Alexis Thomson and Alexander Miles - Manual of Surgery

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

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

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

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

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

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

[Illustration: FIG. 6.--Passive Hyperaemia of Hand and Forearm induced by
Bier's Bandage.]

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

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

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

[Illustration: FIG. 7.--Passive Hyperaemia of Finger induced by Klapp's
Suction Bell.]

_Klapp's Suction Bells._--In inflammatory conditions to which the
constricting band cannot be applied, as for example an acute mastitis, a
bubo in the groin, or a boil on the neck, the affected area may be
rendered hyperaemic by an appropriately shaped glass bell applied over it
and exhausted by means of a suction-pump, the rarefaction of the air in
the bell determining a flow of blood into the tissues enclosed within it
(Figs. 7 and 8). The edge of the bell is smeared with vaseline, and the
suction applied for from five to ten minutes at a time, with a
corresponding interval between the applications. Each sitting lasts for
from half an hour to an hour, and the treatment may be carried out once
or twice a day according to circumstances. This apparatus acts in the
same way as the old-fashioned _dry cup_, and is more convenient and
equally efficacious.

[Illustration: FIG. 8.--Passive Hyperaemia induced by Klapp's Suction
Bell for Inflammation of Inguinal Gland.]

_Active hyperaemia_ is induced by the local application of heat,
particularly by means of hot air. It has not proved so useful in acute
inflammation as passive hyperaemia, but is of great value in hastening
the absorption of inflammatory products and in overcoming adhesions and
stiffness in tendons and joints.

_General Treatment._--The patient should be kept at rest, preferably in
bed, to diminish the general tissue waste; and the diet should be
restricted to fluids, such as milk, beef-tea, meat juices or gruel, and
these may be rendered more easily assimilable by artificial digestion if
necessary. To counteract the general effect of toxins absorbed into
the circulation, specific antitoxic sera are employed in certain forms
of infection, such as diphtheria, streptococcal septicaemia, and tetanus.
In other forms of infection, vaccines are employed to increase the
opsonic power of the blood. When such means are not available, the
circulating toxins may to some extent be diluted by giving plenty of
bland fluids by the mouth or normal salt solution by the rectum.

The elimination of the toxins is promoted by securing free action of the
emunctories. A saline purge, such as half an ounce of sulphate of
magnesium in a small quantity of water, ensures a free evacuation of the
bowels. The kidneys are flushed by such diluent drinks as equal parts of
milk and lime water, or milk with a dram of liquor calcis saccharatus
added to each tumblerful. Barley-water and "Imperial drink," which
consists of a dram and a half of cream of tartar added to a pint of
boiling water and sweetened with sugar after cooling, are also useful
and non-irritating diuretics. The skin may be stimulated by Dover's
powder (10 grains) or liquor ammoniae acetatis in three-dram doses every
four hours.

Various drugs administered internally, such as quinine, salol,
salicylate of iron, and others, have a reputation, more or less
deserved, as internal antiseptics.

Weakness of the heart, as indicated by the condition of the pulse, is
treated by the use of such drugs as digitalis, strophanthus, or
strychnin, according to circumstances.

Gastro-intestinal disturbances are met by ordinary medical means.
Vomiting, for example, can sometimes be checked by effervescing drinks,
such as citrate of caffein, or by dilute hydrocyanic acid and bismuth.
In severe cases, and especially when the vomited matter resembles
coffee-grounds from admixture with altered blood--the so-called
post-operative haematemesis--the best means of arresting the vomiting is
by washing out the stomach. Thirst is relieved by rectal injections of
saline solution. The introduction of saline solution into the veins or
by the rectum is also useful in diluting and hastening the elimination
of circulating toxins.

In surgical inflammations, as a rule, nothing is gained by lowering the
temperature, unless at the same time the cause is removed. When severe
or prolonged pyrexia becomes a source of danger, the use of hot or cold
sponging, or even the cold bath, is preferable to the administration of
drugs.

_Relief of Symptoms._--For the relief of _pain_, rest is essential. The
inflamed part should be placed in a splint or other appliance which will
prevent movement, and steps must be taken to reduce its functional
activity as far as possible. Locally, warm and moist dressings, such as
a poultice or fomentation, may be used. To make a fomentation, a piece
of flannel or lint is wrung out of very hot water or antiseptic lotion
and applied under a sheet of mackintosh. Fomentations should be renewed
as often as they cool. An ordinary india-rubber bag filled with hot
water and fixed over the fomentation, by retaining the heat, obviates
the necessity of frequently changing the application. The addition of a
few drops of laudanum sprinkled on the flannel has a soothing effect.
Lead and opium lotion is a useful, soothing application employed as a
fomentation. We prefer the application of lint soaked in a 10 per cent.
aqueous or glycerine solution of ichthyol, or smeared with ichthyol
ointment (1 in 3). Belladonna and glycerine, equal parts, may be used.

Dry cold obtained by means of icebags, or by Leiter's lead tubes through
which a continuous stream of ice-cold water is kept flowing, is
sometimes soothing to the patient, but when the vessels in the inflamed
part are greatly congested its use is attended with considerable risk,
as it not only contracts the arterioles supplying the part, but also
diminishes the outflow of venous blood, and so may determine gangrene of
tissues already devitalised.

A milder form of employing cold is by means of evaporating lotions: a
thin piece of lint or gauze is applied over the inflamed part and kept
constantly moist with the lotion, the dressing being left freely exposed
to allow of continuous evaporation. A useful evaporating lotion is made
up as follows: take of chloride of ammonium, half an ounce; rectified
spirit, one ounce; and water, seven ounces.

The administration of opiates may be necessary for the relief of pain.

The accumulation of an excessive amount of inflammatory exudate may
endanger the vitality of the tissues by pressing on the blood vessels to
such an extent as to cause stasis, and by concentrating the local action
of the toxins. Under such conditions the tension should be relieved and
the exudate with its contained toxins removed by making an incision into
the inflamed tissues, and applying a suction bell. When the exudate has
collected in a synovial cavity, such as a joint or bursa, it may be
withdrawn by means of a trocar and cannula. There are other methods of
withdrawing blood and exudate from an inflamed area, for example by
leeches or wet-cupping, but they are seldom employed now.

Before applying leeches the part must be thoroughly cleansed, and if
the leech is slow to bite, may be smeared with cream. The leech is
retained in position under an inverted wine-glass or wide test-tube till
it takes hold. After it has sucked its fill it usually drops off, having
withdrawn a dram or a dram and a half of blood. If it be desirable to
withdraw more blood, hot fomentations should be applied to the bite. As
it is sometimes necessary to employ considerable pressure to stop the
bleeding, leeches should, if possible, be applied over a bone which will
furnish the necessary resistance. The use of styptics may be called for.

_Wet-cupping_ has almost entirely been superseded by the use of Klapp's
suction bells.

_General blood-letting_ consists in opening a superficial vein
(venesection) and allowing from eight to ten ounces of blood to flow
from it. It is seldom used in the treatment of surgical forms of
inflammation.

_Counter-irritants._--In deep-seated inflammations, counter-irritants
are sometimes employed in the form of mustard leaves or blisters,
according to the degree of irritation required. A mustard leaf or
plaster should not be left on longer than ten or fifteen minutes, unless
it is desired to produce a blister. Blistering may be produced by a
_cantharides plaster_, or by painting with _liquor epispasticus_. The
plaster should be left on from eight to ten hours, and if it has failed
to raise a blister, a hot fomentation should be applied to the part.
_Liquor epispasticus_, alone or mixed with equal parts of collodion, is
painted on the part with a brush. Several paintings are often required
before a blister is raised. The preliminary removal of the natural
grease from the skin favours the action of these applications.

The treatment of inflammation in special tissues and organs will be
considered in the sections devoted to regional surgery.

#Chronic Inflammation.#--A variety of types of chronic and subacute
inflammation are met with which, owing to ignorance of their causations,
cannot at present be satisfactorily classified.

The best defined group is that of the _granulomata_, which includes such
important diseases as tuberculosis and syphilis, and in which different
types of chronic inflammation are caused by infection with a specific
organism, all having the common character, however, that abundant
granulation tissue is formed in which cellular changes are more in
evidence than changes in the blood vessels, and in which the subsequent
degeneration and necrosis of the granulation tissue results in the
breaking down and destruction of the tissue in which it is formed.
Another group is that in which chronic inflammation is due to mild or
attenuated forms of pyogenic infection affecting especially the lymph
glands and the bone marrow. In the glands of the groin, for example,
associated with various forms of irritation about the external genitals,
different types of _chronic lymphadenitis_ are met with; they do not
frankly suppurate as do the acute types, but are attended with a
hyperplasia of the tissue elements which results in enlargement of the
affected glands of a persistent, and sometimes of a relapsing character.
Similar varieties of _osteomyelitis_ are met with that do not, like the
acute forms, go on to suppuration or to death of bone, but result in
thickening of the bone affected, both on the surface and in the
interior, resulting in obliteration of the medullary canal.

A third group of chronic inflammations are those that begin as an acute
pyogenic inflammation, which, instead of resolving completely, persists
in a chronic form. It does so apparently because there is some factor
aiding the organisms and handicapping the tissues, such as the presence
of a foreign body, a piece of glass or metal, or a piece of dead bone;
in these circumstances the inflammation persists in a chronic form,
attended with the formation of fibrous tissue, and, in the case of bone,
with the formation of new bone in excess. It will be evident that in
this group, chronic inflammation and repair are practically
interchangeable terms.

There are other groups of chronic inflammation, the origin of which
continues to be the subject of controversy. Reference is here made to
the chronic inflammations of the synovial membrane of joints, of tendon
sheaths and of bursae--_chronic synovitis_, _teno-synovitis_ and
_bursitis_; of the fibrous tissues of joints--chronic forms of
_arthritis_; of the blood vessels--chronic forms of _endarteritis_ and
of _phlebitis_ and of the peripheral nerves--_neuritis_. Also in the
breast and in the prostate, with the waning of sexual life there may
occur a formation of fibrous tissue--chronic _interstitial mastitis_,
_chronic prostatitis_, having analogies with the chronic interstitial
inflammations of internal organs like the kidney--_chronic interstitial
nephritis_; and in the breast and prostate, as in the kidney, the
formation of fibrous tissue leads to changes in the secreting epithelium
resulting in the formation of cysts.

Lastly, there are still other types of chronic inflammation attended
with the formation of fibrous tissue on such a liberal scale as to
suggest analogies with new growths. The best known of these are the
systematic forms of fibromatosis met with in the central nervous system
and in the peripheral nerves--_neuro-fibromatosis_; in the submucous
coat of the stomach--_gastric fibromatosis_; and in the
colon--_intestinal fibromatosis_.

These conditions will be described with the tissues and organs in which
they occur.

In the _treatment of chronic inflammations_, pending further knowledge
as to their causation, and beyond such obvious indications as to help
the tissues by removing a foreign body or a piece of dead bone, there
are employed--empirically--a number of procedures such as the induction
of hyperaemia, exposure to the X-rays, and the employment of blisters,
cauteries, and setons. Vaccines may be had recourse to in those of
bacterial origin.

CHAPTER IV

SUPPURATION

Definition--Pus--_Varieties_--Acute circumscribed abscess--_Acute
suppuration in a wound_--_Acute Suppuration in a mucous
membrane_--Diffuse cellulitis and diffuse suppuration--
_Whitlow_--_Suppurative cellulitis in different situations_--Chronic
suppuration--Sinus, Fistula--Constitutional manifestations of
pyogenic infection--_Sapraemia_--_Septicaemia_--_Pyaemia_.

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

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

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

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

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

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

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

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

The pus may form and collect within a circumscribed area, constituting a
localised _abscess_; or it may infiltrate the tissues over a wide
area--_diffuse suppuration_.

ACUTE CIRCUMSCRIBED ABSCESS

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

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

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

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

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

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