Alexis Thomson and Alexander Miles - Manual of Surgery

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

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

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

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

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

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

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

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

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

ANTHRAX

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

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

[Illustration: FIG. 27.--Bacillus of Anthrax in section of skin, from a
case of malignant pustule; shows vesicle containing bacilli. x 400 diam.
Gram's stain.]

_Clinical Varieties of Anthrax._--In man, anthrax may manifest itself in
one of three clinical forms.

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

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

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

#Clinical Features of Malignant Pustule.#--We shall here confine
ourselves to the consideration of the local lesion as it occurs in the
skin--_the malignant pustule_.

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

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

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

[Illustration: FIG. 28.--Malignant Pustule, third day after infection
with Anthrax, showing great oedema of upper extremity and pectoral region
(cf. Fig. 29).]

[Illustration: FIG. 29.--Malignant Pustule, fourteen days after
infection, showing black eschar in process of separation. The oedema has
largely disappeared. Treated by Sclavo's serum (cf. Fig. 28).]

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

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

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

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

GLANDERS

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

_Clinical Features._--Both in the lower animals and in man the bacillus
gives rise to two distinct types of disease--_acute glanders_, and
_chronic glanders_ or _farcy_.

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

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

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

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

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

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

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

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

#Chronic Glanders.#--_In the horse_ the chronic form of glanders is
known as _farcy_, and follows infection through an abrasion of the skin,
involving chiefly the superficial lymph vessels and glands. The
lymphatics become indurated and nodular, constituting what veterinarians
call _farcy pipes_ and _farcy buds_.

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

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

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

ACTINOMYCOSIS

Actinomycosis is a chronic disease due to the action of an organism
somewhat higher in the vegetable scale than ordinary bacteria--the
_streptothrix actinomyces_ or _ray fungus_.

[Illustration: FIG. 30.--Section of Actinomycosis Colony in Pus from
Abscess of Liver, showing filaments and clubs of streptothrix
actinomyces. x 400 diam. Gram's stain.]

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

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

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

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

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

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

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

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

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

[Illustration: FIG. 31.--Actinomycosis of Maxilla. The disease spread to
opposite side; finally implicated base of skull, and proved fatal.
Treated by radium.

(Mr. D. P. D. Wilkie's case.)]

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

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

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

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

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

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

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

[Illustration: FIG. 32.--Mycetoma, or Madura Foot. (Museum of Royal
College of Surgeons, Edinburgh.)]

DELHI BOIL.--_Synonyms_--Aleppo boil, Biskra button, Furunculus
orientalis, Natal sore.

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

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

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

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