES OF SURGERY. advice given above as to the use of the needle for the liver, pleura, kidney, or deeper structures of the limbs and trunk. The time element and the absence of sys- temic symptoms should exclude any probability of error arising from cysts, malignant tumors, or aneurysms, the differential diagnosis between such conditions and ab- scess being rarely, if ever, requisite in acute suppura- tions. When a chronic or '' cold abscess '' is concerned, the reverse is true, and under this head the differential diagnosis will be mentioned. Diagnosis.—To recapitulate, in a supposed superficial abscess, circumscription of induration, softening, then fluctuation, the portion of the inflamed area showing the last two signs becoming more acuminated—i. e., point- ing—preceded by fever and often chill, indicate pus- formation. In deep-seated abscess, the same or more severe constitutional symptoms, edema, and venous or nerve pressure-symptoms, possibly evidences of com- pression of the esophagus, trachea, rectum, or urethra, when all of short duration and accompanied by a rapid increase in area of the induration, tumor, or area of dulness upon percussion, with lessened resistance over the swelling, still more fluctuation, are reliable signs of deep-seated pus. Of course, in both superficial and deep abscesses, all these signs may not be present in every case, but there are enough detectable to admit of a cor- rect diagnosis being made. Treatment.—Until rupture is imminent, heat and moisture will both hasten and limit the suppurative process, as has already been explained. When it is pos- sible that pus may evacuate itself before the surgeon's knife is permitted to do so, antiseptic poultices must alone be used. Whenever feasible, pus must be evacu- ated at the earliest possible moment by a free incision made at the most dependent point when this is ana- tomically safe. This injunction applies to pus wherever situated, in brain, bone, or the skin. Tension and ac- cumulation of pus must be obviated by counter-openings SUPPURA TION. J93 if necessary, by drainage-tubes, compresses, and some- times by bandaging. The incision should be free enough to permit spontaneous evacuation of the pus, doing away with any necessity for pressure which might damage the protective barrier of granulations and thus spread the infection. For similar reasons, irrigation is often harm- ful ; but if employed, free exit must be provided for the fluid, lest overdistention force infective materials into the surrounding tissues. Pus is always destructive, travelling in the direction of least resistance, hence the danger of leaving accumulations of pus unopened when located near the peritoneum, a joint or tendon-sheath. Beneath dense fasciae, pent-up pus not only gives rise to intense pain but also may exercise dangerous or occlu- sive pressure upon a canal, such as the urethra, trachea, etc., while in other regions it may burrow extensively, producing widespread destruction of tissues. The scar left by an incision through intact skin is always less un- sightly than that following spontaneous evacuation by ulceration. Where a free incision might compromise the integrity of important vessels or nerves, after cutting parallel to their course only through the skin and deep fascia, a grooved director can be bored down into the cavity, pus then passing out by the groove along which a closed pair of dressing forceps can be passed and, being with- drawn opened, a sufficiently large orifice will be made, the vessels and nerves being safely pushed aside. This is Hilton's method for opening deep-seated abscesses. Complications.—Owing to the removal of support, sometimes severe oozing or actual hemorrhage may fol- low the opening of an abscess, even when the patient is not a "bleeder." It comes from vessels in the wall of, or traversing, the cavity. Later, because of weakening of their walls by ulceration, a large vein or artery may open into the abscess, as the deep jugular vein or carotid artery in cases of abscess following scarlet fever and diph- theria. Sometimes this occurs before these abscesses are 13 i94 PRINCIPLES OF SURGERY. opened. Any of the complications common to infected wounds are possible, such as pyemia, erysipelas, etc. The method of healing has been already described in a former lecture. Moist antiseptic dressings are indicated so long as pus or much fluid is being formed, after which dry aseptic ones may be employed, although in an ab- scess of any magnitude moist dressings are usually requisite until the cavity has been effaced. Sinus and Fistula.—A sinus or fistula is a conse- quence of the failure to heal of an abscess or wound opening into some canal, a more or less tortuous, narrow channel being left, lined with avascular granulations secreting thin pus, and opening into the midst of un- healthy and usually exuberant granulations. A '' sinus'' technically is a suppurating tract open at one end, while the term "fistula" strictly interpreted indicates a similar condition which is open at both ends. Either condition results from the persistence of a source of irri- tation and infection, as dead bone, a foreign body, the constant escape of the contents of a canal, hollow viscus, or gland, as the bowel, gall-bladder, urinary bladder, or a salivary duct. An unhealed wound of a salivary duct, intestine, etc., will give rise to a fistula, as will also sloughing—for instance, the destruction of the vesico- vaginal or vesicorectal septum by this process. Congen- ital failure to close on the part of an entire branchial cleft will give rise to a "congenital" or "branchial fistula." These will not be specifically considered here. Causes.—Obliteration of an abscess-cavity or closure of a wound of a hollow viscus being effected by fusion, organization, and contraction of the granulations, if the fusion is mechanically prevented, the deeper portions will form scar-tissue, which by its contraction gradually obliterates the blood-supply to the more superficial layers of cells, rendering them incapable of fusion and definitive healing, even if their surfaces were not mechanically kept apart by wound or other secretions. Treatment.—Healing of a sinus is prevented then by SINUS AND FISTULA. 195 two differing conditions, one vital, the other physical. The first often results from the second, because attempts at healing having been thwarted for long periods by mechanical separation and disturbance of the parts, organization in the deeper parts has gone on until the blood-supply of the surface-granulations has been so di- minished that now removal of mechanical obstacles alone will be useless, adequate reparative material being ab- sent. The mechanical disturbance may result from muscular action, as the alternate contractions and re- laxations of the sphincter ani, the movements imparted to the tissues of the groin during walking. Imperfect drainage prevents the maintenance of contact, and sepa- rates from time to time the sinus-walls. As discharge must persist if a foreign body or infection remains present, the removal of such causes is imperative. The next question is, Is the blood-supply adequate to enable the lining granulations to be healthy, fuse, and develop into scar-tissue ? If this condition exist, prevent separation of the walls by securing free drainage and maintain them in contact with compresses, bandages, and splints, thus securing rest of the sinus and the part also. The tube or gauze employed for drainage must be shortened from day to day, permitting the granulations to coalesce behind ; these measures will usually succeed with a recent case where the granulations are vascular. If it is believed or known that the lining layer of granu- lations is incapable of securing healing from lack of vascularity, the use of means to induce hyperemia will be requisite, in addition to the measures already de- scribed. Sometimes sufficient hyperemia can be secured by packing with iodoform gauze, the application of tincture of iodin, nitrate of silver fused upon a wire, the galvano- or thermo-cautery, or curettage. Again, in certain localities the whole sinus-track with its useless granulations can be dissected out and the tissues main- tained in contact by layer sutures. At other times counter-openings will secure the necessary rest from 196 PRINCIPLES OF SURGERY. better drainage, while the requisite hyperemia can be induced by some of the agents mentioned. In many cases, laying the sinus open throughout its whole extent fulfils every indication, securing the drainage, rest, and reparative hyperemia. These measures are more espe- cially adapted for the treatment of a sinus, but, in addi- tion, it is usually requisite when dealing with a fistula either to divert entirely any secretion—as urine or bile —from passing into and separating its walls, or render it easier for this to get out of the natural canal than to escape through the fistula. The complete diversion of any secretion is only pos- sible by a plastic operation, securing permanent coapta- tion of healthy tissues, rest, and the exclusion of any- thing which can mechanically separate the tissues or interfere with healing. Plastic operation is practically the only method applicable for the treatment of vesico- vaginal, vesicorectal, and many intestinal and other varieties of fistula, resulting from the opening of the hollow viscera by disease or accident. Gradual, and therefore partial diversion of a secretion, for instance urine, from a urethral fistula is usually all that can be done or is necessary. Just so soon as any stricture of the urethra in front of the fistula is sufficiently dilated to render it much easier for the urine to pass out by the meatus than by the fistula, the fistula begins to diminish in size and heals, if the normal caliber of the urethra is maintained. In like manner the removal of the spur of bowel in an intestinal fistula will often secure closure of an artificial anus by permitting the feces to pass along the gut more readily than—being diverted by the ob- struction—through the artificial opening. The foregoing statements embrace all the principles involved in the treatment of any sinus or fistula, re- quiring, of course, modification to meet the peculiarities of special cases. LECTURE XIX. GANGRENE, MOIST AND DRY; RAYNAUD'S DISEASE; SPREADING TRAUMATIC GANGRENE; MALIGNANT EDEMA ; PERFORATING ULCER. Gangrene {Sphacelus, Necrosis).—Gangrene is not a termination, but a result of inflammation, usually due to accidental conditions which are chiefly physical. Gangrene can occur independently of any inflammation, as in anemic gangrene from the tying or thrombotic oc- clusion of an artery. Sphacelus, gangrene, and necrosis, often used interchangeably, are also restricted by some to certain phases of death of tissue. Sphacelus has been thus employed to designate death of all the tissues of a limb in contradistinction to death of some of the tissues, as gangrene of the skin, partial gangrene of a leg. Necrosis is chiefly used when speaking of death of osseous tissue en masse as contrasted with molecular death of bone, " caries; " but it should always be qual- ified by the word bone—i. e., "caries of bone"—be- cause the phrase necrosis is also applied to death of other tissues. There being no rule respecting the use of these terms, the varying significance with which they are em- ployed is mentioned to assist you in your studies. Gangrene has usually been described as "traumatic" and " spontaneous," yet this is faulty, the essential cause of death in many instances of so-called traumatic gan- grene being identical with that in the spontaneous variety—viz., deprivation of arterial blood. Indeed, except when the traumatism physically disintegrates tissues as a stone is reduced to powder, heat or strong acids physically or chemically destroy structure, or cold suspends cellular nutrition so long that when this nutri- 197 198 PRINCIPLES OF SURGERY. tion becomes a physical possibility, vital metabolism cannot be resumed, gangrene always results from total deprivation of pabulum. Tissues normally poorly vas- cularized, epecially if of such loose texture as readily to permit accumulation of exudates, as the scrotum, are especially prone to the occurrence of sloughing and gan- grene. In whatever manner effected, the cutting off of pabulum to the cells is the determining factor, because even if bacterial poisons help to kill the cells, com- paratively few would perish if all were properly nour- ished. But as gangrene often occurs in the absence of all germs or their products, their direct action in deter- mining gangrene is clearly only of secondary importance. The interference with nutrition may be a gross one, as obstruction of a main artery producing direct tissue-starva- tion, or the return of venous blood being impossible, arte- rial blood cannot reach the tissue ; moreover, this over- plus of blood so compresses the plasma-channels that cell-nutrition is arrested. Germs causing, by the inflam- mation excited, the most intense forms of hyperemia and the maximum accumulation of solid and liquid exudate in the tissues, similar interference with cell-nutrition re- sults, so that the tissues perish, partly from starvation, partly from chemical action. In proof of the statement that interruption of the blood-supply to the cells, or the pabulum thence de- rived, is the essential cause of gangrene, it is only necessary to point out that when the direct blood-sup- ply of a limb is destroyed, no gangrene results unless the tissues are so tensely filled with exudate that the collateral blood-supply with the access of plasma to the cells is arrested, when gangrene will follow, whether the compressing material be normal blood or the most toxic of germ-products. This is well seen in injuries of limbs where the direct arterial supply is destroyed and the tissues in which the collateral circulation must develop are tensely filled with effused blood. Trauma- tism sometimes produces gangrene by pure physical de- GANGRENE, MOIST AND DRY. 199 struction of tissue, with partial devitalization of a small surrounding area where the effusion of blood and repara- tive material so adds to the pressure that vascular stasis results. Again, trauma may produce widespread damage to the vitality of the tissues, but not their actual destruc- tion, the effused blood and reparative exudate, as just said, by determining stasis, causing death of the part, which is nearly always hastened by infection. Finally, infected traumatisms produce such free exudation that the consequent severe strangulation, assisted by the chem- ically destructive action of germ-products, overwhelms the vitality of the part. Injuries of the cerebrospinal axis or the peripheral nerves often so disturb the vaso- motor equilibrium that imperfect nutrition of the tissues results, rendering them vulnerable to germs. Absence of pain in such cases also permits prolonged pressure, which mechanically deprives the tissues of their blood-supply ; but, this pressure removed, vasomotor paralysis will be found to have in some measure resulted, often ending in stasis and thrombosis. These facts, with infection of the enfeebled tissues by skin germs, account for the variety of gangrene termed "decubitus." It is a mistake to think that the terms "moist" and '' dry '' gangrene indicate a necessary difference of caus- ation. It is true that, because fluids in excess are present during inflammation, when gangrene follows inflammatory strangulation and infection it is always moist. It is equally true that anemic gangrene, due to the gradual diminution and final arrest of blood-supply —the result of diseased arteries and, finally, thrombosis —is, when uncomplicated, a dry gangrene. In the first form, death of tissue results from the inflammatory exu- dates depriving the cells of pabulum, by compression of the small vessels and plasma-channels ; in the second, starvation occurs because all arterial blood is cut off from the limb. Yet, let accidental inflammation have preceded the final blocking of the artery, or let ligation of the main artery cause gangrene because the collateral 200 PRINCIPLES OF SURGERY. circulation cannot become developed, and if an aneu- rysmal sac is so disposed as to interfere with a free return of venous blood and lymph, this anemic gan- grene will in both instances prove "moist," not "dry." Thus it is clear that the presence or absence of fluid in the part at the time gangrene commences determines whether it shall be moist or dry, not the cause of the gangrene. Dry gangrene must always be due to arte- rial anemia, so gradually induced that the venous blood readily escapes from the part. Although it may follow embolism, it is far more commonly the consequence of a gradual diminution in the arterial blood-supply to the tissues, resulting from loss of elasticity of the arteries with a consecutive total, but slowly produced, blocking of the vessel by thrombosis. Because arterial atheroma and calcification are rarely pronounced except in old age, too often "senile gangrene" and "dry gangrene" are used as synonymous terms. "Anemic gangrene" is bet- ter than either of these names. The vasomotor spasm of the arterioles and smaller arteries induced by the pro- longed ingestion of ergotted rye will produce a dry gan- grene exactly like that which is the result of diseased arteries. The fingers, toes, and tips of the nose and ears are most commonly the parts lost by ergotism. Symptoms of Dry Gangrene.—After a longer or shorter period of coldness and numbness of the toes and feet, even when not exposed to cold, with occasional cramps involving the calf-muscles—i. e., evidences of deficient peripheral capillary blood-supply—a corn is trimmed too closely or the shoe chafes the foot, pro- ducing perhaps nothing but some non-inflammatory hy- peremia. This is just enough to determine stasis and thrombosis ; the hyperemic area and the tissues around the corn or chafed spot become purplish, insensitive, and cold, although quite frequently complaint is made of severe pain in the circumjacent living tissues. The dead parts become blackened, shrivelled, and offensive, while the still living parts are reddened, somewhat ede- GANGRENE, MOIST AND DRY. matous and swollen, and are promptly attacked with genuine inflammation due to the infective germs resi- dent upon the skin. The line of intense hyperemia at the junction of the dead and living tissues is sometimes called the "line of demarcation," while the ulcerative one which succeeds this at about the same place is also called the " line of demarcation," or, more properly, the "line of separa- tion." This limitation of the process is often only tem- porary, the gangrene resuming its progress from time to time, or it is continuous, usually, however, becoming arrested just below the knee, because the popliteal artery is often blocked just above the bifurcation, and the tis- sues below and around the knee receive their blood- supply through anastomoses with the inferior branches of the femoral. When the gangrene is limited in extent there is no constitutional disturbance, although the pain may, by preventing sleep, damage the health and nutri- tion, but if the death of the parts is extensive, evidences of constitutional sepsis appear early. Raynaud's disease, or symmetrical gangrene, is an anemic gangrene due to vasoconstrictor spasm of central cerebral or spinal origin, with possibly secondary changes in the peripheral nerves. Symptoms.—First pallor, coldness and numbness; "lo- cal syncope" is noticed at intervals, affecting the fingers, toes, tip of the nose, the ears, etc. This is the stage of invasion, which lasts for from a few days to a month or more. Next, cyanosis with much pain occurs—"local asphyxia.'' Finally, a dry gangrene (perhaps preceded by vesication) sets in, producing characteristic conical, pointed, shrivelled, gangrenous finger-tips. This proc- ess with separation of the eschars and the subsequent healing of the granulating surfaces occupies from ten days to as many months, averaging from three to four months. Although often associated with various chronic ailments, as no apparent cause is often detectable, renal and cardiac disease, with grippe, etc., can hardly be 202 PRINCIPLES OF SURGERY. considered as standing in any essential causative relation to Raynaud's disease. Symptoms of Moist Gangrene.—There are two forms —viz., that limited to the areas actually killed by a traumatism, with some surrounding tissue which dies from causes already explained ; and that which tends to spread widely, this latter usually being caused by specific micro-organisms, an intense, widespread pyogenic in- flammation resulting, involving the subcutaneous and intermuscular cellular planes, by strangulation of the vessels of which all blood-supply to the remaining soft parts is destroyed. In both forms the primary burning, stinging pain of the inflammation ceases, the skin is pale, cold, insensitive, mottled, greenish, purplish, or red and livid. Blebs containing brownish serum quickly form, beneath which the derm resembles smoked beef and has lost all sensibility. These blebs, being caused by the accumulation of serum beneath epithelium which has lost its vital connection with the derm, can be slipped around upon the surrounding true skin, the epithelium readily separating for long distances around, as in a cadaver, thus permitting their easy differentia- tion from the blebs forming after severe contusions, where the tension and discoloration of the parts often suggest the idea of gangrene to the inexperienced. If a wound be attacked with gangrene, its surfaces becomes pulpy, yellowish or grayish, profuse offensive discharge occurs, the surrounding tissues are swollen, brawny, and then boggy, intensely hyperemic, and the skin presents in various degrees the conditions just de- scribed. The line of demarcation forms by the same septic ulcerative processes already indicated. If life is prolonged, this ulcerative process will effect complete amputation of a limb, even the bone becoming divided. Hemorrhage is uncommon, because in advance of the ulceration thrombosis of the vessels takes place. Gan- grene following injuries causing free division of all the soft parts, especially the skin, because vent is afforded GANGRENE, MOIST AND DRY. 203 for all discharges, are less dangerous to life and limb than slighter traumatisms which mechanically favor the retention of the inflammatory and gangrenous products. Noma, or cancrum oris, is a gangrenous stomatitis, is apt to attack children convalescing from scarlatina, measles, etc., is mycotic in origin—often truly diph- theritic—and produces death of the tissues by inducing capillary thrombosis. Spreading traumatic gangrene is, as was incidentally stated, an acute infectious or septic process, or a result of a mixed septic and infective inoculation. Undoubt- edly some cases result from infection with a gas-produc- ing bacillus. This variety of gangrene advances with lightning speed, extending most rapidly along that side of the limb where the lymphatic vessels lie. Some- times it follows infection after extensive crushes of a limb, where both the main and the collateral arterial supply is destroyed ; but it often arises from a compara- tively slight injury, where either a virulent mixed infec- tion has taken place, or one by a specific aerogenetic bacillus. Symptoms of Spreading Traumatic Gangrene.—The limb quickly becomes intensely swollen and brawny, the skin becomes bronze-colored or resembles bacon rind, streaked or marbled with greenish or purplish lines. Emphysematous crackling can be felt extending beyond the apparent limits of the disease, whose progress can be followed by the eye from hour to hour. Marked sapre- mic symptoms soon appear because of the rapid absorp- tion of the chemical products of putrefaction caused by the great pressure exerted by the confined fluids and gases ; of course, genuine septicemia may follow if life be sufficiently prolonged by operation or otherwise. When the cellular tissue and fat are incised they re- semble spoilt fat pork. Gangrene in Diabetes.—In glycosuria, whether gen- uine diabetes or occurring in conjunction with gout, arteriosclerosis and chronic neuritis are not uncommon. 204 PRINCIPLES OF SURGERY. Slight inflammation excited in the ill-nourished tissues of such patients, in tissues rich in sugar, a substance which has been proven to favor the development of pyo- genic organisms, often determines a variety of moist gangrene. Operations in glycosuriacs are apt to do badly ; but, if infection can be avoided, they are not nearly so hopeless as was formerly taught. Perforating Ulcer.—While in the condition termed "perforating ulcer" the process is rather ulcerative than gangrenous, this slowly destructive process, in time involving the integrity of the foot, can best be consid- ered here, because largely due to chronic neuritis—often coinciding with glycosuria—plus infection of the con- sequently lowly vitalized tissues. It is characterized by a painless, progressive destruction of the parts, the bones succumbing iii time, while the ulcer is insensitive, and resembling a physical removal of tissue rather than one produced by ulceration. Cutaneous anesthesia is always present in some degree, often extending almost to the knee. Treatment of Gangrene.—Nothing but the promptest possible amputation well above all external evidences of the disease will avail to save life in the spreading form of gangrene, the freest possible incisions usually fail- ing to secure against the absorption of a fatal dose of ptomains. Less radical procedures are often possible in other forms of gangrene, at least there is more time for deliberation. Prevent as far as possible the action of, or the access of, germs from without, especially in senile gangrene; secure free drainage and the relief of tension by incisions in appropriate cases. Favor the return of venous blood and lymph, and the development of the collateral circulation. Disinfect and employ dry, ab- sorbent dressings, because moisture favors putrefaction. Abundance of sterilized powdered charcoal, with or with- out chemical disinfectants, is invaluable. Amputation for localized traumatic gangrene should be done only after the line of demarcation has clearly formed, other- GANGRENE, MOIST AND DRY. 205 wise an unnecessary sacrifice of parts will often result. When spreading rapidly do not wait for the line of demarcation to form, cutting many inches above the apparent limit of the disease. When undoubtedly the result of arterial embolism, or following the ligation of a main artery, amputate at, or slightly above, the point of lodgement or ligature, so as to secure flaps vascular- ized by vessels coming off from the artery well above the site of the embolus or ligation. As experience shows that in senile gangrene the superficial femoral artery is often thrombosed far up the thigh, amputation at the junction of the middle and lower thirds, or about the middle of the thigh, should be done rather than a low operation. Of course, many patients are in no condition to stand such an operation. Removal of the limb at the point designated will secure flaps nourished by branches of the profunda femoris artery, which is never throm- bosed in senile gangrene. It is true that in rare instances spontaneous amputation may take place in senile gan- grene just below the knee ; but if an operation be done, the point advised had better be chosen. Many cases of senile gangrene, if limited to the toes, are best treated by dry antiseptic dressings and removal of the dead parts as they separate, satisfactory healing often following this plan of treatment. Extra long flaps should be employed, especially when the amputation is done for gangrene fol- lowing traumatism, and they should be held in con- tact by the dressings, not by sutures ; or iodoform gauze should be placed between them, secondary suturing being resorted to later if deemed requisite. Stretching of the nerves and free excision of the dis- eased structures will at times permanently arrest the progress of a "perforating ulcer," but amputation above the line of anesthesia is usually the only satisfactory procedure. The treatment of hospital gangrene by de- struction of the infected tissues by the cautery, bromin, nitric acid, potassium permanganate, etc., has already been mentioned and will later be again described. 206 PRINCIPLES OF SURGERY. The treatment of Raynaud''s disease consists in the use of the continuous descending current, warmth, pro- tection of the parts, local anodyne applications, massage, and the administration of nitroglycerin before gangrene has taken place. When gangrene is present, the gen- eral principles of treatment applicable to this condition should guide the surgeon. Noma, being a microbic disease, must be treated upon the same principles which have proved applicable to hospital gangrene and sloughing phagedena, except when proven to result from the action of the diphtheria bacil- lus, when serum-treatment should be instituted. Malignant Bdema; Gangrene Foudroyante; Gan- grene Gaseuse.—This is an acute, infectious, mycotic, primarily non-suppurative gangrenous process chiefly involving the cellular tissue, and results from inocula- tion with an aerogenetic bacillus having for its favorite habitat garden-loam. Clinically, the free development of offensive gases seems to be dependent upon the pres- ence of saprophytic organisms in addition to the specific bacillus; in other words, the disease results from a '' mixed infection.'' Symptoms.—These do not materially differ from those just mentioned as characterizing ordinary spreading traumatic gangrene, except by the more pronounced gaseous distention, producing a crepitation like that of normal lung when handled. A thin, stinking fluid can be expressed in large quantities from any wound present, or after incision of the skin. The temperature quickly reaches a high point, where it remains with but slight fluctuations. Delirium appears early, a typhoid condi- tion soon develops, coma appears, and death soon occurs, the whole course of the disease being often run in from eighteen to thirty-six hours. The same bronzing and mottling of the skin already mentioned on page 203 is seen, and blebs containing bloody fluid frequently form. Post mortem, the cellular tissue and the muscles are bathed in and permeated by a thin gas-containing, red- GANGRENE, MOIST AND DRY. 207 dish, evil-smelling fluid. Softening thrombi are found in the veins, while the heart and larger vessels may con- tain gas set free from the decomposing blood. Prognosis.—This is grave, for even if recovery ensues, destruction of the part or loss of the limb is the price paid. Treatment.—While free incisions and the subsequent use of antiseptic dressings or the antiseptic bath are all that can be done locally, when the disease is so situated that the affected tissues cannot be physically removed, amputation should be performed if a limb be the site of the trouble. Appropriate constitutional treatment must be employed, as indicated by the condition of the patient. LECTURE XX. ULCERATION; ULCERS. Ulceration is molecular destruction of tissue, strictly speaking, always the result of infection. An "ulcer" is a solution of continuity situated upon the skin or a mucous surface, produced by molecular loss of sub- stance, sometimes increased by sloughing—the result of microbic inflammation. Any granulating surface left after accident or operation is also incorrectly termed an "ulcer." The differing appearances presented by many ulcers are due solely to local conditions which may vary, from accidental causes, from day to day, obscuring any char- acteristic features the sore may possess. Others owe their peculiarities to specific or constitutional causes, although varying local conditions may produce in them also such changes as will prevent, at least for a time, the recognition of the true causation of the ulcer. These latter forms of ulcers will not be considered here. As all ulcers must attain to the conditions character- izing the "simple," "healthy," or "healing ulcer" in order to cicatrize, this variety must be studied first. All variations from this type are non-specific and are caused by obstacles presented to nature's attempts to heal by organization of granulations and the covering in of this organized tissue by epidermic cells. The margins of a healthy ulcer are smooth, shelve down to a level base, which is covered with healthy granulations, moistened by a little creamy, inodorous pus, or, if asepsis has been maintained or later secured, by an opalescent fluid, rendered opaque, not by dead phagocytes—i. e., pus-cells—but by living cells which have been mechanically extruded with 208 ULCER A TION. 209 the outflowing serum. The surrounding skin is healthy, the edges of the sore are not sensitive, and merge gradu- ally into the granulations by a bluish-white film, opaque and whiter upon the skin side, distinctly bluer and more translucent where joining the granulations. These ap- pearances are due to the advancing growth of epithelium, there being many layers on the older, comparatively avascular organized granulation-tissue where white and opaque, permitting the more recently organized, hence more vascular, granulations to show through a smaller number of layers of epidermic cells where the bluish appearance is seen. Treatment.—As the name implies, if protected from irritation and if the part is kept at rest, healing will take place. Should the surface be so extensive that the regenerative powers of the epithelium are not equal to the task, Thiersch or Reverdin skin-grafting should be employed. Fungous Ulcer.—Let anything persistently interfere with the return circulation, even from a healing ulcer, still more from one that has not attained this condition, and the granulations will become congested, deep-red, overgrown, and ill-formed. They will project above the healthy margins, readily bleed, and give exit to a free, thin, purulent, or blood-stained discharge. Healing ceases to progress and may even retrograde slightly. The dependent position and excessive scar-production in and around the margins of the ulcer, the latter becoming pronounced because of the delay in cicatrization, are the most common causes of degeneration of a healthy ulcer into a fungous one, or of its original formation. Treatment.—The indications are removal of the cause, as the dependent position of the limb, favoring venous return, the employment of remedies to constringe the vessels of the granulations, and mechanical support of the circulation. These indications can be carried out by applying solutions of astringent salts, as those of silver, copper, and zinc, touching the granulations with the 14 2IO PRINCIPLES OF SURGERY. solid stick of nitrate of silver or a crystal of copper sul- phate, and elevation and bandaging of the limb. Edematous Ulcer.—If persistently employed, poul- tices or wet dressings will convert any ulcer more or less completely into an edematous one, although a feeble venous circulation, however produced, favors edema of granulations and may very rarely be the chief cause. Sometimes maceration of the ulcer by its own discharges produces the edematous condition. If the ulcer has pre- viously been healing, the margins may remain fairly healthy, although further progress in the formation of epidermis ceases. The granulations are swollen, flabby, pale, semi-translucent and friable, a large amount of watery pus being secreted, while the margins of the ulcer eventually become sodden and macerated. Treatment.—More blood and that circulating at a proper rate of speed is clearly demanded. Stimulant and astringent applications, such as chloral, grs. x to aqua Ij, resin ointment, balsam of Peru, dry dressings, elevation of the part, and mechanical support of the circu- lation by gentle pressure over the ulcer and bandaging of the limb distal and proximal to the ulcer, are the indica- tions, and their fulfilment will usually soon correct the condition. Indeed, the substitution of dry dressings, in conjunction with desiccating powders such as boric acid or zereform, renewed frequently enough to prevent mace- ration by the discharge, will often be all that is requisite. Inflammatory Ulcer; Inflamed Ulcer.—Trauma- tisms which would produce in healthy individuals no especial result, or at the worst an ordinary ulcer, will often cause in those addicted to the use of alcohol and who are ill-fed and poorly nourished, a rapidly enlarging ulcer, irregular in outline, with sharp-cut, ragged mar- gins. The base of such an ulcer is formed not of granu- lations but of the red, inflamed tissues themselves, which freely secrete a serosanguinolent discharge often contain- ing shreds of dead tissue. If the process be hyperacute, the base may be covered with yellowish sloughs. The ULCERATION. 211 circumjacent skin is reddened, inflamed, edematous, and tender. Inflamed Ulcer.—A previously healthy ulcer, if irri- tated, neglected, and allowed to become fouled with dirt, especially in drinkers after a spree, will often be attacked with inflammation, the granulations becoming intensely red, swollen, and sloughing ; the margins break down, and the surrounding parts become inflamed. Treatment.—In both the inflammatory and inflamed forms of ulcer the indications are to remove irritation, diminish hyperemia, disinfect, limit the amount of the alcoholic poison, secure elimination of effete matters, improve the general nutrition, and secure sleep. Eleva- tion of the part, the application of warm, moist, non- irritating antiseptic lotions—best of all, immersion of the part in the continuous warm bath—moderation in drink, the ingestion of more and better food, and the use of laxatives, diuretics, and diaphoretics will in time trans- form the unhealthy into the healing ulcer. The sloughing ulcer, except when the term is applied to the worst varieties of the inflamed or inflammatory ulcer, is rarely seen except in venereal disease attacking broken-down alcoholics. The parts rapidly melt away, and as the cellular tissue is destroyed more rapidly than the skin, the latter becomes undermined, and the edges of dusky-red integument are consequently inverted. The base is covered with gray or blackened sloughs and the discharge is free and foul-smelling. Great pain is ex- perienced and much constitutional disturbance accom- panies the progressive destruction of tissue. Treatment.—This differs in no important particulars from that appropriate for an inflamed ulcer, except for the greater need of anodynes, tonics, and stimulants. Even in syphilitics mercury is rarely indicated, and when employed must be used with great caution, because the real trouble is acute pyogenic infection, not syphilis. Phagedenic Ulcer; Sloughing Phagedena.—It has been contended that this results from infection by a 212 PRINCIPLES OF SURGERY. specific microbe. As it occurs chiefly in broken-down intemperates after chancroidal infection, this explanation is questionable. In most cases a virulent mixed pyogenic infection attacking the poorly nourished tissues of indi- viduals whose powers of elimination are seriously im- paired by their habits and whose blood is already satu- rated with imperfectly elaborated excreta, would account for the results without invoking the action of a specific germ. Symptoms.—For a wide area around the ulcer, the inflamed skin presents a dusky-red, purplish hue, the margins of the sore are ragged and undermined and rapidly break down, the base is a bloody, sloughing mass, from which exudes a free, sanious, and offensive dis- charge. In its worst forms the tissues disappear with great rapidity by a combined process of ulceration and sloughing, until, for instance, the whole external geni- tals are destroyed. Great pain and constitutional dis- turbance attend the progress of the ulceration. Treatment.—Because of the virulence of the mycotic infection destruction of the germs and the tissues into which they have penetrated is requisite. For this pur- pose—in the severe cases under anesthesia—after careful removal of all sloughs by the scissors or curet, pure bromin, nitric acid, or the actual cautery should be thoroughly applied. In milder cases after removal of sloughs thorough mopping with a i : iooo mercuric chlorid solution followed by the free use of iodoform may suffice. The continuous warm antiseptic bath may be employed to supplement or supersede the methods recommended. The exhibition of opium, tonics, and stimulants, with the administration of abundance of nutritious food, and improvement in the hygienic sur- roundings are both desirable and usually essential. Hospital gangrene is probably a variety of sloughing phagedena, due to a streptococcus infection ; but as it has practically disappeared, no reliable bacteriological examinations have been made. It attacks open wounds, ULCER A TION. 213 producing destructions of tissue which tend to assume a rounded form. The diphtheritic form consists in a co- agulation-necrosis of the granulations, moderate inflam- mation of the wound-margins, diminution of the puru- lent discharge, followed by a free watery one, and finally separation of the sloughs takes place, leaving a " crater- shaped " loss of substance with everted edges. An ulcerating form occurs accompanied by a rather super- ficial enlargement of the sore, the granulations becoming gray and sloughing, and the discharge free. Finally, a pulpy variety is seen, where the granulations become edematous and necrotic, producing excessive swelling of the wound-surfaces, which give exit to large amounts of fetid discharge. The margins are swollen, everted, very sensitive, and the surrounding parts are discolored and swollen. Marked constitutional disturbance exists. Secondary hemorrhage is common, joints may be laid open, and death results from sapremia or septicemia, hastened by loss of blood in many cases, even where no very large vessel is opened; of course, recovery may occur. Treatment.—Asepsis should prevent and isolation ar- rest the spread of this disease, which is clearly con- tagious. Placing the patients in tents will often serve the double purpose of isolation and improve the condi- tion of the patients. The local treatment recommended for sloughing phagedena is applicable to the treatment of hospital gangrene, adding to the list of destructive agents permanganate of potassium and perchlorid of iron. Amputation may become requisite in the presence of severe hemorrhage or destruction of a joint. Indolent or Chronic Ulcer.—Let any granulating surface have its healing processes repeatedly thwarted by mechanical or other irritation, and the formation of epidermis will be prevented, while the embryonic tissue of the margins and base will develop into dense fibrous tissue fixing them to the subjacent bone or fascia. Aided bv a weak action of the heart and interference with the return of venous blood, for instance that produced by 214 PRINCIPLES OF SURGERY. varicosity of the veins, venous hyperemia will be main- tained ; moreover, the arterial supply will be still further diminished by the pressure exercised upon the vessels by the condensing scar-tissue. From a combination of all these causes, the formation of healthy, organizable granulations ceases. As ulcers heal chiefly by the dimi- nution in their superficial area, effected by the contrac- tion of the granulation-tissue forming their bases during organization, only a comparatively small extent of the original surface requiring to be covered by epidermis, fixation of the base and margins of a chronic ulcer is one of the chief obstacles to healing, and the loosening of these parts is essential for cicatrization. Symptoms.—The lower third of the leg is the favorite site for a chronic ulcer. The edges are smooth, rounded, elevated, and indolent, while the circumjacent skin is bronzed, purplish, and often eczematous. Very few granulations can be seen on the base of the ulcer, any present being scattered, pale, and ill-formed. The dis- charge is thin and puruloid or sanious, and usually very offensive. Pain is nearly always insignificant. The duration is from a few to forty years. Some undergo a pseudo-epitheliomatous change, and a few a genuine one, productive of the so-called "Marjolin's ulcer." The terms "eczematous" and "varicose ulcer" merely mean ulcers complicated with eczema or with varicose veins, the former probably largely caused by the latter on account of the chronic hyperemia and malnutrition thus induced. Treatment.—Two distinct indications exist, the first to secure loosening of the base and indurated margins of the ulcer from the underlying tissues, and, second, to so improve the vascular supply of the ulcer that venous return and arterial supply will become normal, resulting in the formation of healthy, organizable granulations. Radiating incisions through the thickened margins reaching down to the fascia will serve the double pur- pose of loosening attachments and inducing hyperemia. ULCER A TION. 215 More or less extensively encircling incisions made down to the fascia, about one inch from the margins of the ulcer, may be employed in extreme cases, and will per- mit the base to contract. Pressure by strapping will stimulate absorption of exudate, thus loosening the ad- hesions and removing pressure from the vessels, permit- ting easier ingress and egress of blood. Blistering will effect the same results and also induce an acute hyper- emia. Free removal of the base of the ulcer with the curet, followed by disinfection with a solution of zinc chlorid, hydrogen peroxid, etc., will often secure asepsis, which must be maintained, and with removal of thick- ening of the margins by incisions, pressure, etc., will often also secure the hyperemia requisite to induce repair. Rest in bed, with elevation of the limb, is a most important adjuvant and is almost always essen- tial. If this cannot be done, and certainly for some time after healing has been secured, moderate support must be afforded to the circulation of the limb by bandages, or an elastic stocking. This support must be permanently employed if decided varicosity of the veins exists, or the veins must be ligated or excised. This latter operation is sometimes advisable as one of the curative measures. When asepsis is not attempted, some one of the measures adapted to remove the thick- ening of the margins with the use of stimulant applica- tions will be best, as resin ointment, blistering, etc. Strapping with resin adhesive plaster by causing absorp- tion from pressure, and at the same time supporting the circulation and stimulating the surface, is an old and reliable method. Although aseptic measures are best in theory, in private practice among the poorer classes they are often impracticable. Skin-grafting, when healthy granulations have been secured, may prove use- ful. Extensive ulcers which have destroyed much of the skin and completely encircle the limb are often in- curable, and either palliation or amputation have to be resorted to. 2i6 PRINCIPLES OF SURGERY. Irritable or Painful Ulcer.—This usually occurs in women over forty years of age, is situated above and near the ankle, and is congested, very sensitive, and a constant source of suffering. Sometimes by gently going over the surface of the ulcer with a probe, a limited point or points of increased sensibility can be made out, due to a partially exposed or irritated nerve- filament or filaments of some magnitude. At other times, especially tender points cannot be detected. The congestion which prevents healing is due to irritation of the exposed sensory nerves, which, as we have learnt, will induce hyperemia in the parts supplied by them. Treatment.—When distinctly painful points can be made out, a section of the base of the ulcer at such places with a tenotome will, by dividing the nerve-filaments, at once relieve the pain and congestion and lead to healing. If sensitive points are absent, rest, elevation, and asepsis must be tried, and full doses of opium administered, which latter often promptly relieves the congestion and causes healing by obtunding the irritability of the im- plicated nerve-filaments. Syphilitic, gouty, tubercular, lupous, scorbutic, car- cinomatous, and rodent ulcers, being special conditions not occurring in some one of the forms described as present after destruction of normal structures by inflam- mation, are not amenable to any general laws or princi- ples, hence must be studied elsewhere. LECTURE XXI. ERYSIPELAS; TETANUS; TETANY. It will now be proper to take up the consideration of certain wound-diseases, because any wound, however slight, may serve as their starting-point, or have its course and nature of its treatment decided by the pres- ence of the complicating ailment. As special instruction is given in bacteriology in all medical schools, no description will be attempted of the morphology, staining qualities, or culture methods of the germs causing the diseases now to be mentioned. Erysipelas.—This is an acute, non-suppurative, in- fectious inflammation of the skin or a mucous mem- brane, due to a streptococcus-infection which tends to travel widely along the superficial lymph-vessels but sometimes extends to the deeper parts. The germs are found in the lymph-spaces, especially at the advancing border. Erysipelas is always due to an open trauma- tism, but this may be most trivial, may have healed before the outbreak of the disease, or may be concealed in a cavity, as that of the nose or pharynx, either of which often contains the infection-atrium of a facial erysipelas ; hence the term "idiopathic erysipelas" is a misnomer, indicating merely that the point of infection has not been detected. It has frequently appeared as an epidemic, often when puerperal fever was prevailing, both proving specially virulent, and apparently closely related to one another. Prognosis.—This is usually good, but owing to com- plications, the result of a mixed or secondary infec- tion, it must be guarded, as meningitis, peritonitis, and 217 2l8 PRINCIPLES OF SURGERY. various septic or infective conditions may supervene. Thus, the comparatively innocent Bacillus prodigiosus when grown with the streptococcus of erysipelas increases by many fold the virulence of the streptococcus, which is taken advantage of in preparing the antistreptococ- cus serum for the treatment of malignant growths. When the inflammation attacks the subcutaneous tissues it is called " cellulocutaneous erysipelas," while if pyo- genic infection is present producing suppuration the term "phlegmonous erysipelas" is applied to the dis- ease. When all the deeper tissues of a part are attacked by a pyogenic inflammation in which the skin is in- volved, the process should not be considered as erysipe- las, but what it really is, a diffuse spreading pyogenic infective inflammation of the cellular tissue of a part, an "infective cellulitis." Although it is quite possible to have an infective cellulitis secondary to true erysipelas, or even under certain circumstances have the erysipelas coccus cause suppuration, yet, dermatitis being a necessary result of deep cellulitis, the skin-lesion does not prove that the disease-process bears any relation to erysipelas ; moreover, suppuration in erysipelas is nearly always the result of secondary staphylococcus infection originating from the germs present upon or in the skin, or deposited from the blood in the congested, inflamed parts. In- flammations of the salivary glands in facial erysipelas and a form of pneumonia may complicate erysipelas; hence, with all the risks incident to any pyogenic proc- ess, the prognosis must be uncertain and dependent rather upon the absence or presence and nature of the complications. Symptoms.—These are both constitutional and local. Malaise is complained of, and sometimes the lymph- nodes nearest to the point of infection may be swollen, tender, and painful twenty-four or more hours before other symptoms are detectable, with reddened lines of inflamed lymphatic vessels leading to them. A chill usually ushers in the attack, sometimes replaced in chil- ERYSIPELAS. 21C) dren by a convulsion. A prompt rise of temperature follows the chill, although an abrupt temperature eleva- tion may precede the chill. The pyrexia is irregular, with a gradual subsidence to the norm, if no complica- tions occur, in the course of about ten days; but in some cases, owing to the tendency to attack fresh por- tions of the skin—the "wandering erysipelas"—con- valescence may be indefinitely delayed. Gastro-intes- tinal disturbance is evidenced by anorexia, a coated tongue, nausea, and possibly diarrhea, which may even be bloody from intestinal ulceration. In phlegmonous erysipelas all the evidences of constitutional infection are present in varying degrees, death taking place in a typhoid state in the worst cases. Delirium and apparent evidences of implication of the central nervous system may be present, especially in facial erysipelas, without any inflammation of the brain or its membranes, due to plugging of the cortical vessels with lymphocytes, although true infective meningitis does sometimes occur. As has already been incidentally mentioned, any or all of the complications of pyogenic infection may occur, many of which have been mentioned when speaking of prognosis ; others will be described when giving the local symptoms of the phlegmonous form. The local symptoms of the cutaneous variety are due to a derma- titis resulting in decided infiltration and edema of the skin, which presents a brightly reddened, sharply defined area, with an elevated irregularly outlined border on the advancing side, which gradually fades into the surround- ing healthy parts at the point first attacked. Vesication is common, the blebs rupture, and, drying, leave brown- ish scabs ; marked desquamation of the epidermis takes place after recovery. In lax tissues as those of the eye- lids and scrotum, the edema is so excessive that great disfigurement is thereby produced. From the great dis- tention of these comparatively avascular parts, gangrene or ulceration of the skin sometimes occurs, which if re- inforced by secondary pyogenic infection may give rise 220 PRINCIPLES OF SURGERY. to serious consequences, as, for instance, deep orbital ab- scess with possible involvement of the meninges by con- tinuity of tissue. When attacking a wound, any union present breaks down, sloughing occurs, and the dis- charge becomes profuse and seropurulent. If a granu- lating surface is concerned, the granulations become dry and glazed, coagulation-necrosis takes place, an apparent pseudomembrane forming, and this in turn is succeeded by sloughing of the granulations, which next attacks the deeper parts, the disease progressing by preference along the cellular tissue. The enormous amount of exudate poured out in phlegmonous erysipelas causes extreme tension ; the parts are brawny and covered with bullae, and the induration is followed by bogginess and later by obscure fluctuation, which becomes more dis- tinct as time elapses. There is decided pain from the great tension, which produces death of the skin, partly by strangulation of its blood-supply, partly from actual destruction of the same, because of death of the sub- jacent tissues. When the skin yields from sloughing or is incised over the softened areas described, pus and sloughs, the latter composed chiefly of cellular tissue resembling wet wash-leather, will be exposed. Because the lymphatic vessels, by which the streptococcus infec- tion travels most readily, run in the intermuscular planes and fasciae, the muscles are often extensively dissected from one another, the pus burrowing deeply, even baring the bone of periosteum and causing necrosis, possibly producing involvement and subsequent destruction of joints. The alleged rheumatic joint-affections some- times observed during an attack of erysipelas are either due to spreading of the inflammation to the joint struct- ures by continuity from a neighboring streptococcus process, or are merely instances of septicemic or pyemic arthritis. If the risk of sloughing of the skin of the eyelids or scrotum from accumulation of exudate is present in ordinary cutaneous erysipelas, this becomes a practical certainty when the same parts are attacked by ERYSIPELAS. 221 phlegmonous erysipelas. It is not uncommon for con- siderable portions of the aponeurosis of the occipito- frontalis muscle to slough, and even necrosis of the skull may occur. Erysipelas attacking the mouth, fauces, or pharynx, is a most serious affair, because of the probability of acute edema of the glottis ; indeed, this accident is thought by many to invariably be due to erysipelatous laryngitis. The older surgeons thought that the intense hyperemia caused by an attack of erysipelas was favorable to subsequent heal- ing ; this can hardly be true except for a chronic or indolent condition, where the vascular supply has been deficient. Post mortem, nothing characteristic will be found ex- cept the local conditions described and the changes common to septic infections. Diagnosis.—Only the cutaneous form is likely to be confused with any other ailment, and this only with erythema and drug-eruptions. Rashes from ptomain- poisoning are commonly generalized, and are not fol- lowed by vesication. Erythema has no elevated, sharply defined border, but the redness fades out into the hue of the surrounding healthy skin. Drug-erythemas are either confined to the areas to which the application has been made, or appear at points far distant from the wound. Still further, constitutional symptoms are absent in drug-erythemas. Treatment.—Isolation is necessary because erysipelas is contagious, and if possible special nurses should at- tend to erysipelas cases to lessen the risk of contagion, while all dressings should be promptly destroyed. Proper action of the secretory organs must be secured and maintained. Avoid or remove intestinal sepsis. Secure sleep by the administration of hypnotics. Em- ploy supporting measures and administer alcoholic stimulants freely, especially in drinkers, supplement- ino- this with strychnin. See that the patient ingests a sufficient amount of proper food. Tincture of the 222 PRINCIPLES OF SURGERY. chlorid of iron, so much in vogue at one time in the treat- ment of erysipelas, is probably of no value beyond, per- haps, its diuretic effects, and later to relieve the anemia. Curative measures must aim to destroy or inhibit the growth of the streptococci producing the disease. This the antistreptococcus serum is supposed to do, and there seem to be good grounds for this belief; yet the whole matter is still upon trial. Maintaining germicidal sub- stances in contact with the skin will result in their absorption by the skin lymphatics—i. e., the tissues in which streptococci flourish. Thus, weak solutions of carbolic acid or corrosive sublimate sometimes exert a decided effect. Ichthyol in the form of 10 per cent. ointment is apparently still more efficacious. Park extols an ointment composed of resorcin 5 parts, ichthyol 5 parts, mercurial ointment 40 parts, and lanolin 50 parts. The use of a 15 per cent, ointment of Crede's colloid silver will probably be still more efficacious. Injections twice daily of small amounts of a 2 to 3 per cent, solution of carbolic acid into the skin or subcu- taneous tissues around, or, better, in advance of the spreading borders of the disease, have seemed to arrest its progress. Recently it has been claimed that the light passage of an alcohol flame twice daily for one or two days over the inflamed surface, covered with one or two layers of moistened gauze, will destroy the germs at the expense of slight vesication of the surface ; this is a radical measure and would seem not entirely devoid of danger. Free antiseptic incision made down to the bone in case of whitlow, before pus has formed, will usually abort the inflammation and prevent the sloughing and necrosis in this probably erysipelatous ailment. The suppurations and sloughings of the phlegmonous variety must be met by incisions, disinfection, and the general and local treatment adapted to similar conditions pro- duced by pyogenic infection, such as those which have already been described, or which will later be adverted to. Amputation may become requisite to avert death TETANUS. 223 from exhaustion or infection, and to remove at the same time a hopelessly damaged joint or limb. Intubation of tracheotomy is usually requisite to save life in edema of the larynx, but free scarification of the infiltrated tissues will sometimes suffice. Tetanus.—This is an acute, non-suppurative, microbic disease, characterized by tonic followed by clonic con- tractions of the voluntary muscles. The germ is an anaerobic one, hence the danger of lacerated and punct- ured wounds which provide anaerobic culture-chambers. Suppuration favors tetanic infection because the pyogenic organisms consume the oxygen and thus render possible the multiplication of the tetanus bacillus and its spores, which latter are in the majority of instances the infec- tive agents. Valagussa has apparently demonstrated that the tetanus germ is only toxic when, developing anae- robically, losing its virulence when exposed to sunlight and air, although still continuing to grow. It cannot be isolated from the surface of the soil, being there killed by the agencies described—i. e., sunlight and air. The aerobic form, if old and grown with common saprophytic germs anaerobically in the dark for long periods at a proper temperature, becomes again pathogenic. These observations explain the toxicity of the germs found in the excreta of some of the domestic animals, notably the horse. The microbes are found in the deeper portions of the superficial layers of black loam, particularly garden soil which has been manured with horse- dung, animals in whose alimentary canal tetanus germs flourish. Although certain races seem more prone to develop tetanus, as the negro, the Hindoo, and the South Sea islanders, this may be more ap- parent than real, owing to their unclad feet and bodies, the use of mud- or dung-poultices for wounds, mud for arrow-poison, a constant temperature favor- able to the development of the bacillus, and their often filthy habits of life. Conditions favoring lowered vi- tality and congestion, as the relatively cold tropical 224 PRINCIPLES OF SURGERY, nights following the hot days, predispose to tetanus, as Larry found in his Egyptian campaign. The specific microbe is never found in the tissues at any distance from the wound, hence it acts by its toxins, tetanin, tetanotoxin, and spasmotoxin. Idiopathic teta- nus does not exist, the name being a mere confession of ignorance as to the locality of the site of infection ; thus I am cognizant of a case where the portal of entry was proved to be a carious tooth, the child constantly putting the finger, soiled with garden mould in which it played, into the painful hollow tooth. Slight traumatisms of the respiratory and alimentary tract may be the sources of the infection. Tetanus occurring in consequence of wounds of parts supplied by the trifacial nerves is apt to show predominance of spasm of the facial, pharyngeal, and cervical muscles, and a comparative absence of in- volvement of the abdominal muscles ; indeed, from the superficial resemblance to hydrophobia, it is often called "Tetanus Hydrophobica," and is asserted to be one of the least fatal varieties of tetanus. Symptoms.—While in the laboratory the incubation period is about forty-eight hours, it must be clear from what has been said that clinically it must vary, because a less virulent form of microbe may acquire toxicity by long growth with saprophytes in the wound, and the nec- essary anaerobic conditions may supervene at different periods. Thus, although the disease usually appears in from two to four days after the reception of the wound, and rarely later than three weeks, yet it may show its first symptoms as late as between six and eight weeks, as in one reported case. The first symptoms noted by the patient are stiffness of the posterior cervical muscles, preventing the chin from being readily depressed, and difficulty in moving the jaw frbm "stiffness" of the temporal and masseter muscles, this condition being often described by the patient as a "sore throat." The mouth cannot be fully opened, and the maximum point is slowly reached with manifest effort. The mus- TETANUS. 225 cles mentioned are rigidly contracted, which condition soon renders them sore and painful. Owing to tonic contraction of the risorius muscles and the depressors of the angles of the mouth, a peculiar "sardonic grin" is noticeable. The abdominal muscles are so tensely contracted that the abdominal wall feels "as hard as a board." The extensor muscles of the trunk and limbs gradually become rigidly contracted, producing over- extension, "opisthotonos." " Pleurosthotonos " is the term employed to designate lateral flexion, while, if the abdominal muscles and flexors of the thighs gain the mastery, the body is bowed forward, " emprosthotonos " resulting. Opisthotonos is almost the rule, and is often so extremely pronounced that the patient rests upon the occiput and the heels, and can be lifted by the latter, touching the bed only with the head. Both the tonic rigidity and the clonic spasms are apt to commence in the limb injured, although there is no invariable rule. Even during the early stages of the disease, clonic spasms occur from time to time, induced by light, noise, a waft of cold air, or the slightest touch, owing to the intense excitability of all the reflexes. Tonic spasm of the sphincters produces constipation of the bowels and retention of urine. The mind remains clear, and the temperature is often not abnormal for the first few days. As the case progresses, the clonic exacerbations increase in frequency and severity, and add to the difficulty of respiration constantly present from slight tonic contrac- tion of the diaphragm, complete spasm of this muscle with violent contraction of the accessory muscles of respiration and of the glottis, until death seems immi- nent from apnea. Occasionally a little air enters or escapes from the chest with a hissing sound through the tightly clinched teeth, the patient presenting a most dis- tressing appearance, the face cyanosed, with foam- covered lips, protruding eyeballs and beaded with sweat. The violence of the paroxysm gradually diminishes, and a return to the rigid tonic contraction occurs, or death 15 226 PRINCIPLES OF SURGERY. takes place from apnea. Pain is not so severe as would seem must result from the violent contraction of the muscles. Later in the disease, generalized sweating is not uncommon. The temperature may rise and con- tinue to ascend even after death, touching a high point. The case may reach its acme, and death, due to apnea, occur in from a few hours to three or four days; or again the disease may commence more gradually, progress slowly, and only occasionally exhibit the violence de- scribed, when it is called "chronic tetanus." The in- cubation in such cases is usually much longer, and the whole course is much milder, justifying a more favorable prognosis than for acute tetanus. Post mortem, there is nothing really characteristic to be found either in the wound or elsewhere. Diagnosis.—Strychnin-poisoning contrasted with tet- anus shows spasms of the masseters last, the convulsions are clonic not tonic, and there is often green vision. Hydrophobia has distinct mental symptoms, hallucina- tions and paralysis of deglutition, a thick tenacious mucus is secreted, and death takes place after apparent amelioration of the convulsive phenomena—i. e., paresis or paralysis occurs, sharply contrasted with the increas- ing violence of the paroxysms and death during a con- vulsion, as is usual in tetanus. As tetany, a pure neurosis, may supervene after thyroidectomy, the chief points in which it differs from tetanus require mention. The symptoms may appear almost immediately or as late as ten days after operation. Facial muscular spasm appears late or not at all, when present sometimes producing trismus and the sardonic grin. The hands are flexed and drawn to the ulnar side, the fingers are extended at the interphalangeal joints but flexed at the metacarpophalangeal joints, the thumb being drawn into the palm of the hand ; "the elbows are bent and the arms folded over the chest." This results from tonic spasm of the affected muscles, which may be partly overcome by firm traction. Pain is ex- TETANUS. 227 perienced during these tonic spasms, which last for a number of minutes, recurring at fairly regular intervals. Similar pedal spasms are also noted ; hence the name " carpopedal spasm." There may be elevation of the pulse and temperature in acute cases. Compression of the main vessels or nerves of a limb will induce the spasms, as will a sharp tap over the facial nerve as it comes out from the parotid gland. The post-operative disease is always dangerous and is frequently fatal. Its connection with dilatation of the stomach and other affec- tions does not here concern us. Prognosis of Tetanus.—Although the prospects of re- covery are poor in an acute case, the epigrammatic French saying '' tant des cas taut des morts'' is not justified. The prospects are better in the subacute form, and in cases of chronic and of head tetanus. Any patient who lives over six days has a fair chance of recovery. Lambert claims that even with the older methods of treatment the mortality is for acute cases only 80 per cent., and for chronic cases 40 per cent., being an average mortality of 60 per cent, for all forms. While the antitoxin treat- ment has effected only a reduction of 5 per cent, in the mortality of acute tetanus, it has reduced that of the chronic variety to 16 per cent., a very material improve- ment. This increase in the chances of recovery is un- fortunately limited to cases where the incubation period is seven days or over. LECTURE XXII. TREATMENT OF TETANUS; HYDROPHOBIA. Treatment of Tetanus.—From careful observations it would seem that a peculiar affinity exists between the nerve-cells and the tetanus toxins, and their fixation by them has been seemingly demonstrated. This explains the failure of antitoxin when employed late and by the cellular tissue or by the veins, because of the weaker affinity of the antitoxin than of the toxins for the nerve- cells. A number of clinical observations apparently indicate that the serum is not strictly antidotal, but confers immunity on the nerve-cells, hence must be used chiefly as a prophylactic, although of course serviceable during an attack in protecting such nerve-cells as have not absorbed the poisons. Intravenous injections should be used to neutralize the toxins in the blood ; intra- cranial ones can alone reach those fixed by the nerve- cells. Intracranial injections must be thrown in drop by drop, with the strictest of aseptic precautions.1 Ram- baud recommends doses of 3C.C, thrown in by means of a special syringe with a piston working through the cap by a screw-thread, the fluid being forced out of the instrument by screwing the piston down. The point must be conical, to fit a trephine opening through the skull 7 mm. in diameter, the needle being connected with the syringe by rubber tubing, to prevent laceration of the brain ; the needle should be grooved on one side to permit the escape of any fluid. Ten to twelve minutes should be occupied in making each injection, 1 A death from brain-abscess weeks after recovery from the tetanus has recently been reported. 228 TREATMENT OF TETANUS. 229 which should be made into the brain-substance in one of the neutral zones. Several points of injec- tion may be deemed requisite, as well as a repetition of the process. Intravenous injections should also be employed in conjunction with the intracranial ones, for reasons already mentioned. Perfect rest must be en- joined, because Lambert reports five cases of sudden death after apparent recovery, occurring during a con- vulsion excited by the patient being suddenly aroused out of a sound sleep. The only probable means of averting such an accident, besides quiet, is keeping the patient under the influence of chloral. As the vitality of tetanus bacilli and their spores is not affected by the antitoxin, both retaining their vitality in a wound for weeks, successive increments of toxins may be formed as the spores develop, although the effects of the primary dose may have been neutralized by the antitoxin. Repe- tition of the remedy in doses of 10 to 20 c.c. once a week for at least three weeks has been recommended to main- tain the immunization. What therapeutic doses of antitoxin shall be employed? From 15 to 30 c.c. repeated at intervals of six hours until improvement is noticed ; then smaller doses at increasing intervals. When used by the intravenous route, either smaller doses should be employed or the intervals must be greater. But in the absence of anti- toxin, or until this can be procured, can nothing be done? Such a measure of success attends the use of drugs which physiologically antagonize the symptoms induced by the tetanus toxemia, that prolongation of life is often secured until all the poison is eliminated and the tetanus spores cease to develop; indeed, some of the drugs to be mentioned, notably chloral, have frequently been used in conjunction with the antitoxin. The twofold end should always be kept in view, of antagonizing the effects of the toxemia and preventing the further formation of toxins by destruction or removal of the germs and their spores. Considering this last indication first, amputation 230 PRINCIPLES OF SURGERY. of a limb or excision of the tissues for some distance around the wound has been practised. Rose has seen 42 cases recover after the first procedure, and it is cer- tainly the surest method of disinfection, because remov- ing the source of infection. Destruction of the infected tissues by the free use of the actual or potential cautery has seemed occasionally beneficial, while in the more chronic forms, hypodermic injections of from 2 to 5 per cent, solutions of carbolic acid or weak solutions of corrosive sublimate seem to have exercised a curative effect. Neurotomy and nerve-stretching still have advo- cates, as Rose. As several toxins have been isolated, and as some cases of tetanus begin with pains in the wound and spasms of the adjacent muscles, while others show trismus—i. e., "lock-jaw"—first, it has been sug- gested that different toxins are operative in these two classes ; restriction of amputation and nerve-section to cases where local symptoms are the primary ones, may demonstrate the real value of these procedures. A col- league obtained a recovery after an amputation of a finger, cause and effect seeming to be distinctly related. Of the drugs which diminish reflex excitability and the tendency to clonic convulsions, chloral occupies the first place. When difficult to administer by the mouth it may be given by the rectum, and by either route acts better when combined with a bromid. Chloroform, cautiously employed, certainly relieves suffering, and its use is claimed to have reduced the death-rate by 10 per cent. Morphin is beneficial by mitigating the tonic spasm and securing sleep. Inhalations of nitrite of amyl, administered between the paroxysms, has in my experience given great relief. When one remedy ceases to benefit, another should be tried for a time, perhaps returning again to the former remedy later. Absolute quiet in a dark room, daily evacuation of the bowels, catheterization of the bladder at proper intervals, and the administration of nourishment, by a catheter passed through one nostril if food cannot otherwise be ingested, TREATMENT OF TETANUS. 231 or by the stomach-tube under anesthesia if necessary, are all imperatively demanded. Comparing the antitoxin treatment with that by drugs, Goodrich's statements may be accepted as true in the present state of science : (1) "The rate of recovery is higher under the anti- toxin treatment in those cases having short incubation. (2) " The supremacy of antispasmodic treatment seems most marked in cases of unknown incubation, where, in most instances, no wound was discovered. (3) '' Most of the cases treated by antitoxin have prob- ably been reported, whereas the great majority of fatal cases treated by other methods are quite as probably withheld from publication. "Thus it would seem that .... antitoxin holds a very important place in the treatment of tetanus, although whether it is established there positively is as yet a question. . . . Tizzoni's product has undoubt- edly been the most successful." The prophylaxis of tetanus is of great moment. Eat- ing raw fruits or vegetables which have not been thor- oughly cleansed should be avoided, especially fruit which has fallen to the ground, lest an abrasion of the mouth or a carious tooth become infected ; again, fissures of the anus, a lacerated perineum, etc., might permit infection by germs passed with the feces. Absolute asepsis of all dressings is imperative, for one surgeon relates two cases where tetanus resulted from the appli- cation of dressings which had been laid upon the floor. All wounds, however trivial, should be disinfected and protected. When well-grounded suspicion of tetanus infection exists, after the ordinary scrubbing and disin- fection employed for any infected wound, such remedies as hydrogen peroxid, a 1 per cent, solution of silver nitrate, tincture of iodin or iodoform powder, should be used. Dennis states that a y2 per cent, solution of iodin trichlorid should be tried, when procurable, because this " destroys the action of the toxins in less than an hour." 232 PRINCIPLES OF SURGERY. If a finger or toe be the part wounded it should be at once removed, if the vulnerating object can be shown to have tetanus germs upon it; this is, of course, often im- possible to do, but immunization by antitoxin should be effected in all suspicious cases, especially in localities where tetanus is known to be rife. Hydrophobia.—This is an acute infectious disease never originating in man. It usually results from the bite of some rabid animal, as the dog, fox, wolf, skunk, or cat, although the saliva applied to a scratch, as by a dog licking the hand, may cause the disease. Although the saliva is the usual vehicle of the contagium, yet the other fluids or tissues of an infected body may, if applied to a wound, produce hydrophobia, as has occurred dur- ing a post-mortem examination. As the teeth of the animals mentioned are not grooved or hollow, as are those of venomous serpents, they are often wiped clean from any saliva, if the wound is inflicted through the clothing. This is especially true for those last injured if a number of other animals or persons have been bitten in rapid succession ; hence the greater danger of face and hand wounds. Skunks usually bite the face or hands during sleep, and in consequence, these animals convey the disease with great certainty. From 5 to 15 per cent, of those bitten acquire the disease where the bites are received in all parts and through clothing, etc. The mere fact that typical cases occur in infants dis- poses of the absurd contention of some that the disease is a psychic one, the result of fear and a knowledge of the symptoms. Because of the risk of this disease being conveyed to man by pet dogs during the incubation stage, it is important to study the symptoms of hydro- phobia as exhibited by the animal. Symptoms in the Dog.—After a variable period, if a bite has been received, there is fever, which is of course rarely detected. The animal is dull, and shows distinct evidences of mental disturbance ; he is shy, restless, hides himself; has illusions shown by snapping at in- HYDROPHOBIA. 233 visible objects and listening to sounds, neither of which have any existence. When caressed he will snap at the hand, and then suddenly fawn on his master, evidently having at first failed to recognize his owner. Additional proof of the altered mental state is shown by the ten- dency to roam unless chained, due to a desire to avoid association with either men or animals ; indeed, the sight of another dog will often give rise to an access of fury. Perversion of appetite is shown by eating coal, gravel, excrement, his own hair or tail. Free salivation is an early symptom, the fluid being thick, tenacious, possibly frothy. Owing to congestion, with edema of the fauces and pharynx, the bark is nearly always much altered, muffled, hoarse "ending with a peculiar howl." Partial paralysis of deglutition appears, rendering it hard to swallow, but a rabid animal will often plunge his muzzle beneath water in the effort to drink ; indeed, there is no fear of water in the dog, although, finding that he cannot swallow readily, he may abandon the effort. In one form the '' furious'' fever, rapid respira- tion, dilated pupils, and active delirium become pro- nounced, the animal, if roaming away from home, at- tacking all objects animate, or, occasionally, inanimate in his path; or, again, he may now for the first time start on his wanderings. Gradually increasing paralysis, com- mencing in the hind limbs and extending forward, suc- ceeds the "furious" stage, the hind quarters dragging helplessly ; then all power of locomotion is lost, and the animal dies exhausted. The dumb form results from early paralysis of the muscles of the jaw, which drops, permitting a constant dribbling of frothy saliva ; the animal is "dumb" because he cannot bark without con- trol of his jaw-muscles. During the feverish stage, and for some days preceding this, the saliva is infectious, which explains the cases of hydrophobia caused by the bite of a supposedly healthy dog which unfortunately has not been allowed to live long enough to demonstrate that it is really suffering from rabies. Death is almost 234 PRINCIPLES OF SURGERY. invariably the result in the dog, taking place in from twenty-four hours (rare), to so late as ten days (very rare), the majority perishing in from six to seven days. A few recover. The incubation period is very variable, lasting usually in the dog about six weeks, although it has recently been alleged to have extended to two hun- dred and seventy-six days. The possibilities of error are so great in such exceptional cases, that, unless the animal has been caged all the time, a reasonable doubt must exist whether a later inoculation has not occurred. In man the incubation varies from eight days to as many months, averaging between fourteen and thirty days. The microbe has never been isolated, but seems to locate itself chiefly in the central nervous system, although the virus is also found in the peripheral nerves and the salivary glands. Drying in the air will destroy the activity of the spinal cord in fourteen days ; 500 C. will do the same in one hour, as well as prolonged expos- ure to the direct rays of the sun, or to the action of a 1 per cent, solution of either carbolic acid or corrosive sub- limate. Pasteur's theory of the causation and treatment is founded upon the, as yet, unproved hypothesis that rabies is a germ disease, the microbes locating and de- veloping chiefly in the nervous system, and that either the germs or the tissues produce an antitoxin capable both of neutralizing the bacterial poison and destroying the specific microbes. Post mortem, the changes are not very characteristic. In dogs the mucous membrane of the mouth and fauces is congested and coated with thick, tenacious mucus or mucopus, "often mixed with dirt." The mucous mem- brane of the respiratory tract may present similar appear- ances, minus the dirt. Congestion of the lungs, with subpleural ecchymoses, is common. The stomach is usually filled with a miscellaneous collection of feces, stones, coal, etc., unless the animal has been prevented from securing anything but its food. The upper por- tion of the small intestines also is apt to contain similar HYDROPHOBIA. 235 objects. Intense hyperemia and swelling of the mucous membrane of the stomach exists, with extravasation of blood and erosions. The same covering of thick, tena- cious mucus is seen. The small intestines present minor degrees of the same conditions. Marked hyperemia of the kidneys is present, and, possibly, small ecchymoses in the floor of the fourth ventricle. Sometimes all these conditions are practically absent. In man definite, gross lesions are absent, the appearances presented being those common in an acute infectious disease ; as Biggs says, there is " possibly more marked congestion of the mucous membrane of the alimentary and respiratory tracts, and more hyperemia of the brain and spinal cord and their meninges, than is usually present in other types of infectious disease." Sections through the bulb or cervical division of the cord show microscopically decided hyperemia, with perivascular cell-proliferation and accumulation. Minute nodules, composed of em- bryonal cells surrounding degenerated or proliferating nerve-cells, are said to be almost diagnostic when occur- ing in the nuclei of the glossopharyngeal, pneumogastric, and hypoglossal nerves. Hyperemia, edema of the mem- branes, occasional hemorrhages around a few vessels, thrombosis or obliteration of the minute vessels of the gray matter from hyaline degeneration; blocking of the same by hyaline pigmented material or leukocytes ; pro- liferation of the lining cells of the central canal of the cord ; hemorrhages into the gray matter and small foci of degeneration in the same, have all been described. According to one writer, mononuclear, and less often poly nuclear, lymph-cells " invade the protoplasm of the cell and fill the pericellular lymphatic spaces, dilating them to form nodes." Apparently the nerve-cells them- selves proliferate, several smaller cells replacing one larger one ; or more extensive, evenly distributed de- generation takes place. These changes not only involve the gray matter of the centers of the nerves already mentioned, but also the cerebral cortex, thus accounting 236 PRINCIPLES OF SURGERY. for the hallucinations. The changes induced in all these centers diminish their power of control over reflex irritations, death eventually resulting from exhaustion- paralysis of these nerve centers—the maintenance of whose functions is so essential to life—because they are no longer capable of responding to the vital reflexes. Symptoms.—Prodromal Stage in Man.—During the incubation period the healed wound may itch, become painful, swollen, and cyanotic; very rarely vesicles form. Darting neuralgic pains starting from the wound are sometimes complained of; gastric disturbance and men- tal depression are the rule ; hyperesthesia is marked, and undue irritability of the special senses is shown by the distress caused by ordinary light and sounds. Chilliness may be felt, while the bodily temperature is elevated one or more degrees. A peculiar catching of the inspiratory act, due to incipient spasm of the diaphragm, next appears. Stage of Excitement.—Stiffness and pain are expe- rienced in swallowing, soon followed by spasmodic con- tractions of the musculature of the pharynx, and to this is added pronounced spasm of the diaphragm, which before existed only in its incipiency. Excited at first by actual attempts to swallow, by association of ideas aided by the increased sensibilities of all the reflexes, the sight or sound of pouring water, a sudden sound, bright light, touching the skin, etc., will now start the paroxysms of choking and dyspnea, during which attempts to hawk up and expectorate the tenacious mucus which cannot be swallowed take place, causing sounds which it is imagined resemble the bark of a dog. In the intervals irregular, spasmodic action of the diaphragm causes distressing dyspnea. Delirium is absent at first, but later is often present, especially during the paroxysms, when the patient may become maniacal, even attempting to do violence to others. Vomiting is common, and incon- tinence of urine and feces is not rare, the urine being apt to be albuminous. Moderate pyrexia is the rule, HYDROPHOBIA. 237 although even 1050 F. has been observed. This stage may last from a few hours to ten days, averaging, how- ever, from four to five days. Paralytic Stage.—For a variable period before death, the paroxysms diminish in frequency and severity, swal- lowing now often becomes possible, delirium disappears, and a delusive calm comes on ; but the pulse becomes rapid and weak, death resulting possibly in coma—the end being often preceded by a varying degree of paralysis which usually commences in the muscles of mastication and deglutition. Prognosis.—Death is almost invariable in genuine rabies, but as only about 5 to 15 per cent, of those bitten in all parts of the body by all varieties of animals capable of conveying the disease acquire hydrophobia, the dis- ease is a rare one. Diagnosis.—This is far easier in practice to one famil- iar with tetanus, hysteria, and cerebral affections, than is generally believed. In a well-marked case of hydro- phobia, the great mental excitement, the delirium, the intense hyperesthesia, the characteristic respiratory spasms steadily increasing in " frequency and intensity," the free secretion of tenacious mucus, the illusory im- provement before death, with paresis or actual paralysis, and the absence, post mortem, of "gross lesions sufficient to account for the symptoms during life," and the micro- scopic finding already described, should suffice for a cor- rect diagnosis. The history of a bite, especially if healed for weeks, and not anywhere in the distribution of the fifth pair of cranial nerves is important corroborative evidence, because tetanus never occurs weeks after the healing of a wound, and the only form likely to be con- founded with hydrophobia, the " tetanus hydrophobica," never occurs excepting when the injury involves the dis- tribution of these nerves. Subdural inoculation of rab- bits with portions of the cord will settle the diagnosis. Treatment.—This must be prophylactic. Excise when possible the infected tissues for some distance around the 238 PRINCIPLES OF SURGERY. wound, and preferably cauterize them afterward with the hot iron, although other caustics will serve. If ex- cision is impracticable, use the hot iron or any other caustic available. When possible, employ Pasteur's prophylactic vaccination. As this cannot possibly be done outside of specially equipped hospitals, a minute de- scription of the method would be here out of place. Suffice it to say that rabic virus, with a fixed period of incubation, is secured by subdural inoculation of rab- bits; that the virulence is attenuated by drying over caustic potash at about 73°F.; and that daily inocula- tions are practised with virus of increasing potency until, by the fourteenth day, a cord dried for only three days is employed. The use of a too active cord may produce fatal paralytic rabies, as sometimes happens when treat- ing bites about the face by the " intensive method." To be successful, the method must be inaugurated early, before the poison gains a firm foothold in the central nervous system. After the disease has commenced, pal- liative treatment on general principles, similar to that advised for tetanus, must be adopted. Prophylaxis.—If proper laws be enforced, requiring the registering and muzzling of all dogs, this disease could be readily stamped out; where wolves abound, this source of hydrophobia must always exist. The treatment of supposedly rabid dogs which have bitten men or animals must be considered. All suspected animals should be confined for at least two weeks, while those bitten must be either kept in co7ifinement for at least six weeks, or killed. When an animal cannot be kept alive long enough to determine whether it is or is not rabid, it should be killed and an emulsion of its brain and spinal cord be injected beneath the dura of several rabbits, who will soon develop hydrophobia if the dog has been rabid. By a resort to this procedure, the intolerable anxiety of the patient can either be re- lieved or the necessity for inoculation be demonstrated. LECTURE XXIII. GLANDERS, FARCY; ANTHRAX, OR MALIGNANT PUSTULE. Glanders, Farcy.—This is a specific, infectious, my- cotic disease, caused by the Bacillus mallei, which induces the rapid formation of nodules composed of a species of granulation-tissue, in the skin, subcutaneous tissue, and the mucous membrane of the nares and that of the respi- ratory passages. These nodules are peculiarly prone to degenerate, liquefy, and rupture, leaving ulcers with un- dermined edges surrounded by an extensive area of phlegmonous inflammation. Although these lesions are at first chiefly located in the skin and respiratory mucous membrane, later by continuity, by the lymph-stream and by vascular embolism, dissemination takes place, the viscera, muscles, bones and joints, becoming in- volved, sometimes by continuity, sometimes by meta- stasis. Pyemic lesions are also common late in the dis- ease. Usually acquired from the germs contained in the nasal discharges of glandered horses, this is not invari- ably the case, as the source may have been another human being, possibly sheep or goats ; the disease has also been contracted in the laboratory from careless handling of cultures of the Bacillus mallei. Practically, whatever may be possible from a theoretical standpoint, glanders is commonly acquired through some open but trivial lesion of the skin or a mucous membrane, as the conjunctiva, or that of the nose or mouth. Coachmen are apt to dust harness or polish the horses' coat here and there with their handkerchiefs; hostlers and those about stables often drink out of horse buckets, thus explaining 239 240 PRINCIPLES OF SURGERY. the infection. The wind will carry the nasal discharges when a horse snorts, into the eyes and face of the driver, and in the same way infection of animals grazing in a field separated by a lane from the diseased animal has been reported. Very rare in this country, glanders was found among the army horses during the late war ; it is not uncommon in Cuba, hence must be carefully studied. It has been experimentally produced by rubbing the germs into the intact skin. Symptoms in the Horse.—A brief account of the dis- ease as seen in the horse is advisable as a possible aid in diagnosis and an important one for prophylaxis. The nasal secretion is first slightly increased, possibly only from one nostril, but it constantly flows, is watery, mixed with a small amount of mucus, later becoming peculiarly viscid, "gluey," as it is termed. The quan- tity rapidly increases, soon becomes bloody, and in the later stages offensive. In very exceptional cases, this " gluey " discharge may persist for long periods without other symptoms. The submaxillary lymphatic glands early become enlarged on the side of the diseased nostril. At first a diffused swelling is formed, but later most of this subsides, leaving one or two hardened glands firmly adherent to the jaw-bone. The nasal mucous membrane presents a cyanotic hue, with probably circular, deep ulcers with abrupt, prominent margins situated upon the cartilaginous septum. These ulcers increase, finally so obstructing the nasal cavities that a peculiar "grat- ing" or "choking" sound is heard during respiration. Later, owing to involvement of the frontal sinuses, the skin covering them becomes thickened and tender ; the facial, cervical, and general lymphatic vessels become diseased, constituting "farcy," the enlargements pro- duced by the valves or interposed nodes forming the so-called "farcy buds"; these soon ulcerate. The lymphatics of the extremities are attacked, causing great swelling, heat, and disability of the limbs ; ulcerations occur here also. Loss of flesh, appetite, strength, and • GLANDERS, FARCY. 241 urgent cough supervene, the coat is roughened and staring, and death occurs from exhaustion. When infec- tion has taken place elsewhere than in the nasal cavities, the hardened, nodular, tender, inflamed lymph-vessels about the lips, nose, neck, axillae, and thighs, followed by ulceration, producing rounded sores with elevated, indurated borders and pallid bases, combined with loss of appetite, flesh, and staring coat, present a character- istic picture. A temporary improvement sometimes occurs, generally to be followed by a relapse, generaliza- tion, and death. The discharges from all ulcers are quite as infective as those from the nasal cavities, and will give rise to glanders when properly inoculated. All animals presenting either of the foregoing sets of symptoms should be destroyed and their carcasses burned. The mangers, racks, and partitions of the stall occupied by the diseased animal should be scraped down, scoured with plenty of soft soap and hot water, and coated with a thick layer of chlorid of lime mixed with water. Although whitewashing of the walls is consid- ered sufficient, chlorid of lime had better be also used for this purpose. All head gear and harness of the affected animal must be destroyed, and wooden drinking pails ; those of metal, and all iron work, can be disin- fected by fire and paint. Symptoms in Man.—The incubation period in acute cases varies from three days to eight days, although it may be longer. Malaise with febrile symptoms, then shiverings, pains in the limbs, perhaps rigors and sweats, are noticed. If internal infection has taken place, "the gastro-intestinal disturbance, the fever, and the general prostration, may cause the case for a time to simulate typhoid fever;" but the development of the external lesions will soon correct this error, assisted by the bac- teriological and other tests now at our disposal for the determination of typhoid fever. When accessible to the eye, the point of primary infection gives evidence of a more or less distinct phlegmonous cellulitis ; in addi- ifi 242 PRINCIPLES OF SURGERY. tion, there is probably inflammation of the lymph-vessels and nodes, and possibly there is also phlebitis. Vesicles soon form over the diseased areas, hemorrhage takes place into them, and suppuration promptly follows, phagedenic ulcers resulting. When primarily situated in the nasal cavities, extensive destruction of both the soft and the hard parts of the nose, palate, and mouth occurs. If originating in some other part, after the premonitory constitutional symptoms, secondary nodules appear, usually during the second or third week, in the nasal chambers, giving rise to, first a thin, then to a gluey, and finally to a mucopurulent, often bloody and offen- sive discharge from the nostrils. The conjunctivae may also be attacked, marked edema of the eyelids resulting, causing, with that incident upon the nasal and buccal lesions, generalized facial edema and a peculiar shiny, dusky-red appearance of the face and neck, extending to the scalp. Multiple skin and mucous membrane lesions may occur within the first few days, but are more apt to be delayed until the period mentioned. As any mucous membrane may be attacked, that of the lungs or intes- tinal tract often becomes diseased. Severe pain in the muscles of the extremities is common. A very hard, papular or nodular generalized skin-eruption, not unlike that of small-pox, especially marked upon the face, appears in from a few days to the second or third week. This soon becomes pustular, often confluent, giving rise to irregular ulcers "encrusted with a soft, brownish, sloughy coating." Occasionally the eruption is vesicu- lar from the outset, resembling that of varicella. In many cases '' acute farcy '' is superadded—i. e., specific- ally inflamed lymphatics forming tortuous, knotted cords, with enlargements at the site of the valves. The lymph-nodes are also involved, and suppuration of these and the lymph-vessels with diffuse suppuration in the limbs is apt to follow. Distinct and early symptoms of sepsis are shown in acute cases, and in all forms, later. Delirium sets in with stupor, sooner or later, and a GLANDERS, FARCY. 243 typhoid state and death result, sometimes accelerated by bronchial, pulmonary or pyemic accidents. In chronic cases, the lesions develop more slowly and are less nu- merous. They may gradually improve, ulcers and ab- scesses healing, and recovery ensuing after many months. Nevertheless, chronic glanders, after progressing slowly for long periods and involving chiefly the lymphatics, sometimes terminates in acute glanders. Diagnosis.—Early in the disease, rheumatism and typhoid fever, and, later, pyemia—which, indeed, often complicates glanders—must be excluded. The peculiar exanthem, the coincident nasal discharge, the peculiar ulcers, and the dusky-red, glossy, edematous swelling of the face, head, and neck, especially if the lymph-vessels and nodes are diseased as has been described, should render a clinical diagnosis possible. Bacteriological examination and inoculations of susceptible animals will render the diagnosis positive. Prognosis.—Acute glanders is probably always fatal in from three days (very rarely) to several weeks. As just said, a certain number of chronic cases recover after much disfigurement and crippling. Treatment.—Prompt destruction of diseased animals and of everything which may be soiled by the discharges is imperative as a prophylactic measure. Thorough dis- infection of any accessible point of primary infection by excision and the actual cautery should be tried. Second- ary nodules and abscesses must be opened, curetted, the hot iron freely used, or zinc chlorid solution, 1 part to 8, be applied ; moist antiseptic dressings should after- ward be employed. In all other respects the surgeon must be guided by the general principles applicable to the treatment of any septic and infective process accom- panied with exhausting discharges. Mallein has not yet been applied to the treatment of glanders in man; hence its therapeutic value, if any, is unknown. Anthrax {Malignant Pustule ; Charbon ; Wool-sort- er1's Disease).—This is an acute, infectious, usually non- 244 PRINCIPLES OF SURGERY. suppurative, microbic disease, produced by the spores or adult organisms of the Bacillus anthracis. The point of entrance for the germs may be the respiratory or the ali- mentary tract, but most commonly is some slight exter- nal traumatism, perhaps the bite of a fly, whose proboscis serves to convey the infective material with which it has become covered by feeding upon the bodies of animals dead from anthrax ; fetal infection through the placenta has also been reported. The destructive effects of the Bacillus anthracis are both local and systemic, the large size of the organisms serving to block the capillaries of a part, thus determining gangrene ; while the toxic sub- stances generated produce fatal systemic poisoning. The spores are among the most resistant of those produced by any pathogenic organism. Many interesting facts, re- lated in any work on bacteriology, must be omitted as not pertinent to our present studies, but some are of importance to bear in mind because diagnostically sug- gestive. Thus, anthrax is prevalent in Russia, Siberia, and especially in portions of Hungary, France, and Ger- many. While not common in the United States, it is by no means unknown. In South American countries, whence many hides come, and also wool and horse-hair, this disease is quite prevalent. Drying does not destroy the virulence of anthrax germs, which, when desiccated, retain their vitality for years. In this country, infection usually occurs from handling the hides of infected ani- mals, or sorting wool or horse-hair from animals who have died of anthrax, hence the origin of one of the names, "wool-sorter's disease." Therefore, butchers, wool-sorters, and curriers are the classes of patients who may reasonably be suspected of suffering from anthrax when presenting suspicious symptoms. Symptoms.—Wool-sorter's disease belonging to inter- nal medicine will not be considered here. In anthrax proper, after a short incubation of from one to three days, a small papule—there may be more than one point of infection—is noticed upon the face, hands, or arms, ANTHRAX. 245 which quickly gives rise to discomfort. Soon a* vesicle forms, and the papule becomes surrounded with a con- stantly increasing area of cellulitis and widespread edema. The central vesicle ruptures, showing beneath a gangren- ous, blackened mass, while an encircling ring of second- ary vesicles forms around the primary one. In most in- stances cellulitis, infiltration, and sloughing continue to spread, lymphangitis and phlebitis develop, and rapid toxemia and death result. In a very few cases the infil- trated, gangrenous areas separate, leaving imperfectly granulating surfaces, which eventually heal. Pain is not a prominent symptom, and systemic symptoms are mild while the disease remains local, usually consisting of slight chills and a little fever. In fatal cases, death is usually the result of toxemia, although thrombosis of the cerebral sinuses by extension of the process through the facial vein, and various pyemic and septicemic acci- dents, may prove lethal. When systemic intoxication is well marked, rigors occur with high fever and great weakness, general infection is present, and these symp- toms are succeeded by delirium, weak pulse, sweating, diarrhea, and more or less generalized pain. Pulmonary disturbance is evidenced by cough, dyspnea, etc. Sud- den death in collapse is quite common. An edematous form of anthrax has been described, in which a diffuse edema rapidly spreads from the point of infection, the superjacent skin being of a livid color. The degree and extent of this edema is sometimes enormous. Blebs form at various points over spots of local gangrene of the skin and cellular tissue. Suppuration, as in ordinary anthrax, is unusual and the result of secondary infection. Post mortem, the lymph- and blood-capillaries are found blocked by bacilli, which produce gangrene of the tissues partly by directly cutting off the blood-supply, partly by causing such an outpouring of exudate that the remaining vascular supply is destroyed by the strangulation thereby induced. Sepsis often having been present, the usual evidences of this will be found. 246 PRINCIPLES OF SURGERY. Prognosis.—With early diagnosis and energetic treat- ment, external anthrax is quite manageable, but if gen- eral infection has taken place, death is inevitable, and the prospects of recovery are poor indeed if treatment, however appropriate, is commenced late. Diagnosis.—The central bleb beneath which is a gan- grenous patch of skin, the ring of secondary vesicles, the firmly attached sloughs, the lack of pus primarily, the comparative absence of pain, the widespread infiltration, and later, the general toxemia, can hardly be confounded with the symptoms of any other ailment. The differ- entiation from a disease, already described when speak- ing of gangrene, will become apparent when the symp- toms of " malignant edema" are reviewed ; but in pass- ing, it may be said that the rapid disintegration and lique- faction of the tissues seen in the latter disease stand in sharp contrast with the dense, adherent sloughs charac- teristic of anthrax. In any suspicious case the use of the microscope or inoculation of a mouse with a little of the wound-fluids will settle the question beyond all cavil. Treatment.—When possible, the infected tissues should be removed with the knife, cutting widely through the healthy tissues, and, to prevent their infection, the fresh surfaces should be seared with the hot iron, be wiped over with pure carbolic acid, or a solution of zinc chlorid, 1 part in 8. The actual cautery, freely used, will often alone suffice, if the infected area be not too large to be readily destroyed by this means. When excision is impracticable, deep crucial incisions freely cauterized with the hot iron or pure carbolic acid have been successfully employed, these measures having been reinforced by the injection of a 3 or even 10 per cent. solution of carbolic acid by means of a hypodermic needle, so employed as to reach beneath the deeper por- tions of the infected area and well beyond its spreading borders. The diseased tissue should be also thoroughly infiltrated with the same solution. Subsequently, dress- ANTHRAX. 247 ings wet with a 1-1000 solution of mercuric chlorid should be applied, over which an ice-bag had better be placed, because the bacillus grows feebly below 200 C. (68° F.), and ceases to develop below 120 C. The injections may be repeated every six or eight hours, until the process ceases to extend or symptoms of carbolic-acid poisoning appear, an accident which must be carefully guarded against, by frequent examinations of the urine and scrutiny of the patient's condition. Taking advantage of the fact that the bacillus ceases to develop at temper- atures above 420 to 450 C, hot poultices have been em- ployed with decided benefit at 500 to 550 C, reapplied every ten minutes, in conjunction with repeated injec- tions of a 3 per cent, solution of carbolic acid. The strength of the patient must be maintained by the free use of alcoholic stimulants, strychnin, digitalis, abundance of nutritious food, etc. The secretions of the skin, kidneys, and intestines must be maintained and regulated, and a proper amount of sleep must be secured. LECTURE XXIV. ACTINOMYCOSIS; TUBERCLE; COLD ABSCESS. Actinomycosis.—This is a subacute or chronic ail- ment caused by a variety of ray-fungus, which by its growth in the tissues produces granulation-cell tumors, often in the past mistaken for sarcoma. In man, sup- puration is the rule, resulting usually from a mixed infection, while in animals the appearance of pus may be long delayed. The initial lesions in animals are usually situated in the buccal cavity, due to injuries Fig. 12.—Actinomycosis, showing nodule. From a case of actinomycosis in man. received during grazing, whence the respiratory tract may become infected by inspiration of, or the alimentary by swallowing, the actinomyces. Because the jaw is so often attacked in animals, the disease in them is popu- 248 A CTINOMYCOSIS. 249 larly known as '' lumpy-jaw " or " swelled-head.'' Owing to the habit so common among farm-laborers of chewing pieces of grass or beards of grain, infection in man also frequently occurs in the mouth, often through a carious tooth. The " Madura-foot " of India is now believed to result from a variety of actinomycis. The actinomycetis granules found in the tissues or pus are pin-head in size, or may be aggregated, forming masses the "size of a pea," or they may be microscopic. They present vari- ous appearance—i. e., "grayish and translucent like sago particles, or opaque, or white, greenish-yellow or yellow, brownish, even black." They are soft and gelatinous when young, but become harder later, and "gritty" from calcareous degeneration. In suppurating cases these bodies may be so scarce in the pus as to re- quire long search to find any, in other cases they are innumerable. The granules perceptible to the eye are "colonies or clumps of colonies." These colonies are composed of a central portion formed of rods and threads branching dichotomously, which become densely inter- woven more peripherally, and radiating, terminate in bulbous enlargements ; this bulbous enlargement, which is not always present, is, with calcification, a degenera- tive change. Although secondary pyogenic infection is usually the cause of suppuration, it has been claimed that the actinomycis is itself pyogenic. As the granula- tion-tissue formed by the action of this fungus is, as a rule, permeated with bacilli and bacteria, this proposition is difficult to prove. The first histological changes caused by the presence of the parasite are "necrosis and lique- faction of tissue with emigration of white blood-corpus- cles," to which succeeds the formation of "vascular granulation-tissue.'' Diagnosis.—Although resembling in many respects sarcoma, the free suppuration, with the detection of the characteristic bodies in the discharge, should prevent mistake. The possible simulation of sarcoma, carci- noma, tubercle, and syphilis, by actinomycosis, especially 250 PRINCIPLES OF SURGERY. in those dealing with cattle, ought to suggest an exami- nation of the discharge, all the more if investigation reveals that "lumpy-jaw" has been noticed among the animals with which the patient has been brought into contact. Again "metastases do not appear to occur in the lymphatic nodes communicating w7ith a primary focus of actinomycosis," although pyogenic infection may simulate this ; this absence of lymph-involvement is more suggestive in the cervicofacial region than else- where, because sarcomatous tumors are here more apt to secondarily involve the lymph-nodes, while in carci- noma of these parts, early infection of the nodes is the rule. Prognosis.—If thoroughly accessible, the prognosis is good ; if in regions where radical measures are impossi- ble, the reverse is true, especially if secondary visceral involvements have taken place. Still, being a chronic, almost painless, ailment, destroying by slow infection producing exhaustion, much can often be done. Treatment. — Complete extirpation by the knife, curet, and cautery will often cure. An affected jaw or tongue should be totally or partially excised. Even actinomycosis of the lung, pleura or liver, when accessi- ble externally may be benefited by free removal of the diseased structures. Great advantage will accrue in some cases from the internal use of large doses of potas- sium iodid in conjunction with potassium iodid gargles, and the local action of iodin introduced into the tissues by cataphoresis. Tuberculosis. — Tuberculosis is a chronic or sub- acute, very rarely an acute, microbic disease caused by the action of the Bacillus tuberculosis, which induces the formation of a peculiar, low-grade, granulation- tissue. So long as the bacilli and their products are active, the tubercular process extends peripherally, while in spots, usually those more centrally located, coagula- tion-necrosis occurs, followed by caseation and often liquefaction, although calcification may take place : TUBERCULOSIS. 251 these changes are favored by the relative or absolute avascularity of the older—i. c., the more central, por- tions of the tubercular masses, but probably directly result from the action of the germ-products. Although some patients, presenting certain anatomical peculiarities, are prone to develop tubercular lesions, and these are often said to be "strumous," I have maintained for many years that all active, so-called '' scrofulous'' or "strumous" manifestations are really tubercular and should be so described. A "scrofulous" or "strumous" diathesis therefore does not exist, what is so termed being either an expression of active tubercle, or is merely indicative of that anatomical structure of the tissues which is most favorable for the arrest and multi- plication of tubercle bacilli. None can deny that those patients with flabby muscles, rounded limbs, thin, blue- veined skin, brilliant coloring, finely chiselled features, grey, blue, or even dark, humid eyes with sluggish pupils shaded by long lashes, fine auburn or blonde hair —possibly dark hair—and tumid upper lips, are more apt to succumb to tuberculosis, when exposed, as are also those with coarse reddish hair, thick muddy complex- ions, coarsely modelled features, a tendency to various eruptions and to chronic inflammations of the conjunc- tiva, eyelids, etc. Nevertheless, tubercle is frequently seen in those who present none of the characteristics men- tioned. Tuberculosis seems to require a conjunction of the following favoring conditions : A lowering of normal cell-resistance, either peculiar to the individual or the result of an injury so slight as not to invite the accumu- lation of numerous phagocytes, yet severe enough to promote the development of such a hyperemia as will mechanically favor the local aggregation of germs ; these may be introduced at the point of traumatism, but more usually reach the locus minoris resistentics by the circu- lation, having gained access thereto at some distant infec- tion-atrium where the germs have failed to effect a per- manent lodgement. Thus gonorrhea is well known to 252 PRINCIPLES OF SURGERY. favor the development of tuberculosis of the testicle and female genital tract, probably by damaging or destroying the resistance of the surface-epithelium. Such a large proportion of cases in surgical practice depend upon tubercular infection or its sequelse that a comprehensive survey of this disease is requisite, although detailed descriptions of the many phases assumed would be out of place here, belonging to the practice, not to the principles, of surgery. As you have elsewhere learned all that is essential con- cerning the tubercle bacillus and the histology of tuber- cle, it would be superfluous to enlarge upon these points. A study of the natural terminations of tuberculosis shows that at times nature is equal to the task of cure, and this study serves the practical purpose of providing us with valuable suggestions as to how we can best aid, not thwart her. Degenerative changes leading to massive necrosis and separation of the diseased tissue is seen in lupus, and more rarely in an ordinary tubercular focus, when, after caseation, evacuation of the liquefied tissue occurs, the thin environing layer of tubercular tissue either being destroyed by pyogenic infection producing sloughing, or the consecutive hyperemia providing sufficient phagocytes to successfully contend with the few remaining tubercle bacilli. Tubercular tissue con- sists of a modified granulation-tissue, and if the bacilli or their products which cause necrobiotic changes in the component cells, are either removed or the latter chemi- cally neutralized, this granulation-tissue, like any other, will develop into scar-tissue ; this is often observed occur- ring either spontaneously or as the result of treatment. In the former case, the resistance of the tissues becomes increased so that the germs are destroyed and the effects of their toxins prevented; in the latter, substances inimical to the life of the bacilli are brought into contact with them, or chemical changes are effected in the toxic sub- stances rendering them inert : probably both results are secured. It has been explained that the local spread of TUBERCULOSIS. 253 a tubercular focus depends upon peripheral infiltration of the tissues. If the infection be slight, the soil poor, possibly because exceptional phagocytosis is excited and thus the resistance of the environing tissues increased, a non-tubercular envelope of granulations may form which develops into scar-tissue encapsulating the tubercular nodule, a temporary, possibly a permanent cure result- ing. This encapsulation may persist indefinitely, the tubercle becoming absorbed or converted into scar-tissue, or it may become obsolete by one of the changes to be de- scribed. Again, after long quiescence the tubercular process may become active, the capsule becoming con- verted into tubercular tissue, and the disease resumes its interrupted march, perhaps after many years of apparent cure. Caseation, as has already been said, results partly from lack of blood-supply in the tubercular tissue, chiefly from chemical changes following the coagulation-necrosis induced by the bacillus and its poisons. Although the bulk of the tubercular tissue is converted into a yellowish, cheesy, friable mass, yet, at the periphery, living miliary tubercles surround it, forming, with a low-grade young connective tissue, the mistermed " pyogenic membrane," which would be more properly termed " tuberculogenic," because, if not destroyed, the specific process will con- tinue to maintain itself, or spread from this "membrane " as a center. It must not be thought that the degene- rated caseous mass is harmless. Far from it. However difficult it may be, at times, to detect tubercle bacilli in liquefied tubercle by the microscope, let caseated tuber- cle be inoculated into a susceptible animal, and no doubt will be entertained of its virulence nor that it contains the germs of tuberculosis. It is of great importance to recall this fact when operating, that all possible pre- cautions may be adopted to prevent the inoculation of the fresh surfaces of the wound by contact with caseated materials or with tubercular pus. Calcification.—Under certain circumstances lime salts are deposited in tubercular foci, the process usually com- 254 PRINCIPLES OF SURGERY. mencing in the central portions of the giant-cells, whence it spreads. Considerable masses of tubercular tissue may be thus rendered obsolete. Cold Abscess {Chronic Abscess; Congestive Abscess). —Abscess is nearly always a misnomer for this condition, the fluid contents, while resembling pus, being usually in reality only caseated tubercular material which has become liquefied. Although it has been contended that under especially favorable conditions tubercle bacilli can produce suppuration unaided by any other organisms, in practice, when genuine suppuration occurs in a tuber- cular focus, secondary pyogenic infection is the cause. It is a well-known clinical fact that a cold abscess may present not a symptom in common with acute abscess beyond a gradually increasing accumulation of pyoid fluid which will spontaneously evacuate itself, and that again, a cold abscess of large dimensions may suddenly appear, and present all the symptoms of an acute affec- tion ; yet, when the contents are evacuated, it becomes clear that the greater part of the process was one of long standing, most of the fluid being not pus but liquefied caseated tubercle. Although cold abscesses may be found in any organ or part, as the brain or any other viscus, they are vastly more common in connection with lymphatic, articular, or osseous tubercular disease. As already stated, a cold abscess is surrounded by a layer of ill-organized neoplastic connective tissue which contains tubercular tissue in greater or less amount, usually in the form of miliary nodules, some of which may present evidences of caseation. This "membrane" results from the invincible tendency of granulation- tissue, however produced, of forming scar-tissue, and, in this instance, is developed in the surrounding layers of tissues which, although intensely hyperemic, are not infiltrated with tubercle or are but slightly infected. This—so incorrectly called a "pyogenic membrane" — if in any sense an active factor in the process, serves merely to aid in the circumscription of the tubercular TUBERCULOSIS. 255 process, and if genuine suppuration be present, to limit this. A similar membrane—except the tubercular tissue —is seen lining old sinuses, as explained when speaking of sinus and fistula, and it is incorrect to make the presence of a so-called "pyogenic membrane" a deter- mining point as to the presence of a tubercular process, as has been unfortunately done by a recent author. Of course, in a tubercular process this "membrane" is more marked than in non-specific conditions, yet it cannot be considered a diagnostic point, but merely a cause for suspicion when strongly marked, especially in a relatively acute process. Despite the partial protection afforded by the tubercular membrane, this is a constant menance, and to secure a local cure it, or the contained bacilli, must be destroyed. Two different courses may be pursued by any tubercular focus which undergoes caseation. In one, the caseated material, whether first distinctly undergoing liquefaction or not, has its fluid portions gradually absorbed until nothing but a rela- tively small putty-like or friable, cheesy mass is left ; or small areas of the same are interspersed in an irregular mass of scar-tissue, all being isolated from the surround- ing tissues by cicatricial tissue. This latter appearance results from the partial conversion of the specific granu- lation-tissue into cicatricial tissue, or a similar change in the remains of the uninfiltrated environing normal tis- sues, the bacilli either being destroyed or inhibited. This statement contains a pregnant truth—i. e., the proc- ess may only be quiescent, ready to break out anew if anything, like a slight traumatism or deterioration of health, lowers the resistance of the tissues. Relapses may thus occur a score of years after apparent cure, often resulting in the formation of the "residual abscess" of Paget. In such cases, within a very few days, a large collection of pyoid fluid may occur, which is chiefly composed of liquefied caseated material which has lain dormant for years, the immediate cause of the change being usually a recent pyogenic infection. When these 256 PRINCIPLES OF SURGERY. "residual abscesses" are of more gradual formation, it is possible that the intense hyperemia following the trau- matism inflicted, say by " brisement force," may supply sufficient fluids to cause liquefaction of the old solid caseated mass, but this is probably very rare, genuine pyogenic infection usually producing the change. The contents of a typical cold abscess consist of a yellowish, whey-like fluid, containing, suspended, more deeply tinged particles or masses of "curdy material," which, when examined, are found to consist of numerous caseated cells entangled in what resembles altered coagu- lated fibrin. In such cases, not a single pus-cell can be detected, nor do pyogenic organisms develop after the most careful culture experiments. It is futile to say that these organisms did exist but that they died for want of pabulum, the tubercle bacilli proving the more resistant. This is a mere clinging to antiquated notions, the liquid contents of the so-called abscess resulting from degeneration of tubercle, and no pyogenic organ- isms are detectable because none ever were present. In one class of cases of cold abscesses, the caseated tubercle liquefies, more fluids accumulate, thus gradually en- larging the cavity, while at the same time the process extends peripherally, until the superjacent structures including the skin are converted into tubercle. These infiltrated tissues in turn caseate and break down, spon- taneous evacuation taking place. In the remaining class, secondary pyogenic infection supervening, symp- toms of acute suppuration are noticed, evacuation result- ing from rapid pyogenic destruction of the infiltrated tissues. Symptoms.—When accessible, from the first there is an area of induration detectable, which softens without any inflammatory phenomena, while at the same time enlarging. If not readily accessible, the first symptoms may be those of nerve-irritation from pressure, the pain being referred to the terminal distribution of one or many branches of a plexus. In many cases, no symp- TUBERCULOSIS. 257 toms are noticed indicative of an abscess until a more or less distinctly fluctuating tumor is discovered in the groin, the pharynx, the lumbar or some other region, although the patient may have complained of pain or soreness in these localities, leading to a futile examina- tion only a short time before. There are usually present evidences of some chronic osseous or articular lesion, or a history of the existence of some such in the past. The skin is not reddened nor otherwise altered, except when the accumulation becomes superficial, when the cutane- ous veins become enlarged and the skin bluish or dusky. If pyogenic infection now supervenes, the ordinary ap- pearances of an acute abscess are present in varying degrees. When secondary infection does not take place, the skin becomes purplish and gradually thinned until it gives way, the originally small opening rapidly en- larging to form an irregular, ragged hole. Of course, suppurating joints, diseased bone, or softening lung- tubercle, may coincide, and produce constitutional symptoms, but otherwise there are usually no constitu- tional symptoms in cold abscess until the accumula- tion has been opened and infection has taken place or this accident has preceded the evacuation, when rapid death may result from sapremia; later, hectic fever and lardaceous disease of the viscera may be caused by the prolonged suppuration. Sometimes a deterioration of the general health precedes the detection of large cold abscesses, no adequate cause being discernible until the softening tubercular focus is detected. If deeply seated, cold abscesses may be mistaken for cysts, or, earlier, for fatty tumors, differentiation often being impossible ex- cept by aspiration or the use of the exploring needle. The associated presence of old osseous or other possible sources of tubercular disease when a slowly forming mass is detected, even far distant from these lesions, although all suspicion of fluctuation is absent, should suggest cold abscess, especially if the general health be causelessly deteriorating. When no tumor is detectable, 17 258 PRINCIPLES OF SURGERY. increasing or recurring neuralgic pains in the parts dis- tant from any perceptible lesion should give rise to the suspicion of abscess, especially if the health is failing without pyrexia or any reasonable explanation. The detection of evidences of old lymphatic, chronic articu- lar, or osseous lesions, even if apparently cured, will give still more color to this suspicion. The differential diagnosis between cold abscesses located in certain re- gions, as the groin, and other conditions, as aneurysm or hernia, with which they may be confounded cannot be discussed here but must be sought in treatises deal- ing with the practice of surgery demanded in each special region. LECTURE XXV. TUBERCULOSIS (CONTINUED) : METHODS OF INFEC- TION ; DESTRUCTIVE PROCESSES ; TREATMENT. Diagnosis.—This is involved in the description of the symptoms and course of tubercle as it is shown in various organs and parts ; in doubtful cases the injection of tuberculin may be tried. No attempt will be made to minutely consider the endless manifestations of tubercular conditions, modified as they are by locality and anatomical structure ; but there are some peculiarities common to the disease, wherever located, which require mention. Wherever the tubercle-germ multiplies, there results a form of granulation-tissue, which, as has been said, is formed at the expense of the tissue-elements. This tissue is de- ficient in vascularity, and therefore predisposed to undergo degeneration, the inherent tendency to develop- ment into a permanent tissue—scar-tissue—which it possesses in common with other granulation-tissue being repressed, as it were, because of lack of pabulum ; still further, so long as the bacilli multiply, there is a steady increase in the amount of the toxic substances which are attacking and will eventually destroy the vitality of the feebly nourished cells : nevertheless, the tendency to repair, although partially thwarted, is pres- ent. Tubercular granulation-tissue always extends by infiltrating the surrounding tissues, destroying their in- dividuality, and, therefore, not only their vital but also their physical functioning powers. Thus, in osseous tis- sue the lime salts disappear, and the once dense, resist- ing, compact bone, or the cancellous tissue so capable of 259 260 PRINCIPLES OF SURGERY. resisting a crushing force, alike disappear, producing many of the characteristic symptoms of tubercular bone- and joint-disease, because physically incapable of nor- mal function. The head of the femur and the cup of the acetabulum, once smooth and mutually adapted, irregularly disappear ; the firm bodies of the vertebrae, capable of sustaining the superincumbent weight, yield to this as they are gradually converted into granulation- tissue, producing the characteristic spinal deformities so often seen. Still further, owing to its tendency to spread along lymph-routes, tuberculosis may be found disseminated around the primary focus, with healthy tissue intervening, as is so frequently seen in the medulla of bone, a fact it is well to bear in mind when operating. This regional infection is due to the predilection shown by the tubercle bacillus for endothelium-covered tissues, the germs, travelling along the perivascular lymph- sheaths and lymph-vessels and locating at various points, become new centers of the disease. Again, bacilli reaching the blood indirectly, through the medium of the lymph-circulation, or directly, microscopic masses of the infected tissue or of germs alone being swept away by the blood as emboli, tubercle is liable to give rise to metastasis exactly as malignant neoplasms do. In this possibility lies much of the danger of local tuber- culosis. So long as one focus is present, the viscera or other structures may become involved ; in the removal of a focus, fragments of the infected tissue may be dis- lodged to become emboli, whereby generalization of tuberculosis is effected. The recognition of such a possibility is important because deciding the propriety of adopting one method of operation in preference to another. It must be here emphasized that a number of diseases whose pathology was formerly entirely mis- understood are now recognized to be due to the action of the tubercle bacillus. Thus all varieties of lupus are tubercular, as are many cutaneous lesions and those of mucous membranes, some of which were considered can- TUBERCULOSIS. 261 cerous, others, syphilitic. "Anatotnical tubercle" is tubercular, and the importance of its prompt eradication has thus become apparent. The proper method of cure for the various scrofulodermata and their sequences, "strumous cutaneous ulcers," is now clear. Many cases of tubercular ulcerations of the tongue, mouth, and nasopharynx are no longer aggravated by a mer- curial cause or abandoned as hopeless because "can- cerous." Most of these conditions are "primary"— i. e., the infection occurs at or near the spot where the tubercular "gumma," as it is sometimes called, de- velops. Very exceptionally, tubercle bacilli which may gain access to the tissues at once enter the lymph- stream, and, becoming arrested in a lymph-node (gland), give rise to a primary lymphatic tuberculosis; but almost invariably tuberculosis of the lymphatics is sec- ondary to an often non-infected lesion in the mouth, nose, respiratory, intestinal, or genito-urinary tract. Osseous tubercle is always secondary, never primary; that is to say, the germs can only reach the bone through the medium of the circulation. While, as has just been said, it is theoretically true that bacilli may enter through a distant infection-atrium, the point of entrance escaping infection, clinically this remains to be proved. It must be plain that the majority of the bacilli which gain access to the tissues enter the lymph- spaces or migrate into them, hence nearly invariably they are first arrested by those "filters," the lymph-nodes (glands), where, setting up tuberculosis, this new center serves for a point of departure for germs. Again a similar course is pursued if infection of any mucous or cutaneous surface occurs, the only possible exception being as already stated, if the germs directly enter a blood-vessel or escape the filtering action of the lymph-nodes. A demonstration is often afforded of the secondary nature of bone tubercle by the shape of the sequestra often noted in tubercular disease of the epiphyseal extremities of long bones, these sequestra being wedge-shaped or conical, 262 PRINCIPLES OF SURGERY. this form evidently resulting from the occlusion of a vessel by a tubercular embolus, the cone-shaped infarct becoming eventually necrotic from anemia, or possibly infiltrated with tubercle and then perishing. Owing to the anatomical peculiarities of the circulation of the epiphyses of the long bones and the mechanical strains to which these regions are subjected, tubercle bacilli most frequently locate at these portions of the bones, although the medulla is often attacked with tuberculosis. While the area infiltrated with tubercle softens and is destroyed, outside the disease-process the hyperemia induces an excess of bone-formation productive of "osteosclerosis." This formation of bone at a little distance from the disease-focus in consequence of the hyperemia caused by the active changes taking place in the tubercular focus, explains the "travelling acetabu- lum" of hip-joint disease and the buttresses of bone which unite carious vertebrae. Bone-tubercle evacuates itself by the same process of conversion of the overlying tissues into tubercular tissue and their subsequent de- generation and liquefaction, as has been described for the soft parts. Tuberculosis of synovial membranes is of special sur- gical interest because of the changes effected in joints and the sheaths of tendons. All the soft parts of the joint, ligaments as well as synovial membrane, are replaced by layers or masses of soft, gelatinous, fungous granulation-tissue, until, when the bone becomes seriously diseased with consequent partial or complete destruction of the encrusting cartilages, the articulation ceases to exist as such, the constituent bones being held together by little more than a soft mass of cells. Note carefully, however, that in many instances numerous disseminated areas of cicatrical tissue are to be found among the tubercular granulation-tissue, showing that a tendency exists toward the formation of permanent tis- sue, hence a partial victory has been won over the bacilli. Many of the more characteristic symptoms of tubercular TUBERCULOSIS. 263 joint-disease are due to the massive formation of this granulation-tissue. Instead of the characteristic form assumed by each joint when its synovial cavity is dis- tended with fluid, tubercular joints, for instance the knee, appear squared or rounded. Pseudo-fluctuation, not true fluctuation, is felt, due to the gelatinous condi- tion of the granulations. Free mobility in abnormal directions shows that in advanced cases the ligaments are extensively disorganized, and the same condition accounts for the spontaneous partial or complete luxa- tions so commonly observed. The tubercular process not being accompanied by acute hyperemia, the dis- tended skin presents a peculiar white appearance, with perhaps a few enlarged veins; this absence of color over an advancing enlargement has given rise to the term " white swelling." Fungous, gelatinous granulations are also common in tubercular disease of the tendon-sheaths, small masses of which tissue, separated from the main portions, con- stitute one of the varieties of " rice-bodies " so character- istic of many cases of chronic thecitis ; it is not main- tained, however, that all instances of chronic thecitis in which "rice-bodies" occur are tubercular, although the majority unquestionably are. Although many of the numberless phases of tuber- culosis as it occurs in different tissues and organs have not been touched upon, yet the essential types have been described, leaving for works treating of the surgery of the special tissues and organs all minute description of the symptoms and appearances presented by tuberculosis as it is modified by anatomical peculiarities of structure or surroundings. Treatment.—It must be plain, from the preceding statements, that there are two general indications for the treatment of tubercle. The first, radical, complete ablation of the diseased structures, which is unquestiona- bly the better plan if the process be localized and the operative measures capable of execution without inflict- 264 PRINCIPLES OF SURGERY. ing unnecessary crippling or destruction of the function of important organs or parts ; even this latter evil is often to be deliberately chosen if all tubercular disease can be thereby removed. Ablation is however at times impossible or inadvisable, either from the operative standpoint alone, because its absolute necessity is doubt- ful in the face of the dangers or destruction entailed, or most commonly, because only one focus of the disease can be reached, leaving other more dangerous foci which will of themselves entail 'death as advanced phthisis. This last objection should be given due weight, if the operation itself will put an additional strain upon the already lowered vital powers of the patient and thus favor the more rapid progress of the inaccessible lesion. Nevertheless, ablation should always be effected with incipient visceral tuberculosis—as that of the lung—if it can be done by an operation which will entail only a short confinement to the house and the. absence of, or the minimum of, suppuration, as amputation of a limb for articular disease. Such an operation should always be chosen in these cases, rather than erasion or excision, either of which would perhaps be theoretically the proper operation if no other focus of tubercle were present. The second indication is to call into action the natural tendencies of the least infected portions of the granula- tion-tissue to develop into scar-tissue, to induce destruc- tion and absorption of the hopelessly infected portions, and to neutralize the action of the toxic bacterial pro- ducts as well as to remove or destroy the bacilli which are manufacturing them. The measures calculated to carry into effect this indication are also often put in practice after attempted ablation of the disease, where a complete operation has proved impossible or there are good grounds to suspect that this is the fact ; this is common when operating for many cold abscesses where it is impossible to be sure that all the tubercular lining membrane, which is often very adherent to the subjacent structures, has been completely removed. Clinical experi- TUBERCULOSIS. 265 ence has long since demonstrated that certain general measures occasionally enable the tissues to resist the action or overcome the results of the implantation of the tubercle bacillus. Science now shows why sunlight, dry air, altitude, fatty food, etc., are useful. For instance, direct sunlight will kill tubercle bacilli. Albuminous food is not so readily assimilated if a proper proportion of fatty food be not present, and tubercular patients often both have a distaste for fat and also cannot assimilate it in its ordinary forms. What then are the indications for the constitutional treatment of tuberculosis? To improve the resistance of the tissues, to destroy or inhibit the multiplication of the bacilli, and to neutral- ize the effect of the toxic substances they generate, so that the least infected portions of the granulations may develop into a permanent tissue—i. e., scar-tissue. Sun- light, abundance of germ-free air, stimulation of the cuta- neous and general circulation by sea-bathing, when stim- ulation, not depression, follows its use, as is too frequently the case ; the administration of fatty substances, by inunc- tion with cod-liver or other oils if they disagree when taken by the mouth ; regulation of all the secretions and excre- tions, with such drugs as will probably induce a leuko- cytosis, so that the bacilli may be removed or destroyed by phagocytic cells—are the general measures calculated to fulfill these indications. The now abandoned tuberculin certainly, by inducing congestion, brought more phago- cytes to the tubercular foci, and nucleinic acid and the so-called nucleins produce an artificial leukocytosis. Iodin in the nascent form is certainly inimical to the multiplication of tubercle bacilli, either directly or by alteration of the soil, while it seems to chemically neu- tralize the bacillary poisons. The attempt to secure encapsulation by injecting the tissues around the tuber- cular area with irritating substances, such as solutions of zinc chlorid, has not met with much favor, whatever benefit accrued probably resulting from the antibacillary action of the substance employed. At present, two 266 PRINCIPLES OF SURGERY. drugs alone seem to have stood the test of prolonged use —viz., iodoform and balsam of Peru. The former to be efficacious must be maintained in contact with the tissues, all air being excluded. Thus, if a cold abscess is opened, after the most thorough removal possible of the tubercular lining membrane, iodoform emulsion must be introduced into the cavity and the soft-tissue wound tightly closed by accurate suturing, and sealing with collodion, even if it be certain that no permanent healing can be secured. Firm packing with iodoform gauze probably secures the same result in a minor degree, because the iodoform in contact with the tissues acts in the absence of much, if any, air. The best results are attained from injecting iodoform directly into the tubercular tissue or into a tubercular joint. The action of iodoform has already been partly explained. Besides the direct action on the germs and the neutrali- zation of their products, the tubercular tissue becomes infiltrated by round cells (phagocytes), the diseased tissue undergoes fatty degeneration, liquefies, and is absorbed, and healthy, organizable granulation-tissue appears. Balsam of Peru stimulates to a remarkable degree the transformation of the pale, flabby, avascular granula- tions of tubercular tissue into the healthy, florid, fully vascularized non-specific granulations capable of defin- itive healing. As has been explained, normal granu- lations contain numerous phagocytic leukocytes, hence probably the beneficial action of the balsam is to be ascribed to the attraction of blood to the part which primarily brings the leukocytes necessary to restrain the action of the tubercle bacilli, and then granulations form, both capable of defending themselves against future attacks of the bacilli in virtue of the phagocytes they contain and also of cicatrizing. Ignipuncture, both for tubercle of the soft part and of the bones, is too much neglected. When employed to evacuate a tubercular focus, the track is sealed against infection, while the radiated and conducted heat destroys the infection for a TUBERCULOSIS. 267 wide area outside the portions of tissue actually brought into contact with the cautery ; in this way numerous softened tubercular lymph-nodes can be successfully treated in the neck with the minimum of scarring, annoyance, and risk to the patient. While much more time might be occupied in illustra- ting the application of the principles enunciated, nothing really essential could be added without trenching upon the technic of operations in each special region, which would be manifestly out of place. LECTURE XXVI. HEMORRHAGE: SYMPTOMS, GENERAL AND LOCAL; NATURAL HEMOSTASIS ; ARTIFICIAL ARREST OF HEMORRHAGE. Hemorrhage.—Hemorrhage may be arterial, venous, or capillary, or it may arise from all three sources. The blood issuing from a wound usually comes from all three sets of vessels, but unless arteries of a certain magnitude be opened, natural hemostasis soon checks the venous hemorrhage, next the arterial ceases, while later only the capillary oozing has to be contended with. A special tendency to bleed from inadequate causes exists in cer- tain individuals (hemophiliacs), but is also seen in pur- pura, scurvy, and poisonings by drugs such as phospho- rus—in this last condition fatty degeneration of the vascular walls having been detected. When the blood finds exit upon a free surface, as the exterior of the body, one of the hollow viscera or a serous cavity, or into the substances of organs or the general cellular tis- sue, certain descriptive terms are employed, as "exter- nal"; " internal " when occupying the abdomen, pleura, mediastinum, etc.; "ecchymoses" when the blood is effused into the cellular tissue, in which locality, if it is of large amount, it is sometimes called an "extravasa- tion." Localized collections of fluid blood are called "hematomata," and sometimes even when occupying the cellular tissue, "hematoceles," as those of the neck or spermatic cord; but this same term "hematocele" is employed to designate effusions of blood into some of the serous sacs, as that of the tunica vaginalis testis. Traumatic hemorrhages—i. e., those produced by in- 268 HEMORRHAGE. 269 jury, can best be considered under four heads—viz., Primary, Intermediary or Consecutive, Secondary, and Parenchymatous. Primary hemorrhage is that which immediately follows the injury, and in amount varies with the vessel wounded or with the kind of trauma- tism. An incised wound bleeds more freely than a con- tused or lacerated one, whole limbs being often avulsed with only an insignificant loss of blood. Intermediary or consecutive hemorrhage is that which comes on between the stage of shock and that marked by sup- puration, but usually appears shortly after reaction is established. This variety of bleeding results most fre- quently from the increased vascular tension induced by reaction, from the same caused by the violent struggles of the patient or the straining of vomiting. Again, the too early removal of external pressure permits the loosen- ing of the coagulum occluding the mouth of some vessel of considerable size which has ceased bleeding because of the feeble heart-action induced by the shock. Second- ary hemorrhage is that which comes on after suppuration has been established, and is the result of infective inflam- mation causing disintegration of the hemostatic throm- bus, ulceration, or sloughing of the vessel ; possibly the aseptic separation of a slough, if this be forcibly re- moved by some movement of the patient before the vessel has become firmly sealed, may explain a second- ary hemorrhage. Parenchymatous hemorrhage is a gen- eral capillary oozing, due either to inflammatory dilata- tion of the capillaries, or to thrombosis of the principal veins. A few words must be devoted to a consideration of the results of loss of blood. Constitutional Signs of Hemorrhage.—The counte- nance, especially the ears, lips, and conjunctivae, as well as the general integument, are of a pallid color and shrivelled, pinched appearance. The general surface is bathed in a clammy sweat, the countenance is vacant, the pupils are dilated. Because the brain is anemic, 270 PRINCIPLES OF SURGERY. humming, roaring, or ringing sounds are heard. The pa- tient complains of the passage before the eyes of a thick mist, or even darkness alternating, perhaps, with flashes of light. General sensibility is benumbed, and uncon- sciousness, with syncope or convulsions, follows if the loss of blood be severe. Intervals of consciousness occur during which the debility is great, evinced by the faint whispering voice, feeble sighing respiration, marked dyspnea, and small, frequent, fluttering, almost imper- ceptible pulse. The patient rallies for a time if the loss of blood be not fatal. With each renewal of the hemor- rhage, the patient faints and is restored to consciousness with increasi ng difficulty. Dyspnea becomes more marked, and the pulse increasingly frequent and feeble, while the slightest elevation of the head, if the patient be recumbent, still more certainly the attempt to assume the upright posture, will insure fainting. The face is waxy pale, the lips and mucous surfaces almost bloodless, the flesh is soft, the movements languid, and any blood now effused is little more than bloody serum; anasarca and other forms of dropsy now appear, and the slightest loss of blood will prove fatal. When from the wound of a great vessel or the rupture of an aneurysm death results from sudden hemorrhage, the blood, instead of being forced onward by the elastic recoil of the arteries, runs backward from all parts of the body toward the opening in the vessel. The pressure in the veins being thus relieved, the blood no longer flows toward the heart, which ceases to act, and the face, as in asphyxia, becomes somewhat livid in hue, from the stagnation of venous blood. Before the fatal issue, the face suddenly becomes deathly pale, except a livid circle around the eyes, the lips are purplish, and the extremities cold. Syncope occurs, is recovered from and recurs, the voice becomes whispering, nausea sets in, the pulse becomes almost imperceptible. Marked and incessant tossing of the limbs begins, the head is at times suddenly raised or the patient struggles to rise, gasping for breath with an HEMORRHAGE. 271 agonized expression of face ; convulsive, sighing respi- ration, with loss of pulse at the wrist, comes on and the patient expires. The face has not the waxen, trans- lucent pallor of one dead from slow loss of blood, but is of a clayey, leaden hue. In both varieties of fatal hemor- rhage, the previous constitutional state, whether robust or the reverse, has much to do with the result from a given loss of blood, as has also the age of the patient, neither the young nor the old bearing the loss of blood well. Because of the deficiency of the oxygen carriers—i. e., the red cells—great frequency and irritability of the heart's action follows severe losses of blood, often resulting in the phenomena formerly called "hemorrhagic fever." .There is a hurried, jerking, irregular pulse, slight flush- ings of the face, with brilliancy of the eyes, alternating with pallor and syncope, while if the hemorrhage prove fatal, delirium with convulsions and an extreme, inde- scribable restlessness, precede death. It is hardly requisite to state that there is no rise of temperature in uncomplicated cases, the phenomena resulting from deficiency of pabulum to the nerve centers and of oxygen to the whole economy. The convulsions mentioned are epileptiform in character, and are rare except after sud- den, copious losses of blood. When treated properly— viz., as for bad syncope, they are generally not danger- ous. In those predisposed to convulsions, especially former epileptics, a small loss of blood may cause eclampsia. Treatment of Hemorrhage.—Needless repetition will be best avoided by a few preliminary remarks applicable to the treatment of hemorrhage in general. Its primary effects are to be combatted by all those means which will favor the retention of a functioning amount of blood in the brain, especially the respiratory centers because of the risk of fatal syncope. The head and shoulders should at once be lowered, and kept so by raising the foot of the bed twelve or more inches, not even a bolster being left 272 PRINCIPLES OF SURGERY. beneath the head. The limbs should, in addition, be raised nearly at right angles to the body, and so main- tained. In the worst cases, Esmarch's elastic bandages can be applied to one or all of the limbs, thus utilizing most of the blood of the extremities. If elastic bandages are not available, ordinary muslin ones may be used, and finally, in default of either variety of bandage, digital or instrumental compression of the arteries of the limbs in the raised position may be tried. The most essential, if not all, of the above measures can always be put into practice at once, without attempting the removal of the patient to a perhaps distant home or hospital ; by ne- glecting an immediate resort to these expedients, many lives are lost. Next, stimulants by the mouth or rectum must be administered. Turpentine, } to i fluidounce, best emulsified by beating up with a raw egg and water, although this is not essential, is an admirable stimulant to administer by the rectum. Subcutaneously, strychnin, whiskey, brandy, or, better still, ether when the patient has not been anesthetized, as frequently repeated as seems necessary to ward off syncope, are indicated, and at times atropin subcutaneously acts well as a respiratory and car- diac stimulant. External heat by hot-water bottles, etc., should be assiduously applied, and a sinapism over the heart is never amiss. Normal salt solution, at a temper- ature of ioo° to 105° F. as it emerges from the needle or cannula, should be unhesitatingly injected into a vein, the subcutaneous tissue of the mammary or abdominal regions (hypodermatoclysis) in severe cases, or into the rectum. The first two methods require no apparatus beyond a large-sized hypodermic needle (a small cannula is preferable for introduction into a vein if such an in- strument is procurable), a few feet of rubber tubing, and a funnel or a small vial with its bottom broken out. The amount to be injected varies from a few ounces to several pints, administered at intervals in such quantities as will secure the desired effect upon the circulation. Indeed, I have succeeded in throwing enough saline solution into HEMORRHAGE. 273 the cellular tissue to save life in cases of severe hemor- rhage, by means of three of four hypodermic syringes rapidly used by as many assistants. As soon as possible, hot, concentrated meat-essences, to which abundance of sodium chlorid has been added, and milk, must be given, with any reasonable amount of water the patient can dispose of, the rectum being also utilizable for this last purpose, especially if the stomach be irritable, employing enemata of about 4 to 8 ounces of the saline solution every four hours : the main object being to secure the rapid absorption of a sufficient bulk of fluid to mechanically enable the circulation to be properly carried on. As the pa- tient rallies, first the bandage on one limb (if such has been applied) may be partially removed, then en- tirely. If the pulse does not flag after an interval, the bandage from another limb should be removed, and finally from all the limbs, similar advice being applica- ble to those cases where instrumental or digital com- pression has been used. Last of all, the limbs may be lowered one by one, but the dependent position of the head and shoulders must be uninterruptedly maintained, sometimes even for days, and always for some hours, until the bulk or quality of the blood has improved to a degree compatible with a more ordinary position, which must also be gradually assumed by lowering the foot of the bed by degrees. The above remarks chiefly apply to a first and copious hemorrhage, but are applicable according to their degree to recurrent attacks. As soon as seems advisable, the internal use of iron and albuminous articles of food must be resorted to : after a single copious hemorrhage, to obviate the secondary evil consequences of the blood loss ; in the recurrent form of hemorrhage, to keep up the supply of the vital fluid so that new losses may not prove fatal, and also to prevent or cure the dropsical condition often induced by repeated hemorrhages. Although the internal use of acetate of lead, oil of 18 274 PRINCIPLES OF SURGERY. erigeron, dilute aromatic sulphuric acid, ergot, and opium have been relied upon in the past to control internal hemorrhages or prevent the return of external ones, it is a serious question in my mind whether, with the exception of the two last named, they are of any real value. The value of subcutaneous injections of sterilized solutions of gelatin in normal salt solution will be considered when speaking of the treatment of hemo- philia. The local means for the temporary arrest of hemorrhage are in the order of their availability : local compression over the wound by means of fingers, com- presses, bandage, tourniquet, etc. ; compression of the wounded vessel in the wound by similar means—it mat- ters not whether the wounded vessel be artery or vein ; compression of the main trunk-vessel, either by the finger, improvised tourniquet (Fig. 13) or an ordinary Fig. 13.—Showing so-called Spanish windlass, an improvised tourniquet, com- pressing the brachial artery. tourniquet, including forced flexion and position. For- cible flexion has often proved useful in cases of injury of the arteries of the forearm and hand, or of the leg and foot. A roll of lint or some other soft material should HEMORRHAGE. 275 be placed in the flexure of the joint, and the limb then bent until the hemorrhage is arrested, and maintained in this position by a handkerchief or bandage. When the bleeding is from the vessels of the leg or foot, the effect of the flexion is materially increased by flexion of the thigh upon the abdomen, as well as of the leg upon the thigh. Some of these measures may also be relied upon for the permanent arrest of certain varieties of hem- orrhage, and may be, in very exceptional cases, available for all. Baron Larrey reports a successful case of com- pression of the external carotid artery ; a solitary excep- tion, not a rule. I have myself succeeded in perma- nently arresting the bleeding from a wounded vertebral artery by firm packing of the ball-wound track through the transverse process of the vertebra. From the multitude of styptics such only "should be selected for use by the surgeon as imitate, hasten, or assist the natural processes of hemostasis." Natural hemostasis is effected first by the passive retraction of the artery within its sheath caused by the recoil of the elastic tissue it contains. Retraction is still further induced by the contraction of the longitudinal muscular fibers of the arterial wall, while the circular fibers diminish the size of the aperture. An external clot forms within the roughened sheath around the orifice of the severed vessel, the thrombus thence gradually ex- tending into its lumen until, usually, it reaches the first collateral branch above, if completely divided, or above and below if wounded in continuity (Fig. 14). The internal and external clots, acting as "buffers" to the circulation, permit the undisturbed formation and organization of granulation-tissue formed by the vessel- walls where divided : this process has already been de- scribed in Lecture IV. when speaking of the repair of blood-vessels. Cold is the oldest and best known hem- ostatic. After removing all clots, mere exposure to the air frequently stops troublesome bleeding from wounds that ooze continuously when closed and covered up with 276 PRINCIPLES OF SURGERY. cumbersome dressings. Fanning or blowing upon the wound-surface increases the effects of atmospheric cold. Still more powerful in their effects are compresses, dipped in ice-water, squeezing the contents of a sponge dipped in ice-water over the wound, or syringing it out with the same. Finally, ice itself, either in substance or in bladders or India-rubber bags may be tried. Hot water at the temperature of about 1250 F. to 1300 F. — roughly estimated, the greatest heat bear- able by the back of the hand—directed upon the wound in a stream from a sponge or syringe, but best of all applied by means of a towel wrung out in it and steadily pressed upon the wound, is far more efficacious than cold, is sterile, and not depressing but actu- ally stimulant. Alcohol, either pure or diluted, acts admirably, both.con- tracting the blood-ves- sels and forming coagula around and in their orifices. The direct application of ice to arrest bleeding, or the use of ice-water, is objec- tionable, because asepsis is hardly possible. Rubber bags can of course be sterilized, Iodin, either in the form of the pure tincture or vari- ously diluted, acts well, both it and alcohol possessing the additional advantage of being sterile and probably actively germicidal. Turpentine, applied by means of Fig. 14.—Clot (H INDEX. Pasteur's antirabic, prophylactic vac- cination, 238 theory of causation of hydrophobia, 234 Pathogenic bacteria, action of, in in- flammation, 92 Perforating ulcer, 204 treatment, 205 Peripheral vessels, regulation of blood- supply in, 22 Peritoneum, protection of, during opera- tion, 301 Perivascular ganglia, 23 illustration of their action, 24 Peroxid of hydrogen in antiseptic surgery, 305 Phagedena, sloughing, 211 Phagedenic ulcer, 211 Phagocytes, 68 action of, in combating tubercular germs, 253 in infective processes, 98 protective power of, in inflammation, 95 Phagocytosis a cause of atrophy, 34 Phlegmonous erysipelas, 218 Physiological rest, value of, in treat- ment of inflammation, 112 Plastic operation in fistula, 196 Pleurosthotonos, 225 Pointing of abscess, 190 assisted by moist heat, 118 Poisoning by carbolic acid, 177 by iodoform, 176 Polynuclear leukocytes in thrombosis, !34 Positive chemotaxis, 69 Post-mortem changes in anthrax, 246 in pyemia, 172 in rabies, 234, 235 in sapremia, 154 in septicemia, 162 findings in erysipelas, 221 in tetanus, 226 Potassium permanganate, 317 Poultice, antiseptic, 117 carrot, 116 charcoal, 117 flaxseed, 117 Poultices, 116 materials of, 116, 117 medicated, 116 when to use, 117 Power of resistance of tissues to infec- tion reduced by injury, 292 Practitioner, definition of, 18 Pressure a cause of atrophy, 34 forces toxic substances into the tissues, 18 Pressure-sores as a result of hyper- emia, 30 Primary emboli, 140 ether-anesthesia, 346, 364 infection, 97 infective thrombosis, 136 thrombi, 136 Processes of repair, 39 Propagated thrombi, 136 Prophylactic measures to be taken to exclude germs from wounds, 291 Protection of cerebral membranes against infection, 302 Protective power of granulations in inflammation, 94 Pseudo-fluctuation in articular tuber- culosis, 263 Puerperal cases, sapremia in, 152 Pulse in inflammation, 102 in aseptic fever, 103 Pulse-rate in relation to amount of hemoglobin, 133 Punctured wounds, symptoms, 326 treatment, 326 Purgatives in inflammation, 126 Purulent infiltration, 190 Puruloid fluid, 80 Pus, 80 composition of, 82 Pyemia, 165 definition, 165 causes, 165 erroneous definition, 166 infective form, 167 post-mortem changes in, 172 predisposing factors in, 167 prognosis, 172 septic form, 167 spontaneous, 166 symptoms, 168, 170 temperature in, 169 treatment, 173 Pyogenic infection of cold abscesses, 256 membrane, 253, 254 of cold abscesses, 254 Pyoid materials, 20 Pyrogenous substances, aseptic, 151 Rabies, 232. See also Hydrophobia. Racial immunity, 66 Railway spine, 339 Raynaud's disease, 201 treatment, 206 Rectal enemata in shock, 334 Rectum, sterilization of, 301 Red blood-cells, regeneration of, 133 thrombi, 137. INDEX. 395 Redness in inflammation, 99 Reduction of hemoglobin below 20 per cent., 132 Reflected and radiated pain, 100 Regeneration of blood-cells, 133 of blood-vessels, 55 of bone, 59 action of osteoclasts during, 60 osteoid tissue, 62 definitive callus, 63 healing by second intention, 64 resulting only in fibrous union, 63 of epidermis, 52 of fascia, 53 of hair-follicles, 53 of lymphatics, 52 of muscle, 53 of nerves, 57 return of function, 58 of sebaceous follicles, 53 of skin, 53 of sweat-follicles, 53 of tendons, 53 of tendon-sheaths, 53 Regulation of blood-supply in periph- eral vessels, 22 Relief of pain, 124 of pressure prevents dissemination of toxins into tissues, 18 of tension, 119 by incisions, 112 by position, 112 by pressure, 112 removes many of effects of pyo- genic germs, 18 Remedies for specific conditions, 123 Remove all morbid conditions, indica- tions to, 18 Removing all morbid conditions, theoretical possibility of, 18 Repair, 17 and hyperemia, 21 fever during, 102 healing by first intention, 40 of non-vascular tissues, 51 temperature during, 102 Residual abscess of Paget, 255 Resolution, 78 consecutive steps in, 79 in hyperemia, 28 Rest, complete and "physiological," 121 during inflammation, 108 how secured, 121 in inflammation, value of, 95 Restitutio ad integram, 78 Restriction of food in the young and healthy, 128 Results of hyperemia, 25, 28 Retrograde metastasis, 141 Return of function of nerves, 58 Rhigolene, local anesthesia by, 366 Rice bodies in synovial tuberculosis, 263 Rokitansky, views concerning inflam- mation, 377 Rubor, 35 Salicylic acid, 317 Saline injections in the treatment of hemorrhage, 272 transfusion, effects of, ^^ for shock, 333 materials for, 333 temperature of fluid for, ^^2 Salt-solution, sterilized, 316 Sapremia, 152, 153 as predisposing to septicemia, 158 compared with septicemia, 158 conditions favoring, 153 develops soon after traumatism, 153 differential diagnosis between it and septicemia, 177 general treatment, 157 in puerperal cases, 152 local treatment, 157 mistaken for shock, 153 post-mortem changes in, 154 prognosis, 154 symptoms, 155 treatment, 156 Saprophytic organisms, time required to multiply, 152 Sarcoma, amount of hemoglobin re- duced in, 133 Scab, healing under, 48 Scar-tissue, 78 as a result of hyperemia, 28 Scars, contraction of, 49 Schimmelbusch's dressing sterilizer, 3H Schimmelbusch's instrument sterilizer, 310 Schklarewsky, views concerning in- flammation, 380 Schleich's infiltration-anesthesia, 367 Sebaceous follicles, regeneration of, 53 Second intention, healing by, 40 stage of inflammation, 82 Secondary emboli, 140 infective thrombosis, 136 or composite law, 17 suturing, 49 Secretions during inflammation, 102 in aseptic fever, 103 Senile hypertrophy, ^ Septic chill, 150 form of pyemia, 167 39° INDEX. Septic germs in inflammation, 95 intoxication, 153 Septicemia, comparison with sapremia, 158 fever in, 161 general changes in, 160 general treatment, 164 Hoffa's views of nature of skin lesions in, 160 local changes in, 159 local treatment, 163 Marmorek's serum in, 164 point of infection in, 158 post-mortem changes in, 162 predisposed to by sapremia, 158 symptoms, 158, 159, 160 time of development of, 158 wound changes in, 161 Sequelse of anesthesia, treatment, 356 Serofibrinous exudate, 31 Seropurulent exudate, 31 Serous exudate, 31 Serum, intravenous injections in treat- ment of tetanus, 228 Severe injuries, inflammation follow- ing, 83 Shock, 327 and operation, 332 erethistic type, 329 exciting causes, 330 from crushed limb, 334 hypodermatoclysis in, 334 importance of prevention of, 331 pathology, 327 predisposing causes, 329 prophylaxis, 332 rectal enemata in, 334 saline transfusion in, 333 symptoms, 327 treatment, 331 Simple ulcer, treatment of, 209 Sinus, 194 and fistula, causes of, 194 definition, 194 Skin, deficient excretion by, 186 regeneration of, 53 Skin-grafting, principles of, 49 Slight injuries, inflammation following, 84 Sloughing, aseptic, 46 in erysipelas, 220 infective, 47 ulcer, 211 treatment, 211 Soaps as disinfectants, 297 Softening of thrombi, 138 Solutions, aseptic, 316 Sources of germs in wounds, 291 Spasmotoxin, 224 Special danger from wounds of certain veins, 286 Specific conditions, remedies for, 123 Spine, concussion of, 339 railway, 339 Splints for incised wounds, 323 Spontaneous gangrene, 197 pyemia, 166 Spreading gangrene, treatment of, 204 thrombi, 136 traumatic gangrene, 203 Square knot, 282 Starvation of inflammation, 119 Stasis, effects of cold upon, 107 Steam bath, 122 how to employ, 123 Sterilization by chemicals, 296 in clinical work, 296 mechanical, of hands, 297 of utensils, 297 of animal ligatures, 315 of bladder, 303 of catheters, 311 of dressings, in Schimmelbusch's boxes, 313 of sponges and ligatures by chem- icals, 314 of field of operation, 299 of hypodermic syringes, 312 of instruments, methods of, 309 of ligature and suture materials, 315 of mouth, 300 of rectum and intestines, 301 of stomach, 302 of vagina, ^ Sterilized salt-solution, 316 Stimulating the action of the elimina- tive organs, importance of, 122 Stimulants in inflammation, 124 Stitch-hke pain, 100 Stomach, sterilization of, 302 Strieker, view concerning inflamma- tion, 381 Strumous and scrofulous diathesis, 251 cutaneous ulcers really tubercular, 261 Subacute inflammation, 82 Substances causing aseptic fever, 103 Supplemental or vicarious sensibility, 5.8 Supporting pressure, 126 Suppuration, 189 bleb-formation in, 190 complications, 193 diagnosis, 192 dressings in, 194 edema in, 190 in " bleeders," 193 pain in, 90 INDEX. 397 Suppuration, sweating in, 191 symptoms, 190 temperature in, 191 treatment, 192 use of exploring needle in, 191 Suppurative inflammation, leukocytosis in, 132 Surgeon's knot, 282, 283 Surgical fevers, 158 Suture material, sterilization of, 315 Sweat-follicles, regeneration of, 53 Sweats in suppuration, 191 Swelled head of cattle, 249 Swelling in inflammation, 101 Symmetrical gangrene, 201 Syncope in hemorrhage, 271 Synovial membranes, tuberculosis of, 262 Temperature in inflammation, 102 during repair, 102 in pyemia, 169 Tendons, regeneration of, 53 Tendon-sheaths, regeneration of, 53 Tension, relief of, by incision, 112 by position, 112 Terminations of inflammation, 86 Tetanin, 224 Tetanotoxin, 224 Tetanus, amputation of part in treat- ment of, 229 antitoxin, when and in what amount to be used, 229 cause, 223 chronic, 226 definition, 223 description, 223 hydrophobica, 224, 237 intracranial injections of serum in the treatment of, 228 predisposing causes of, 223 prophylaxis in, 231 prognosis, 227 symptoms, 224 toxins of, 224 treatment, 228 trismus or lockjaw in, 230 value of absolute quiet in treatment of, 230 value of antitoxin in, 231 value of narcotics in the treatment of, 229 Tetany, 226 symptoms, 226 Third intention, healing by, 41 stage of inflammation, 83 Throbbing pain, 100 Thrombi, annular, 136 arterial, 137 Thrombi, calcification of, 138 changes in, 137 extension of, 137 fibrinous, 137 hematoblastic, 137 hemostatic, 137 in mesenteric veins, 137 in veins, 137 infection of, 136 laminated, 137 leukocytic, 137 obstructive, 136 parietal, 136 primary, 136 propagated, 136 red, 137 softening of, 138 Thrombo-arteritis, 139 Thrombophlebitis, 139 Thrombosis, 134 liability of, in inflammation, 134 marasmic, 135 of cerebral sinuses, 137 polynuclear leukocytes in, 134 predisposing causes, 130, 135 primary infective, 136 treatment, 142 Tissues, regeneration of, 52 Torsion for arrest of hemorrhage, 279 Towels, use of, after sterilization, 298 Toxic alkaloids, composition of, 180 in normal tissues, 179 Toxicity of urine, loss of, dangerous, 184 Toxins of tetanus, 224 Transfusion, venous, 334 Traumatic delirium, 335 nervous, 335 prognosis, 335 treatment, 335 gangrene, 197 spreading, 203 hemorrhage, 268 hysteria, 338 prognosis, 341 symptoms, 340 treatment, 341 insanity, 338 mania, 341 neurasthenia, 339 symptoms, 340 Travelling acetabulum, 262 Trismus, 230 Trophic changes a factor in inflamma- tion, 90 Tubercle, anatomical, 261 articular, pseudo-fluctuation in, 263 Tubercular germs, how disposed of, 252 398 INL Tubercular glands, ignipuncture in treatment of, 266 gummata, 261 Tuberculin test for diagnosis, 259 Tuberculogenic membrane, 253 Tuberculosis, description, 250 diagnosis, 259 encapsulation of, 253 how it extends in bone, 260 how it extends in lymphatics, 260 local treatment, 265 of synovial membranes, 262 treatment, 263 Ulcer, definition of, 208 eczematous, 214 edematous, 210 fungous, 209 treatment, 209 indolent, 213 symptoms, 214 inflamed, 211 inflammatory, 210 irritable, 216 Marjolin's, 214 perforating, 204 phagedenic, 211 simple, description of, 208 simple, healthy or healing, 208 treatment, 209 sloughing, 211 varicose, 214 Ulceration, 82 and ulcers, 208 from hyperemia, 29 Ulcers, " atheromatous," a cause of thrombosis, 136 varieties of, 208 Urea, specific action of, 181 Urinary secretion as a depurating agent, 184 Urine, deficient excretion by, 185 loss of toxicity of, dangerous, 184 Utensils, sterilization of, 297 Vagina, sterilization of, 333 Varicose ulcer, 214 Vasoconstrictor nerves, 22 Vasodilator nerves, action of, 22, 23 Vasomotor apparatus, 22 Veins, wounds of, 286 Venesection, 108 Venous blood, effect of gravity upon, 114 hemorrhage, 268 diagnosis from capillary, 286 transfusion, 334 thrombi, 137 Vicarious sensibility, 58 Virchow, view concerning inflamma- tion, 378 Vomiting after anesthesia, treatment of, 356 Von Recklinghausen, views concerning inflammation, 381 Walls of blood-vessels, changes in, 133 Warmth, use of, in inflammation, in Weigert, views concerning inflamma- tion, 381 Wet-cupping, 119 White swelling, why so termed, 263 " Wool-sorters' disease," 244 Wound, contused, 319 definition, 319 fluids predisposed to infection, 292 incised, 319 aseptic, 320 description, 319 infected, 320 lacerated, 319 punctured, 319 subcutaneous, 319 Wound-changes in septicemia, 161 Wounds, antiseptic treatment of, 294 constitutional effects, 323 constitutional treatment, 326 contused, treatment, 324 healing of, conditions influencing, 293 incised, treatment, 320 lacerated, symptoms, 324 sources of germs in, 291 treatment, 291, 319 varieties, 319 Ziegler, views concerning inflamma- tion, 383 Zinc chlorid, 318 oxid, 318 CATALOGUE OF THE MEDICAL PUBLICATIONS OF W* B* SAUNDERS, No. 925 WALNUT STREET, PHILADELPHIA. Arranged Alphabetically and Classified under Subjects. THE books advertised in this Catalogue as being sold by subscription are usually to be obtained from travelling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. All the other books advertised are commonly for sale by booksellers in all parts of the United States; but books will be sent to any address, carriage prepaid, on receipt of the published price. Money may be sent at the risk of the publisher in either of the following ways: A post- office money order, an express money order, a bank check, and in a registered letter. Money sent in any other way is at the risk of the sender. See pages 30, 31, for a List of Contents classified according to subjects. LATEST PUBLICATIONS. American Text-Book of Dis. of Eye, Ear, Nose, and Throat. Page 3, American Text-Book of Genito-Urinary and Skin Diseases. Page 4. American Text-Book of Diseases of Children—Rev. Edition. Page 3. American Text-Book of Gynecology—Revised Edition. See page 4. American Year-Book of Medicine and Surgery. See page 6. Anders' Practice of Medicine—Revised Edition. See page 6. Vierordt's Medical Diagnosis—Fourth (Revised) Edition. See page 29. Kyle on the Nose and Throat. See page 15. Church and Peterson's Nervous and Mental Diseases. See page 8. Da Costa's Surgery—Revised and Enlarged Edition. See page 10. Saunders' Medical Hand-Atlases. See page 2. Griffith on The Baby—Revised Edition. See page 12. Butler's Materia Medica and Therapeutics—Revised Edition. Page 8. De Schweinitz' Diseases of the Eye—Revised Edition. See page 10. Vecki's Sexual Impotence. See page 28. Stoney's Materia Medica for Nurses. See page 28. Penrose's Diseases of Women—Second Edition. See page 18. McFarland's Pathogenic Bacteria—Revised Edition. See page 17< American Pocket Medical Dictionary. See page 10. Stengel's Text-Book of Pathology. See page 26. Hirst's Text-Book of Obstetrics. See page 13. Grafstrom's Massage and Medical Gymnastics. Page 12. Saunders' Pocket Formulary—Fifth (Revised) Edition. See page 24. Stevens' Practice of Medicine—Fifth (Revised) Edition. See page 27. SAUNDERS' MEDICAL HAND-ATLASES. The series of books included under this title consists of authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which for sci- entific accuracy, pictorial beauty, compactness, and cheapness surpass any similar volumes ever published. Each volume contains from 50 to 100 colored plates, executed by the most skilful German lithographers, besides numerous illustrations in the text. There is a full and appropriate description of each plate, and each book contains a condensed but adequate outline of the subject to which it is devoted. One of the most valuable features of these atlases is that they offer a ready and satis- factory substitute for clinical observation. To those unable to attend important clinics these books will be absolutely indispensable. In planning this series of books arrangements were made with representative publishers in the chief medical centers of the world for the publication of translations of the atlases into nine different languages, the lithographic plates for ail these editions being made in Ger- many, where work of this kind has been brought to the greatest perfection. The expense of making the plates being shared by the various publishers, the cost to each one was materially reduced. Thus by reason of their universal translation and reproduction, the publish- ers have been enabled to secure for these atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. The success of the undertaking is demon- strated by the fact that the volumes have already appeared in nine different languages —German, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. In view of the striking success of these works, Mr. Saunders has contracted with the publisher of the original German edition for one hundred thousand copies of the atlases. In consideration of this enormous undertaking, the publisher has been enabled to prepare and furnish special additional colored plates, making the series even handsomer and more complete than was originally intended. As an indication of the practical value of the atlases and of the favor with which they have been received, it should be noted that the Medical Department of the U. S. Army has adopted the " Atlas of Operative Surgery " as its standard, and has ordered the book in large quantities for distribution to the various regiments and army posts. 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Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid Anatomy in the University of Pennsylvania; and David Riesman, M.D., Demonstrator of Pathological Histology in the University of Pennsylvania. In Preparation. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By io of the Leading Physiologists of America. Edited by William H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- kins University, Baltimore, Md. One handsome imperial octavo volume of 1052 pages. Illustrated. Cloth, $6.00 net; Sheep or Half Morocco, $7.00 net. Sold by Subscription. "We can commend it most heartily, not only to all students of physiology, but to every physician and pathologist, as a valuable and comprehensive work of reference, written by men who are of eminent authority in their own special subjects."—London Lancet. " To the practitioner of medicine and to the advanced student this volume constitutes, we believe, the best exposition of the present status of the science of physiology in the English language."—American Journal of the Medical Sciences. AN AMERICAN TEXT-BOOK OF SURGERY. Second Edition. By 13 Eminent Professors of Surgery. Edited by William W. Keen, M.D., LL.D., and J. William White, M.D., Ph.D. Handsome imperial octavo volume of 1250 pages, with 500 wood-cuts in the text, and 39 colored and half-tone plates. Thoroughly revised and enlarged, with a section devoted to " The Use of the Rontgen Rays in Surgery." Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Sub- scription. *' Personally, I should not mind it being called THE Text-Book (instead of A Text- Book) , for I know of no single volume which contains so readable and complete an account of the science and art of Surgery as this does."—Edmund Owen, F.R.C.S., Member of the Board of Examiners of the Royal College of Surgeons, England. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet. AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE OF MEDICINE. By 12 Distinguished American Practitioners. Edited by William Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi- cine and of Clinical Medicine in the University of Pennsylvania. Two handsome imperial octavo volumes of about 1000 pages each. Illus- trated. Prices per volume : Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. Sold by Subscription. " I am quite sure it will commend itself both to practitioners and students of medicine, and become one of our most popular text-books."—Alfred Loomis, M.D., LL.D., Pro- fessor of Pathology and Practice of Medicine, University of the City of New York. " We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is in our opinion the best of its kind it has ever been our fortune to see."—ATew York Medical fournal. ___________________ Illustrated Catalogue of the " American Text-Books" sent free upon application. 6 Medical Publications of W. B. Saunders. AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. A Yearly Digest of Scientific Progress and Authoritative Opinion in all branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and Foreign authors and investigators. Collected and arranged, with critical editorial com- ments, by eminent American specialists and teachers, under the general editorial charge of George M. Gould, M.D. One handsome imperial octavo volume of about 1200 pages. Uniform in style, size, and general make-up with the "American Text-Book" Series. Cloth, $6.50 net; Half Morocco, $7.50 net. Sold by Subscription. " It is difficult to know which to admire most—the research and industry of the distin- . guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the wealth and abundance of the contributions to every department of science that have been deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, for, as each section is entrusted to experienced and able contributors, the reader has the advantage of certain critical commentaries and expositions . . . proceeding from writers fully qualified to perform these tasks. . . . It is emphatically a book which should find a place in every medical library, and is in several respects more useful than the famous ' Jahrbiicher' of Germany."—London Lancet. THE AMERICAN POCKET MEDICAL DICTIONARY. [See D or land's Pocket Dictionary, page 10.] ANDERS' PRACTICE OF MEDICINE. Second Edition. A Text-Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, $5.50 net; Sheep or Half Morocco, $6.50 net. " It is an excellent book,—concise, comprehensive, thorough, and up to date. It is a credit to you ; but, more than that, it is a credit to the profession of Philadelphia—to us." James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson Medical College, Philadelphia. ASHTON'S OBSTETRICS. Fourth Edition, Revised. Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Embodies the whole subject in a nut-shell. We cordially recommend it to our read ers."—Chicago Medical Times. BALL'S BACTERIOLOGY. Third Edition, Revised. Essentials of Bacteriology ; a Concise and Systematic Introduction to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] '' The student or practitioner can readily obtain a knowledge of the subject from a perusal of this book. The illustrations are clear and satisfactory."—Medical Record, New York. Medical Publications of W. B. Saunders. 7 BASTIN'S BOTANY. Laboratory Exercises in Botany. By Edson S. Bastin, M.A., late Professor of Materia Medica and Botany, Philadelphia College of Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50. "It is unquestionably the best text-book on the subject that has yet appeared. The work is eminently a practical one. We regard the issuance of this book as an important event in the history of pharmaceutical teaching in this country, and predict for it an unquali- fied success."—Alumni Report to the Philadelphia College of Pharmacy. '' There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation."—American Journal of Pharmacy. BECK'S SURGICAL ASEPSIS. A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and the New York German Poliklinik, etc. 306 pages; 65 text-illustrations, and 12 full-page plates. Cloth, #1.25 net. " An excellent exposition of the ' very latest' in the treatment of wounds as practised by leading German and American surgeons."—Birmingham (Eng.) Medical Review. "This little volume can be recommended to any who are desirous of learning the details of asepsis in surgery, for it will serve as a trustworthy guide."—London Lancet. BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERATIONS. Obstetric Accidents, Emergencies, and Operations. By L. Ch. Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. " It is clearly and concisely written, and is evidently the work of a teacher and practi- tioner of large experience."—British Medical Journal. " A manual so useful to the student or the general practitioner has not been brought to our notice in a long time. The field embraced in the title is covered in a terse, interesting way."— Yale Medical Journal. BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. Essentials of Medical Physics. By Fred J. Brockwav, M.D., Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. Cloth, $1.00 net; interleaved for notes, $1.25 net. [See Saunders' Question-Compends, page 21.] " The student who is well versed in these pages will certainly prove qualified to com prebend with ease and pleasure the great majority of questions involving physical principles likely to be met with in his medical studies."—American Practitioner and News. "We know of no manual that affords the medical student a better or more concise exposition of physics, and the book may be commended as a most satisfactory presentation of those essentials that are requisite in a course in medicine."—New York Medical Journal. " It contains all that one need know on the subject, is well written, and is copiously illustrated."— Medical Record, New York. BURR ON NERVOUS DISEASES. A Manual of Nervous Diseases. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopedic Hospital and Infirmary for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. In Preparation. 8 Medical Publications of W. B. Saunders. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- MACOLOGY. Second Edition, Revised. A Text=Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 860 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. " Taken as a whole, the book may fairly be considered as one of the most satisfactory of any single-volume works on materia medica in the market,"—Journal of the American Medical Association. CERNA ON THE NEWER REMEDIES. Second Edition, Revised. Notes on the Newer Remedies, their Therapeutic Applications and Modes of Administration. By David Cerna, M.D., Ph.D., formerly Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania; Demonstrator of Physiology in the Medical Department of the University of Texas. Rewritten and greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. " The appearance of this new edition of Dr. Cerna's very valuable work shows that it is properly appreciated. The book ought to be in the possession of every practising physi- cian."—New York Medical Journal. CHAPIN ON INSANITY. A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physi- cian-Superintendent of the Willard State Hospital, New York; Hon- orary Member of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium, nmo, 234 pages, illustrated. Cloth, $1.25 net. " The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We desire especially to call attention to the fact that on the subject of therapeutics of insanity the work is exceedingly valuable. It is not a made book, but a genuine condensed thesis, which has all the value of ripe opinion and all the charm of a vigorous and natural style."— Philadelphia Medical Journal. CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. Second Edition, Revised. Medical Jurisprudence and Toxicology. By Henry C. Chapman, M.D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia. 254 pages, with 55 illustrations and 3 full-page plates in colors. Cloth, $1.50 net. "The best book of its class for the undergraduate that we know of."—New York Medical Times. CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M. D., Professor of Mental Diseases and Medical Jurisprudence in the North- western University Medical School, Chicago; and Frederick Peter- son, M. D., Clinical Professor of Mental Diseases, Woman's Medical College, N. Y.; Chief of Clinic, Nervous Dept., College of Physi- cians and Surgeons, N. Y. Handsome octavo volume of 843 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, $6.00 net. Medical Publications of W. B. Saunders. 9 CLARKSON'S HISTOLOGY. A Text-Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 22 engravings in the text, and 174 beautifully colored original illustra- tions. Cloth, strongly bound, $6.00 net. " The work must be considered a valuable addition to the list of available text-books, and is to be highly recommended."—New York Medical Journal. "This is one of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students."— Chicago Medical Recorder. CLIMATOLOGY. Transactions of the Eighth Annual Meeting of the American Climatological Association, held in Washington, September 22-25, 1891. Forming a handsome octavo volume of 276 pages, uniform with remainder of series. (A limited quantity only.) Cloth, $1.50. COHEN AND ESHNER'S DIAGNOSIS. Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- fessor of Clinical Medicine and Applied Therapeutics in the Philadel- phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 illustrations. Cloth, $1.50 net. [See Saunders' Question-Compends, page 21.] " We can heartily commend the book to all those who contemplate purchasing a 'com- pend.' It is modern and complete, and will give more satisfaction than many other works which are perhaps too prolix as well as behind the times."—Medical Review, St. Louis. CORWIN'S PHYSICAL DIAGNOSIS. Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush Medical College, Chicago ; Attending Physician to Central Free Dis- pensary, Department of Rhinology, Laryngology, and Diseases of the Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. " It is excellent. The student who shall use it as his guide to the careful study of physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good working knowledge of the subject."—Philadelphia Polyclinic. "A most excellent little work. It brightens the memory of the differential diagnostic signs, and it arranges orderly and in sequence the various objective phenomena to logical solution of a careful diagnosis."—Journal of Nervous and Mental Diseases. CRAGIN'S GYNAECOLOGY. Fourth Edition, Revised, Essentials of Gynaecology. By Edwin B. Cragin, M. D., Lecturer in Obstetrics, College of Physicians and Surgeons, New York. Crown octavo, 200 pages; 62 illustrations. Cloth, $1.00 ; interleaved for notes, $l-25- [See Saunders' Question-Compends, page 21.] " A handy volume, and a distinct improvement on students' compends in general. No author v, ho was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has done."—Medical Record, New York. 10 Medical Publications of W. B. Saunders. CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. A Text-Book of Bacteriology. By Edgar M. Crookshank, M.B., Professor of Comparative Pathology and Bacteriology, King's College, London. Octavo volume of 700 pages, with 273 engravings and 22 original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. " To the student who wishes to obtain a good resume of what has been done in bacteri- ology, or who wishes an accurate account of the various methods of research, the book may be recommended with confidence that he will find there what he requires."—London Lancet. Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. Modern Surgery, General and Operative. By John Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Handsome octavo volume of 900 pages, profusely illustrated. Cloth, #4.00 net; Half Morocco, $5.00 net. "We know of no small work on surgery in the English language which so well fulfils the requirements of the modern student."—Medico-Chirurgical Journal, Bristol, England. DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, Revised. Diseases of the Eye. A Handbook of Ophthalmic Practice. By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. Handsome royal octavo volume of 696 pages, with 256 fine illustrations and 2 chromo-litho- graphic plates. Cloth, #4.00 net; Sheep or Half Morocco, $5.00 net. " A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science."—British Medical Journal. '' A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it."—William Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, University of Pennsylvania. DORLAND'S DICTIONARY. Second Edition, Revised. The American Pocket Medical Dictionary. Containing the Pro- nunciation and Definition of all the principal words and phrases, and a large number of useful tables. Edited by W. A. Newman Dorland, M. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Fellow of the American Academy of Medicine. 518 pages ; handsomely bound in full leather, limp, with gilt edges and patent index. Price, $1.25 net. DORLAND'S OBSTETRICS. A Manual of Obstetrics. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. "By far the best book on this subject that has ever come to our notice."—American Medical Review. " It has rarely been our duty to review a book which has given us more pleasure in its perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, a gold mine of practical, concise thoughts."—American Medico-Surgical Bulletin. Medical Publications of W. B. Saunders. 11 FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. Laboratory Guide for the Bacteriologist. By Langdon Froth- S°aA^ MDV> Assistant in Bacteriology and Veterinary Science, bnemeld Scientific School, Yale University. Illustrated. Cloth, 75 cts. " It is a convenient and useful little work, and will more than repay the outlay neces- sary lor its purchase in the saving of time which would otherwise be'consumed in looking up the various points of technique so clearly and concisely laid down in its vases."-Ameri- can Medico-Surgical Bulletin. ^"^ri GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro^ fessor of Gynecology in the New York School of Clinical Medicine; Gynecologist to St. Mark's Hospital and to the German Dispensary, New York City, etc. Handsome octavo volume of 728 pages, illus- trated by 335 engravings and colored plates. Cloth, $4.00 net; Sheep or Half Morocco, #5.00 net. . " °,ne °f the best text-bPoks for students and practitioners which has been published in the English language ; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners to whom experienced consultants may not be available will find in this book invaluable counsel and help."—Thad. A Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. Essentials of Diseases of the Ear. By E. B. Gleason, SB., M.D., Clinical Professor of Otology, Medico-Chirurgical College^ Philadelphia; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- ment of the Northern Dispensary, Philadelphia. 208 pages, with 114 illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "It is just the book to put into the hands of a student, and cannot fail to give him a useful introduction to ear-affections ; while the style of question and answer which is adopted throughout the book is, we believe, the best method of impressing facts permanently on the mind."—Liverpool Medico- Chirurgical Journal. GOULD AND PYLE'S CURIOSITIES OF MEDICINE. Anomalies and Curiosities of Medicine. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collection of rare and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome im- perial octavo volume of 968 pages, with 295 engravings in the text, and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. Sold by Subscription. " One of the most valuable contributions ever made to medical literature. It is, so far as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value: it will serve as a book of reference for all who are interested in general scientific, sociologic, or medico-legal topics. "—Brooklyn Medical Journal. " This is certainly a most remarkable and interesting volume. It stands alone among medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in medical literature. It is a book full of revelations from its first to its last page, and cannot but interest and sometimes almost horrify its readers."—American Medico-Surgical Bulletin. 12 Medical Publications of W. B. Saunders. GRAFSTROM'S MECHANO-THERAPY. A Text-Book of Mechano-Therapy (Massage and Medical Gym- nastics). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in the Royal Swedish Army; late House Physician City Hospital, Black- well's Island, New York. 12mo, 139 pages, illustrated. Cloth, $ 1.00 net. GRIFFITH ON THE BABY. Second Edition, Revised. The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- cal Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404 pages, with 67 illustrations in the text, and 5 plates. Cloth, #1.50. " The best book for the use of the young mother with which we are acquainted. . . . There are very few general practitioners who could not read the book through with advan- tage. ''—Archives of Pediatrics. "The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportunities for observing children."—Ameri- can Journal of Obstetrics. GRIFFITH'S WEIGHT CHART. Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children in the University of Penn- sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. GROSS, SAMUEL D., AUTOBIOGRAPHY OF. Autobiography of Samuel D. Gross, M.D., Emeritus Professor of Surgery in the Jefferson Medical College, Philadelphia, with Remi- niscences of His Times and Contemporaries. Edited by his Sons, Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- gery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In two handsome volumes, each containing over 400 pages, demy octavo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per volume, $2.50 net. "Dr. Gross was perhaps the most eminent exponent of medical science that America has yet produced. His Autobiography, related as it is with a fulness and completeness seldom to be found in such works, is an interesting and valuable book. He comments on many things, especially, of course, on medical men and medical practice, in a very interest- ing way."—The Spectator, London, England. HAMPTON'S NURSING. Second Edition, Revised and Enlarged. Nursing: Its Principles and Practice. By Isabel Adams Hamp- ton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital; late Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 12 mo, 512 pages, illustrated. Cloth, $2.00 net. " Seldom have we perused a book upon the subject that has given us so much pleasure as the one before us. We would strongly urge upon the members of our own profession the need of a book like this, for it will enable each of us to become a training school in him- self."— Ontario Medical Journal. Medical Publications of W. B. Saunders. 13 HARE'S PHYSIOLOGY. Fourth Edition, Revised. Essentials of Physiology. By H. A. Hare, M.D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter- leaved for notes, $1.25 net. [See Saunders' Question- Compends, page 21.] " The best condensation of physiological knowledge we have yet seen."—Medical Record, New York. HART'S DIET IN SICKNESS AND IN HEALTH. Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women; with an Introduction by Sir Henry Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, $1.50. " We recommend it cordially to the attention of all practitioners ; both to them and to their patients it may be of the greatest service."—New York Medical Journal. HAYNES' ANATOMY. A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- ment of the New York University, etc. 680 pages, illustrated with 42 diagrams in the text, and 134 full-page half-tone illustrations from original photographs of the author's dissections. Cloth, $2.50 net. " This book is the work of a practical instructor—one who knows by experience the requirements of the average student, and is able to meet these requirements in a very satis factory way. The book is one that can be commended."—Medical Record, New York. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Pro- fessor of Anatomy in the Medico-Chirurgical College,. Philadelphia. i2mo volume of about 325 pages, handsomely illustrated. HIRST'S OBSTETRICS. A Text-Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstetrics in the University of Pennsylvania. Handsome octavo volume of 848 pages, with 618 illustrations, and 7 colored plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. " The illustrations are numerous and are works of art, many of them appearing for the first time. The arrangement of the subject-matter, the foot-notes, and index are beyond criticism As a true model of what a modern text-book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival."—New York Medical Record. HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL DISEASES. Syphilis and the Venereal Diseases. By James Nevins Hyde, M D Professor of Skin and Venereal Diseases, and Frank H. Mont- gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush'Medical College, Chicago, 111. 618 pages, profusely illustrated. Cloth, $2.50 net. " We can commend this manual to the student as a help to him in his study of venereal diseases.' '—Liverpool Medico- Chirurgical Journal. " The best student's manual which has appeared on the subject."—St. Louis Medical and Surgical Journal. 14 Medical Publications of W. B. Saunders. JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND THROAT. Second Edition, Revised. Essentials of Refraction and Diseases of the Eye. By Edward Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- delphia Polyclinic and College for Graduates in Medicine; and— Essentials of Diseases of the Nose and Throat. By E. Bald- win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia. Two volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Of great value to the beginner in these branches. The authors are both capable men, and know what a student most needs."—Medical Record, New York. KEATING'S DICTIONARY. Second Edition, Revised. A New Pronouncing Dictionary of Medicine, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- delphia; Vice-President of the American Pediatric Society; Editor " Cyclopaedia of the Diseases of Children," etc.; and Henry Hamilton, Author of " A New Translation of Virgil's ^Eneid into English Rhyme," etc.; with the collaboration of J. Chalmers Da- Costa, M.D., and Frederick A. Packard, M.D. With an Appendix containing Tables of Bacilli, Micrococci, Leucoma'ines, Ptomaines; Drugs and Materials used in Antiseptic Surgery; Poisons and their Antidotes; Weights and Measures; Thermometric Scales; New Official and Unofficial Drugs, etc. One volume of over 800 pages. Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 net; Sheep or Half Morocco, #6.00 net; Half Russia, $6.50 net. Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. "lam much pleased with Keating's Dictionary, and shall take pleasure in recommend. ing it to my classes."—Henry M. Lyman, M.D., Professor of the Principles and Practict of Medicine, Rush Medical College, ^Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use."—C. A. Lindsley, M.D., Professor of the Theory and Practice of Medicine, Medical Dept. Yale University. KEATING'S LIFE INSURANCE. How to Examine for Life Insurance. By John M. Keating, M. D., Fellow of the College of Physicians of Philadelphia; Vice- President of the American Pediatric Society; Ex-President of the Association of Life Insurance Medical Directors. Royal octavo, 211 pages; with two large half-tone illustrations, and'a plate prepared by Dr. McClellan from special dissections; also, numerous other illustra- tions. Cloth, $2.00 net. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science."—The Medical News. Medical Publications of W. B. Saunders. 15 KEEN ON THE SURGERY OF TYPHOID FEVER. The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; Corresponding Member of the Societe de Chirurgie, Paris; Honorary Member of the Societe Beige de Chirurgie, etc. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. " This is probably the first and only work in the English language that gives the reader a clear view of what typhoid fever really is, and what it does and can do to the human organism. This book should be in the possession of every medical man in America."— American Medico-Surgical Bulletin. KEEN'S OPERATION BLANK. Second Edition, Revised Form. An Operation Blank, with Lists of Instruments, etc. Required in Various Operations. Prepared by W. W. Keen, M.D., LL.D., Professor of the Principles of Surgery in Jefferson Medical College, Philadelphia. Price per pad, containing blanks for fifty operations, 50 cents net. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Handsome octavo volume of about 630 pages, with over 150 illustrations and 6 lithographic plates. Price, Cloth, $----net; Half Morocco, $—— net. LAINE'S TEMPERATURE CHART. Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ inches. A conveniently arranged Chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. Price, per pad of 25 charts, 50 cents net. " To the busy practitioner this chart will be found of great value in fever cases, and especially for cases of typhoid."—Indian Lancet, Calcutta. LOCKWOOD'S PRACTICE OF MEDICINE. A Manual of the Practice of Medicine. By George Roe Lock- wood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. 935 pages, with 75 illustrations in the text, and 22 full-page plates. Cloth, #2.50 net. " Gives in a most concise manner the points essential to treatment usually enumerated in the most elaborate works."— Massachusetts Medical Journal. LONG'S SYLLABUS OF GYNECOLOGY. A Syllabus of Gynecology, arranged in Conformity with " An American Text-Book of Gynecology." By J. W. Long, M.D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, $1.00 net. " The book is certainly an admirable risumS of what every gynecological student and i nioner should know, and will prove of value not only to those who have the ' American Text-Book of Gynecology,' but to others as well."—Brooklyn Medical Journal. 16 Medical Publications of W. B. Saunders. MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., F.R.C.S., Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline University; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, $6.00 net. " A thorough and complete work on surgical diagnosis and treatment, free from pad- ding, full of valuable material, and in accord with the surgical teaching of the day."—The Medical News, New York. " The work is brimful of just the kind of practical information that is useful alike to students and practitioners. It is a pleasure to commend the book because of its intrinsic value to the medical practitioner."—Cincinnati Lancet-Clinic. MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. Pathological Technique. A Practical Manual for Laboratory Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on Post-Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard University Medical School, Boston; and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard University Medical School, Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. " I have been looking forward to the publication of this book, and I am glad to say that I find it to be a most useful laboratory and post-mortem guide, full of practical information, and well up to date."—William H. Welch, Professor of Pathology, Johns Hopkins Uni- versity, Baltimore, Md. MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. Second Edition, Revised. Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "A very practical and systematic study of the subjects, and shows the author's famil- iarity with the needs of students."—Therapeutic Gazette. MARTIN'S SURGERY. Sixth Edition, Revised. Essentials of Surgery. Containing also Venereal Diseases, Surgi- cal Landmarks, Minor and Operative Surgery, and a complete de- scription, with illustrations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito- Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 pages, illustrated. With an Appendix containing full directions for the preparation of the materials used in Antiseptic Surgery, etc. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Contains all necessary essentials of modern surgery in a comparatively small space. Its style is interesting, and its illustrations are admirable."—Medical and Surgical Reporter- Medical Publications of W. B. Saunders. 17 McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re- vised and Greatly Enlarged. Text=Book upon the Pathogenic Bacteria. By Joseph McFar- i.and, M. D., Professor of Pathology and Bacteriology in the Medico- Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, finely illustrated. Cloth, $2.50 net. " Dr. McFarland has treated the subject in a systematic manner, and has succeeded in presenting in a concise and readable form the essentials of bacteriology up to date. Alto- gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College."—H. B. Anderson, M.D., Professor of Pathology and Bac- teriology, Trinity Medical College, Toronto. MEIGS ON FEEDING IN INFANCY. Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound in limp cloth, flush edges, 25 cents net. " This pamphlet is worth many times over its price to the physician. The author's experiments and conclusions are original, and have been the means of doing much good."— Medical Bulletin. MOORE'S ORTHOPEDIC SURGERY. A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. " A most attractive work. The illustrations and the care with which the book is adapted to the wants of the general practitioner and the student are worthy of great praise."—Chicago Medical Recorder. " A very demonstrative work, every illustration of which conveys a lesson. The work is a most excellent and commendable one, which we can certainly endorse with pleasure."— St. Louis Medical and Surgical Journal. MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth Edition, Revised. Essentials of Materia Medica, Therapeutics, and Prescription- Writing. By Henry Morris, M.D., late Demonstrator of Thera- peutics, Jefferson Medical College, Philadelphia; Fellow of the College of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] « This work, already excellent in the old edition, has been largely improved by revi- sion."—American Practitioner and News. MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. Third Edition, Revised. Essentials of the Practice of Medicine. By Henry Morris, M. D., late Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia ; with an Appendix on the Clinical and Microscopic Examina- tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- tial formulae collected and arranged by William M. Powell, M.D. Post-octavo, 488 pages. Cloth, $2.00. [See Saunders' Question-Compends, page 21.] " Tiit' teaching is sound, the presentation graphic ; matter full as can be desired, and -tvle attractive."—American Practitioner and News. 2 18 Medical Publications of W. B. Saunders. MORTEN'S NURSE'S DICTIONARY. Nurse's Dictionary of Medical Terms and Nursing Treat- ment. Containing Definitions of the Principal Medical and. Nursing Terms and Abbreviations; of the Instruments, Drugs, Diseases, Acci- dents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. By Honnor Morten, author of " How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00. " A handy, compact little volume, containing a large amount of general information, all of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. It is certainly of value to those for whose use it is published."—Chicago Clinical Review. NANCREDE'S ANATOMY. Fifth Edition. Essentials of Anatomy, including the Anatomy of the Viscera. By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 388 pages; 180 illustrations. With an Appendix containing over 60 illustrations of the osteology of the human body. Based upon Gray's Anatomy. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at school, it would not be easy to speak of it in terms too favorable."—American Practitioner. NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. Essentials of Anatomy and Manual of Practical Dissection. By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo; 500 pages, with full-page lithographic plates in colors, and nearly 200 illustrations. Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. " It may in many respects be considered an epitome of Gray '5 popular work on general anatomy, at the same time having some distinguishing characteristics ol its own to commend it. The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting room."—Journal of the A?nerican Medical Association. NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. Syllabus of Obstetrical Lectures in the Medical Department of the University of Pennsylvania. By Richard C. Norris, A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. " This work is so far superior to others on the same subject that we take pleasure in calling attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and_the practitioner."—Medical Record, New York. PENROSE'S DISEASES OF WOMEN. Second Edition, Revised. A Text=Book of Diseases of Women. ,By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- vania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. "I shall value very highly the copy of Penrose's 'Diseases of Women' received. I have already recommended it to my class as THE BEST book."—Howard A. Kellyj Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. " The book is to be commended without reserve, not only to the student but to the general practitioner who wishes to have the latest and best modes of treatment explained with absolute clearness."—Therapeutic Gazette. Medical Publications of W. B. Saunders. 19 POWELL'S DISEASES OF CHILDREN. Second Edition MSDnt£!S H°f DlTaSes of Children. By William M. Powell «'SintSgNhrCi? p,^ MerC6r H°USe f°r Invalid Women Chfldren -n^he'Ho J"-r atef ^^ to ^ Clinic for the Diseases of nrrlv HosFtal of the University of Pennsylvania. Crown octavo, 222 pages. Cloth, $I.QO ; interleaved for notes, $1.25 [See Saunders' Question-Compends, page 21 ] A^^tzSitS^t^ "" works in lhe de"M°'»' - -"** ■« "■—.»- PRINQLES SKIN DISEASES AND SYPHILITIC AFFECTIONS rAmerriacLnAE^t^LSkx D!SeaSeS a"d Syphilitic Affactl^. 1"ph^LM I \ R rT13?0" fr°m thC FrenCh- EdiKd bX J. J. MilNGLE M.B., F.R.C.P., Assistant Physician to the Middlesex Hospital, London. Photo-lithoehromes ftom the famous models in ms andTxf '^ SainpL°UiS H.°Spita1' PaHs' W"h ^LS^oi". %^BJn&£L££££Z>*»-- c°—in PYE'S BANDAGING. Elementary Bandaging and Surgical Dressing. With Direc- tions concerning the Immediate Treatment of Cases of Emergency -b or the use of Dressers and Nurses. By Walter Pye FRCS late Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 illustrations. Cloth, flexible covers, 75 cents net. "The directions are clear and the illustrations are good."—London Lancet. M* 'llTr,6 Tf?" WrUeS WCJ11' thC dia§rams are clear> a»d the book itself is small and port- able, although the paper and type are good."—British Medical Journal. P RAYMOND'S PHYSIOLOGY. A Manual of Physiology. By Joseph H. Raymond, A.M M D Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; Director of Physiology in the Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the text, and 4 full-page colored plates. Cloth, $1.25 net. " Extremely well gotten up, and the illustrations have been selected with care The text is fully abreast with modern physiology. "—British Medical Journal. RONTGEN RAYS. Archives of the Rontgen Ray (Formerly Archives of Clinical Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C S and W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, with descriptive text, illustrating the applications of the new photo- graphy to Medicine and Surgery. Price per Part, Si.oo. Now readv Vol. I , Parts I. to IV.; Vol. II., Parts I., II. *' Arranged in Question and Answer Form. Saunders' V^ UJjO 1 lL^lN npHE MOST COMPLETE AND BEST ^rMVTTTDtnVTTkC ILLUSTRATED SERIES OF V^LALVLr JcJNJLO COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature .... with Students and Practitioners in every City of the United States and Canada. O*- OVER 175,000 COPIES SOLD. ^ ■<* THE REASON WHY. They are the advance guard of "Student's Helps"—that do help. They are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-three volumes, has been kept thoroughly revised and enlarged when necessary, many of the books being in their fifth and sixth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the "Blue Series of Question Compends;" and the claim is made for the following points of excellence : I. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Quality of illustrations, paper, printing, and binding. Any cf these Compends will be mailed on receipt of price (see next page for List). Oaunders' (^uestion-Compend Series* Price, Cloth, $1.00 per copy, except when otherwise noted. "Where the work of preparing students' manuals is to end we cannot say, but the Saunders Series, in our opinion, bears off the palm at present."—New York Medical Record. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, revised and enlarged. ($1.00 net.) 2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, revised, with an Appendix on Antiseptic Surgery. 3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth edition, with an Appendix. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth edition, revised and enlarged. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. Armand Semple, M.D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION-WRITING. By Henry Morris, M.D. Fifth edition, revised. 8, 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulae, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, #2.00.) 10. ESSENTIALS OF GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Third edition, revised and enlarged. ($l.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M. D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored " Vogel Scale." (75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. ($1.50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, revised. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C Shaw, M. D. Third edition, revised. 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. Second edition, revised. ($1.00 net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., and Edward S. Lawrance, M. D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc. sent free upon application. Saunders' New Series of Manuals for Students and Practitioners. 'T'HAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NEW SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered with the introduction of "cases," which so largely expand the ordinary text-book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner: to the latter, too busy to search through page after page of elaborate treatises for what he wants to know, they will prove of inestimable value; to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books now on the market. No other manuals afford so much infor- mation in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work worthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page for List). Saunders' New Series of Manuals* VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $i.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. Octavo, 911 pages, profusely illustrated. Cloth, #4.00 net; Half Morocco, #5.00 net. DOSE=BOOK AND MANUAL OF PRESCRIPTI0N=WR1TING. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Cloth, $1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- delphia. Illustrated. Cloth, $1.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago. Profusely illustrated. Cloth, $2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary; Instructor in Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. Cloth, $2.50 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Beautifully illustrated. Cloth, $2.50 net. MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dis- pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, $2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M. D., B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. Handsomely illustrated. Cloth, #2.50 net. VOLUMES IN PREPARATION. NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- gology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngolo gist, Rhinologist, and Otologist, St. Agnes' Hospital; Bacteriologist to the Philadel- phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic Hospital'and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph Hospital, etc. *** There will be published in the same series, at short intervals, carefully-prepared works on various subjects by prominent specialists. Pamphlet containing specimen pages, etc. sent free upon application. 24 Medical Publications of W. B. Saunders. SAUNDBY'S RENAL AND URINARY DISEASES. Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society ; Physician to the General Hospital; Consulting Physician to the Eye Hospital and to the Hos- pital for Diseases of Women; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illus- trations and 4 colored plates. Cloth, $2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended.''—British Medical Journal. SAUNDERS' MEDICAL HAND=ATLASES. This series of books consists of authorized translations into English of the world-famous Lehmann Medicinische Handatlanten. Each volume contains from 50 to 100 colored lithographic plates, besides numerous illustrations in the text. There is a full description of each plate, and each book contains a condensed but adequate outline of the subject to which it is devoted. For full description of this series, with list of volumes and prices, see page 2. " Lehmann Medicinische Handatlanten belong to that class of books that are too good to be appropriated by any one nation."—"Journal of. Eye, Ear, and Throat Diseases. " The appearance of these works marks a new era in illustrated English medical works."—The Canadian Practitioner. SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, Revised. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. Containing 1800 formulas selected from the best-known authorities. With an Appen- dix containing Posological Table, Formulae and Doses for Hypo- dermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in flexible morocco, with side index, wallet, and flap. *i-75 net- "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and, as the name of the author of each prescription is given, is unusually reliable."—Medical Record, New York. SAYRE'S PHARMACY. Second Edition, Revised. Essentials of the Practice of Pharmacy. By Lucius E. Sayre, M.D., Professor of Pharmacy and Materia Medica in the University of Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " The topics are treated in a simple, practical manner, and the work forms a very useful student's manual."—Boston Medical and Surgical Journal. Medical Publications of W. B. Saunders. 25 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. Essentials of Legal Medicine, Toxicology, and Hygiene. By C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " No general practitioner or student can afford to be without this valuable work. The subjects are dealt with by a masterly hand."—London Hospital Gazette. SEMPLE'S PATHOLOGY AND MORBID ANATOMY. Essentials of Pathology and Morbid Anatomy. By C. E. Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Should take its place among the standard volumes on the bookshelf of both student and practitioner."—London Hospital Gazette. SENN'S GENITO-URINARY TUBERCULOSIS. Tuberculosis of the Genito-Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. " An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day."—Clinical Reporter. " A work which adds another to the many obligations the profession owes the talented author."—Chicago Medical Recorder. SENN'S SYLLABUS OF SURGERY. A Syllabus of Lectures on the Practice of Surgery, arranged in conformity with " An American Text=Book of Surgery." By Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. " This syllabus will be found of service by the teacher as well as the student, the work being superbly done. There is no praise too high for it. No surgeon should be without it."—New York Medical Times. SENN'S TUMORS. Pathology and Surgical Treatment of Tumors. By N. Senn, M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, Rush Medical College; Professor of Surgery, Chicago Polyclinic; Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 engravings, including full-page colored plates. Cloth, $6.00 net; Half Morocco, $7.00 net. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, and the author has given a notable and lasting contribution to surgery."—Journal of the American Medical Association, 26 Medical Publications of W. B. Saunders. SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, Revised. Essentials of Nervous Diseases and Insanity. By John C. Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] "Clearly and intelligently written."—Boston Medical and Surgical Journal. "There is a mass of valuable material crowded into this small compass."—American Medico-Surgical Bulletin. STARR'S DIETS FOR INFANTS AND CHILDREN. Diets for Infants and Children in Health and in Disease. By Louis Starr, M.D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. $1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulae for the preparation of diluents and foods are appended. STELWAGON'S DISEASES OF THE SKIN. Third Edition, Revised. Essentials of Diseases of the Skin. By Henry W. Stelwagon, M.D., Clinical Professor of Dermatology in the Jefferson Medical College, Philadelphia; Dermatologist to the Philadelphia Hospital; Physician to the Skin Department of the Howard Hospital, etc. Crown octavo, 270 pages; 86 illustrations. Cloth, $1.00 net; inter- leaved for notes, $1.25 net. [See Saunders' Question-Compends, page 21.], " The best student's manual on skin diseases we have yet seen."—Times and Register. STENGEL'S PATHOLOGY. Second Edition. A Text=Book of Pathology. By Alfred Stengel, M. D., Physician to the Philadelphia Hospital; Clinical Professor of Medicine in the Woman's Medical College; Physician to the Children's Hospital; late Pathologist to the German Hospital, Philadelphia, etc. Handsome octavo volume of 848 pages, with nearly 400 illustrations, many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00 net. STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second Edition, Revised. A Manual of Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Professor of Pathology in the Woman's Medical College of Pennsylvania. Post- octavo, 445 pages. Flexible leather, $2.25. " The author has faithfully presented modern therapeutics in a comprehensive work, and, while intended particularly for the use of students, it will be found a reliable guide and sufficiently comprehensive for the physician in practice."—University Medical Magazine. Medical Publications of W. B. Saunders. 27 STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Professor of Pathology in the Woman's Medical College of Pennsylvania. Specially intended for students preparing for graduation and hospital examinations. Post- octavo, 519 pages; illustrated. Flexible leather, $2.00 net. "The frequency with which new editions of this manual are demanded bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and may be found also an excellent reminder for the busy physician."—Buffalo Medical Journal. STEWART'S PHYSIOLOGY. Third Edition, Revised. A Manual of Physiology, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc., lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo volume of 848 pages; 300 illustrations in the text, and 5 colored plates. Cloth, $3.75 net. '' It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject."—London Lancet. « '' Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Prof. Stewart's volume."—British Medical Journal. STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. Essentials of Medical Electricity. By D. D. Stewart, M.D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College; and E. S. Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- strator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] " Throughout the whole brief space at their command the authors show a discriminating knowledge of their subject."— Medical News. STONEY'S NURSING. Second Edition, Revised. Practical Points in Nursing. For Nurses in Private Practice, By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated with 73 engravings in the text, and 8 colored and half-tone plates. Cloth, $1.75 net. " There are few books intended for non-professional readers which can be so cordially endorsed by a medical journal as can this one."—Therapeutic Gazette. " This is a well-written, eminently practical volume, which covers the entire range of nrivate nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise, and how to prepare everything ordinarily needed in the illness of her patient."—American Journal of Obstetrics and Diseases of Women and Children. " It is a work that the physician can place in the hands of his private nurses with the assurance of benefit."— Ohio Medical Journal. 28 Medical Publications of W. B. Saunders. STONEY'S MATERIA MEDICA FOR NURSES. Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass. ; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. Handsome octavo volume of 306 pages. Cloth, $1.50 net. The present book differs from other similar works in several features, all of which are intended to render it more practical and generally useful. The general plan of the contents follows the lines laid down in training-schools for nurses, but the book contains much use- ful matter not usually included in works of this character, such as Poison-emergencies, Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms used in Materia Medica, and describing all the latest drugs and remedies, which have been generally neglected by other books of the kind. SUTTON AND GILES' DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- somely illustrated. Cloth, $2.50 net. "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day."—Journal of the American Medical Association. THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. THORNTON'S DOSE=BOOK AND PRESCRIPTION-WRITING. Dose=Book and Manual of Prescription=Writing. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 334 pages, illustrated. Cloth, #1.25 net. "Full of practical suggestions; will take its place in the front rank of works of this sort."—Medical Record, New York. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. Diseases of the Stomach. By William W. Van Valzah, M.D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, $3.50 net. " Its chief claim lies in its clearness and general adaptability to the practical needs of the general practitioner or student. In these relations it is probably the best of the recent special works on diseases of the stomach."—Chicago Clinical Review. VECKI'S SEXUAL IMPOTENCE. The Pathology and Treatment of Sexual Impotence. By Victor G. Vecki, M.D. From the second German edition, revised and en- larged. Demi-octavo, about 300 pages. Cloth, $2.00 net. The subject of impotence has seldom been treated in this country in the truly scientific spirit that it deserves. Dr. Vecki's work has long been favorably known, and the German book has received the highest consideration. This edition is more than a mere translation, tor, although based on the German edition, it has been entirely rewritten in English. Medical Publications of W. B. Saunders. 29 VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the fifth enlarged German edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume of 603 pages; 194 fine wood-cuts in text, many of them in colors. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. " A treasury of practical information which will be found of daily use to every busy practitioner who will consult it."—C. A. Lindslky, M.D., Professor of the Theory and Practice of Medicine, Yale University. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. The reviewer would repeat that the book is one of the best—probably the best—which has fallen into his hands."—University Medical Magazine. WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. Surgical Pathology and Therapeutics. By John Collins Warren, M.D., LL.D., Professor of Surgery, Medical Department Harvard University; Surgeon to the Massachusetts General Hospital, etc. Handsome octavo volume of 832 pages; 136 relief and lithographic illustrations, 33 of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Cloth, $6.00 net; Half Morocco, $7.00 net. "There is the work of Dr. Warren, which I think is the most creditable book on Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that has ever been issued from the American press."—Dr. Roswell Park, in the Harvard Graduate Magazine. " The handsomest specimen of bookmaking that has ever been issued from the American medical press."—American Journal of the Medical Sciences. " A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section."—Annals of Surgery. WOLFF ON EXAMINATION OF URINE. Essentials of Examination of Urine. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Colored (Vogel) urine scale and numerous illustrations. Crown octavo. Cloth, 75 cents. [See Saunders' Question-Compends, page 21.] " A very good work of its kind—very well suited to its purpose."—Times and Register. WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised. Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Crown octavo, 218 pages. Cloth, $1.00; inter- leaved for notes, $1.25. [See Saunders' Question-Compends, page 21.] ■' The scope of this work is certainly equal to that of the best course of lectures on Medical Chemistry.''—Pharmaceutical Era. CLASSIFIED LIST Medical Publications W. B, SAUNDERS, 925 Walnut Street, Philadelphia. ANATOMY, EMBRYOLOGY, HISTOLOGY. Clarkson—A Text-Book of Histology, 9 Haynes—A Manual of Anatomy,... 13 Heisler—A Text-Book of Embryology, 13 Nancrede—Essentials of Anatomy, . . 18 Nancrede—Essentials of Anatomy and Manual of Practical Dissection, ... 18 Semple—Essentials of Pathology and Morbid Anatomy,.........25 BACTERIOLOGY. Ball—Essentials of Bacteriology, ... 6 Crookshank—A Text-Book of Bacteri- ology, ..............lo Frothingham—Laboratory Guide, . . 11 Mallory and Wright — Pathological Technique,...........16 McFarland—Pathogenic Bacteria, . . 17 CHARTS, DIET-LISTS, ETC. Griffith—Infant's Weight Chart, ... 12 Hart—Diet in Sickness and in Health, . 13 Keen—Operation Blank,......15 Laine—Temperature Chart, ... . 15 Meigs—Feeding in Early Infancy, . . 17 Starr—Diets for Infants and Children, . 26 Thomas—Diet-Lists and Sick-Room Dietary,.............28 CHEMISTRY AND PHYSICS. Brockway—Essentials of Medical Phys- ics,......... .....7 Wolff—Essentials of Medical Chemistry, 29 CHILDREN. An American Text-Book of Diseases of Children, . . .......3 Griffith—Care of the Baby,.....12 Griffith—Infant's Weight Chart, ... 12 Meigs—Feeding in Early Infancy, . . 17 Powell—Essentials of Dis. of Children, 19 Starr—Diets for Infants and Children, . 26 DIAGNOSIS. Cohen and Eshner—Essentials of Di- agnosis, ............9 Corwin—Physical Diagnosis, .... 9 Macdonald—Surgical Diagnosis and Treatment, ...........16 Vierordt—Medical Diagnosis, .... 29 DICTIONARIES. Dorland—Pocket Dictionary, .... 10 Keating—Pronouncing Dictionary, . . 14 Morten—Nurse's Dictionary, .... 18 EYE, EAR, NOSE, AND THROAT. An American Text-Book of Diseases of the Eye, Ear, Nose, and Throat, . 3 De Schweinitz—Diseases of the Eye,. 10 Gleason—Essentials of Dis. of the Ear, 11 Jackson and Gleason—Essentials of Diseases of the Eye, Nose, and Throat, 14 Kyle—Diseases of the Nose and Throat, 15 GENITO=URINARY. An American Text-Book of Genito- Urinary and Skin Diseases,.....4 Hyde and Montgomery—Syphilis and the Venereal Diseases.......13 Martin—Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Saundby—Renal and Urinary Diseases, 24 Senn—Genito-Urinary Tuberculosis, . 25 Vecki—Sexual Impotence,.....28 GYNECOLOGY. American Text-Book of Gynecology, 4 Cragin—Essentials of Gynecology, . . g Garrigues—Diseases of Women, ... 11 Long—Syllabus of Gynecology, ... 15 Penrose—Diseases of Women, .... 18 Sutton and Giles—Diseases of Women, 28 MATERIA MEDICA, PHARMACOL- OGY, AND THERAPEUTICS. An American Text-Book of Applied Therapeutics,.........3 Butler—Text-Book of Materia Medica, Therapeutics and Pharmacology, ... 8 Cerna—Notes on the Newer Remedies, 8 Griffin—Materia Med. and Therapeutics, 12 Morris—Essentials of Materia Medica and Therapeutics, . . .... 17 Saunders' Pocket Medical Formulary, 24 Sayre—Essentials of Pharmacy, ... 24 Stevens—Essentials of Materia Medica and Therapeutics,.........26 Stoney—Materia Medica for Nurses, . 28 Thornton—Dose-Book and Manual of Prescription-Writing, ....... 28 MEDICAL JURISPRUDENCE AND TOXICOLOGY. An American Text-Book of Legal Medicine and Toxicology,.....4 Chapman—Medical Jurisprudence and Toxicology,...........8 Semple—Essentials of Legal Medicine, Toxicology, and Hygiene,.....25 Medical Publications of W. B. Saunders. 31 NERVOUS AND MENTAL DISEASES, ETC. Burr—Nervous Diseases,......7 Chapin—Compendium of Insanity, . . 8 Church and Peterson—Nervous and Mental Diseases,.........8 Shaw—Essentials of Nervous Diseases and Insanity,...........26 NURSING. An American Text-Book of Nursing, 29 Griffith—The Care of the Baby, ... 12 Hampton—Nursing,.......12 Hart—Diet in Sickness and in Health, 13 Meigs—Feeding in Early Infancy, . . 17 Morten—Nurse's Dictionary, .... 18 Stoney—Practical Points in Nursing, . 27 OBSTETRICS. An American Text-Book of Obstetrics, Ashton—Essentials of Obstetrics, . . . Boisliniere—Obstetric Accidents, Emer gencies, and Operations, .... Dorland—Manual of Obstetrics, . Hirst—Text-Book of Obstetrics, . Norris—Syllabus of Obstetrics, . . PATHOLOGY. An American Text-Bcok of Pathology, 5 Mallory and Wright—Pathological Technique,...........16 Semple—Essentials of Pathology and Morbid Anatomy,........25 Senn—Pathology and Surgical Treat- ment of Tumors,........25 Stengel—Text-Book of Pathology, . . 26 Warren—Surgical Pathology and Thera- peutics, .............29 PHYSIOLOGY. An American Text-Book of Physi- ology, .............. 5 Hare—Essentials of Physiology, . . . 13 Raymond—Manual of Physiology, . . 19 Stewart—Manual of Physiology, ... 27 PRACTICE OF MEDICINE. An American Text-Book of the The- ory and Practice of Medicine, .... 5 An American Year-Book of Medicine and Surgery,........ 6 Anders—Text-Book of the Practice of Medicine,~............ 6 Lockwood—Manual of the Practice of Medicine,..........15 MorriB—Essentials of the Practice of Medicine,............17 Rowland and Hedley — Archives of the Roentgen Ray,.......19 Stevens—Manual of the Practice of Medicine,............27 SKIN AND VENEREAL. An American Text-Book of Genito- Urinary and Skin Diseases,.....3 Hyde and Montgomery—Syphilis and the Venereal Diseases,.......13 Martin—Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Pringle—Pictorial Atlas of Skin Dis- eases and Syphilitic Affections, ... 19 Stelwagon—Essentials of Diseases of the Skin,............26 SURGERY. An American Text-Book of Surgery, 5 An American Year-Book of Medicine and Surgery,........... 6 Beck—Manual of Surgical Asepsis, . ■ . 7 DaCosta—Manual of Surgery, . . . . IO Keen —Operation Blank,......15 Keen—The Surgical Complications and Sequels of Typhoid Fever,.....15 Macdonald—Surgical Diagnosis and Treatment,...........16 Martin—Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Martin—Essentials of Surgery, .... 16 Moore—Orthopedic Surgery,.....17 Pye—Elementary Bandaging and Surgi- cal Dressing,...........19 Rowland and Hedley—Archives of the Roentgen Ray,........19 Senn—Genito-Urinary Tuberculosis, . 25 Senn —Syllabus of Surgery,.....25 Senn—Pathology and Surgical Treat- ment of Tumors,........25 Warren:—Surgical Pathology and Ther- apeutics, ............29 URINE AND URINARY DISEASES. Saundby—Renal and Urinary Diseases, 24 Wolff—Essentials of Examination of Urine..............29 MISCELLANEOUS. Bastin—Laboratory Exercises in Bot- any, .............7 Gould and Pyle—Anomalies and Curi- osities of Medicine,........n Grafstrom—Massage, ....... 12 Keating—How to Examine for Life Insurance, ....... » .. o 14 Rowland and Hedley—Archives of the Roentgen Ray,........19 Saunders' Medical Hand-Atlases, . . 2 Saunders' New Series of Manuals, 22, 23 Saunders' Pocket Medical Formulary, . 24 Saunders' Question-Compends, . . 20, 21 Senn—Pathology and Surgical Treat- ment of Tumors,.......25 Stewart and Lawrance—Essentials of Medical Electricity,........27 Thornton—Dose-Book and Manual of Prescription-Writing,......28 Van Valzah and Nisbet—Diseases of the Stomach,...........28 IN PRESS FOR PUBLICATION EARLY IN THE FALL OF 1899. THE INTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes. By American and British authors. Edited by J. Collins Warren, M. D., LL.D., Professor of Surgery, Harvard Medical School, Boston; Surgeon to the Massachusetts General Hospital; and A. Pearce Gould, M.S., F. R. C. S., Eng., Lecturer on Practical Surgery and Teacher of Operative Surgery, Middlesex Hospital Medical School; Surgeon to the Middlesex Hospital, London, England. Vol. I. Handsome octavo volume of about 950 pages, with over 400 beautiful illustrations in the text, and 9 lithographic plates. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M. D., Professor of Anatomy in the Medico-Chirurgical College, Philadelphia. l2mo volume of about 325 pages, handsomely illustrated. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro- fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Con- sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Octavo volume of about 630 pages, with over 150 illustrations and 6 lithographic plates. PRYOR—PELVIC INFLAMMATIONS. The Treatment of Pelvic Inflammations through the Vagina. By W. R. Pryor, M. D., Professor of Gynecology in the New York Polyclinic. l2mo volume of about 250 pages, handsomely illustrated. ABBOTT ON TRANSMISSIBLE DISEASES. The Hygiene of Transmissible Diseases: their Causation, Modes of Dissemination, and Methods of Prevention. By A. C. Abkott, M. D., Pro- fessor of Hygiene in the University of Pennsylvania; Director of the Laboratory of Hygiene. Octavo volume of about 325 pages, containing a number of charts and maps, and numerous illustrations. JACKSON—DiSEASES OF THE EYE. A Manual of Diseases of the Eye. By Edward Jackson, A. M., M. D., late Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine. i2mo volume of over 500 pages, with about 175 beautiful illustrations from drawings by the author. HIONAL LIBRARY OF NLM 005(30305 4 ■M:i~- ■■f'V ^tiisiiiiii^w i'fr.'V.*. W*»fi*s«ar»;^^ NLM005603054