i y Los Angeles County Medical Association Barlow Medical Library 1932-1992 Louise M. Darling Biomedical Library UCLA LIBRARY OF THt L ^. CO. i^':Oi»:ALASSN. 63^ SO'JM A'^STLAKE AVE. SYSTEM OF SURGEEY. VOL. I. GENERAL PATHOLOGY. LONDON : PBINTBD Bf sromswooDB and co., nbw-stbeet SQrA.i:E AND PABLIAM£NT STUKET SYSTEM OF SURGERY THEORETICAL AND PRACTICAL IN TEEATISES BY VAKIOUS AUTHORS. EDITED BY T. HOLMES, M.A. Cantab. SURGEON AND LECTURER ON SURGERY AT ST. GEORGE'S HOSPITAL : MEMB. CORRESP. DE LA SOCrflTE DE CHIRURGIE DE PARIS. SECOND EDITION, IN FIVE VOLUMES. Vd\ SHustratiflns. Vol. I. — General Pathology. I i BrtAK! [it IHL LOS ANGELLi COUfN'fY MEDICAL A.SSOClArlO^ 634 SOUTH Wi:STI AKf: AVt. LONDON : LONGMANS, GREEN, AND CO. .^ 1870. The right of translation is reserved. PREFACE THE SECOND EDITION. rE Second Edition of this work will not be found to differ essentially in plan and arrangement from the First. Some changes have been made in the order in which the essays are placed, and the matter of each essay has been revised, so as to bring the work as far as possible up to the latest time, both in authorised teaching and practice ; but the work remains in the main unchanged. The want of illus- trations has been felt as a practical hindrance to its usefulness and this want the Publishers, at the instance of the Editor, have determined to supply, as far as it could be done, without unduly increasing the cost of the book. The aim of the Editor and Contributors has been to supply illus- trations which would be of real service, either in making the text intelligible, or in assisting the diagnosis of disease. On one important subject a deviation from the natural arrangement has been found necessary : viz. the Pathology of Inflammation. The recent researches of Cohnheim and others have thrown so mucli doubt upon the accepted theories on this matter, and these researches were pub- lished so near to the time when the essay on Inflammation was required for the press, that it became necessary either vi PREFACE TO THE SECOND EDITION. to delay the publication of the whole until reasonable time had been given to test these authors' statements, or to post- pone the pathological section of the essay on Inflammation until the completion of the work. For many reasons, the latter course seemed preferable ; but it entails the incon- venience that the chapter on Inflammation will be found to be contained partly in the first volume and partly in the fifth. In conclusion, the Editor has only to acknowledge grate- fully, the favour with which the original work has been received, and to hope that this re-issue of it may deserve and obtain an equally favourable reception. T. HOLMES. Clarges Street: Atfffust 1869. PREFACE TO THE FIKST EDITION. THE object of tliis book is to unite into a complete sys- tem the opinions and experience of many men, most of them Hospital Surgeons in London, and most of them writing on subjects of their own choice. As each subject must be treated with something of the completeness of a monograph, the work must necessarily be voluminous ; but both Contributors and Editor have done their best to present each essay in as moderate a compass as the topic would allow. Where so many men unite in writing on parts of one great subject, it is hardly possible to avoid some differences of opinion ; but none of much import- ance will, it is hoped, be detected in the following pages, and certainly none which can destroy the uniformity of the teaching. The arrangement adopted in this work is as follows : I. The diseases which affect the whole system are first described, and this part comprises the essays ending with that on Cancer. II. The next part treats of injuries which either in- volve the whole or a large part of the body, or which may be met with in any region. This extends to the end of viii PREFACE TO the essay on Gun-shot Wounds, in the Second Volume. These two parts comprise the whole subject of Surgical Pathology. III. The various local injuries are next described ; and in this part the anatomical order has been followed, the body having been divided into eight regions — the Head, Face, Neck, Thorax, Back, Pelvis, Upper and Lower Extremity. By this plan it was thought that the mjuries which affect the same parts, and which in prac- tice have to be diagnosed from each other, would be brought into the same part of the book and under the treatment of the same author. rV. The principles of operative and minor Surgery, and of the employment of anaesthetics, follow the essays on local injuries. V. The next part comprises the surgical diseases of the various organs of the body. These have been ar- ranged according to the function of the parts affected : as diseases of the organs of special sense — the Eye, Ear, and Nose ; of the organs of locomotion — the Bones, Joints, Muscles, Tendons, and their Sheaths, &c, VI. An Appendix completes the work, comprising the Principles of Surgical Diagnosis, of the Surgical Pathology and Treatment of Children's Diseases, the Construction and Management of Hospitals, and various miscellaneous matters which it was found difficult to bring under any of the pre- vious heads. This arrangement has been chosen, not as being free from objections, but as the best which suggested itself. The principal objection, perhaps, is the difficulty of separating the direct effects of injury from those diseases which fre- quently result from injury ; but it is hoped that it wiU be found to have the merit of being intelligible, and of not THE FIRST EDITION. ix making unnecessary artificial separations between things nearly connected in practice. Any difficulty which may be found in discovering the place of any subject will be met by the analytical Tables of Contents at the head of each volume, and the copious Index at the end of the work. For the plan of the work the Editor must be held re- sponsible ; the opinions expressed in each separate essay rest upon the authority of the writer, whose name is signed to it. The Editor must express his deep sense of the honour done him in selecting him for the important task of pre- paring this book and seeing it through the press. He has endeavoured to discharge his difficult duties to the best of his ability ; — had it not been for the unfailing courtesy and willing cooperation which he has experienced from all the Contributors, it would have been impossible to perform them at all ; — nor could the scheme have ever been realised but for the energy and liberality of the Messrs. Parker. The Editor, as well as all connected with it, have to lament, in the premature death of Mr. Parker, Junior, one who was warmly interested in the success of this undertaking, whose friendship the Editor was happy enough to form in conse- quence of their common connection with it, and from whom he constantly received valuable advice and encouragement. T.HOLMES 22 Queen Street, Mayfair December 1860. CONTENTS OF THE FIKST VOLUME. INFLAMMATION. By John Simon, Esq., F.R.S. SUEGEON TO ST. THOMAs's HOSPITAL. J. Etymology .......... 1 1 . Description of the inflammatory process and of its sym^.t' ims and causes A. Tlic process (see Appendix in Vol. V.) B. The symptoms of inflammation 1. Redness 2. Swelling . Inflammatory effusions 3. Pain 4. Heat 5. Feverishness The blood in inflammation C. The causes of inflammation, and their respective modes of action ......... 1. Determining causes ...... a. Generalised according to the sources whence they come — 1. Mechanical and chemical violence 2. Morbid products of the body itself 3. Altered state of the local nerves . 4. Abnormal properties of the circulating blood ...... 5. Contagion ...... b. Determining causes of inflammation, consi- dered with reference to their modes of action ....... 2. Predisposing causes ...... PAGE 3 4 5 6 12 15 21 28 32 32 33 33 36 41 46 53 57 Xll CONTENTS OF THE III. Treatment of inflammation A. General principles — 1. To relieve the part from causes of excitement 2 and 3. To depress the local action, and obviate its hurtful consequences a. Depressants and sedatives . i. Cold . . . , ii. Opium h. Counter-irritants and derivatives i. Caustics, blisters, poultices ii. Local bloodletting iii. Ligature and acupressure of afferent vessels c. Depletory treatment . i. Bloodletting ii. Purgatives iii. Starvation iv. Emetics and nauseant drugs d. Febrifuge treatment . i. Digitalis . ii. Kefrigeration iii. Eliminatives e. Cutting into the inflamed part — pressure f. Changing the action of the inflamed part g. Disinfecting the inflamed part h. Eemoving the products, and results of inflam mation ..... i. Opening abscesses ii. Removing disintegrated parts i. Relieving inflammatory pain k. Specific antidotes .... /. Mercury ...... 7/j. Tonics and stimulants B. Cautions as to the application of antiphlogistic treatment PAGK 71 71 74 76 76 79 80 81 83 85 85 85 89 89 90 91 91 92 92 93 94 95 96 96 96 98 99 101 106 108 ABSCESS. By Holmes Coote, Esq. SURGEON TO ST. BAJRTHOL01tE"W's HOSPITAL. Nature and varieties of pus . Absorption of pus Definition of abscess Symptoms of acute abscess . 115 117 120 121 FIEST VOLUME. xm Local and general treatment of abscess Cicatrices of abscesses Abscesses in various parts — In the neck Around the joints Abdominal abscess . Pelvic abscess . Of the brain Mammary abscess Of the testicle . Of the perinseum Retropharyngeal Chronic abscess . Suppuration in the hand Ligature of arteries in these cases Treatment of abscess with carbolic acid Methods of opening abscess . Setons and drainage-tubes . Injecting abscesses PAGR 122 123 124 127 128 129 130 131 132 132 133 134 135 136 137 138 140 140 SINUS AND FISTULA. By J. Paget, Esq., E.E.S. SURGEON TO ST. BARTHOLOMEW S HOSPITAL. Description Modes of formation Treatment . 141 143 146 GANGRENE. By Holmes Coote, Esq. SURGEON TO ST. BARTHOLOMEWS HOSPITAL. Definition of mortification Causes of mortification .... Deficient nervous power (predisposing) Deficient supply of blood . Inflammatory congestion . Defective nutrition .... From ergot of rye and unsound wheat Separation of mortified parts . 150 151 151 152 153 154 154 155 XIV CONTENTS OF THE Treatment . . . . Special forms of mortification Noma Traumatic gangrene . Secondary „ Hospital „ Frostbite . Senile gangrene Phagedena General treatment Local treatment . PAGK 157 159 160 163 163 169 170 173 176 177 ULCERS. Bt J. Paget, Esq., F.R.S. SUEGEO>- TO ST. BARTHOLOIEeVs HOSPITAl. The process of ulceration Classification of ulcers . Varieties depending on constitutional causes — Simple or healthy vdcers . Inflammatory ,, Eczematous ,, Cold „ Senile „ Strumous „ Scorbutic „ Gouty „ . . Syphilitic „ Lupous „ Eodent „ Cancerous „ Varieties depending on local conditions- Varicose ulcers QLdematous „ ... Exuberant „ ... Haeniorihagic ,, . . . Neuralgic or irritable ,, Inflamed ,, Chronic or callous ,, Phagedenic and sloughing „ Other forms of ulcer 179 181 182 183 184 185 185 186 188 189 190 193 195 197 199 200 200 201 201 201 202 204 204 FIEST VOLUME. XV EEYSIPELAS. By Campbell De Morgan, F.E.S. SURGEON TO THE MIDDLESEX HOSPIT.VL. Definition of erysipelas .... PAGE . 206 Varieties ....... . 207 Erythema and its varieties .... . 209 Symptoms of erysipelas .... . 212 Simple erysipelas ..... . 217 CEdematous erysipelas .... . 218 Erratic and metastatic erysipelas . 219 Phlegmonous erysipelas .... . 220 Diffuse cellular inflammation . 224 Causes of erysipelas ..... . 227 Predisposing ..... . 228 Exciting ....... . 231 Efficient ....... . 232 a. General atmospheric condition or epidemic influence . 232 b. Infection or contagion . . . . . 232 Diagnosis ....... . 235 Prognosis ....... . 236 Treatment — General ..... . 236 Local ..... . 248 „ of phlegmonous erysipelas . . 249 PYAEMIA. By G. W. Callender, Esq. ASSISTAirr-SUEGEON TO ST. BAETHOLOME'Vv's HOSPITAX. Two diseases comprised under this name : 1. A primary disease — general systemic infection 2. Local or secondary complications Predisposing causes of systemic infection An affection of the blood is the most important change Symptoms of pya?mia (secondary complications) Pathological changes ...... Affection of the veins ..... Post-mortem appearances of pya3mia (secondary deposits) Table of cases showing the organs affected . Appearances of secondary deposits in the principal viscera Theories of exciting causes of pyaemia examined — a. Pus introduced into the blood .... b. Disorganised fibrine introduced into the blood. softening ....... VOL. I. a Clot- 253 255 255 256 258 260 260 262 263 263 267 275 XTl CONTENTS OF THE Prognosis . Diagnosis Treatment . Prophylaxis PAGE 279 280 280 284 ON HECTIC AND TRAUMATIC FEVER AND ON THE TREATMENT OF CASES AFTER OPERATION. By John Croft, Esq. ASSISTAXT-SrHGEOX TO ST. THOMAS's HOSPITAX. Symptoms of hectic fever ...... . 287 Etiology „ „ . 290 Pathology „ „ . 291 Treatment „ „ ...... . 292 Sj-mptoms of traumatic fever ..... . 294 Duration, degree, and result of traumatic fever . 295 Treatment „ „ . . . 298 Table of cases „ „ . . . 299 Management of patients after operation .... . 301 Complications — Shock ........ . 306 Chloroform-sickness ...... . 307 Other complications ...... . 308 Thermographs ........ . 308 TETANUS. By a, Poland, Esq. SURGEON TO GTy's HOSPITAL. Definition and divisions ........ 309 Symptoms in the acute form ........ 310 Varieties — trismiis, opisthotonos, emprosthotonos, pleurosthotonos . 313 T.-ismus nascentium ......... 313 Other rarer varieties in the symptoms . . . . . "314 Modes of death 316 Exciting causes — Traumatic tetamis . . . . . . . . .316 Idiopathic ,, ......... 319 Predisposing causes ......... 320 Diagnosis ........... 322 FIRST VOLUME. xvii From strychnia poisoning .... PAGE . 324 Prognosis ....... . 327 Morbid anatomy ...... . 328 Pathology ....... . 330 Treatment ....... . . . 331 DELIEIUM TEEMENS. By a. W. Baeclat, M.D. PHYSICIAN TO ST. GEOEGE's HOSPITAL. First notices of this disease . Pathology .... Clinical histoiy . Diagnosis .... Special characters of the disease Treatment .... Mode of recovery 336 337 338 341 342 345 350 SCROFULA. By W. S. Savory, Esq., F.R.S. SURGEON TO ST. BARTH OL CM E"w's HOSPITAL. Definition of the term ..... Description and varieties of ttibercle Microscopical characters of tubercle Progress of tubercle ..... Relative frequency of tubercle in various organs Nature of tubercle ..... Inoculability of tubercle .... Scrofulous diathesis ..... Causes of scrofula ..... Illustration — tubercle in lymphatic glands Local treatment of scrofula .... Constitutional „ .... 351 352 354 355 357 359 362 363 365 367 370 373 a 2 XVlll CONTENTS OF THE HYSTERIA. By W. S. Savoet, Esq., F.E.S. SVHGEON TO ST. B A R T H O LOMeVs HOSPITAL. Hysterical fit Symptoms of hysterical disease : Of the spine Of the joints Of the mammary gland Hysterical retention of urine „ pain Diagnosis Pathology . Causes Treatment . PAGE 379 381 382 383 383 384 385 387 390 391 SYPHILIS. By Henry Lee, Esq. STJKGEON TO ST. GEORGE's HOSPITAL. lAP. I. Introduction : The four processes which follow syphilitic inoculation Pathology of syphilis ..... Characters of chancre ..... Two kinds of syphilis, local and constitutional II. Suppurating syphilitic sore This form of syphilis is local .... Characters of suppurating sore .... Modifications met with in practice Afiections of the glands in suppurating chancre . Inoculations from suppurating sores — syphilization III. Syphilitic infection Characters of this infection : I. A pimple .... II. An indurated tubercle III. „ chancre . Diagnostic signs of syphilitic infection Incubation „ ,, Inoculability of this form of syphilis . Auto-inoculability not the test of syphilitic infection, but the reverse ..... Affection of the glands in syphilitic infection 395 397 398 399 400 400 401 402 404 405 405 405 406 407 408 409 411 FIEST VOLUME. XIX CHAP. IV. VI. VII. VIII. IX. X. XL PAGE Lymphatic absorption ....... 414 Hunter's and other experiments ..... 415 Application of these physiological facts to the affections of the glands in syphilis ....... 418 ' Physiological absorption ' ...... 425 Destructive syphilitic inflammation Mortification . ...... 426 Phageda3na . 427 Serpiginous chancre ....... 428 Local treatment of syphilis Treatment of suppurating syphilitic sores . . . .429 ,, the diiferent kinds of suppurating bubo . . 432 Local treatment of primary specific inflammation . . 434 Syphilitic inoculation modified by previous disease. Twofold inoculation Inoculation modified by previous disease .... 435 Twofold inoculation ........ 442 Transmission of secondary syphilis Different opinions as to the inoculability of secondary syphilis 443 Syphilis propagated by transplantation of teeth . . . 445 Cases of transmission of secondary syphilis, and of mixed gonorrhoea and syphilis ...... 447 Conclusions on this subject ...... 453 Hereditary transmission of disease ; Vaccino-syphilitic inoculation Question how far hereditary syphilis protects from constitu- tional infection ........ 453 Differences in national characteristics of syphilis . . 454 Also in syphilis as seen in different ranks of life ' . . 455 Hereditary syphilis ........ 457 Vaccino-syphilitic inoculation ...... 458 Constitutional syphilis Early symptoms of constitutional syphilis .... 461 Secondary symptoms . ..... 463 Syphilitic eruptions of the adhesive form .... 463 Pustular syphilitic eruptions ...... 468 Vesicular .syphilitic eruptions ...... 475 Secondary syphilitic ulceration ...... 475 „ „ disease of mucous membranes . . 477 Tertiaiy syphilis ....... . 479 Tertiary diseases of the skin and mucous membrar.es . . 480 Onychia 480 Diseases of the teeth ....... 481 Diseases of the bones, periosteum, and joints . . . 482 Syphilitic orchitis ........ 483 Glands in tertiary syphilis ...... 484 Treatment of tertiary syphilis ...... 484 XX CONTENTS OF THE XII. Administration of mercury Internal use of mercury Mercurial inunction . Mercurial fumigation 486 487 488 TUMOURS AND CANCEE. By J. Paget, Esq., F.E.S. SURGEON TO ST. BABTHGLOlIEW's HOSPITAL, AND C. H. Moore, Esq. STJEGEON TO THE MIDDLESEX HOSPITAL. Introduction (By C. H. Moore, Esq.). Division of new growths according to tlieir clinical chiuracters Anatomical principle of classification Common characters of innocent and malignant tumours Source of new growths ..... Causes of new growths ...... Composition and progress of new growths Diagnosis ... .... 496 497 498 499 500 502 503 TUMOURS. By J. Paget, Esq., Re-edited by C. H. Moore, Esq. Classification ..... I. Cystic tumours .... Simple or barren cysts — Serous ..... Synovial ..... Mucous ..... Sanguineous .... Oily and coUoid Compound or proliferous cysts — Complex cystic or cystigerous cysts Cysts proliferous, with vascular grow Cutaneous cysts Dentigerous cysts II. Solid tumours and outgrowths Fatty tumours Fibro-ceUular tumom-s Myxoma .... Psammoraa .... ths 505 505 506 509 509 509 510 511 511 514 518 518 522 525 526 FIEST VOLUME. XXI Glioma ........ Fibrous, fibro-muscular, and fibro-cystic tumom" Cartilaginous tumours, or enchondromata Myeloid ,, Osseous „ Glandular ,, Vascular or erectile tumours Kecurrent tumours . . . . Irritable or neuralgic tumours Pulsating ,, . . Floating „ Phantom PAOE 526 527 530 535 536 539 541 546 549 550 550 551 CANCER. By C. H. Moore, Esq. Differences between innocent tumours and malignant diseases Varieties of cancer .... Scirrhous cancer .... 1 . Description of the circumscribed form Mode of growth of this form . Kate of growth Variations in size . Cancerous ulcer . Cicatrix of such an ulcer 2. The diffused or phagedtenic form — its mode of growth Affection of the glands in scirrhus Anatomy of a scirrhous tumour Microscopic appearances of scirrhus in its growth and Diagnosis of scirrhus Encephaloid or medullary cancer Its mode of growth Its usual situations Its vascularity .... Ulceration of eocephaloid tumours . Ossification in ,, „ Course of encephaloid cancer Anatomy and microscopic apjjcarances Melanosis ..... Epithelial cancer, or epithelioma Its usual situations Its various forms .... Microscopic appearances Course of epithelioma — idceratiou . Duration ,, . . Connection with previous local disease Osteoid cancer .... Colloid tumours .... Villous growths .... lecay 552 553 553 554 554 556 557 558 558 559 559 561 562 563 564 564 565 565 566 566 567 568 569 570 570 571 571 571 572 573 574 575 573 xxu CONTENTS OF THE Mode of death in cancer .... Nature of cancer (various theories of) . Origin of cancer : primary and secondary tumours The hereditary nature of cancer . INIethod of dissemination of cancer The effect of external agencies and of other diseases Effects of pregnancy and lactation Effects of concomitant diseases Treatment of cancer I. Constitutional treatment II. Local treatment . Local applications Question of operating . Arguments for the operation Contra-indications to operation Favourable conditions for operation . Method of operating — necessity for thorough Treatment by caustics ,, ,, injections ,, ,, congelation „ ,, pressure „ „ ligature . PACK . 577 . 579 . . 581 , • . 583 , . 585 s on cancer . 589 . 591 . 592 . . 593 . 593 . 595 . 595 . . 597 . 598 . 600 . 602 extirpation . 603 . . 605 . 608 . 608 . . 609 , . 610 THE MICROSCOPIC STKUCTURE OF TUMOURS AND CANCER. Plates and Explanatiox by H. Arnott, Esq. SURGICAL REGISTEAR TO THE MIDDLESEX HOSPITAL 611 CONTUSIONS. By J. Paget, Esq., F.E.S. SURGEON TO ST. BARTHOLOME-W S HOSPITAL. The state of contused parts studied: (1) In their proper textures (2) In their blood-vessels and blood . Symptoms of contusion Ecchymosis ..... Colours of ecchymosed blood . Organisation of extravasated blood Consequences or sequelae of contusion . Treatment ...... 617 618 619 620 620 623 623 624 FIEST VOLUME. XXlll WOUNDS. By J. Paget, Esq., E.E.S. SURGEON TO ST. BARTHOLOMEW S HOSPITAL, Definition and cLassification of wounds .... Incised wounds (described as typical of Avounds in general) Retraction of tissues in a wound .... Bleeding ........ Pain of wounds ....... Consequences of wounds ...... Local consequences ...... General consequences — shock — reaction . The healing process in open incised wounds — • 1. Healing by immediate union .... 2. ,, primary adhesion or adhesive union . 3. „ granulation — structure of granulations 4. „ secondary adhesion .... 5. ,, scabbing, or under a scab Nature of the healing process ..... Local treatment of incised wounds .... „ ,, for primary union . ,, „ „ secondary union '. „ „ secondary adhesion and scabb General treatment Punctured wounds Contused „ Lacerated „ Poisoned „ Subcutaneous wounds Healing of subcutaneous wounds Complications of wounds — HEemorrhage, primary, recurrent, and secondary Pain ..... Spasms .... Foreign bodies, needles, &c. . Defects of the healing process — Defective union Inflammation Morbid states of granulations Diseases of cicatrices, viz. Defective scars . Painful ,, . Excess of scar-formation Cheloid scars Ulceration of scars Tumours ,, Cancer ,, PAGE 626 626 627 628 629 630 630 631 632 632 633 635 636 636 637 639 642 643 644 646 647 648 649 649 650 652 655 655 656 658 659 660 661 662 663 665 667 66S XXIV CONTENTS OF THE ANIMAL POISONS. By a. Poland, Esq. SURGEON TO GUY's HOSPITAL. Definition of poisoned wounds ...... . 670 Poisoned wounds received in dissection . . . . . . 670 Anatomical tubercle, or ' verruca necroirenica ' . . . . 671 Two forms of poisoned wound described, as mild and acute . . 671 Pathology of these wounds ...... . 673 Treatment ......... . 674 Poisoned wounds from healthy animals : Insect stings ......... . 675 Bites of serpents ........ . 676 Symptoms ......... Pathology ......... . 676 . 679 Treatment ........ . 682 Poisoned wounds from diseased animals : Hydrophobia ........ Symptoms of the disease in the dog . . . . . 684 . 685 ,, „_ man .... . 687 First stage, premonitory or melancholic Second stage, specific, or stage of irritation . . 687 . 689 Third stage, or paralytic ..... Diagnosis ........ . 690 . 691 Post-mortem appearances ..... . 692 Pathology ........ . 693 Exciting cause ....... . 694 Period of latency ....... . 695 Predisposing causes, as sex, age, climate, season, &c. . 695 Treatment ........ . 697 Glanders and farcy ....... . 699 Symptoms of glanders in the horse . • . . 700 „ farcy _„.... ,, glanders in man .... . 701 . 701 Chronic glanders and farcy ..... . 705 Diagnosis in the horse ...... . 706 „ man ....... . 706 Post-mortem appearances ..... Pathology ........ . 707 . 708 Causes and treatment in the horse .... .. 709 Treatment in man ...... . 710 FIRST VOLUME. XXV WOUNDS OF VESSELS. By Charles H. Moore, Esq. SUEGEON TO THE MIDDLESEX HOSPITAL. Hspmorrliage ....... Symptoms produced by hajmorrhage . H£emorrbage from diseased vessels and in diseased states of blood Periodical ha3morrhages ...... The ha^morrhagic diathesis ..... Symptoms and cases ...... Treatment ........ Treatment of haemorrhage ..... Acupressure ....... Torsion ........ Transfusion ........ General considerations respecting injuries of vessels Wounds of arteries ....... 1. Contusions of arteries ...... 2. Laceration of the inner coats, the outer being entire Ligature of arteries, and the changes produced thereby Aneurisms caused by ligature Collateral circulation ..... o. Wounds of the outer coat, the others being entire -4. Penetrating wounds ..... Cautions in estimating haemorrhage Cases illustrating the cessation of hcemorrhage without ture ...... Recurrent haemorrhage Wounds incurable without ligature, inclusive of those plicated by the presence of a foreign body Complete division .... Treatment of wounded ai'teries . Wounds of veins ...... On the entrance of air into wounded veins Examples of this lesion Explanation of the cause of the entrance of air Mode in which death ensues Treatment for prevention and cure of this accident lica- PAGE 712 713 715 717 718 721 722 724 726 729 730 731 732 734 736 736 739 741 742 743 743 744 746 746 748 749 755 756 757 758 759 761 COLLAPSE ; AND THE GENERAL EFFECTS OF SHOCK UPON THE SYSTEM. By W. S. Savory, Esq., F.R.S. SURGEON TO ST. B A KTH OLOM Ew' S HOSPITAL. Mode of death by shock ....... Post-mortem appearances ..... 764 765 CONTENTS OF THE FIEST VOLUME. Definition and symptoms of collapse Relation between syncope and collapse Prognosis ....... Symptoms of reaction ..... Defective reaction, or prostration with excitement Causes of collapse ...... Relations between collapse and ha?morrhage Circumstances Avhich influence collapise Influence of the mind .... Treatment of collapse ..... „ deficient reaction Prophylactic treatment of siirgical operations Questions of operating in collapse from injury Use of chloroform in such operations PAGE . 765 . 766 . 767 . 767 . 768 . 771 . 772 . 774 . 775 . 776 . 779 . 781 . 782 . 783 LIST OF ILLUSTRATIONS. Lithographs and Chromo-lithograijhs. TETANUS. TO FACE PAGE Plate 1. Microscopical appearances of the Spinal Cord in Tetanus . . 330 Fig. 1. Showing lesions of central part of cord and displace- of anterior median fissure, from a preparation by Mr. Lock- hart Clarke. Fig. 2. Showing similar lesions with extravasation in grey matter and change of shape of cord, from a preparation by Dr. Dickinson. SYPHILIS. Plate 2. Suppurating syphilitic sores 401 Fig. 1. Inoculations of secretion from a suppurating sore, as they appeared on the forty-first day. Phlegmonoid variety. Fig. 2. Secretion from suppurating sore, treated with acetic acid and magnified 700 diameters. Plate 3. Syphilitic infection ......... 405 Fig. 3. Primary syphilitic inoculation. Fig. 4. Secretion from indurated sore, examined in the same way as Fig. 2. Fig. 5. Indurated sore, not secreting pus, not inoculable on the same patient. After Cullerier. Plate 4. Destructive syphilitic inflammation. Twofold inoculation . . 428 Fig. 6. Sloughing of indurated sore. After Cullerier. Fig. 7. Twofold inoculation. Sore suppurating, reinoculable on the patient, and followed by secondary symptoms. Plate 5. Destructive syphilitic inflammation. {To follow Plate ^.) . . 428 Fig. 8. Serpiginous phagedsemic chancre, cured by a single application of the actual cautery. After Cullerier. Fig. 9. Inoculation from serpiginous sore. Fig. 10. Inoculation, second in order, from sei-piginous sore. xxviii LIST OF ILLUSTRATIONS. TO FACE PAGE Plate 6. Syphilitic inoculation 440 Fig. 11. Irritated indurated sore. Fig. 12. Lioculation from the above on the thigh, eighth day Fig. 12 a. Inoculation, second in order, from the above, eighth day. Fig. 13. Inoculated syphilis (on a surgeon). Plate 7. Chancre on breast. Vaccino-syphilis 452 Fig. 14. Chancre on breast. Fig. 15. Vaccino-syphilis. Plate 8. Hereditary transmission of sj'^hilis 458 Fig. 16. Eruption on daughter at puberty. Fig. 17. Arm of mother. TUMOUES AND CANCEE. Plate 9. Tumours 611 Fig. 1. Oval-celled sarcoma. Fig. 2. Spindle-celled sarcoma. Fig. 3. Myeloid tumour. Fig. 4. Enchondroma. Fig. 5. Fibrous tumour. Fig. 6. Lipoma. Plate 10. Tumours , 612 Fig. 7. Fibro-muscular tumour. Fig. 8. Osseous tumour. Fig. 9. Glandular tumour. Fig. 10. Lymphoma. Fig. 11. Glioma. Fig. 12. Myxoma. Plate 11. Cancer 614 Fig. 13. Scirrhus. Fig. 14. "Withering scirrhus. Fig. 15. Medullary cancer. Fig. 16. Cancer invading muscle. Fig. 17. Melanosis. Fig. 18. Cancer-stroma. Plate 12. Cancer 616 Fig. 10. Epithelioma. Fig. 20. Fig. 21. Fig. 22. Osteoid cancer. Fig. 23. Colloid. Fig. 24. CoUoid. LIST OF ILLUSTRATIONS. xxix ANIMAL POISONS. TO FACE PAGE Plate 13. Glanders 703 Fig. 1. Glanders-eruption. Fior. 2. Subcutaneous tumours in glanders. WOUNDS OF VESSELS. Plate 14. Acupressure 72S Fig. 1. First method. Fig. 2. Second method, over the artery. Needle introduced. Fig. 3. „ „ „ „ Needle fixed. Fig. 4. Second method, under the artery. Needle introduced Fig. 5, „ „ „ „ Needle fixed. Fig. 6. Third method, the ends together. Fiff. 7. „ „ the ends crossed. Woodcuts. PAGE 1. Softening clot in the femoral vein 262 2. Secondary deposit in liver ......... 265 3. Diagram of clot-formation in veins ....... 276 4. Microscopical appearances of softening clots 276 5. Softening clot from pulmonary artery 277 Thermographs of Traumatic fever and its complications, and of Hectic fever 308 INFLAMMATION. THE purpose of tlie present article (with one wliich will here- after appear as its supplement) is to consider generally the Pathology and Treatment of Inflammatiok". In those sections of the work which refer to diseases and injuries of j)articular organs, there will be better opportunity for discussing how far this or that organ, when inflamed, gives distinctive characters to the inflammation affecting it, or re- quires that such inflammation should be treated by peculiar means. In the present essay, therefore, such ' local specialities ' of the subject will be but lightly touched upon ; only so far, indeed, as may be necessary to illustrate general statements, or to render them correct and complete. Thus, for instance, the student who wishes to learn all that may practically aid him with reference to the diagnosis or treatment of ophthalmia or of synovitis will refer to those afterpages in which diseases op THE EYE and DISEASES OP THE JOINTS are considered. Likewise what relates to ' specific varieties ' of inflammation may be more advantageously studied in the sections which are devoted to SYPHILIS, SCROFULA, CARBUNCLE, ERYSIPELAS, and otllCr like subjects. Even the so-called ' terminations ' of inflammation will not be exhaustively considered in this general article ; for many of the facts connected with them can, at least for practical l)urposes, be more conveniently classed under such special heads as those of abscess, ulcer, and gangrene. Notwithstanding these limitations, the present subject is of large scope and of equally large importance. To the student whose acquaintance with it is first beginning, it seems to branch almost throughout the whole subject-matter of surgery. Nor does a more critical inquiry tend very greatly to abate this first impression. For among the infinite varieties of surgical casualty and disease, singularly few are the cases which do not at some moment of their course — either in their origin, or in VOL. I. B 2 INFLAMMATION. their complications, or in their treatment, involve an appeal to those laws of textural irritability which govern the phenomena of inflammation. And it is no exaggeration to say, that rational surgery depends more upon a knowledge of the inflammatory process than upon all other pathological knowledge put to- gether. I. Etymology. The word ' inflammation ' is a very old one. That burnt or wounded external parts are apt to become hot, red, painful, and swollen, must have been among the first observations of man- kind. The increased heat of the injured part, or the suff'erer's feeling of increased heat in it, seems especially to have fixed popular attention ; and thus, however far back in time we trace the nomenclature of disease, always we find that such words as our ' inflammation ' — deriv. flamma, <^\sy^ia, (pXsysiv — words which denote the physical fact of having been set on fire, have been used with regard to textures of the living body, in order to express that peculiar morbid change which external injury excites in them.* But such words have not, in their application, been restricted to the results of local injury. So far back as medical literature extends, they have embraced cases, both of external and of in- ternal affection, where like phenomena arise independently of exterior lesion. The earliest observers of gout, carbuncle, or erysipelas, must have seen exterior parts of the body becoming hot, swollen, red, and painful, though with no ostensible injury, mechanical or chemical, from without ; and conclusions which were formed as to external diseases would soon extend them- • Every one who reads the German language will recognise that the above statement applies to it (in respect of its word Entzundung) and generally to the languages having nearest affinity with German, as much as to the Greek and its derivatives. And the following memorandum, for whicli the writer is indebted to the kindness and learning of Mr. Charles Rieu of the British Museum, shows the same thought to have been at work in other languages : ' 1 find that the Arabic equivalents of " inflammation " in its medical sense are < Aj^.\ iUihdh (literally a blazing-up), and also ii\.>. hardrah and roportion to its heated venous outflow, necessarily raises the temperature of the common mass of circulating blood ; that thus the local disorder represents an influence which tends to diff'usion throughout the body. Reviewing, then, the four classical symptoms — pain, redness, heat, and swelling- — we find that in every examinable case of in- flammation, they, or signs equivalent to them, may be locally dis- covered : — if not alwaj'S pain, at least always increased sensibility; if not always redness of the inflamed part, at least always m- creased affiux of hlood towards it ; if not always swelling, at least always increased quantity of matter ; and finally, under all circumstances, increased heat. Other local symptoms may be added to these. For, first, something complicative may come to them by mere accident of position. Where the walls of a visceral cavity are affected, the contained organs, originally free from disease, may be in- juriously pressed uj)on or denuded. Where the neighbourhood of a canal is inflamed, the canal may be encroached upon by swelling. Where large blood-vessels are concerned, ulceration may be dangerous by haimorrhage. And so forth. And further, an inflamed part often gives rise to special symp- toms of its own ; for its function is interfered with by the disease, and signs of this functio^ia I disturbance are added to the common symptoms of inflammation. Thus, if the kidneys be inflamed, the urine will be altered in quality, will more or less tend to represent a mere filtration from the blood, or perhaps will be entirely suppressed ; and, secondarily, there will arise the consequences of that general blood-poisoning which en- sues whenever urine is imperfectly discharged from the system. Thus again, if the lungs be extensively inflamed, due aeration of the blood becomes impossible ; and, while the patient is tending to die by sufibcation, chemical analysis may show that waste carbon which his lungs cannot oxidise and discharge is passing SYMPTOMS. FEVEE. 21 hj other channels from the body.* In these, and in almost all cases of inflammation, the nature of the functional disturbance is, that the function is more or less suppressed. To some extent this comes mechanically, and is, so to speak, an accidental com- plication of inflamrnatory swelling in the part. But greatly also, at least in most cases, it has to do with another influence, and implies for function what disorganisation implies for structure — Death. And just as, amid the structural disorganisation of inflamed parts, we recognise traces of mere hypertrophy where- with the process (if gradual) commenced; similarly, were our knowledge of function more complete, we should probably find that, so far as functional disturbance in inflammation is not of mechanical origin, thus far it also begins with mere over-per- formance of natural acts, and thus far the eventual suppression of function denotes exhaustion subsequent to excitement. It is only with respect to the nervous system that observation can here be appealed to ; but the relations of cramp to paralysis, of delirium to coma, and of madness to dementia, may be quoted as of the kind in question. It remains to be stated that inflammation has, besides its local symptoms, another essential characteristic. In proportion as any considerable part of the body becomes acutely inflamed, the patient's blood (if not affected by perturbing causes) invari- ably rises in temperature, and herewith the patient complains of what is commonly called Feverishness. Taking, for instance, a case of severe compound fracture, without much hajmorrhage, in a person otherwise sound and strong, we find that, before twenty-four hours have elapsed from the time of injury, his general system begins to be thus afiected. He feels hot, or alter- nately very hot and chilly. His skin and lips and mouth are dry. He passes urine in less quantity, but of higher colour, than usual. His pulse is quickened. A sense of general disorder gains upon him. He becomes restless and intolerant of disturb- ance. Signs of drought increase with him. His urine becomes scantier and more coloured. His skin feels hotter to the surgeon's hand, and his pulse, whether full or hard, is quicker and stronger than before. He craves more and more for water. His face has a flushed anxious look. He is thoroughly uncom- * See Beale, op. cit. p. S^i ; where an instance is given of melituria thus dependent on pneumonia. 22 INFLAMIMATIOK fortable ; for the most part feeling distressingly hot, but at iiTe- o-iilar intervals feelinfj touches of chilliness — sometimes even of such cold that he shivers with it. His sleep is troubled and un- refreshing ; or, as night comes, he gets delirious. His tongue, besides being dry, is furred. If his bowels act (which commonly they are inapt to do without laxatives) the excretions are mor- bidly offensive. Gradually these symptoms give way : in pro- portion as the injured limb ceases to be tense, and passes into suppuration, the skin and mouth become moist again; the excretions lose their concentrated character; the hard pulse softens, and the heart's action becomes quiet ; the nervous sys- tem is no longer restless ; the look of trouble passes from the countenance ; and the patient can again take solid food. The constitutional affection which thus runs its course in sym- pathy with the local inflammation is commonly known by the name of ' inflammatory fever.' The description just given of its symptoms purports only to represent the chief facts of a typical and uncomplicated case. But practically the affection shows numberless grades and differences and complications. First there are wide differences of degree and duration : for, in proportion as the local process is less acute and less extensive, there is less attendant febrility ; and in proportion as the local process has to invade fewer successive strata of texture, the fever is of shorter course. On the one hand, it may be so slight as readily to escape notice, and may end within a few hours of its commencement ; on the other hand, it may last in full force during many successive days, and may be so severe as to shake the patient's life to its foundations. And besides these differences, there are varieties of result — sometimes from complicative local conditions, sometimes from peculiar susceptibilities of the patient. If the wound become the seat of some large textural disorganisation, with consequent soakage of putrefying material, signs of blood-pollution may be expected to mix with or supersede those of common inflamma- tory fever; the patient's general state will then incline to be one of depression and apathy ; his tongue will be more than com- monly foul, and foetid diarrhoea will probably exist. Or if perchance during the local process it happen (as is especially apt to be the case Avhere cancellous bone-structure is affected, and generally at a time when common febrile excitement has passed its maximum) that pus passes up a vein into the genera] stream of blood, the patient's improvement is abruptly cut short SY^IPTOMS. TEVER. 23 by the severe recurrent rigors and sweatings of pysemia, accom- panied by local signs of secondary suppuration in parts to which the pus is conveyed. Further, the quality of the pulse during inflammation, and generally that look of vehemence in the febrile process which depends upon the circulatory system takmg an active part in the production of symptoms, will be almost un- liniitedly influenced by the more or less vigour of the patient. With weakened nerve-power, with feeble heart-structure, there can be no strong, hard pulse ; nor can the pulse be otherwise than soft or small, when the blood-vessels are half-emptied of their contents. Old age, and every kind of depressing, debili- tating, or exhausting influence, must therefore tend to prevent certain symptoms of fever from developing themselves ; and the surgeon who wishes rightly to estimate the degree in which his patient's general system is sympathising with some existino- inflammation, must guard himself against these sources of fallacy, by referring in all doubtful cases to what is the one sure measure of fever. It has already been said that in proportion as any considerable part of the body becomes acutely inflamed, the patient's blood (if not afiected by perturbing causes) invariably rises in tempe- rature. This is the essential fact of inflammatory fever. It is to this fact, that the familiar language of feverishness bears wit- ness ; the thirst, the scanty urine, the heat and the shivering, the troubled brain, the excited circulation. As the blood gets hotter and hotter, more and more do these symptoms become developed. As the blood subsequently gets cooler, so, more and more, do they decline.* It is necessary to remark that what is here said specially of the symptoms of inflammatory fever, is true generally of the fe- brile state. Whether we are dealing with the effects of mechanical injury, or with a case of small-pox or pneumonia, the symptoms which in common medical language are called feverish, are es- sentially the signs of heated blood. This in effect is no new doctrine; for even Galen, seventeen centuries ago, when maintaining that fever was but a preternatural bodily heat {Trapa (pvaiv dspfiaaia), disclaimed for himself that he had any origin- * The following observations of temperature in common inflammatory fever were made for the writer by Dr. Montgomery during the compilation of the present paper, January 18G0. The cases were all in the wards of St. Thomas's Hospital ; the first three imder the writer's care, the fourth under that of a 24 INFLAMMATION. ality of opinion, and declared that popular instinct, on the present point, concurred with the teaching of all competent physicians. But it is only of late, only with aid of exact thermometric observations, that the facts have been scientifically established ; and hitherto the subject has been much less studied in surgical j)ractice than in connection with infected fevers and colleague. The subject is further illustrated by the observations of general temperature made in counection with the experiments recorded at page I'J. . a .2 i n o O I Man, aged 29. Amputation above knee for osteosarcoma of the tibia. Man, aged 4:1. Injection of tincture of iodine into the knee-joint for chronic hydrarthrosis. Man, aged 36. Small tumour removed from the upper sur- face of the foot, 44 hours before the first tem- perature was taken. £m/, aged IG. Syme's operation, 46 hours before the first temperature was taken. mom. 10—1] aftem. 3—4 36-15 even. 8-9 morn. 1 94— lOi aftem. 3-4 even. 8-9 mom. 10—11 aftem. 4—5 even. 8-9 mom. 9—94 noon. 114—12 aftern. 4—5 36-50 36-55' 36-50 II 36-40 36-50 36-60 36-30 36-50 36-70 III 36-40 Opera- tion at 2-30 36-75 35-90 Opera- tion at 3-20 37-00 38-20' 38-30 38-90 36-60 37-90 i IV V 38-30 38-30 38-20 37-70' 37-70 38-30 38-30- 38-30 38-20 37-30 37-80 38-40 37-90 38-40 38-30 37-60 37-45' 38-20 37-^^5^ 3810 3810 37-20 37-15 39-40' 1 ^^ VII 39-20' 37-70 37-30 38-05 36-70* 36-90 37-20 37-10 37-10 37-20 36-80 38-80 39-10 38-20 36-35" 36-50 36-20 36-70 36-70 37-10 36-40 39-40^ 38-00 VIII 37-50 3800 37-80 36-30 36-60 36-70 36-60 37-40 IX X XI XII 36-85 37-30 37-7 30 30 37-30 36-80 37-20 36-20 37-00 36-25 36-45 1 36-25 36-60 1 ' At 7 mom. slight shivering. ' Patient keeping his bed. " Pain began after n afternoon. ^ Knee swollen aiul painful. " Fain also in oppo- site knee, and iu liotli k'i.'s from knees down wards. '- I )iminution of pain and swelling has begun. ■■• Scarcely any more pain. ' Inflammation of the tissue surrounding the wound ; foul tongue ;— sickness : hesulache. '•' Inflammation sprea1 scarlatina only because they contain, and only while they con- tain, in combination with their texture, certain other effete material ; and so forth. Generally, then, respecting these textural predispositions to be inflamed by morbid poisons, and by most of them (as a rule) to be thus affected only once in life, the probable argument may be thus summed up. In the first evolution of certain textures, there normally arise certain waste-products, which, it seems, under ordinary circumstances, are difiicult of destructive con- version, and therefore tend to an indefinite loitering in the part or in the system. As regards each such stuff respectively, one particular stimulus is always effectual to convert it — the con- tact, namely, of similar stuff already thrown into its specific process of decay. Let this stimulus remain absent, and the subject retains, even apparently to the end of life, the peculiar susceptibility which ic alone can awaken and extinguish.^ Let the stimulus come, and forthwith the stagnant material fer- ments more or less explosively, commonly with destruction of tissue, often with destruction of life ; passing, while it wastes from the body, through a stage of contagiousness similar to that which has stimulated its own change ; and leaving the body, when this discharge is accomplished, more or less perma- nently incapable of renewing the process, or at least only so far capable of renewing it as the predisponent material is capable of being renewed. It has been intimated that the specific predispositions here spoken of are normal facts in the development of the body. To this rule indeed there may be exceptions, as to other rules in the same category. Just as, by faulty development of bodily forms, hare-lip or spina bifida or twelve fingers or webbed toes * The existence of that specific stimulus may reasonably be considered to have been an accident in the pathological history of man ; for millions, no doubt, have reached the natural term of life, healthy in mind and body, to whom measles, or small-pox, or scarlatina has never come, but who to the very last moment have retained their susceptibility to the disease. And of two alternatives it may perhaps rather seem to have been contemplated, in the scheme of construction for man, that the ingredients in question should in- definitely remain in his body, as inactive, indiflerent constituents, than tliat, for a normal process, they should be worked out of him by the fiery ordeal of fever. When the contagion of measles, after an absence of sixty-five years, was imported into the Faroe Islands, the disease did not show itself as an infantine epidemic, but as an epidemic equally atiecting all ages which were junior to the last visitation. F 2 08 INFLAMMATION. may occur as an exceptional phenomenon ; so it appears the chemical development may exceptionally omit to complete, or not less exceptionally may hasten to renew, some one of the organic compounds which are respectively fermentable by the several morbid poisons. Such exceptions, however, like the rule itself, mark the developmental source of the predisposition. Either by falling short of what is normal, or by going beyond it, a child may be excepted from the rule of liability once in life to variolous, rubeolar, or scarlatinal inflammation, as he may be excepted from the rule of having ten fingers, or from the rule of having an uncleft palate ; and in either case the peculiarity tends to be hereditary. As it is with the one child, so it probably is with his brothers or sisters or some of them, and so it probably was with one or other of his parents : it is part of the familj'-likeness among them that they do not deve- lope the stuff which makes the liability to measles, or that they develope again and again (if it be removed by successive fermen- tations) that other stuff which makes the liability to small-pox. The tendency of particular families to suffer particular infections with unusually great, or unusually slight, severity, is another fact of the same signification."^ The kind of predisposition to inflame which consists in the textural accumulation of unstable chemical compounds is per- haps further illustrated by other influences in our list. When, for instance, we have the fact before us that great consumers of strong drink, on receiving slight local injuries, especially if the injury be such as to create an open wound, are apt to suffer severe sloughy inflammation, we cannot but advert to what now seems well established respecting the action of alcoholic stimulants — that they retard the excretory changes of tissue, and tend to j^roduce an artificial diathesis in which the organic substance is unduly loaded with refuse. Similarly, that kind of albuminous plethora which exists in persons who over-feed and under-exercise their bodies is probably incon- sistent with a due defsecation of the system ; and this considera- tion naturally connects itself with the fact that such persons are peculiarly susceptible of bronchial and muscular inflamma- * [Some exceptions to liability to morbid poisons are, I think, undoubtedly due to the disease having been undergone in utero. A case lately came under my notice of apparent insusceptibility to vaccinia, in spite of repeated attempts of vaccination, in an infant whose mother during its utero-gestation had beeu ,re-vaccinated with full effect.] I PEEDISPOSING CAUSES. 69 tions. So, again, when we see the infants of the poor in crowded town-dwellings suffer many times the mortality which is natural to their period of life, and this mortality mainly from inflam- mations, we are reminded that, in the animalised atmosphere of those dwellings, respiration can furnish no due excretory cleansing to the blood, nor adequately assist the tissues to get rid of theu' eflete elements. The characteristic intestinal in- flammations of cholera and typhoid fever, excited as each of them is by a specific ferment which developes itself in the decomposition of excrement, strongly suggest the existence of specific textura-l predispositions, natural or to some extent acquired, and founded on the textural presence of half-elimi- nated excremental material.* Even in that already-discussed predisposition to inflame which is evinced by ill-nourished textures, and still more in that heightened susceptibility to typhus which arises under the influence of starvation, it seems probable that the chemical conditions are of the kind now spoken of, and, at least in the latter case, are of essential impor- tance to the result.f That, under many of the circumstances here * Parts of the mucous membrane of the intestinal canal serve as a gi-eat dis- infectant influence for the blood : foetid contaminations of the body almost invariably excite diarrhoea; and it is a well-known observation of dissectors, that, in flatus voided from their bowels they can recognise the distinctive stench of whatever putrefying matter the}^ may have been busied with — of human gangrene, for instance, or (as the case may bej of porpoise, cuttle-fish, or dog. It is therefore probable that, in persons habitually exposed to putridity, those parts of the mucous membrane of the intestines are constantly in a state more or less approaching satm-ation with impurities. The urban poor, for instance — frequently dwelling in crowded, imventilated, filthy places, where they breathe a faecal air, and sometimes also drink a faecal water, present one great type of such cases ; and whatever chemical changes can occur in ftecal matters removed from the system may reasonably be expected to affect, in persons thus circumstanced, that intra-textural excess of fsecal or half-f;ecal matter with which the eliminatory parts of the intestinal surface are charged and .sodden. How greatly such persons suffer from the various diarrha^al infections is now well known. Probably the relations of cholera and typhoid fever to specific putrefactions of excrement is as definite as that of small-pox infection to smaU-pox virus ; and the aSection of the intestinal mucous membrane by the diarrhoea! ferments represents the extension of a putrefactive process from refuse matters without the body to refuse matters within it. t No such ravages have been made by typhus as when it has been associated with famine and, apparently by reason of this association, has prevailed as a national epidemic. There are analogies between the state of persons dwelling in foul atmospheres and the state of persons suffering stan-ation. ' The starved body, which cannot renew the waste of its texture by the ordinary resources 70 INFLAMMATION. adverted to, there actually does prevail in certain materials of the body a less than normal fixity of chemical constitution, is not altogether a conclusion from analogy. A very curious generalisa- tion bearing on the subject has recently been published by Dr. Inman of Liverpool, to the effect that during man}^ states of debility the patient's excretions are preternaturally prone to decomposition.^ Dr. Inman especially refers to the alvine dis- charges, to the urine, and to the organic matters -which are ehminated vt-ith the breath. And so little is this generalisa- tion an effort of medical theory, that Dr. Inman refers his first reflections on the subject to a hint given him by a chemist twelve years ago, during some experimental deodorisations of excrement ; for the operator professed to estimate the magni- tude of illness with which patients were suffering by the va- rious amounts of putrefaction which their excrements (some hours after evacuation) had undergone ; and he alleged that ' he had found, in the course of his experiments, that faeces decomposed rapidly or otherwise, according to the debility of the individual passing them.' Finally, with respect to the climatic conditions which pre- dispose to inflammation, it seems probable that they act only by affecting that chemical mobility of which so much has been said. Thus it may be that continuous atmospheric deficiencies of ozone predispose to those inflammations Avhich are contin- gent on imperfect defsecation of texture. And thus apparently it is that heat of climate greatly favours the outbreak of all inflammations which arise in anything like putrid infection; as is illustrated byMagendie's statement f that, by injecting into of food, probably ekes out its being and maintains the continuity of its organs by stuff, which, under ordinary circumstances of ntitrition, would have been discharged as effete. Tlius, probably, it comes to consist to an abnormal extent of stale material in a state verging on dissolution. And just as the rags of poverty may by a touch be torn asunder, so those half-starved tissues which they cover fall under very small injuries into disproportionate ulceration and gangrene. The fact that during times of famine masses of population are found with their textures and juices in this state (undeffecated because unrenewed) may perhaps have something to do with their fatal susceptibility to typhus; for, under such circumstances, the contagion of this form of disease will spread and multiply (like the contagion of small-pox amid an unprotected population) at a rate quite disproportionate to the sanitary defects of localities.' — Papci-s reluting to the Sanitary State of the People of Englaiid, 1858, p. xvi. * Foundation for a New Theory and Practice of Medicine. London, 18G0, p. 214. t L' Union medicale, 1852, p. 23G. PEINCIPLES OF TEEATMENT. 71 the blood-vessels two grammes, or even one gramme of putrid material, during very hot weather, he could produce death as certainly as by injecting three, four, or even ten grammes during winter. in. The Treatment of Inflammation. A. GENERAL PRENTIPLES. Subject to explanations which will presently appear, it may be said that the treatment of inflammation has for its immediate aim to reduce that excitement of tissue which essentially constitutes the disease. And our endeavours to attain this object — endeavours so various that the detail of them can here be only partially attempted — may, as regards their nature, be generalised under two heads which express the main rational rules of antiphlo- gistic treatment. These rules are the following : — first, with careful regard to all influences which are operating on the inflamed part, to procure the discontinuance of the special cause of the inflammation, and, as far as possible, to relieve the part from the action of other stimulants ; secondly, by direct and indirect action on the inflamed part, to counteract there, as far as possible, the working of such irritant causes as remain in operation. And, concurrently with all such setiological treatment of inflammation, this third object also has to be ful- filled : that the organised products and waste-products of the disease, and generally its complications and consequences, be so dealt with as to prevent them from re-acting hurtfully on the part, or originating other mischief to the body. 1. To relieve the part from causes of excitement. That inflamed parts spontaneously tend to recovery as soon as inflaming causes are withdrawn from them is a truth which, simple and rudimentary though it appear, is of more funda- mental importance than anything else which can be said in reference to the treatment of inflammation. And if our know- ledge of the causes of inflammation were complete, all other than setiological principles of cure would become relatively in- significant. Under present circumstances, however, there is but one group 72 INFLAJSIMATION. of cases in which inflammation is knowingly and habitually cured by the mere withdraAval of its cause ; and fortunately for the surgeon this group lies for the most pai-t within his province of practice. The chronic inflammation which is produced in the mucous membrane of the bladder by the presence and friction of an urinary calcvdus, the acute inflammation which begins in the cornea when some small fragment of steel is driven into its texture, the repeated suppuration and inveterate sinuses which attend the deep-seated retention of any foreign body, or (as operating in the same way) of sequestra of dead bone, — these are common illustrations of the gi'oup of cases referred to. Not all the pharmacopoeia of antiphlogistics is so effectual in these cases as the mere mechanical act of removing the calculus, the splinter, or the sequestrum. The thickening and eventually the ulceration of skin which (as in the course of ordinary corns) result from undue pressure and friction on the surface, the inflammation of subcutaneous bursa) under similar circumstances, the nebulous state of cornea which the scrubbing of inverted eyelashes produces, the ulcers which arise in the varicose leg fi'om the stagnifying vertical pressure of an unvalved column of blood, the bronchitis which associates itself with those various kinds of factoiy-labour wherem the workman has to inhale mechanical or chemical irritants, — these are further familiar cases where morbid con- ditions are essentially co-endurmg with their respective tan- gible causes, and are best treated by the removal of these causes. Taking from among them, for example, the case where an ulcer of the leg is enlarging and deepening itself day after day by uninterrupted acts of inflammation : let the pa- tient be confined to bed with his leg horizontal or raised ; no sooner is the local circulation thus relieved from its pre- vious mechanical impediments than inflammation ceases in the part, and the foulness of the sore almost immediately gives place to healthy granulations which attest the commencement of repair. It is amongst the highest problems of pathology to discover new groups of cases capable of being treated, like the above, by the simple removal of their respective causes. With the various dyscrasial inflammations, for instance, which are now treated exclusively from an empirical basis, and consequently PRINCIPLES OF TEEATMENT. 73 often without success, how great an achievement it would be, if their immediate causes could be made as palpable as the mechanical causes just spoken of, and could, like them, be dis- tinctly aimed at and destroyed ! Only second in importance to the principle of procuring-, where possible, the discontinuance of the special cause of the inflammation, is the kindred principle — that the inflamed part should be as far as possible relieved from the action of other stimulants, and from all inconveniences of posture. Setting the inflamed part thoroughly at rest, as regards the exercise of its own functional activity, is one great step towards fulfilling this rule. It is thus that, with so much advantage, we exclude from an inflamed eye the natural stimulus of light. It is thus again that in the case of inflamed joints (especially where there is subarticular caries) the simple expedient of tho- roughly immobilising the part by the application of an appro- priate splint will often give chances of recovery which cannot otherwise be attained. But further : so intimate is the sympathy between all com- ponent parts of the living body, that, in order to get the fullest measure of repose for any one organ, it is requisite that other organs be restrained from exercise. In proportion as an inflam- mation is considerable, and especially in proportion as it is attended with febrile symptoms, we find it of importance to obtain thorough quiet for all the animal functions ; to reduce to a minimum all muscular movements, all impressions on the senses, all appeals to the intellect or feelings, and all exer- tions of the will. Probably every inflammation admits of being treated to most advantage when the patient is kept entirely recumbent ; but, at least in every case where there is appreciable feverishness, it is essential that the patient keep bed, in a cool and well-ventilated apartment, with every kind of disturbance excluded, and with every available facility for sleep. It is necessary that the inflamed part be not left in a depen- dent or constrained posture, but be sufficiently raised to favour its return of blood ; and that, by appropriate covering, it be kept free from all irritative contact. Any existing mal-condition of body by which inflammation or fever may be aggravated will of course at the same time be attended to. And although purgative medicines ought not to 74 INFLAMMATION. be given as a matter of routine, tlie surgeon will always have regard to the state of the bowels, and particularly will see that vitiated secretions be not retained in them. [Since the publication of the first edition of this work it has been shown with regard to a large class of surgical cases — the class, namely, where open wounds exist or have to be surgically made, that a very important principle of antiphlogistic treat- ment, in the sense of preventing inflammation, consists in the careful antiseptic management of the part, as specially insisted on by Professor Lister of Glasgow.* The improvement is of the simplest sort. The free use of diluted carbolic acid (or any equivalent chemical) to the whole interior of some unpromising wound, and the closing of the wound, so far as circumstances permit, with dressings of the same antiseptic ; the dressings, till the wound is healed, only to be removed of necessity, and always with the least possible admission of air, and the anti- septic to be renewed from day to day ; this seems no great thing to do : but practically, as those who have adopted the system can certify, it will often insure the recovery of such compound fractures of bone, or such free openings of joints, as, without it, might fairly be despaired of. And in the opening of great abscesses, acute and chronic, the advantages of the same system are not less conspicuous.] 2 and 3. To depress the local action, and obviate its hurtful con- sequences. All treatment hitherto spoken of is, in principle, preventive. The treatment next to be discussed — the treatment to which recourse must be had when the progress of inflammation can no longer be prevented by the removal of its determining cause, is, on the contrary, of the nature of an antidote. The cause not being removable, we have to counteract its effects : to counter- act them primarily, as consisting in the local excitement ; to counteract them secondarily, as consisting in results which the local excitement originates. In this curative treatment of inflammation and its results, the following objects, or some of them, are aimed at : — a) by depressors and sedatives, either (like cold) outwardly applied to the inflamed part, or (like opium) administered to it Lancet, and Brit. Med, Joum., 1867. PEINCIPLES OF TREATMENT. 75 through, the blood, to directly reduce its excitement and irrita- bility; h) by stimulants applied to uninflamed parts of the body, to create counter-excitement, which (as regards attractive influence on the blood, and perhaps also as regards other conditions of existence) shall outbalance the excitement of the inflamed part ; or by other derivative means, of which local bleeding is the principal, to attract into collateral channels the flow of blood which otherwise would feed the inflammation ; c) by general depletory measures — of which bleeding and purging are the principal — and by withdrawal of food, and by use of emetics or nauseants, so to impoverish and weaken the general circulation that the entire body (including of course its inflamed part) shall be brought into circumstances of scantier nourishment, and be freed from vascular tension ; d) by febrifuge treatment (not necessarily depletive) to re- lieve the blood from sympathetic derangement, and render it in temperature and constitution as capable as it can be of contri- buting to resolve the inflammation. Further, with reference more particularly to special symptoms or results of the inflammatory process, or to special varieties of inflammation, the practitioner may propose to himself one or more of the following objects : — e) by cutting into an inflamed part, to relieve it from ex- treme vascular tension ; or, by uniform mechanical pressure on an inflamed part, or otherwise, to promote the emptying of its vessels ; /) by cauterising or intensely irritating an inflamed part, to break the continuity of its particular moi'bid process ; g) by the use of antiseptics, locally or generally, to cleanse the sources, and obviate the evil results, of putrid infection ; h) by surgical operation, where admissible, to effect the dis- charge of collected inflammatory fluids, and the removal of gangrenous parts, or of parts rendered irreparable and incon- venient, or of parts which threaten life ; i) by the use of narcotics, to procure the discontinuance of extreme pain ; k) by the use of specific drugs, to counteract specific dys- crasial states ; I) by the use of mercury, to develope such a constitutional state as will resist the formation, or cause the destruction of false membranes and adhesions j 76 INPLAM^IATION. m) finally, with respect to parts where only the consequences of inflammation remain, to excite by stimulants, so far as de- ficient, the local actions of defsecation and repair. a, i.) To no exterior influence is textural excitement so directly amenable as to changes of temperature. Cold, continuously applied, is the sedative of every vital manifestation. Under its influence, rhA-thmical actions become slow or null, sense and volition slumber, reflex phenomena cease, common growth and embryonic development alike stand still, injured parts are un- able to repair themselves. In theory, then, it may be said that continuous cold, locally applied, is in direct and essential op- position to the causes of inflammation. But in practice it is by no means common that cold can be thus used as an anti- phlogistic. Not only are there many cases of inflammation (internal in- flammations, for instance) where it is mechanically difiicult or impossible to apply the agency of cold ; not only are there many other cases (exanthematic inflammations, for instance) where, rightly or wi'ongly, the external repressor is deemed dangerous to life ; but, further, the principle on which continuous cold operates is such that, even with external traumatic inflamma- tions, somewhat narrow limits must be assigned to its use. Though clinically it is not always easy to fix these limits with precision, the guiding thought may probably be thus ex- j)ressed : that, as continuous cold is rather an antidote to the causes of inflammation than a remedy for the resulting changes, so, in order to get full advantage from its use, we must employ it almost from the moment when the causes begin to operate. Thus used in cases to which it is applicable, cold serves as it were to subtract something from the efiiciency of the exciting causes of inflammation, and to regulate, from its very start, the momentum of the inflammatory process. In confonnity with the above prmciples, cold is of great antiphlogistic value in the treatment of wounds, including such as are made in surgical operations. Here, commencing its employment almost from the moment of injiu-y, and thus continuously moderating the local temperature, we are enabled to restrict textural activity within the limits of what is just necessary for the adhesive process ; to restrict it in degree, so that it does not run on to suppuration or gangrene ; to restrict TEEATMENT. USE OF COLD. 77 it also in extent, so tliat it does not involve more than tlie im- mediate neighbourhood of the injured surface. Among cases in which the power of attaining these results has more than common importance, may be instanced the wounds of large joints, whether made by accidental incision, or designed for the removal of spiovial concretions. Under an effective use of cold (together, of course, with absolute immo- bilisation of the limb) many a knee-joint recovers without per- manent injury fi'om even some considerable incision. The antiphlogistic use of cold is often turned to good ac- count, not curatively indeed, but retardatively, in cases (if not too far advanced) of strangulated hernia : a first taxis has been unsuccessful ; the sac and bowel are beginning to inflame and becoming too sensitive for manipulation ; a second surgeon is sent for to oj^erate. Application of cold during the hour or two which may elapse before his coming, will not only prevent the development of symptoms, but often effect their temporary reduction to a point at which the taxis may properly be tried again before the knife is had recourse to. Though it be the fact (as above stated) that in many internal inflammations the local use of cold is mechanically difiicult or impossible, yet there are others to which it is applied with suc- cess. I am told that in the great hospitals of Yienna and Prague, an ordinary treatment of peritonitis is treatment by local cold ; and it is said by those who have witnessed the practice that the results are of the most satisfactory description. Local cooling for common antiphlogistic purposes is well effected by water of the desired temperature. Cloths thus wetted are spread over the surface which is to be acted on. It is essential to the result that these cloths should be kept as nearly as j)ossible at their original low temperature, either by being continuously dripped upon from a reservoir of cold water, or by being very frequently changed or re- wetted by hand. Their surface meanwhile should be freely exposed to the air, or, if necessarily within bed, should have ample space for evapora- tion secured to it ; and arrangements should be made to pre- vent needless and uncomfortable soaking of the patient's bed and clothing. As regards the temperature of water to be employed, it may range, according to the exigencies of the case, from that which the average healthy hand feels to be decidedly cold — say about 45° F. — to the lowest above congelation. And the maintenance of this temperature in a bed-side reservoir of 78 INFLAMMATION. water can be regulated by ice or freezing mixture. Every application which the inflamed part recognises as cold is, ac- cording to its degree, antiphlogistic ; but, except in cases where very rapid action is required, the efficiency of the appli- cation depends less on extreme degrees of cold than on the con- tinuous and uniform operation of even a moderately reducing temperature. Failing the continuous action of cold, cold is worse than useless. And the too frequent slovenly nursing which lets water-cloths remain for hours unwetted, or swaddles them up under other coverings, is fatal to this method of treat- ment. The surgeon who wishes to see what can really be effected by the continuous application of cold, must either bestow a little mechanical ingenuity on the construction of a self-acting irrigator for his patient, or must secure such scrupu- lous attendance at the bed-side as to render interruptions im- possible. Bladders of pounded ice are sometimes employed, instead of wetted cloths, for the purpose of local refrigeration ; but the cold thus produced is greater than, commonly speaking, is necessary, and greater than can for long periods be con- tinued. Perhaps the best use which can be made of ice is, in certain cases of intense onset of inflammation, to make a first local impression which minor degrees of cold will afterwards maintain. [Leaving the above passages as they stood in the first edition of the work, I am glad to be able to mention that since 1860 our appliances for refrigerating inflamed parts have been much im- proved, and the practice of treating inflammation by the local use of cold has in consequence received ver}'- great extension. The improvement has been mainly due to an admirable paper by ProfessorEsmarch of Kiel (translated in 1861 by Dr. Montgomery for the New Sydenham Society) on the use of Cold in Surgery. This paper, besides showing the incomparable surgical advan- tages which in appropriate cases can be got by a right use of cold, brought into currency the very simple but singularly con- venient contrivance of india-rubber bags for the local applica- tion of ice : a contrivance which enables us to make effective use of ice with about as little inconvenience as would attach to the employment of a poultice. And having myself now for the last eight years habitually followed Professor Esmarch's im- provement in practice, I may confidently say that he does not over-rate its advantages; that applied in certain cases separately, and conjoined in certain other cases with the antiseptic manage- TEEATMENT. OPIU]\I. 79' ment of wounds, it very often enables us to get successful results where of old we should commonly liave had failure.] Both as regards a first decision to use cold in the treatment of a particular case of inflammation, and as regards the time when it becomes desirable to discontinue this employment of cold, the surgeon may wisely consult the sensations of his pa- tient. While cold gives comfort, it almost certainly does good ; while it gives discomfort, it almost certainly does harm. ii.) Whether, besides cold, there be other agents which act as direct depressors of textural change, and which may on this principle be used as antagonists to the causes of inflammation, is hitherto very imperfectly known. But it seems probable that the antiphlogistic action of opium (and possibly of other nar- cotics) is somewhat of the same kind; and the present may therefore be a convenient opportunity for referring to it. With opium, as with cold, our best chance of doing good is where we can adopt the treatment almost as soon as a cause of mflamma- tion begins to operate ; where, for instance, after some wound, accidental or operative, we can at once bring our patient under the influence of opium, and keep him, as long as necessary, more or less narcotised by renewed doses of the drug. This method of proceeding is often of signal advantage where the peritoneum has been injured ; it often constitutes the main feature of after-treatment in cases where ovarian tumours are re- moved or ceesarian sections performed, and is oftenof the utmost benefit after operations for hernia. Its utility under these cir- cumstances is no doubt partly due to its indirect influence in preventing such muscular movement as might displace or irritate the injured parts ; for the soporised patient does not care to move from one fixed position, nor do his bowels care to be per- forming their peristaltic movements. But it seems probable that the same tranquillising power affects the injured texture itself — renders it, so to speak, less percipient or more tolerant of injury than it otherwise would have been, less disj^osed to undergo diffuse excitement, less apt to invite increased deter- mination of blood. There are other uses of opium only inferior to that which has been named. Where inflammation has received a considerable check by depletive treatment, and further measures of the same kind are inadmissible, opium often prevents the textural excite- ment from rekindling. Where (as is particularly apt to be the 80 INFLAMMATION. case with persons whose constitutions are damaged by irregular and exhaustive modes of life) inflammation is attended rather by nervous irritability than by true feverishness and vascular ten- sion, here, especially if the inflammation be ulcerative or gan- grenous, opium, either alone or in aid of any specific drug which an existing specific cachexia requu'es, may be of indispensable value. h) The practice of treating certain inflammations by counter- irritant and other derivative measures is believed to represent the application of a pathological princijjle. Different parts of the body naturally exercise a sort of competition with each other in their several claims on the blood, one part necessarily tending to receive less in proportion as other parts receive more. Un- doubtedly to a certain extent this rivalry is exercised through the medium of the general circulation ; and thus it is that, for instance, any great determination of blood to the skin may diminish supply to the kidneys. But besides this antagonism effected through the general circulation, there probably are antagonisms of a local character ; and parts which are respec- tively supplied by different contiguously -rising branches of one arterial trunk seem specially able thus to antagonise each other. For, assuming the flow through an arterial trunk to remain the same, one branch or set of branches can only transmit more blood, if simultaneously another branch or set of branches trans- mit less ; and we may well conceive it to be an important func- tion of vasi-motor nerves to provide for the adjustment of this antagonism, by establishing such inter-arterial sympathies that the relative opening of one branch shall determine the relative closure of another. As the claim of each part to receive less or more blood is measured by the degree in which it is indolent or active, so to stimulate a part is the sure way of determining blood to it. Uhi stimulus, illuc affluxus. And thus by artifici- ally irritating one part, we may, it is believed, divert blood from another. The irritated part, attracting blood to itself through arteries which open wider to facilitate the process, is supposed to become increasedly antagonistic to all parts which are in arterial sympathy with it, including of course any inflamed part which is thus circumstanced ; and in proportion as it succeeds in diverting blood to itself, the arteries of these latter parts are supposed to become (relatively speaking) constricted, and the parts themselves to be relieved from pressure of blood. I TEEATMENT. COUNTER-IRRITANTS. 81 Here, then, apparently is one considerable channel of influence for counter-irritant applications ; that, through inter-arterial sympathies which vasi-motor nerves maintain, or contribute to maintain, and in some cases through the general circulation, they tend to divert blood from flowing into the inflamed part. And, so far as the local process depends upon vascular fulness, counter-irritant treatment may, under certain qualifications, be expected, on this principle, to reduce it. But counter-irritants may have a value beyond this : for pro- bably it is not only as joint competitors for blood that the several bodily parts influence one another's life. Textural excitability perhaps is not so exclusively local but that in this respect also there may be conditions of inter-textural balance ; the total ex- citability of the body at any given moment being perhaps of fixed amount ; so that with regard to excitement, just as with regard to blood supply, ' plus ' in one organ would imply ' minus ' in another. Possibly too the nerves during counter- irritation may operate in other ways than through arterial contractility to modify the vital actions of parts which counter- irritation is intended to relieve. These possibilities deserve to be borne in mind ; lest, relying too exclusively on the derivative element in counter-irritation, we should unduly ignore methods of treatment which seem to require other principles for their explanation. i. Surgical appliances of the class under consideration are of three grades of intensity. The most intense is illustrated when by caustic potash, or hot iron, or burning moxa, we make a slough of skin ; or when, by running a seton under some inches of integument, we establish a track of subcutaneous suppura- tion ; as is often done (and now chiefly in the form of caustic issue) in the neighbourhood of joints or of the spine, where can- cellous bone-structure is chronicly inflamed and carious. A second grade is illustrated by the various agents which cause vesication or, if they be more sparingly used, des-ina.uifition of the skin ; as when we apply various preparations of cantharides, iodine, or mustard, to the integument of the chest with the object of relieving some pulmonary or cardiac inflammation. A tJiircl is illustrated (where perhaps the illustration is not always looked for) in the action of common poultices ; as when, on account of a whitlow, we envelope the whole hand and wrist in poultice, and thus solicit from the radial and ulnar arteries into VOL. I. G 82 INFLAMMATION. collateral circulation a share of the blood which before was beinjr so partially distributed that every beat of the heart was felt as a throb in the finger. The more intense forms of counter-irritant treatment are so painful that it is well worth while to be critical as to their value. And it deserves more general notice than it has yet re- ceived, that some of the most accurate clinical observers of the day are profoundly sceptical on this subject. In various cases of thoracic inflammation, for instance, where thousands of prac- titioners employ blistering as a matter of course, the unsurpassed authority of Professor Skoda pronounces such treatment to be always powerless for good, though sometimes powerful for harm. And probably a large proportion of treatment by long continued setons and issues has subsisted, less from any sure knowledge of its doing good, than as a remnant of the old belief that morbid humours could thus be set running from the body. Assuredly the whole subject requires careful clinical reconsideration; towards which, in this place, only two suggestions are offered. In the first place, particularly with regard to the uses of blistering, there is a soiu'ce of fallacy against which the student will do well to guard himself. Not every cutaneous inflamma- tion excited for surgical purposes is intended to be counter- irritant and derivative. There are cases (presently to be again adverted to) where it acts simply as a further stimulant to the part originally inflamed. When, for instance, we ajjply strong blistering fluid directly over a knee-joint with chronic inflam- matory effusion, the action of the irritant propagates itself, in lessening degrees, through the intervening small thickness of parts, and sensibly afiects the synovial surface ; where frequently at first it causes some increase of effusion ; and where at any rate the desired removal of fluid only begins when the super- induced excitement has begun to subside. And it is by reason of this action that, with regard to superficial parts, blistering, if it does not resolve their inflammation, commonly determines them to suppurate : a fact, sometimes illustrated in the treat- ment of indolent inguinal buboes, where it may happen that blistering is deliberate! v used in order to force this alternative on the part, and, either by one way or the other, to bring the inflammation to a close. Similarl}^ we may sometimes be proceeding rather too dras- tically when we blister the walls of the visceral cavities. I have often seen cerebral distress appear to be much aggravated TREATMENT. DERIVATIVES. 83 by the application of a blister to the scalp ; and it has hap- pened, in making the post-mortem examination of a patient to whose abdomen a blister had been applied, to find on the inner surface of the abdominal wall a red patch (probably of more injected muscular substance seen through the peritoneum) cor- responding to the area of blistered skin. In the second place, it deserves full trial whether every in- tense and consequently painful form of counter-irritation might not be superseded by the employment of other means, less in- tense, but more extensively applied ; whether, for instance, ten inches of poultice may not be equivalent to three inches of blister, or to one inch of issue. For probably among the agencies now spoken of there is none to which we can look with better-grounded confidence than to the diffuse local action of warmth, as supplied by poultices and fomentations ; par- ticularly when it can be so administered as to affect a surface of skin very greatly larger than the quantity of inflamed tex- ture which we desire to relieve. In many chronic — probably also in some acute — inflamma- tions, especially in those which arise from catching- cold, or are associated with gout or chronic rheumatism, the excite- ment of the entire skin by baths of hot air or hot vapour is often of the most striking and immediate benefit. And though in most of these cases the result of the exterior heat is probably something more than mere blood-derivation to the skin, yet not the less on that account are they important illus- trations of counter-stimulant treatment. Pending the better settlement of what is doubtful in the present subject, there are cautions which every one admits to be necessary if the counter-irritant treatment of inflammation is to succeed according to its intention. In proportion, namely, as the counter-irritants which we employ are of severe local action, we must take care — first, that they be not so applied as to involve the inflamed part in their direct irritant opera- tion ; and, secondly, that they be not so applied as to aggra- vate any existing febrile disturbance. ii. It remains to be stated that there are derivatives which are not counter-stimulant. The abstraction of a very few ounces of blood from the vicinity of an inflamed part often gives relief which apparently is quite out of proportion to any effect produced on the general circulation. And there seems g2 84 mFLAMMATION. no way of accounting for this result, unless tlie action be re- garded (on the principles already suggested) as a derivation of blood effected through inter-arterial sympathy. Local blood-letting is effected by leeches or cupping;* of which methods each has its advantages ; leeches, that they are commonly less formidable and admit of being more uni- versally applied ; cupping, that, if the abstraction of blood is to be large, its quantity can thus be more exactly regulated. It is also believed that cupping exerts its influence through a greater thickness of tissue ; and that if we wish, for instance, to affect the kidneys, we can better attain our object by cup- ping than by leeching the loins. Small local abstractions of blood are proper for innumerable cases in which general blood- letting (as requiring to be much more coj)ious in order to produce the same local result) would be wrong or even dan- gerous. And in cases where recourse is had to general blood- letting, sometimes local blood-letting is thought desirable as an adjunct. For the objects of local blood-letting it is not necessaiy that the blood should be drawn actually from the part which is inflamed : to draw blood fi'om the neighbourhood answers our purpose : and indeed, where it is possible to apply leeches directly to an inflamed texture, the results are not always as satisfactory as where some uninflamed textnre intervenes. It seems very questionable whether inflammation of lymphatic glands is ever benefited by leeching ; indeed, in some cases the evil is undoubtedly aggravated. In cases of chronic inflam- mation, less advantage is got by applying, at once and for all, any given large number of leeches, than by applying fewer leeches several times in succession at intervals of two or three days ; a method which (in aid of other necessary treatment) often seems particularly useful with chronic inflammations of the breast and testicle. Finally, in reference to the subject-matter of the present sec- tion, dry-cupping ought to be mentioned. By this procedure, and others which resemble it, we can effect temporary deriva- tions of blood, without at the same time depleting or counter- irritating our patient. And there may be cases for which this immixed derivatory treatment is more suitable than local bleeding or blistering. * The practice of opening a branch of the temporal artery, with a view to relieve inflammations of the eye, has probably now fallen into deserved disuse. TREATMENT. DEPLETION. 85 [iii. Since the publication of the first edition of this work it has been alleged by different practitioners that in certain cases of rn- flammation great results maybe obtained by directly impeding the afflux of blood to the part. Professor Campbell of New Orleans, who during the American civil war was consulting surgeon to the Georgia Hospital, Richmond, has published, as illustra- ting this law, several cases of gun-shot wound of an extremity; where accidentally, because of secondary hssmorrhage, he was obliged, during severe inflammation of the limb, to tie the main artery, and did so, not on Guthrie's plan of dipping into the wound, but on Hunter's plan, as though for aneurism ; and the Hunterian operation, he says, ' was chosen with the distinct end in view of combating and checking if possible the destructive progress, and in some the septic tendency of the inflammation. In all of these the pain, the swelling, and the turgescence were almost immediately relieved, and the most remarkable change was soon presented, as seen in the character of the discharges.' And he maintains ' that no hand, wrist, forearm, or elbow, no foot, ankle, leg, or knee, should ever be amputated for excessive or destructive inflammation — especially those cases resulting from traumatic causes, without resorting, whenever the state of the patient will admit of it, to a previous experimental ligation of the artery supplying the affected region.' Professor Vanzetti of Padaa, who advocates the treatment of aneurism by con- tinuous digital compression of the artery, has recommended the same method for controlling temporarily the afflux of blood to inflamed parts ; and the plan seems to have been followed with success in Paris, and on a large scale in Prague, as well as in his own hands. In England, for the same end, and with satis- factory results, Mr. Moore, of the Middlesex Hospital, in one case used compression, and Mr. Maunder, of the London Hospital, applied a ligature, to the artery,"^] (c) Depletory treatment includes the oldest and many of the most familiar antiphlogistic measures — blood-letting, purg- ing, vomiting, and starving. i. Blood-letting, almost beyond any curative agent, has had strange vicissitudes of repute ; sometimes judged to be the one * See New Sydenham Society's Biennial Retrospect of Medicine and Surgeiij for 1867-8, pp. 284 at seq. 86 INFLMIMATION. cure for inflammation, sometimes regarded as the deadliest aggravator of what is dangerous in the disease. Reasonable observers of this discord have beheved that it must be more ajDparent than real ; that the inflammation spoken of at one time as cured by bleeding cannot but be different from the inflamma- tion spoken of at another time as rendered fatal by bleeding. And especially Sir T. Watson (always as candid towards the opinions of others as he is enlightened and thoughful in his own) has strongly stated his belief that ' there are waves of time through which the sthenic and asthenic characters of disease j)revail in succession.' Probably this is the fact. But also it is cer- tain that differences of opinion as to the good or harm of bleeding in inflammation have not^ by any means exclusively, been diffe- rences between one time and another : for contemporaries, living under the same sky, and pi-actising in the same year on the same disease, have waged controversy on the subject ; and not infre- quently it has seemed probable that medical juries, inquestmg any given dead patient, would divide in equal numbers whether much bleeding or little bleeding had killed the man. ' Neither to exclude bleeding, nor to bleed in excess of the present neces- sity — so to bleed as to secure the advantages of the remedy and to avoid its disadvantages,' here, says Sir T. Watson, is ' the accredited practice and the precept of all teachers.' To estimate that ' present necessity ' is the art of the skilled practitioner, treating each case according to its own particular claims ; an art which cannot be learnt except at the bedside of the sick, and towards which, in the present place, only some general sugges- tions can be offered. It is scarcely needful to say that local nutritive changes are powerfully affected by loss of blood from the general circulation. Occasionally it happens, during some process of repair, that a large accidental haemorrhage occurs — as, for instance, from a stump which, having at first been sloughy, has cleansed itself and is healing by granulation at the time when its main artery gives way ; and in any such case we are able to observe how thoroughly the local action is arrested, how the granulations shrink, and how for some days (if the patient survive) the stump looks almost as though it did not belong to a living body. But because this kind of depletion can so suddenly stop the actions of repair, it does not therefore follow that it can with equal facility stop all that we wish to stop in any given inflammatory process ; or that blood-letting is an antiphlogistic in that uncon- TREATMENT. BLOOD -LETTING. 87 ditional sense which is implied in some arguments respecting it.* The notion, that ' if we could completely command the supply of blood to a part, the increased action might be effectu- ally controlled or arrested,' cannot even in speculation be ad- mitted without some reserve. The prudent practitioner will incline to remember John Hunter's terse statement of the meaning of all local determinations of blood — ' Action creates the necessity for support, and supplies it ; ' and regarding in- flammatory hyperasmia as but the symptom and legitimate consequence of an existing textural excitement, he will doubt as to the expediency of striking vdth much abruptness at the continuity of this natural dependence. For if the entire cir- culatory system could gradually be drained of its contents, would not the inflamed part of the body be the last of all to become bloodless? would it not to the last remain relatively congested? would it not be more prone than other parts to fall into gangrene from anaemia ? Practically, all impartial observers seem now to agree that, while on the one hand there are inflammations which bleeding can relieve, yet on the other hand there are inflammations which every act of depletion, instead of diminishing, will increase. And the obvious inference from this fact is one which certainly pathology would sanction, that the therapeutical value of blood-letting does not so much consist in its directly controlling inflammatory excitement, as in its controlling some condition which may or may not be concomitant. The condition which in this point of view deserves especial notice is that state of the circulatory system which (often spoken of by the name of * vascular tension ') is characterised by a hard pulse. It has already been suggested, as part of the arrange- ment by which an inflamed part is able to attract so much blood to itself, that, in proportion as arteries going to the focus of inflammation dilate themselves, collateral arteries become more or less constricted. When inflammation of any magni- tude occurs in strong and otherwise healthy subjects, this sym- pathetic phenomenon diffuses itself widely over the body ; the * 'Blood is the material by which the increased action of the part is main- tained. In the figurative language, which the obviously increased heat has suggested, we may say that it is the fuel by which the fire is kept up. If we could completely command the supply of blood, the increased action might be effectuallv controlled or arrested.' — Lawrence on Diseases of the Et/c, 1844, p. 182. 88 mFLAMMATIOTs^. arteries generally (in contrast with those of the inflamed part) getting, by contraction of their circular fibres, into a more or less rigid state of reduced calibre : a state dm-ing which the heart's action (being of not less than normal force) gives to the arterial pulse its morbid quality of hardness. This quality of hardness in the general arterial pulse is therefore, according to its different degrees, a standard for estimating the pressure which an inflamed part sustains from the heart's action, and the extent to which that pressure may be aggravating the local disorder. Further, it is a symptom which is directly controlled by bleeding, and which probably never has considerable deve- lopment except in cases where bleeding can be borne without injury. Generally speaking, then, it seems that any inflamma- tion accompanied by hardness of j)ulse is likely to be relieved by the abstraction of so much blood as shall remove this sign of vascular tension ; that bleeding (or some equivalent measure) becomes necessary in proportion as such an inflammation affects important organs or causes urgent distress ; ^ and that, em- ployed on these principles, as distinguished from that of attempting to exsanguinate and starve the inflamed part, blood-letting is an important resource in the treatment of severe inflammations. Always before having recourse to bleeding we must remem- ber that its eff'ects will be more than momentary. Blood cannot renew itself ofi'-hand ; and, while it remains scanty, all actions of repair are enfeebled. Therefore, in proportion as the patient's illness is likely to be protracted and exhaustive, the surgeon will be chary of bleeding for any inflammation which he can affect by less long-acting remedies. Especially he will hesitate to bleed for inflammations which depend on dyscrasial states, and, above all, for those which depend on the infection of mor- bid poisons. Nor of course will he lightly bleed for inflamma- tions, even though severe, if they be of comparatively unim- portant organs. Moreover, it is not conceivable that bleeding can ever be wanted where ulceration or gangrene is in progress. And the delirium of inflammatory fever is in itself no reason for bleeding. • The peculiarities of the pulmonaiy circulation render the lung, when its substance is inflamed, more apt than other organs to be embarrassed by fulness of the circulation ; and in cases of traumatic pleuro-pneumonia, a given amount of hardness of pulse may be rendered much more significant by the presence oi considerable dyspnoea. I TREATMENT. PUEGATIVES. STAEVATION. 89 ii. Purgatives are in tliis countrj very largely (perhaps some- what extravagantly) used in the treatment of surgical inflam- mations. Proportionately to the fluid discharges occasioned by them, they act, like blood-letting, in relief of vascular ten- sion; and often perhaps all the more so, because, besides reducing the volume of the circidation, they may act (for instance, with regard to encephalitis) in a somewhat counter- irritant and derivative way. But this is not the total of their antiphlogistic action. For, since the purged bowels discharge albumen as well as water, the blood is to some extent impove- rished by purging. And further, since the intestinal surface is a great emunctory for some effete matters, purging (as will pre- sently again be mentioned) has an important place among febrifuge remedies. It is not at present possible to assign a relative value to these different elements in the antiphlogistic action of purgative medicines ; but provisionally we know that purging, in its compound influence, is effective against many inflammations. A sufficient dose of some mercurial, followed after some six hours or more by our old-fashioned ' black dose,' is a convenient way of getting an antiphlogistic result. And in cases where almost continuous bowel-action is desirable (as, for instance, often in cases of encephalitis after injury) this kind of proceeding may be repeated on many successive or alternate days. In the few instances where sudden drastic purging is desired, croton oil (which needs not exclude mercury) may be had recourse to. And there are other cases, though probably not where purging is meant for a depletive remedy, where the patient requires more cordial treatment, and the compound tincture of rhubarb is eligible. iii. With respect to starvation as a part of depletive treat- ment, but little needs be said. Active depletion on the one hand, and supply of nourishment on the other, are influences in mutual opposition ; and, in proportion as depletive measures are thought necessary, food must for the time be thought super- fluous. And thus in all grave cases of inflammation the patient instinctively settles the thing for himself : incapable of taking a morsel of food, at any time when he is pi'operly being bled ; and, at the utmost, not capable of hunger at any time when he is properly being depleted by purging. Therefore in this respect the surgeon has little more to do than to warn the patient's friends against injudiciously pressing him to take 90 INFLAJMMATTON. food. In cases where the fullest effects of depletion are desired, there is no reason why tlie patient's drink should exceed the innutritiveness of pure water. iv. The antiphlogistic action of certain emetic and nauseant drugs appears in part very much to resemble the action of blood-letting. Under the action of full doses of antimony, for instance, the pulse, till vomiting occurs, becomes progressively quicker and feebler, till sometimes it is scarcely perceptible ; it then almost instantly changes its character, becoming fuller and much less rapid, but retaining a marked quality of soft- ness ; and during this state, in which any pre-existing vascular tension is for the time effectually removed, there is greatly increased action of the skin, increased secretion of urine, and increased discharge from the bowels."^ If the inflammation with which we are dealing is one on a very small scale but with very marked painfuhiess (as, for instance, that which occasions common ear-ache), we find that it is now, perhaps permanently, relieved ; that in the great vascular relaxation which has taken place, the little local hypersemia has ceased to exist. And in more considerable inflammations, the relief, if less complete, is often not less striking. Moreover, by renewed small doses of the drug (which now probably will not produce vomitmg) the relaxed state of the arterial system can be main- tained, and inflamed parts can thus be continuously kept with all the advantages of lessened vascular tension. Besides these advantages relative to the distribution of blood, there probably are other ways in which antimony serves to reduce acute inflammation, and some of these will hereafter be referred to. The student who wishes fully to appreciate what can be done by this method of treatment should observe it in medical as well as in surgical cases ; and perhaps especially he should observe it in cases of pneumonia, since it was here that fifty years ago the Italian contro-stimolanti first established its great antiphlogistic virtues. But many ordinary surgical cases will sufiice 10 show him its power ; severe cases of acute orchitis, for instance, where the symptoms commonly yield with great rapidity to moderate antimonial treatment. Antimony, like bleeding, is distinctively applicable to such inflammations as are Comp. Ackermann, quoted by Clarus in Heilmittellehre. TEBEirUGE TREATMENT. 91 acute, commencing, accompanied with vascular tension, and occurring in unenfeebled subjects. Some of the properties of antimony are equally possessed by ipecacuan, and at the onset of many inflammations, especially when we are dealing with children, an emetic of ipecacuan is often a very convenient way of making a general impression on the vascular system. But as regards any ulterior use of the drug, there is no evidence that ipecacuan possesses the anti- plilogistic powers of antimony ; while on the other hand it has this disadvantage, that after-doses are less easily borne without producing renewed vomiting. (d) Although inflammatory fever be but a symptom and con- sequence of the local disease, it does not therefore follow that the blood is entirely passive in the process. For the blood, not less than the tissues, contains declming material ; and we may well conceive it to be the case that this material or some part G^ it gets infected by the inflaming tissue, or gets thrown into change by the greater heat of its menstruum, and, if so, con- tributes, both in respect of temperature and in respect of excretable products, to the signs of general febrility. If this be the case, the inflammatory fever would be capable of re-acting injuriously on the inflamed part, and would on this account require treatment. But, even it be not the case, there are other reasonable grounds for believing that febeifuge treat- ment may be serviceable ; since probably the circulating blood, in proportion as its febrile temperature is reduced and its effete ingredients are eliminated, becomes more and more capable of contributmg (by equalisation of effect) to reduce the local heat and to absorb the waste-products of inflammation. As regards our known means of febrifuge treatment, it must first be noticed that all dejjletive oneasures tend to reduce the temperature of the blood. During inanition, there is a progres- sive lowering of temperature ; and it is by means of this cooling (as Chossat's classical experiments have shown) that starvation at last produces unconsciousness and death. Marshall Hall's researches on the effects of blood-letting have shown that, during slow exsanguination of the body there is the same decline of temperature. i. To some extent the temperature of the blood can be reduced by other than depletive treatment. Digitalis, for 92 INFLAMMATION. instance, under many conditions of disease, will, by lowering the pulse, reduce the heat of the body ; but it seems certain * that where active inflammation exists, the pulse-retarding action of digitalis is by no means easily or uniformly obtained ; and the use of the drug in large doses requires so much watch- fulness that, under this limitation, little recourse can be had to it. ii. Efitectually and universally the temperature of the blood can be reduced by exposing the surface of the body to cold air or cold water. The former influence is made useful in cases of febrility, when we order the sick-room to be kept cool, and the patient (unless we are treating him with diaphoretics) to be but sHghtly covered with clothing. The latter influence is available in the form of baths or afl'usions ; respecting the febrifuge value of which in surgical practice, it is hitherto, from the absence of sufficient data, not possible to speak with confidence. It is of course evident that, with many surgical fevers, there would be local conditions which might render it practically impossible (even if, on other grounds, it were desirable) to immerse the patient in a bath, or to afiuse his entire body with water. But the student, while mindful of this probable restriction in respect of surgical cases, ought to be informed of the very decided febrifuge powers which, abstractedly speaking, belong to the method of treatment. Especially it deserves notice that pro- longed immersion in water which commonly would not be called cold, even in water as warm as 95° F., may be made the means of reducing febrile temperature. f iii. A remaining important object of febrifuge treatment is, as * See Clarus's JleilmitteUchre, edit. 1800, pp. 507, 603. And compare Spiel- mann,Z)es Modijicatiotis de la Temperature animale dans les Maladies fehr ties ait/iies et chroniqties. Strasburg, 1856. t Tliis is well shown in one of the cases which Dr. Armitage (in his instruc- tive little volume on Hydropathy in Acute Disease) describes as having been treated by him under Professor Traube in the CharittS Hospital of Berlin. A female typhus-patient, having a temperature of 105° F., being put into a bath at 95° F., and kept in it for fifty-seven minutes, lest during this time nearly 2° F. of temperature. So many writings on the present suliject have come from inexpert persons and quacks, that it is satisfactory to be able to refer to Dr. Armitage's observations as to those of an accomplished and accurate physician. The wet-sheet packing of the German water-curers, in the form in which they recommend it during febrile conditions of the system, appears to act a5 a cool bath. TEEATMENT. INCISIONS. 93 far as possible, to promote the due excretion of those waste- products which in part probably arise within the febrile blood, and in part accrue to it from the disorganisation of the inflamed textuies. The tendency of these products, as they become eliminable, is chiefly to the intestinal canal and to the kidneys, and their final discharge from the body can be assisted in the one direction by laxative medicines (which need not be of the more depletive kind) and in the other direction by diluent drinks. That more latent part of the eliminative process which is prior to the act of excretion can also, it apj^ears, be aided by treat- ment : water, which the febrile patient so thirsts for, is itself an effectual mover of those chemical changes which eventuate in excretion ; and alkalies, which from time immemorial have en- joyed a febrifuge reputation, are, in the same respect, perhaps the most useful adjuncts which the pharmacopoeia can supply. The unlimited allowance of soda-water or potash-water is a method of treatment which the febrile patient commonly finds in the highest degree agreeable, and which probably does as much as can usefully be done to facilitate the chemical clearing of his blood. In some cases of inflammatory fever — perhaps especially in cases of erysipelas — it seems that ammonia has particular advantages, as it is said also to have in the treatment of eruptive fevers. It may be given either alone or together with the fixed alkalies.'^ Both mercury and antimony belong to the class of medicines which simultaneously increase several discharges from the body, and which (it is hence j)resumed) promote declensive change in the blood and tissues. They too, in small repeated doses, are often used to fulfil a mere febrifuge intention ; but unless there be special reasons for employing drugs which also are depletive and depressing, they probably, for the present j)urpose, are not preferable to alkalies. (e) The cases are but few where an inflaaiedi^art, not contain- ing pus or sloughs, is cut into for the mere relief of vascular tension. In case of severe purulent ophthalmia it used to be deemed good to incise the swollen conjunctiva ; f and in some * See Mr. Witt's interesting pamphlet on the Use of Ammonia in Scarlet- fever. t See Tyrrell on the Treatment of Acute Purulent Ophthalmia, Med.-CMr. Transact, vol. xxi. 94 mrLAlMMATION. cases of throat-inflammation, it was advised to scarify the surface of the tonsils and soft palate ; but these expedients are of very doubtful advantage. If inflammation of the skin and subcutaneous texture be diffusing itself -widely and rapidly from a first focus of intenser action, where still the inflammation runs high, here, even though as yet there be no pus or slough, a free incision of the most inflamed pai-t often seems to relieve the remainder, and perhaps sometimes averts what otherwise would be a considerable destruction of tissue. Pressure, which often has been recommended, and often very injuriousl}" tried in the treatment of sundry acute inflammations, is probably now used only in one such case — namely, in that of orchitis ; where perhaps it may be, that the quantity of serous effusion which the tunica vaginaKs contains renders surgical pressure more tolerable, because more uniform, than we can elsewhere render it. In common cases of gonorrhoeal orchitis, a patient who cannot or will not keep his bed may move about with comparative impunity (especially when a first good im- pression has been made by other treatment) if the swelling be firmly and quite evenly compressed by an application of adhesive strapping. In chronic inflammations, treatment by pressure is more extensively applicable : not only in those where (as in chronic ulcers of the lower extremity) it antagonises the mechanical causes of the complaint ; but likewise in others (such as chronic inflammation of lymph-glands, and most especially chronic inflammation of the breast) in which the disease is not mechanically caused. In the latter class of cases pressure exerts considei'able influence in procuring the removal of morbid tumefaction : an influence which doubtless is not exclusively due to its power of relieving the blood-vessels. (/) Tliere are certain cases of inflammation — cases which at present do not admit of being well explained, where, irrespect- ively of any known cause, the process goes on by a sort of local habit, as though the morbid action of to-day were a cause for the morbid action of to-morrow. And, with reference to many of such cases, we practically know that to interrupt the process is to cure it. The slight chronic inflammation which occasions ordinary hydrocele of the tunica vaginalis is without known cause, and resists common measures of treatment: the sac may be tapped a hundred times, and a hundred times it will fill again ; but let the tapping on any occasion be combined with such an TREATMENT. DISINFECTANTS. 95 injection of iodine as shall cause an access of acute (non-suppur- ative) inflammation, and it will generally be found, on the subsi- dence of this attack, that the hydrocele is permanently cured. In analogous affections of synovial membranes, the same principle of treatment is successfully acted on ; and even more strikingly in some cases of irritable ulceration, we find the great advantage of thus ' changing the action of the part.' Years ago, when beginning surgical practice, I saw this fact illustrated in a way which many times since it has been useful to me to remember. A young man, of generally weak health, had all one side of his neck affected with very painful ulceration — not deep, but extensive and irregularly spreading ; during some months all sorts of tonic and contra-scrofulous treatment had been unsuccessfully tried, and latterly, on account of the patient's continued suffering and broken rest, it had been requisite to give opium freely ; when at last, after so much fruitless treatment, it occurred to me that perhaps caustic might do good, and the whole large irregularly ulcerated area was in consequence carefully sponged over with a strong solution of nitrate of silver ; from which moment (so soon as the smart of the operation had passed away) no more pain was experienced, ulceration was entirely at an end, and without further treatment the surface forthwith proceeded, like any common healing sore, to complete and permanent cicatri- sation. If due care be taken to discriminate cases to which this principle of treatment may properly be applied, results not less striking than that just quoted may often be seen to follow its adoption : for instance, the most painful paronychial ulceration may often be cured, as though with a specific, if the strong iodine-paint be once thoroughly applied to its surface. (g) Where the inflamed part is the seat of a putrefactive process (as, of course, is the case wherever gangrene is present) the use of chlorinous ivashes — or, perhaps better, where practic- able, the abundant application of powdered vegetable charcoal — is to be recommended ; and this, not only for deodorising-purposes, but also with a view to reduce as far as possible the entrance of putrid matter into the patient's circulation. Where this putrid infection is occurring (and probably its occurrence in connection with inflammation is not altogether confined to cases where there is gangrene in mass), the resulting diarrhoea seems specifically controllable by kreosote, internally given. 96 INFLAMMATION. (/() In treating particular cases of inflammation it often becomes of g-reat importance to prevent those evils which may accrue, as it were secondarily from the process : evils, that is to say, which depend on products and results of inflammation. i. Look, for instance, at this common case : a patient has some, perhaps inconsiderable, lumbo-vertebral disease, which occasions an abscess to form in front of his spine ; this abscess having- no ready outward way to empty itself, goes on from day to day slowly getting larger by addition to its contents, extends within the sheath of the psoas muscle on one side, or perhaps on both sides, of the body, and occupies more and more space till presently it reaches the inner side of the thigh ; still restrained by fasciae which it can only slowly traverse, it grows larger and tighter within the belly, and branches in whatever direction offers least impediment to its increase ; so that the patient, whose primary disease affected perhaps not a cubic inch of bone, has got, as a secondary result, an abscess reaching from loins almost to mid-thigh ; and when at length this abscess bursts or is opened, there at once begins over the whole wall of its enormous cavity a greatly-excited process of suppuration, under which the patient rapidly becomes hectic, and oftener dies than recovers. There are evident anatomical reasons why, in the case described, the surgeon can do comparatively little to prevent the dangerous accumulation ; but in innumerable other cases, where similar secondary mischief tends to arise, it is almost entirely under control. For, except where pus is out of reach because of im- portant intervening viscera, an incision can at once render accumulation impossible ; and it is one of the most imperative rules of sound surgery, never to let any reachable abscess enlarge for want of this simple proceeding. Especially this rule claims to be well recognised in the management of arti- cular inflammations. For there was an old surgical super- stition, that, because wounds of healthy joints are dangerous accidents, therefore abscesses of joints must be specially danger- ous to open ; and even now sometimes a surgeon can be found, who, with this stupid fear, will let the pus of an articular abscess increase and spread till it disorganises a limb, rather than use his knife to give it a timely escape. ii. With respect to the removal of parts which inflammation has killed, or rendered unpreservable, only a few general TEEATMENT. OPEEATIONS. 97 remarks are here necessary. Dead soft parts are dealt with by nature so inimitably well, that the surgeon during this natural process has, as a rule, nothing further to do, than to take pre- cautions (already adverted to) against putrid infection, and to see that subcutaneous or deeper sloughs are not retained or made noxious by the want of sufficient outward opening. With dead bone the case is different : for though the living bone becomes discontinuous from the dead, as completely as any living soft part from its slough, yet the bony sequestrum, some- times held by overlying textures, sometimes locked within its capsule or cylinder of callus, almost invariably requires surgical assistance for its removal. And this assistance has to be given with due regard to two considerations : first, that it cannot be effectual till the natural discontinuation is complete— a period which varies from less than three weeks in the case of small superficial sequestra, to perhaps more than two months where the entire thickness of a shaft has to divide itself across ; and secondly, that, when this period has arrived, the sequestrum (since it is a continuing cause of inflammation) ought without delay to be removed. Also, when an inflamed extremity becomes in its whole thick - ness gangrenous, bone and soft parts together, surgery must in most instances be the agent of its separation ; and here, even more than in the last-mentioned case, the moment for surgical interference requires to be judiciously chosen. In reference to this choice, the only general principle which can here be stated (and it is one which transfers the discussion to future pages of the present work) is, that, in order to amputate with success for gangrene resulting from inflammation, we must wait till the inflammation have ceased to be a spreading process — wait, till nothing more of it be left than that which the gangrenous tissues maintain in their own immediate vicinity. Indeed, not only where inflammation is gangrenous,, but commonly with the results of local injury or disease, in proportion as advancing inflammation and inflammatory fever are present, amputation is likely to bring worse evils than it can remove. And with every inflammation which suggests a necessity to amputate, the same principle applies as that which is recognised with inflam- matory gangrenes : to wait till nature have arrested the pro- cess, and have circumscribed its results by her own line of demarcation. VOL. I. H 98 INFLAMIMATION. Long-continued exliaustive suppuration, and perhaps in some very few eases the mere pain and irritativeness of an intractable chronic inflammation, are other conditions which (for instance, where joints are affected) may oblige the surgeon to excise or amputate. But the rules which are appropriate to these cases, as well as the rules which relate to the treatment of parts ren- dered useless and inconvenient by inflammation, are of too special a kind to be considered in the present essay. (i) The j;af/i of inflamed 'parts is very often sufficiently con- siderable to require that special means slionld he taJcen for its relief. And often under such circumstances, unless in the indi- vidual case there be reasons against it, opium, or other like treatment, must be had recourse to. But before concluding that this is necessary (especially where severe pain outlasts or outmeasures the apparent intensity of an inflammation) the sur- geon will carefully consider whether, instead of thus palliating the patient's pain, he cannot in other ways more effectually remove it. Some of the worst pains depend on the presence of pus : a patient, who perhaps for years has been racked with pain in one or other end of his tibia to an extent that no nar- cotics could render tolerable, is instantly and permanently relieved by the trephine, which lets out, it may be, not a tea- spoonful of confined pus from within the bone ; and in innume- rable suppurations of soft jjarts (breasts, joints, tonsils, lymph- glands, even cellular membrane) all which is severest in the pain depends upon the pressure of pus, and may be ended with the stroke of a bistoury. Other extreme pains have other removable causes : the j^ain of simple subarticular caries, so severe while the joint is let move, becomes tolerable under the proper use of the splint ; and in the frequent case where sub- articular caries is kept up by the constant irritation of some small sequestrum of bone, its teiTible pain will cease if this sequestrum be withdrawn. And there are other cases where some atrocious pain, together with the inflammation which it characterises, can be treated (as our next section will show) by drugs more effectual than opium. Inflammatory pain is often relieved by the moist warmth of poultices and fomentations. The diffuse derivative action thus exerted is, no doubt, often the immediate cause of the relief. In some cases, especially in those of superficial phlegmonoid inflammation, the relaxative influence which moist warmth exerts TEEATMENT. SPECIFICS. 99 on tlie contractile tissue of the skin may liave more to do with the results. Poultices and fomentations at higher degrees of temperature — indeed as hot as the patient can bear them — are used by some practitioners in order to accelerate the formation and discharge of pus. And there can be no doubt that the stimulus of heat thus applied may produce the proposed effects — may quicken the actions which give pus, and may expedite the ulcerative changes which allow an abscess to empty itself. But in both respects the method of treatment is objectionable : for, on the one hand, if pus have not formed, its formation ought, if possible, to be prevented ; and, on the other hand, if pus have formed, the course is infinitely better that at once we discharge it by incision, than that, during the slow action of poultices, we allow the abscess painfully to become j)erhaps many times larerer than it needs have been.* (k) There are kinds of inflammation which have their specijic antidotes. The periostitis and rupial phagedsena of tertiary sy]_>hilis cease when iodide of potassium begins to act. The paroxysm of gout is relieved by colchicum. Many chronic skin- inflammations are more or less amenable to arsenic. Others are tractable by pitch. Sometimes a fibrous inflammation (perhaps especially sclero-iritis) will abruptly yield to a few doses of turpentine. Mercurial inflammation of the mouth is cured by chlorate of potash. For some chronic rheumatisms sulphur seems to be a cure. The inflammations of secondary syphilis are subdued by mercury. Occasionally, but not often, an inflammation called scrofulous will suddenly hegiu to go when cod-liver oil is given. To some cases of inflammation, alcoholic stimulants are a benefit; to others, the tonic influence of quinine. Malarious neuralgia (but how far this is inflammatory may be questioned) is stopped by the drugs which cure common ague. And other cases, more or less satisfactory, might be adduced to the same general effect. It would be impossible here to discuss at any length, either the circumstances under which these several specific agencies * It is a venerable practice which the writer ventures to condemn. More than two thousand years agfo, Aristotle seems to have been puzzled by the therapeutics of poulticing. Why is it (he asks) that one man ripens inflamma- tion with heat, while another man resolves it with cold ? Sui ri rdf avrd^ tpXtyfiaaiaQ oi fxkv i^j^oirtt; v-^ia(,ovatient died suddenly during the night from severe hEemorrhage, which had recurred after an interval of fourteen days. On examination after death, a carious piece of bone was found on the front surface of the body of the atlas. In the cellular tissue, between the tonsil and parotid gland and about the branches of the carotid artery, there was a cavity, the size of a hen's egg, filled with bloody coagulum. The immediate source of the ha3morrhage was still uncertain. There were two small openings through the wall of the abscess into the mouth. The formation of abscesses may occuj)y either a few days or several months ; and we are justified in applying to the former the term ' acute,' and the latter ' chronic ;' but we must re- member that between these two the ' shades are infinite.' The following is a good illustration of a chronic abscess : 'A healthy- looking girl, aged nineteen, experienced sharp, darting pains in the left buttock eight months previously. She soon after noticed a swelling, which has gradually increased up to the present time. When quite quiet she is easy, when she walks she limps, and feels pain. The integuments, loose and healthy, cover a tumour the size of the closed fist, hard and aj)parently bony, but with one softer point, attached to the left ilium near the sacro- iliac symphysis. There is no preternatural heat, nor is the part l^amful when examined. The girl has once experienced diffi- culty in making water.' She was ordered generous diet and quiidne, and rested in bed, poultices being applied from time to time. In the course of a month one part became more promi- nent and fluctuating ; and in the course of a few days a large collection of fluid was detected. The patient went to the sea- side, where shortly afterwards the abscess gave way and dis- charged itself. The last accounts of the girl were that she was convalescent. The interesting point in the case is the length of time which elapsed between the first symptoms and the clear manifestation of the disease. The term ahces froid, cold abscess, is applied to such a case as the following : A man, set. 65, while nursing his Avife, who was dying of a lingering disease, fell from a chair, overj)owered with sleep, three weeks previously. He was admitted into St. SUPPUEATION IN THE HAND. 135 Bartliolomew's Hospital, April 7, 1857, witlialarge abscess, un- attended with, heat, redness, or pain, situated in the right thigh. An opening was made by Sir W. Lawrence, and three quarts by •measurement of thick purulent fluid were evacuated. The open- ing was then closed, and the case ultimately did well. Such abscesses may form in any part or tissue of the body. They may be small or large ; the cyst thick or thin. They may slowly come to the surface, or remain stationary for years. The cyst may be so full as to present a tumour of incompressible hard- ness ; or it may be thick-walled, and contain only a moderate amount of fluid. In the latter case it may, ujjon examination, convey to the fingers the sensation of a sharp rim of bone with a depressed centre, such as is common in cases of extravasation of blood under the scalp. Mr. Erichsen attended with Dr. Boott a gentleman who had a large abscess in the iliac fossa, which bad been perfectly stationary for nearly two years. ' In the cancellous tissue of bone,' observes the same surgeon, ' ab- scesses may exist for an indefinite period, unless opened by surgical operation.' To Sir B. Brodie is due the merit of first directing the attention of the profession to the last class of eases, and of pointing out how relief is to be obtained from pain by the timely use of the trephine, as well as how the extension of the disease towards a neighbouring joint is arrested by the evacuation of the cyst [vide ' Diseases op Bone '). Inflammation and suppuration of the hand scarcely comes under the strict definition of an ' abscess.' The same remark applies to suppuration within the tliecse of tendons. In both these instances we commonly have an absence of that distinct cyst which gives to an abscess its distinguishing characteristic".. Yet we should not pass over in silence so important a disease, which, as it occurs for the most part from accident in the vigorous and healthy, requires some peculiarity in treatment. Acute inflammation of the hand may supervene, on a comparatively trifling injury, such as a wound with a small splinter of wood, or a scratch with a piece of bone. In the course of a few days the hand and forearm become red, swelled, and tense, the former being by comparison twice the thickness of the normal member. Abscesses may form both on the back and palm of the hand ; or suppuration may ensvie in the thecse of the ten- dons, and spread under the annular ligament among the muscles of the forearm. The hand is heavy ; the fingers stiff" and semi- flexed ; the patient is deprived of rest, and has no appetite ; the 136 ABSCESS. tongue is furred, and tlie pulse of the affected side beats with twice the fulness and force of that on the opposite. If the disease be not checked, the tendons slough, or become contracted ; the muscles get glued together ; portions of the phalanges may die and exfoliate; and the patient, after months of suffering, recovers with a useless limb. From considerable experience in the treatment of these accidents, I should say that the abstraction of blood from the inflamed limb most effectually relieves the engorgement of the blood-vessels. The pain, previously ex- cruciating, becomes more supportable ; while the parts are soon ready to resume their normal state. In the class of cases here alluded to Ave have not so often to deal with an enfeebled constitution. The attack is of purely local origin, and is j)roportionately sharp and severe. It is surprising how small an amount of disease, in this part of the body, will excite almost insupportable suffering. During the month of October 1859, a woman who had had suppuration at the end of the last phalanx of the forefinger, came to St. Bartholomew's Hospital. For several days and nights she had been ceaselessly racked with pain, which nothing except large doses of mor- phine could alleviate. In more violent forms the inflammation may spread to the wrist-joint, when death of the carpal bones ensues, and the movements of the hand become permanently impaired. Suppuration along the thecse will be followed by contraction of one or more of the fingers from adhesion of the tendons to the sheath. A proposition has emanated from the American School of Surgery, to treat cases such as indicate a liability to extensive or even destructive inflammation by the operation termed the ' Hunterian ligation of arteries ' — namely, by putting a ligature on the main arteiy of the limb between the diseased part and the heart. Dr. Henry F. Campbell, Professor of Anatomy in the New Orleans School of Medicine, and Consulting Surgeon to the Georgia Hosj)itals durmg the late war, says that in such cases experience very early in the war taught that the risk of haemorrhage by the recurrent circulation was not to be weighed against the great advantage of curing, or at least controUing, the inflammation — indeed, saving the limb and life by the liga- tion of the main arterial trunk which supported this inflamma- tion. Although the trials of this operation were first made in cases of gunshot injury, yet Dr. Campbell raises the question whether the principle be not one of much wider extension and CAEBOLIC ACID TEEATMENT. 137 adaptation. He affirms that no liand, wrist, forearm or elbow, no foot, ankle, leg, or knee, should ever be amputated for excessive or destructive inflammation, especially those cases resulting from traumatic causes, without the surgeon first resort- ing, whenever the state of the patient will admit of it, to a previous experimental ligation of the artery supplying the affected region. The simpler method proposed by Vanzetti in 1867^ and by i^elaton f of treating cases of severe inflamma- tions by digital compression of the main artery, merits yet stricter investigation. Both surgeons have reported favour- able cases, especially the former, who noticed marked local and general improvement after twenty-four hours compression. Neu- dorfer J warmly recommends the practice as moreover diminish- ing in many cases the very copious secretions. Mr. Moore, of the Middlesex Hospital, has successfully treated a case by an acupressm-e; and Mr. Mamider, in a letter to the British Medical Journal, 1868, speaks as follows : — ' Twelve months ago I pro- posed the applicationof a ligature to the superficial femoral artery to check acute inflammation of the limb following wound of the knee-joint. The operation was performed with immediate and continuous benefit, and the patient recovered. I need scarcely say that at that time I believed the suggestion to be original, and have only now been undeceived by the perusal of a short paper upon the subject in the American Journal of Medical Science of April, 1868. It thus appears that the femoral artery was ligatured first, for wound of the knee-joint, by H. U.Onder- donk, M.D., in the year 1813, and occasionally since that date also in America.' Mr. Lister, who is a great advocate for the exclusion of air from the cavity of an abscess, and of guarding against the absorption of septic material, employs carbolic or phenic acid — a volatile organic compound which, he says, aj)pears to exercise a peculiarly destructive influence upon low forms of life, and hence is a most powerful antiseptic. He states that the results of his treatment in the case of abscesses have been extremely satis- factory, and in beautiful harmony with the principle indicated. The pyogenic membrane, like the granulations of a sore, form pus, not from any inherent disposition to do so, but only because it is subjected to some preternatural stimulation. In an ordinary Gaz. des Hop. 18G7, p. 54o. t Ibid. p. 114. \ ISeudorfer, Lancet, Dec. 7, 1807. 138 ABSCESS. abscess the stimulus wliich maintains the suppuration is derived from the presence of pent-up pus. When a free opening is made in the ordinary way this stimulus is got rid of; but the atmo- sphere gaining access to its contents, the potent stimulus of decomjDOsition comes into operation, and pus is generated in greater abundance than before. When, however, the evacuation is effected on the antiseptic principle, the pyogenic membrane, freed fi-om the influence of the former stimulus without the sub- stitution of a new one, ceases to suppurate, and furnishing only a triflmg amount of clear serum, rapidly contracts and coalesces ; at the same time the usual constitutional symj)toms are got rid of without the slightest risk of irritative fever or hectic. In the unopened abscess there are no septic organisms, except in very rare cases. All therefore that is requisite is to guard against the introduction of living atmosj)heric germs, at the time that free opportunity is afforded for the escape of dis- charge within. A piece of rag, dipped in a solution of carbolic acid and oil, serves as an antiseptic curtain, under cover of which the abscess is evacuated by free incision. Over this is laid the antiseptic jDaste,* to guard against decomposition occurring in the stream of jjus that flows out beneath it ; the dressings are changed daily till the sinus has closed. It is premature to speak decisively either as to the truth of the theory on which this j^lan of treatment depends, or on the success which may follow it. On various methods of opening an abscess. The employment of small knives, not unlike those used for the subcutaneous di\asion of tendons, has been strongly recommended by some surgeons for the purpose of opening abscesses. It has been urged that a minute aperture relieves tension, and allows the escape of the matter as satisfactorily as a larger one. The plan has been recommended in cases of suppuration in the thecse of tendons, of psoas or lumbar abscess, of mammary abscess. See. I am not in favour of the proceeding, regarding it as generally insufficient. In some cases, where it is desirable to secure the complete evacuation of the cyst, a trochar and canula may be employed ; but this measure does not offer any advantages over the common incision, Avhile the canula is apt to become clogged * The antiseptic paste is made of common -whiting (carbonate of lime), mixed -with a solution of one part of carbonic acid in four parts of boiled linseed oil, so as to form a firm putty. OPENING ABSCESSES. 139 by some of the thick matter which is often found floating in the midst of the pus. It received the sanction, however, of the late Mr. Vincent. If it were very desirable to evacuate the contents of a large abscess without admitting air into the cyst, the surgeon might accomplish his purpose with * Thompson's trochar,'^ which provides for the escape of the pus through an elastic tube fitted to the under part of the canula. It is an error, however, to suppose that the admixture of air with the pus is the great danger to be apprehended, or that exploring needles and small canulas may be used with impunity in all cases. Many large abscesses, freely opened, continue to discharge healthy matter for many weeks ; while the introduction of a small needle has been followed by inflammation of the cyst of the abscess, and general constitutional disturbance. In opening chronic ab- scesses, a valvular incision is recommended. This may be eflected either by passing the knife obliquely, or by drawing the skin in such a way that when it resumes its normal station the opening made through it does not correspond with the opening in the cyst. To such a proceeding there can be no objection, especially when it is wished, as in cases of lumbar abscess, to let out some of the matter, and then to close the opening with adhesive plaster. A method recommended and practised by some surgeons, namely, to pass a long narrow knife through the skin at a little distance from the abscess, and then under the skin into the sac, so that the pus may pass througli a subcutaneous canal that shall be perfectly valvular and ex- clude the air, finds favour in modern works. The proceeding is harmless, provided there be a sutiicient aperture for the escape of the pus ; but I am not aware that it possesses any real ad- vantages over the usual method. The destruction of a portion of the skin with caustics, such as potassa fusa, or potassa cum calce, is generally objectionable, inasmuch as it inflicts on the patient needless pain without any corresponding advantage. The part is first covered with a piece of adhesive plaster, which has a portion cut out exactly of the same figure and size as the opening intended to be made in the abscess. The best way of making the eschar is to moisten the surface, and to rub the caustic on the part till the skin becomes brown. The active sub- stance is then to be immediately washed off with some wet tow, the plaster is to be removed, and an emollient poultice applied. * Invented by Mr. Thompson, Surgeon, of "Westerham. 140 ABSCESS. The practice of opening an abscess by a seton needle, and of leaving in the silk, that the matter may drain away, is in every respect objectionable ; the opening is of necessity small, and the presence of a foreign body dangerous. And the latter objection holds good with regard to the drainage-tubes recommended by M. Chassaignac, and now so universally popular. If a proper opening be made, there can be rarely any occasion for a drain- age-tube; and however carefully it is inserted, it must of ne- cessity inconvenience and distress the patient. I have tried this plan, and seen it tried, in cases of empyema. The irritation excited was considerable, and the pus did not always flow out through the tube. Injections of bromine or iodine have been employed with ad- vantage in cases of chronic abscess ; they seem to check the secretion of pus by changing the action of the vessels on the cyst-wall. Inflammation is not a necessary result. The abscess should not be complicated with any deep-seated source of irri- tation, such as disease of the bone. The strength of the in- jection is usually one part of the tincture to seven or five of water. I think, however, that the practice, once much extolled, has become very limited ; those cases being best suited for it w^hich do very well when treated on the usual plan. The odour of pus may be so faint as to be scarcely perceptible, or foetid in the highest degree. The foetid odour may continue after the opening of the abscess, or cease in the course of a day or two. In other instances the pus seems to undergo a process of decomposition, and to acquire a foetid smell from exposure to air. With these different points the surgeon should be ac- quainted, that he may employ such remedies as the charcoal poultice, chloride of lime, Condy's fluid, carbolic acid, &c., to correct the effects on the atmosphere which the patient must of necessity breathe. HOLMES COOTE. SINUS AND FISTULA. FISTULA and Sinus, terms of nearly similar meaning, are tlie surgical names of (1) long, narrow, suppurating canals {e.g. fistula in ano, mammary sinus, &c.) ; (2) canals giving unnatural exit to secretions {e.g. gastric fistula, biliary fistula) ; and (3) unnatural apertures of communication between mucous canals or cavities {e.g. vesico-vaginal fistula). If a dis- tinction is to be made between tlie terms, fistula should be applied to the second and third of the above-named three forms of disease, and to those examples of the first form in which the suppurating canal has two openings ; and si7ius should be applied exclusively to those of the first form in which the canal has but one opening. In these meanings the two names will be here used, although the diseases to which they are applied have so many things in common that it is advisable to consider them under one headino-. If we except the fistula?, or fistulous openings, that are formed by direct communication of two closely-adjacent canals, as the vesico-vaginal, or the vagino-rectal, the most general characters of fistula) and sinuses are, that they are canals of much less width than length, lined with ill-formed granulations, dis- charging a diseased purulent fluid. The canal may be of equal width throughout, as in many perineal and anal fistula) ; or, being narrow at one end, it may at the other dilate into a large cavity, as in many cases of sinus in the breast or the subcuta- neous tissue. No general account can be given of the length, or direction, or branchings of such canals ; in all these respects there are multiform varieties. So, of their number in any part : one is more common than two or more ; but ten, or perhaps more, may exist, as in the worst cases of urinary fistula). In structure, the walls of fistula) and sinuses differ according to their duration and many other circumstances. When they have existed long, e.g. for one or more years, and are not 142 SINUS AND FISTULA. inflamed, the walls are commonly hard, ' callous,' not highly sensitive or easily bleeding-, and formed of condensed connec- tive tissue, inseparable from the adjacent structures. In the more recent states, the walls are soft, like ordinary layers of recent granulations, sensitive, readily bleeding, and easily broken through. In disea,sed states, they may be, as the sur- faces of ulcers may be, inflamed, spongy or cedematous, exqui- sitely sensitive, or sloughing. In correspondence with these differences in the obvious characters of the walls of fistulse and sinuses, the granulations lining them are various. In old cases, they are dense and firm, smooth on their free surface, with scarcely a trace of granular or papillary arrangement. In recent cases they are often coarsely granular, dusky, and soft. In all cases, they are unhealthy, having little or none of that tendency to mutual union, or the development of cuticle, which belongs to the typical granulations of healing wounds and ulcers. And this unhealthiness may be traced in their minute structure ; for, of the granulation-cells, few show marks of healthy development, and many are granular, or filled with fatty jjarticles, or not distinguishable from pus-cells, or imbedded in molecular debris- like substance. The pus agrees with this character of the granulations. It is never like that of a healing wound (the type of good pusj iinless the fistula or sinus be healing ; but is thin, watery, turbid, or flocculent. Moreover, it may be mixed with the secretions of the part into which the fistula opens — as urine, ftecal matter, saliva, &c. The orifices of fistulce, by their varieties, determine certain designations. If there be two, the fistula (or sinus, as some would still name it) is called complete or open ; if only one, incomplete, closed, blind, or occult ; if the one orifice open through integument, the fistula is called external ; if into a mucous cavity or canal, internal. The external or integumental orifice is commonly very small ; so small that it often closes, or is covered with a thin scab, till discharge accumulating beneath breaks it open again. Often, when the walls of the canal are soft and cedema- tous, as in cases of abiding irritation from a foreign body, or from dead or diseased bone, a small lobe of soft granulations — vulgarly, proud fiesh — projects at and conceals the orifice, or elevates it above the surrounding skin. In very chronic cases, GENERAL DESCRIPTION. 143 the outer orifice is often depressed in hard and thickened integument, and is like a hole in a scar ; in some more recent cases, especially near the anus, it is wide and with compressed margins, like those of the Eustachian tube. The internal orifice has fewer varieties. It may be, or form part of, a deep ulcer of mucous membrane ; but, more com- monly, it is a simple round opening, through apparently healthy membrane, level with or slightly upraised from the surrounding surface. The structures through which a fistula or sinus passes may, in recent cases, be little changed ; in old cases they are usually hardened just round it ; and where repeated suppurations have taken place, forming new canals or branches of those already existing, it is common to find all the adjacent structures con- fused in a hard, brawny, sodden substance, covered with coarse granular or almost warty skin. Such is the state in many of the worst old cases of perineal and rectal fistulse. Where sinuses extend into bone, the immediately surrounding bone is, in recent cases, usually soft or not obviously changed in structure ; but in those of long standing it is commonly solidi- fied and hardened, forming a kind of compact osseous canal or cavity lined with a firm, smooth layer of granulations. The foregoing account relates exclusively to the fistulse and sinuses that open through either the integument or a mucous surface, or through both. When a fistula is a communication between two mucous cavities or canals, as in the vesico- vaginal, recto-urethral, and others of the like kind, the state of parts may be similar to any of those just described, if the origin of the fistula were in suppuration between the two cavities. But if its origin were in sloughing, or violence, or wound, the fistula is more commonly like a simple short canal or aperture between the two cavities, and the boundaries of the ajDerture are not granulating or suppurating surfaces, but like healing or healed wounds. In the latter case the edges of the aperture are scarred, and the respective mucous membranes of the two cavities are continuous over them. The modes of formation of fistulse and sinuses are numerous, but may be referred to three chief divisions, as dependent on abscess, wound, or gangrene and ulceration.* * Congenital fistulae, such as the branchial, urachal, and others, are not con- sidered here. We know their anatomical, but not usually their pathological, origin. 144 SINUS AND FISTULA. Abscess is by far the most frequent origin of these diseases. The simplest cases of sinus (or incomplete fistulse) are those in which an abscess, -with a comparatively large cavity formed in loose tissue, has an opening too small for the discharge of its contents. The chances of such an abscess becoming sinuoiis, through defect of healing, are inci'eased if a great part of its cavity is below its opening and is 'bagging,' or if the cavity is deep, and the opening traverses textures of various densities, as muscle, or tough fascia, or the mammary gland. In these cases, which include a great proportion of the sinuses extending under muscles, as the orbicularis, glutei, and rectus abdominis, or under fascite, as those in the calf and thigh and pelvis, the hindrances to healing are chiefly mechanical. The pus cannot get away so fast as it is formed, and it not only keeps the walls of the abscess apart, but irritates and presses them till, even though they may be very nearly in contact, they will not cicatrise or unite. The tendency of an abscess to become sinuous through me- chanical hindrances to healing is greatly increased by coincident disease, whether constitutional or local. Hence the greater frequency of sinuses after chronic than after acute abscesses, because the former generally occur in those of defective health ; and hence, in part, the frequency of rectal fistula in the phthisi- cal. In like manner, fistulse and sinuses are especially likely to remain after suppuration in strumous inguinal and cervical Ijmph-glands, or in a strumous testicle, or in the tissue about a diseased rectum, vagina, or urethra. Another group of cases of sinuses (or incomplete fistulse) are to be referred to the formation of abscess in connection with the presence cf foreign bodies or some abiding irritation, as dead or diseased bone or tooth. Such are the sinuses connected Avith necrosis, caries, diseased joint ; the so-called dental fistula, leading to a dead or diseased tooth-fang ; the sinuses leading to bullets or other foreign bodies. Abscess is, again, the most frequent origin of complete fistula. Thus, an abscess forming in the neighbourhood of the rectum, after burrowing in the soft adjacent tissue till it nearly lays bare the wall of the bowel, may open or be opened through the integument by the anus. At any time after its discharge, but usually soon after, ulceration through the bared and thinned waU of the rectum forms its second or internal opening, and the contracting abscess becomes a fistula. So, a perineal FEOM WOUNDS. FROM ULCERATION. 145 abscess may first discliarge through the integument and then open into the urethra. But in either situation the course of events may be other than this, i.e. an abscess may open, first into the mucous canal, and then through the integument ; or ulceration from within the mucous canal may penetrate its wall, and give rise to the formation of an abscess external to it, which may then open through the integument, and thus finish what is requisite for a complete fistula. In an old case of fistula it may be impossible to determine in which of the three modes of formation just indicated it had its origin, for the result is in all the same. But the observation of cases in process of formation makes it certain that the order of events may be thus threefold ; and proves that there is a remarkable liability both to the formation of abscess in the immediate vicinity of disease in a mucous canal, and to the penetration of the walls of the canal by ulceration extend- ing from a discharged abscess. And the liability is not exhausted by the formation and discharge of a single abscess ; for it is to the repetition of similar events that we must ascribe- the multiplication of branches and new tracks of fistulse, which are so frequent in the neighbourhood of diseases of the rectum, urethra, and other canals and cavities. Wounds may be the origins of sinuses and fistulse, in the simplest manner, when they pass, with long or tortuous tracks, through many structures, and do not quickly heal. Thus, gun- shot wounds may become sinuous, even though no foreign bodies remain in them ; and parts of the wounds of stumps that have become indurated may, without death or disease of the bone, remain unhealed though contracted into the shape of canals. But with much greater frequency wounds lead to the formation, of fistulse when they penetrate mucous cavities or canals, and give exit to secretions, such as urine or saliva. The chance of their doing so is greatly increased when the secretion can escape through them more easily than through its natural passage. Thus a cut into a healthy urethra is, on the whole,, rarely followed by urinary fistula ; but a cut into one behind a stricture seldom fails to become fistulous unless the stricture be cured. In like manner, the o^^ening of tracheotomy often fails of healing when the operation has been performed for disease leading to contraction of the glottis ; for the artificial opening will give easier passage to the air than the natural one. Ulceration and sloughing may in many evident ways give rise VOL. I. L 146 SINUS AND FISTULA. to fistula. As already mentioned, ulceration through the wall of the rectum may lead to abscess external to it, and the abscess may open through the skin ; or ulceration behind or through a stricture of the urethra may lead to urinary abscess and fistula. But without abscess-formation, a sloughing or phagedsenic ulceration, or a spreading gangrene, may lay open the urethra or any other canal or cavity, and the opening may become fistu- lous. Cancerous ulceration is a frequent cause of fistulous com- munications between the bladder and vagina, or vagma and rectum, or other adjacent canals ; and sloughing of the walls of the vagina and bladder is the most frequent cause of the vesico- vaginal fistulse after tedious parturition. The general pathology of fistula3 and sinuses which is here recorded will receive full illustration in later portions of the work, in the essays relating to diseases of particular organs, as the rectum, urethra, &g. In them, also, the several methods of treatment appropriate to the disease in each locality will be described. Here only the general methods and jDrincij^les of treatment will be considered. The methods of treatment may be thus enumerated : general improvement of the health ; removal of foreign bodies or occasional irritants ; pressure ; drainage ; injection ; seton ; cautery ; laying-open ; tent ; plastic operation. General mi^rovement of the health may be necessary for the healing of any fistula or sinus, but chiefly it is so for those which follow chronic abscess connected with a strumous constitution, or which remain in the incomplete healing of deep abscesses or wounds, as of stumps. Many such an one, after remaining long unchanging in a hospital, has healed in other air ; or, in an ill-fed patient, has healed with good food. The general condition of the health is always to be looked to ; but the special means of remedying its defect (if any exist) must be determined for each case separately. The o'emoval of foreign bodies, or of occasional irritants, such as excretions when they flow over fistulse, is an obvious remedy. But it is not always sufficient ; for the walls of the fistula may have become so diseased that the removal of the original cause of its formation may leave them too unsound for healing. These, however, are only occasionally disappointing excej^tions to the rule that the removal of a foreign body, e. (/. of a piece of dead bone, a bullet, a ligature, a dead or diseased tooth, or any other, is followed by the healing of any sinus or fistula connected 1 TEEATMENT. 147 ■with it. Similarly, healing generally follows when, for example, in a recent case of urinary perineal fistula, the passage of urine by the urethra is made so completely free that none passes the wrong way, or when, in an older case, all the urine is withdrawn with a catheter. Pressure is seldom effectual for the cure of any fistula or sinus, except those that are recent and subcutaneous, or in a part which can be very uniformly compressed against an unyielding surface, as the mammary gland. In these, or in stumps, it may often be used with good effect ; but in older, deeper, and more compli- cated cases, it is scarcely worth trial. Drainage, — for which the perforated caoutchouc tube of M. Chassaignac is a very happy invention, and the spiral wire tube of Mr. Eobert Ellis'^ is better — is applicable to a great number of cases ; but chiefly to those in which a sinus or incomplete fistula depends mainly on pus collecting at a level below or distant from the aperture of discharge, or, more generally, when pus is apt to be retained. Numerous instances of suppurating tracks about diseased joints, or following chronic abscesses, or lying deep in a limb or mammary gland, or in the course of suppura- ting lymph-glands, are of this kind. In some of these cases it is sufficient to make a counter-opening, through which the pus may, by its own weight, flow away ; but when this is in- sufficient, a drainage-tube should be inserted in the whole length of the canal, for the sake of its use in both securing the exit of pus and acting as a seton. Injection of stimulant fluids is chiefly iiseful for long sinuses of old standing, running deep, and where counter-openings cannot be safely made. Such are many of those that follow pelvic abscess, or lumbar or iliac abscess, not connected with diseased bone (for where bone is diseased, injection is very rarely useful). It may be used also with success in sinuses leading into diseased lymph-glands. The best materials are, the com- pomid tincture of iodine ; or solutions of iodine in water, in the proportion of from 5 to 10 grains of iodine, and 10 to 20 grains * These drainage-tubes consist of a spiral coil of very fine hard brass wire. They are easily made of any required length or size by rolling the -svire over a fine steel rod, either by liand, or bettor, by means of an ordinary lathe. If necessary, they are quickly electro-gilt by a solution of cyanide of gold. They are introduced by an ordinary director, and retained in place by a strip of plaster. A more detailed account will be found in the Lancet for 1869. 148 SINUS AKD FISTULA. of iodide of j)otassium to the ounce of water ; or carbolic acid more or less diluted. Seto7is may find their use in many of the same cases as drain- age-tubes, but are seldom preferable to them, since the tubes not only act as setons, but secure the discharge of pus with more freedom and cleanliness than any other kind of seton can. In some fistulse, however, in which the track is too small for a drainage-tube, a seton of one or more wires or silk threads may be usefull}' employed to vivify the granulating walls and brmg them to coalescence. Ccmterij, actual or potential, and especially the galvanic cautery, is of great value in two classes of cases ; namely (1) in the short canals or mere apertures of communication between adjacent mucous cavities, as the vesico-vaginal and others ; (2) in the old long and narrow fistulse leadmg into the urethra or rectum or salivary duct. Among the former, those which are small and recent, or such as remain after a nearly successful plastic operation, are especially suited for the cautery, which acts by gradually contracting and finally closing the apertures by repeated scarring. Laying open is one of the most generally applicable methods of treatment of nearly all sinuses and fistulse. As examples, the cutting up of long sinuses in strumous inguinal glands, and the ordinary ojDcration for fistula in ano, may be cited. The prin- ciple of all such proceedings is, to expose the whole extent of the suppurating canal or cavity sufficiently to permit its being ' dressed from the bottom,' i. e. covered with lint or other material, prevented from closing, and permitted to heal by its own scarring and by the levelling of its borders. A process, essentially similar to this, but rarely preferable to it, is that of slowly dividing the parts over or enclosing a fistula by gradually tightening a wire or cord passed through it. As the parts enclosed within the loop thus formed are gradually divided, so those without or beyond the loop are gradually healed, being made to granulate directly after they are divided by the loop. In some cases it is necessary not only to lay oj^en the sinus or fistula, but to destroy its walls with caustic, or by cutting or scrapiiig. It is so in some old callous fistulse in the soft ^Jarts, and more generally in those of bones, or in those that lead down to diseased, though not dead, bone. TEEATMENT. 149 When excretions, as urine, pass through, fistulse, neither laying open nor any other proceeding is likely to be useful, unless free passage is provided for the excretion by its natural means of escape. Tents and the like means for gradually widening fistulous passages may be sometimes preferable to the quicker widening by cutting ; but they are rarely used, probably because they are comparatively tedious. Plastic operations are adapted almost exclusivelj^ for such short fistulous canals and apertures as the vesico-vaginal, vagino- rectal, and others that follow violence or sloughing. For the larger apertures of this kind such operations are the only useful means. JAMES PAGET. GANGRENE. BY tlie term ' mortification ' is meant the death of any portion of the living- body. Gangrene may be said to imply a spreading destructive process, attended by progressive loss of vitality in the living tissues, of which sloughing phagedsena, or hospital gangrene, offers a good example. When soft parts are dead, they are said to be in a state of sphacelus. A more limited dead portion of the body is ' a slough.' Death of bone is termed necrosis ; the dead i)iece a sequestrum ; the process by which the dead bone is separated from the living is called exfoliation. Some authors aj)ply the term ' necrosis ' to death of any tissue ; others extend it from bone to death of cartilage only. The modern views of the life of the blood have given rise to the term ' necrsemia,' or death of the blood. But these different terms have been used loosely, and it would lead to no practical result to attempt any very strict definition. When the destructive process goes on internally and in parts concealed from view, such as the lung, the liver, or any similar structure, we say that gangrene is going on in the organ — that its tissue is ' breaking down.' A separated and ejected portion is a slough. In these cases, although we judge of what is taking place by symptoms only, we employ the same terms as are applied to gangrene and mortification of external parts. Pathologicallj' speaking, it is true that what is ejected from the tissues in the ulcerative process is dead ; but so long as it is in the form of minute particles, visible only with the microscope, we speak of the disease as ulceration, not sloughing or mortifi- cation. The two processes are, however, often mingled; a familiar illustration being afforded by sloughing phagedasna, a disease at one time not uncommon in the venereal wards of the London hospitals. Here the ulcerative process proceeds with such rapidity that there is no time for molecular disintegration of the diseased tissues ; the ulcerative and sloughing processes go THE PROCESS OF GANGEENE. 151 on, as it were, hand in hand. There are also cases of syphilitic ulceration, accompanied by death or mortification of a circular portion of the integument and the subjacent areolar tissue ; and Dr. Baly has noticed, in his observations on dysentery, how even the smallest and most superficial ulcers of the intestine are pre- ceded by the death and detachment of portions of the mucous membrane with its covering of basement membrane and epithe- lium.* Still, surgically speaking, there is a wide difierence between ulceration and mortification. A man suffering from an irregular and large syphilitic ulcer of the penis may j)ursue his avocations and indulge in his usual diet ; but when once a l)ortion of the organ jDerishes or sloughs, small as is the part affected, the pulse rapidly sinks, the extremities become cold, the expression of the countenance is anxious, and the muscular strength fails. When a larger j)ortion of the body dies, such as part of a limb, the symptoms are proportionately more severe. Mortification may proceed from a variety of causes : from local violence ; from the application of heat or escharotics ; from the action of certain animal poisons, such as the urine or the variolous poison ; from inflammation in a part where, to use the language of Hunter, there is no increase of power, but, on the contrary, a diminution of it ; from arrest of circulation, or even in some cases, disturbance of it, &c. Two or more of these causes may be combined : mortification may be immediate, or more slow and consequent on other well-marked changes. It may be limited, or may spread ; the parts affected may be dry or soft, &c. We are able to trace in many ways the influence of nerve- force in maintaining the vitality of a part. Suppose a child to have a deformity of a limb, dex^endent upon abnormal position of the bones, as in club-foot ; that limb will attain the same length and admit of development to the same extent as the opposite. Suppose, on the other hand, that the affected limb be sufiering from infantile paralysis, referable to change in the great nervous centres, it will be noticed that there is a want of animal heat, a sluggish circulation, defective nutrition, and arrest of growth. A limb so conditioned, when exposed to cold or otherwise injured, is but little able to maintain the processes proper to repair ; and although, in many cases of loss of nerve- power, death of the tissues seems to result from their inability to * G'uhfo)ii(i/i Lectures, in Medical Gazette, 1847. 152 GANGEENE. bear ordinarj inflammatory disturbance, still there are other cases in which the rapidity of the change from life to death requires another explanation. Such a case, probably, is that related by Sir B. Brodie, who saw mortification of the ankle begin within twenty-four hours after an injuiy to the spine. But diminution of nerve-power generally leads to impairment of nutrition, and to repeated attacks of low inflammation, during which the tissues may slowly perish, A warder in the Bride- well city prison suffered for many months from agonising pain in the head; at times he had scarcely command of himself ; the pain chiefly seemed to follow the course of the branches of the right superior maxillary nerve, but the other branches of the fifth nerve of the right side were likewise affected. In course of time the cornea of the right eye became opaque, and the con- junctiva red. After some weeks the cornea sloughed, and the humours of the eye escaping, the organ collapsed. The termi- nation of the case was singular. One night, after agonising pain in the head, something was felt to burst, when a large quantity of thick matter was discharged from the nose ; the symptoms subsided, the man regained his usual health, and passed into some other avocation. In the Museum of St. Bar- tholomew's Hospital (ser. ix. no. 9) is an example of central penetrating ulceration of the cornea, in consequence of destruc- tion of the trunk of the fifth cerebral nerve by the pressure of a tumour near the pons Varolii. The whole nutrition of the cor- responding side of the face was impaired ; the patient had repeated attacks of erysipelatous inflammation, bleeding from the nose, and at length destructive inflammation of the tunics of the eye, and ulceration of the cornea. Parts die through a deficient supply of blood, and this may be the sole cause, as when mortification follows the api^lication of a ligature to the main artery of a limb, or the sudden lacera- tion of the same vessel by violence ; or it may be combined with diminished nerve-power, as in some cases of gangrana senilis. When death of a part takes place rapidly, the vessels still contain blood and the usual fluids, and the mortified parts are moist and soft. When, on the other hand, the death is slower, there is usually a deficiency of supply of blood ; the vessels become empty, and the part hardens and withers. And hence we read of moist or acute, and of dry or chronic gangrene. Exceptions to this law are apparent and not real. When it was remarked by Mr. James, ' that acute or rapid mortifications are CAUSES. 153 not necessarily liumid, as the slough from the application of caustic potash proves,' ^ he should have added that the caustic action of this application consists in the abstraction of the watery elements of the part on which it acts. Death speedily follows the complete stagnation of blood, as when a part is firmly strangulated. But if there be any circula- tion, however imperfect or slow, nature struggles for life. The surgeon who undertakes to destroy a vascular nsevus, or mother- spot, by the ligature, knows well the importance of using a stout thread and of tying the knot firmly. No half-measures will answer; either the circulation is completely arrested, or the operation is only partially successful. The same effect may be noticed in cases of strangulated hernia : if the strangulation be complete, the part dies at once ; but if it be less in degree, the venous circulation is retarded, while the arterial goes on ; hence congestion and swelling ensue ; inflammation may supervene, or ulceration at the seat of the stricture. It may be questioned, however, whether vitality becomes extinct in any case of this kind until the strangulation is so firm, either directly or from secondary swelling, that complete stagnation of the blood has taken place. I have seen mortification of the whole of a lowly- organised morbid growth in the thigh follow an operation undertaken without success for its extirpation ; but here, doubt- less, the tumour had been displaced from its connections during the proceedings of the operation, and it perished ac- cordingly. It is commonly believed that inflammatory congestion is that which most commonly leads to mortification ; but in accepting this view we must couple with it a modification, which Mr. Paget thus expresses : ' It is perhaps to be regretted that the cases of this class should have been taken as if they were the simplest types of the process of mortification, and that the process should have been studied as an appendage, a so-called termination of inflammation ; for, in truth, the death of an inflamed part is a very complex matter; and, in certain examples of it, all the more simple causes of mortification may be involved. Thus inflammatory congestion may end in the stagnation of the blood, and this, as an indirect cause of morti- fication, may lead to the death of the blood, and that of the tissues that need moving blood for their support. But a On Injlammation, p. 0-1. 154 GANGRENE. degeneration of the proper textures is a constant part of tlie inflammatory process ; and this degeneration may itself proceed to death, while it is concurrent with defects in the condition of nutrition.''^ The formation of bed-sores is referred by the same author to the second of these conditions, for he points out that the intensity of an inflammation is not alone a measure of the probability of mortification ensuing in its course ; neither is ]nere debility, for we daily see inflammation without death of parts in the feeblest patient with phthisis and other diseases. ' It is as if the death of the part were the consequence of the defective nutrition, which concurs with the rest of the inflam- matory process, being superadded to that previously existing in the part.'t Instances of mortification from defective nutrition are illus- trated by the examples of sloughing of the cornea in animals fed upon food deficient in nitrogen. And the influence of improper food upon the blood, rendering it unfit to maintain vitality in the remoter parts of the body, is exemplified by the accounts of gangrene affecting the lower extremities in persons eating bread made of bad black wheat or rye. This occurrence has been known to prevail in districts on the Continent, especially after wet seasons, where rye forms a principal article of food. The name applied to the diseased rye is ergot or cockspur rye. The part of the body affected seemed to become insensible, cold, dry, and withered — to undergo those changes to which the term dry gangrene has been applied. Saviard mentions that, in cases noticed at Orleans in 1694, both upper and lower extremities were affected. Noel, who wrote in 1710, states that he had never seen any one of the female sex affected, and that he had only witnessed one case in which the gangrene attacked the upper extremities. According to Bassau, surgeon to the Hospital St. Antoine, Dauphiny, the cases which he saw were not all of the dry kind, the limb sometimes becoming putrid, and maggots being generated. Cases of mortification from eating unsound wheat have been recorded by Dr. C. Woolaston in the Philosophical Transactions 17G2, But of late years such cases appear to have been rare. The increased facilities of locomotion have proved the means of equalising in some measure the wants and supplies of mankind, Surff. Pathol vol. i. p. 459. t Op. cit. p. 460. PEOCESS OF SEPAEATIOK 155 and have tended, by raising the j)Osition of the very poor, to improve the general sanitary condition. When soft parts are about to mortify, the bright red and shining condition of the skin previously existing, becomes of deeper and more livid hue ; and here and there patches of dusk}^ brown, green, or blue, mottle the surface. The cuticle becomes loosened, and rises in blisters ; the temperature falls ; and the discoloiu-ed parts become cold and insensible. The colour of the skin becomes deeper and blacker, a thin stinking fluid issues from the exj)osed integuments, and gas is evolved from the decomposition of fluids in the deeper-seated structures. If a limb which has undergone this change be cut into, the deeper-seated tissues are found to be soft, putrid, and rotten. They are soaked in a thin foetid serum, mixed with bubbles of gas. The colour varies from ash-colour to brown, but rarely black. The tendons retain much of their normal appearance, except that when handled they are found to be softer than natural. The appearances j)resented by mortified intestine, as observed in the operation for strangulated hernia, differ but slightly from the above. The surface of the gut loses its smooth bright aspect, although the vessels remain congested and the part is black. But on this black surface the death of the tissues is marked by ash-coloured sj)ots of various shapes and sizes, which in some instances map-out the surface of the congested intes- tine. The same thin stinking fluid exudes, and frequently fills the hernial sac ; while the effects of this change are indicated externally by the deeper and more livid colour of the skin, and its yielding and doughy feel to the touch. We have now to speak of the mode by which, after the cessa- tion of the gangrene, the dead are separated from the living pai*ts. It is but seldom that this process is attended by haemor- rhage, for the blood coagulates in the large arteries which lead to a mortified part. ' When a gangrened limb,' observed Petit, ' is cut off in the dead part, no haemorrhage occurs, because the blood is coagulated a great way in the vessels We have several examples of limbs amputated on account of gangrene, in which no haemorrhage occurred, although the amputation was made a considerable way in the living parts ; because the clot was not confined in these cases to the dead part, but was con- tinued forwards into the living as far as the inflammatory 156 GANGEENE. disposition extended.' * When gangrene stops, tlie livid colour of the adjacent integument, whicli marks its onward progress, becomes brighter and redder. It is at this part that the so- called ulcerative process begins, constituting the line of demarca- tion between the dead and living structures. It was at one time believed that this act was accomplished by the ulceration of the portions of the living tissues which are immediately contiguous to the dead ; and that the groove, gradually becoming deeper, undermined the mortified parts until they were completely separated. In proportion as the groove deepens, so do granula- tions rise from the living surface, and pushing, as it were, the slough before them, present upon its removal the aspect of a healthy granulating sore. But in this explanation the ulcera- ting and granulating processes would seem to proceed at one and the same moment, which is impossible ; and perhaps the latter process is of earlier occurrence, and of gi-eater importance in the act of separation, than is commonly believed. The possibility of the living tissues acting by absorption on the dead, at one time disbelieved, has now been proved by instances of the absorption of portions of pegs of ivorj-, driven like nails into bones, to excite inflammation, for the repair of ununited fi-acture. Such a case occurred under the care of Mr. Stanley, some years ago, and more recently in one treated by myself, where, so active was the absorption, the patient being a child, that the pegs dropped out before accomplishing their end, being deprived, as it were, of their fangs. The fact of the upper portion of the peg being untouched, though in contact with the living tissues and im- bedded in i^us, may be due to a law that the absorbents of bone are required to act upon the osseous tissue. Certain it is that the granulating process seems to be contemporary with the separation of the living from the dead tissues. The superficial slough, formed by the application of strong nitric acid, affords us the opportunity of witnessing this process. When the treat- ment is employed for stopping spreading gangrene with success, the first local effect after the charring of the sloughing surface is the disappearance of the livid red colour of the yet living skin ; then, in the course of a few days, the dried slough shrinks and contracts, while from the line between it and the living parts granulations seem to spring in every quarter, and just in proportion to the rapidity of this process of separation are * Mem. de VAcad. des Sciences, 1732, TREATMENT. 157 the granulations the more abundant and the secretion of pus copious. For the phenomena attending exfoliation of bones, see Dis- eases OF BOXE. The treatment of mortification is guided by rules which are much simpler than in times gone by. It is true that the surgeon will have to consider whether the form of the disease be acute or chronic, and whether the patient be suffering from pain, fever, and constitutional disturbance ; but upon one point he may be sure in every case — namely, that he will have to hus- band the patient's strength and to soothe him in all possible ways. The idea of the surgeon 'seeking to afford relief by imposing the antiphlogistic regimen,' which consists in the employment of ' blood-letting, purgatives, diaphoretics, and diluents/"^ is now regarded as preposterous; and cases are not met with in which ' after one bleeding the pulse is quick, hard, and full.' Sir Astley Cooper seems to have understood the im- propriety of abstracting blood in cases of gangrene, although in courtesy to his provincial brethren he limited his condemna- tion to London practice. His plan consisted in giving small mercurial doses at night, in order to restore the secretions of the intestinal canal and liver ; and the liquor ammonise acetatis with a few drops of the tinctura opii, several times a day, Avith the view of lessening irritability and tranquillising the system. We may often read an instructive lesson from transitions of opinion. The practice of bleeding, founded on improper principles, was tacitly condemned ; and no other course substituted except an attempt to palliate symptoms. In 1715, Mr. Rushworth, a surgeon of Northampton, pub- lished his remarks on the value of Peruvian bark; and the most exaggerated statements of its efficacy were made by its supporters, who affirmed, with a want of judgment equal to that of the supporters of venesection, that it ought to be em- ployed in almost all cases of mortification as soon as the vio- lence of the inflammatory symptoms had been appeased. More accurate pathological investigation has taught us that, in truth, the means which we possess of controlling gangrene are few in number, although they often require great discri- mination in their use. We should never lose sight of the cause of the disease. In an instance related further on, where morti- * Thomson on Inflammation, p. 559. 158 GANGRENE. fication of the lower extremities resulted from impairment of the heart's action caused bj effusion of fluid into the pericar- dium, the administration of mercurials tended, by suppressing- inflammation, to remove the offending cause. When a part has perished in consequence of cold and starvation, warmth and generous diet, administered with prudence, is the course clearly indicated. There are instances in which bark or qui- nine ma}^ be indicated in preference to wine or other stimulants ; but in no way do we possess a specific against mortification, either as an external or internal remedy. Of all medicines which need special notice, opium stands jDre- eminent. By its free administration we are enabled to con- trol in some degree the pain which wears out and exhausts the patient. Mr. Pott used to administer one grain every three or four hours; but never less than three or four grains in the twenty-four hours. He recommended it, not as a specific, but, in Hunter's words, as ' a remedy which does good by not letting the disease do harm to the constitution.' The following, then, should be the plan of treatment. If there be heat of skin, combined with^ feverish symptoms — thirst, loss of appetite, sickness, and rapid pulse — let us re- member that this stage will soon pass by and leave the patient in need of all his remaining strength. Let not the surgeon force solid food upon the patient against his will; easily- digestible food, such as milk, puddings, broth, &c., may be freely offered ; port-wine and water, or brandy and soda-water, or effervescing salines, may be prej^ared as drinks. If ice be grateful to the palate, there is no objection to its employ- ment. Pain must be controlled by opium or morphine. In cases where there is absence of fever, preparations of bark may be given ; and of these perhaps the liquor cinchona3 is the best. It may be combined with ammonia, aromatics, chloric sether, camphor, or other similar preparations. In speaking of local applications, we cannot do better than call to mind the words of Mr. Pott : * Whatever heats, irritates, stimulates, or gives uneasiness, apj)ears to me always to in- crease the disorder, and to add to the rapidity of its progress. And, on the contrary, I have always found that whatever tended merely to calm, to appease, and to relax, at least re- tarded the mischief, if it did no more.' It is desirable to keep the living parts warm ; consequently the limb may be wrapped in cotton- wool or flannel. If the mortified part is dry, no par- NOMA. 159 ticnlar local application is needed ; but wherever it is moist or emits an unpleasant odour, it may be enveloped in a charcoal- poultice, made by mixing- powdered charcoal and linseed-meal ; or be surrounded by muslin bags filled with finely-broken wood- charcoal, or folded cloths soaked in Condy's fluid or carbolic acid and oil. Stimulating applications, such as brandy, bal- sams, or resins, are usually worse than useless. On this head exception is made to the treatment of cases of traumatic gangrene, where immediate amputation, when pos- sible, is indicated; to hospital gangrene, which is treated by the application of powerful escharotics ; and to frost-bite ; on each of which subjects the treatment is appended to the proper section. Noma. Among other instances of mortification from de- fective nutrition is that peculiar afiection called Noma, or water-cancer of children ; Wasserh^ebs, water-canker, cancer aquaticus. It has been chiefly described by foreign writers. It is spoken of by Galen and Celsus. Battus, a Dutchman, mentions the particulars of the case of a girl, aged five years, who died, and of a boy, aged three years, who recovered. Van Swieten says that he has seen the first set of teeth faU out, and the second set destroyed, the lower jaw-bone exfoliate, the lips, cheeks, tongue, and chin eaten away before the child died. The disease rarely attacks children older than ten or eleven, or younger than one year; and occurs in those of •weak frame, improperly and insufficiently nourished. It has been noticed after measles, intermittent, remittent, and other forms of fever. The first symptoms are those of constitu- tional disturbance, wasting and loss of aj)petite, followed by swelling of the salivary glands, and a profuse discharge of saliva, which is thin, watery, and foetid, and flows from the mouth involuntarily during sleep. Next, ulceration commences in the gums, which swell, become livid, and separate from the teeth ; the teeth become loose, and are soon covered with dirty sordes. Soon, ash-coloured spots show themselves on the gums and neighbouring mucous membrane ; they turn to dark- coloured sloughy-looking sores, which spread rapidly in every direction, exposing the bone, which subsequently exfoliates. The sore spreads from within outwards, not by ulceration, but by a moist and sometimes dry gangrene, while the parts around swell and become first of livid red hue, then of grayish or black colour, marking the spreading gangrene. A large aper- 160 GANGRENE. tnre is thus made in the cheek, sometimes separated by a frse- num from the mouth, at other times continuous with it. In other cases the tumefaction of the cheek may be shining and hard, resisting the pressure of the finger ; the temperature mnj be increased, and the colom* a rose-red fading away at the circumference. After a few days a blue spot appears externally, surrounded by a well-defined red border; the colour next changes from blue to black ; and the destructive process goes on with such rapidity that in from three to six days the entire cheek has been destroyed. The changes in the bones seem to be jjeculiar ; they are usually confined to the surface lying next to the layer of softened tissues ; the part not in immediate con- tact being healthy. Two different morbid processes have been noticed. First, the separation of the alveolar process from the portion of diseased bone ; secondly, the successive destruction of the remaining surfaces of the bone. The organised constituents take part in the process of softening, the earthy particles being set free ; thus in children the separation of the alveolar process is easil}^ affected, while the rest of the bone acquires a more or less worm-eaten appearance when the destructive process goes more deeply. An examination after death shows the sphacelated part of doughy consistence, black and easil}' torn. Underneath the external gangrenous covering the areolar tissue is greasy and yellow ; serous infiltration, also of yellowish colour, has taken place around. There is effusion under the arachnoid membrane and in the ventricles of the brain. In one case the heart and lungs were bloodless, and there were tubercles in the substance of the latter. The intestines were adherent, from the effects of previous peritonitis, and the mesenteric glands were swollen. In such a disease the obvious indications are, to remove the patient to pure air, to administer stimulants and proper nourishing diet, and to touch the sloughing parts with a solution of nitrate of silver, or some other stimulating applica- tion. There may be cases requiring the use of a strong escharotic. Antiseptics must be freely used. Traumatic gangrene. A part may be destroyed by direct local violence. There is no preceding inflammation, nor vas- cular disturbance of any kind, to account for the change ; the immediate effect of the injury has been to deprive the living tissues of their life, when they become subject to the same laws of decomposition as are applicable to the dead animal. As occui-ring in the lower extremity, the foot becomes cold and pulseless ; there is no sensation, even if the part be pricked TEAUMATIC GANGEENE. 161 ■with, a needle or knife ; the appearance of the limb may not be mucli changed, for the skin is elastic and does not lacerate very easily. In 1835, a brewer's servant was riding asleep on the shaft of a dray drawn by a powerful team of horses. In passing through a turnpike the man's legs were jammed between the dray and the gate-post. The patient was immediately brought to the hospital. The right leg was severely injured, but the left appeared simply cold and without sensation : vitality had left it ; and after amputation it was found that, although the integu- ment was entire, every tissue had been crushed and divided ■down to the bone, the popliteal nerve alone retaining its con- tinuity. The same species of accident is that inflicted by cannon-balls or other heavy missiles, by steam-machmery or railway contusions : the part perishes simply because unable to retain the life inherent in it. The cause of death is not from want of blood. Vitality would be equally extinct, were it pos- sible to maintain the circulation artificially. But the proximity of a mortified part to living tissues cannot be borne with impunity. Nature endeavours to cast off the dead from the living tissues by an inflammatory process in the latter, which speedily lose their vitality from inability to sup- port this action towards repair. According to Hunter, a dimi- nution of power, when joined to an increased action, becomes a cause of mortification, by destroying the balance which ought to subsist between the power and action of every part. Thus the mortification spreads towards the trunk preceded by a blush of dusky red, marking its onward course and illustrating what is called ' traumatic gangrene.' It does not often happen that the surgeon witnesses in such cases death from the unchecked progress of the disease. The indications for immediate amputation are so clear and so gene- rally acknowledged, that he who shrinks from the responsibili- ties of the operation stands exposed to just reproof. A girl once came before my observation in whom the left arm had been crushed by machinery beyond the possibility of repair. Partly yielding to the patient's own strongly expressed wishes, the surgeon did not amputate : mortification took place within a few hours ; it spread upwards towards the chest, the tissues about which became infiltrated and swollen by serous exudation, and the patient expired comatose after periods of sufferings of no ordinary character, during which she frequently implored the performance of that operation which, once delayed, was VOL. I. M 162 GANGRENE. no longer practicable. In the case of a bone, there may be no apparent change of tissue — the part Avhich is dead remains sur- rounded bj, and even attached to, living tissues ; but its circula- tion cannot be restored ; and its removal by absorption, at one time thought impossible, is at least so slow a process as rarely to be contemplated by the surgeon in the light of a curative action. The application of powerful escharotics produces, in the same way as the application of heat, immediate death of a part by chemical decomposition. No inflammatory process is needed to account for the change — the heat and redness which may be noticed in the surrounding tissues being connected with the process of separation of the slough. Let us select as an illus- tration the action of strong nitric acid upon the living tissues. This escharotic applied to any part of the living body causes immediate decomposition of the different elements, which be- come oxidised, leaving the carbon of the tissues as an eschar. Experience has shown that, after a part has been thus pur- posely destroyed, the better mode of treatment consists in leav- ing the diy eschar exposed to the air, the watery parts having been removed by the acid. Immediate death of a j^art may be produced by the extremes of heat and cold ; and although it is commonly believed, and may in some instances be the case, that these agents, as well as caustics, applied in smaller measure do not kill the part at once, but excite an inflammation in it, which, added to the damage already received, may lead to indirect or secondary mortiflcation, yet when we try to accomplish this end in prac- tice as a means of cure, we encounter unforeseen difficulty. The injection of nsevi, or mother spots, with irritating fluids is an example of what has just been said. I know of no means by which a sufficient amount of inflammation so as to cause death of the part can with certainty be produced; we may destroy the vascular system at once by a powerful caustic, but we cannot always induce secondary mortification. Freezing applications, employed to render a part insensible to the pain of a surgical operation, are not followed by secondaiy inflam- mation and mortification, nor has a similar result ensued from the exposure of the body to heat. It is more than probable that, in the healthy subject, the vitality of the different tissues is in little danger from inflammatory disturbance. The death of a part must be effected by powerful agencies coming from without, or by some accidental causes of disturbance to the general health. The only apparent exception to this is in HOSPITAL GANGRENE. 163 the case of sloughing of tendons or areolar tissue after certain forms of inflammation ; but the peculiar character of organisa- tion in such structures is a sufficient explanation of this oc- currence. Secondary mortification. It is difficult in all cases to draw the Hne between immediate and secondary mortification. A boy was under the care of Sir W. Lawrence, in St. Bartho- lomew's Hospital, to whom mortification of the toes had ensued from his sitting with his feet in the water of a running stream one summer's day after a long walk. We camiot believe that this accident could have happened to a perfectly strong and healthy child ; there must have been some cause to render the circulation feeble and the extremities cold. In all probability, the blood never flowed again in its accustomed way through the chilled parts ; and the inflammation which surrounded the mortifying structure was, it is true, due to vascular reaction m living tissues, but in no way comiected with the spread of the gangrene, the exact extent of which was limited by the acci- dent. In other instances we see a patient of habitually intem- perate habits suffering from gangrene of an entire limb ; the integument is of livid red colour, the countenance sunken and anxious, the pvilse rapid and feeble. At one time we accepted the explanation of such cases, that inflammation occurring in a part of low vitality was likely to be followed by gangrene ; but more accurate pathological investigation has shown that the main artery of the limb may be plugged,"^ and that causes, either mechanical or vital, may interfere with the establishment of the collateral circulation. Although it is true that the pro- gress of the mortification is marked by low inflammatory action, yet it would be incorrect to regard such inflammation as the cause of death. The part is perishing from insufficient supply of blood ; and the vascular excitement, the last expiring flame of vitality, does but influence the course which in each case the peculiar method of disorganisation may take. Hospital gangrene. Gangrene consequent upon a low type of inflammation requires for its development the exercise of some of those subtle undefined causes which govern the outbreak of epidemics. We apply to it the terms, phagedccna gangrenosa, gangrsena contagiosa, hospital gangrene, sloughing phagedsena, &c. It is a species of humid gangrene, peculiarly characterised * For further information on this subject see Diseases of Arteries, 112 164 " GANGRENE. bj its contagious and infectious nature. During an outbreak which took place in the year 1846 in St. Bartholomew's Hospital, the extension of the disease in two instances was clearly traced to the use of a sponge which had been first applied to a gan- grenous sore, then boiled, and afterwards applied to a healthy wound. The infectious nature of the disease — that is to say, its rapid extension from patient to patient without personal contact in the same room — has been often witnessed. By this term we mean not only to imply that a number of persons living in the same room, breathing the same atmosphere, and exposed to the same causes, suffer in common, but that the exhalation from the wound of a person suffering from hospital gangrene may become in itself the means of the spread of the disease. A lady living in a low but not unhealthy part of the environs of London underwent the operation of extii'pation of the breast for cancer. She was of excitable temperament, but healthy-looking and country-bred. About ten days after the operation the wound assumed an unhealthy aspect, and became gangrenous in the space of twenty -four hours. She was restless and ii-ritable, although the pain was not insupportable. A single application of the strong nitric acid sufficed to arrest the sloughing process, and the patient recovered. But the odour clmig to the walls of the chamber ; and after her removal, and the apparent purification of the apartment, of two persons who consecutively slept there for a night, the first had a sharp feverish attack, attended with total loss of appetite ; the second had a sudden attack of diarrhoea. There is every reason to believe that had a patient with an ojDen wound been put there, the healing process would have been an-ested. In contrasting the experience gained in the Peninsular with that obtained during the Crimean war, one cannot fail to be struck with the remarkable rarity of gangrene among the British hospitals in the East. ' During the first winter,' says Mr. Macleod, 'it prevailed a good deal in a mild form at Scutari ; but it never became either general or severe. It fre- quently attacked the openings both of entrance and exit (as applied to gunshot wounds) ; but occasionally seized on one only, showing apparently a predilection for the wound of exit.' * Dr. Taylor thought that in India gangrene more commonly appeared in the wounds occasioned by grape or canister. In * Surgery of the Crimean War, p. IGo. HOSPITAL GANGRENE. 165 many cases Mr. Macleod tliouglit the best designation would have been putrid degeneration. ' The abominable state in which the barrack-hospital at Scutari was during its early occupation may well have caused an outbreak of hospital gan- grene among the broken-down men, who lay so thickly around the doors of the offensive latrines ; but I cannot say that I noticed any greater tendency to its appearance at these places than at any other portion of the hospital. The corridors pre- sented, I think, the greatest number of cases. Whenever it appeared, the patients were isolated, and sent into wards set apart for the treatment of the disease.' * The Fi-ench, how- ever, suffered most dreadfully from hospital gangrene in its worst form ; the great evil appearing to have been ' overcrowd- ing.' The disease raged rampant in the hospitals on the Bos- phorus, and likewise in many of the transports. M. Lallour, surgeon to the Euphrate, says, in his paper on the subject, that from one of their ships sixty bodies were thrown overboard during the passage of thirty-eight hours to the Bosphorus. There cannot be a doubt, in speaking of the causes which lead to this fearful disease (which rages under certain circum- stances thus endemically), that it is due to the agency of some unknown poison, which finds for itself a soil fit for propagation. Some circumstances, such as overcrowding and bad drainage, promote its rapid increase ; but they alone are insufficient to account for all the phenomena. In the winter of 1846-47, the buildings constituting the north side of the square of St. Bartholomew's Hospital became invaded by the malady now imder consideration. A healthy man, aged 82, cut his hand in the palm b}' accident, I)ecember 2, He was put into a light and airy ward, in the next bed to a patient suffering from compound luxation of the radius, attended with symptoms of diffuse inflammation of the areolar tissue. The cut hand swelled, became hot and painful, and a small abscess formed, which was opened by the house-surgeon. The wound thus made sloughed and assumed some of the characters of a phagedrenic sore. The man was immediately removed to another part of the hospital, and, after considerable loss of substance, including some of the tendons, the hand ultimately cicatrised, but with impairment of motion. The patient with the dislocated wrist, suil'ering from difl'use cellular inflammation, died on December 23 ; and it was found on examination after death, that suppuration attended with sloughing of the tendinous structures existed in both fore-arms, extending among the muscles under the fascia to near the elbow-joint. From this time a succession of cases of well-marked hospital gangrene ensued, the particulars of which, read before the Medico- Chirm-gical Society, were published in the Lancet, 1857. It was argued, from • Op. cit. p. lOG. 166 GANGEENE. the circumstances attending a similar outbreak in University College Hospital, that the disease was apt to occur in new buildings, that in which it was first noticed at St. Bartholomew's Hospital being quite of recent date. But in op- position to this view, there were at the same time cases in one of the older parts of the hospital quite detached from the preceding, but presenting the same aspect to the north. Now in that year there had been striking thermometrical chano-es from unseasonable heat to extreme cold, and it is remarkable that when the disease prevailed in the Crimea there blew that much dreaded wind, the oppressive sirocco. * In the Crimea,' says Mr. Macleod, ' during the heat of the summer of 1855, after the taking of the Quarries, and the assault on the great Redan in June, not a few amputations of the thigh were lost from moist gangrene of a most rapid and fatal form. In the case of a few, who lived long enough for the full development of the disease, gangrene in its most marked features became established; but most of the men expired previous to any sphacelus of the parts, overwhelmed by the violent poison which seemed to pervade and destroy the whole economy. This form of the disease occurred in four cases imder my ovni charge, in men who had had a limb utterly destroyed by round shot or grape. In all, the knee-joints were crushed ; the collapse was deep and prolonged ; and the operation performed primaiilj^ in the middle third of the thigh. Three of the four were of very intemperate habits. All these cases took place about the same time, at ^Midsummer, when many other similar cases appeared in camp. The wards, though full, were not overcrowded, and could from their construction be freely ventilated. The weather was sultry, and the cholera was in camp. The atmosphere was charged with electricity, and the dreaded sirocco prevailed. Wounds generally assumed an imhealthy aspect for days when this pestilential wind blew. The cases of all those who died in my wards seemed to be doing perfectly well up to sixteen houi-s, at the furthest, before death.' * Tlie statement of Mr. Blackadder,t that hospital gangrene is at first a purely local affection, and that the constitutional symptoms do not make their appearance before the third or fourth, sometimes not till the twentieth day, is "^quite at vari- ance with present experience. In St. Bartholomew's Hospital patients complained of pain and tightness across the forehead, accompanied with severe headache ; the pulse was small, quick, and thready ; the aspect of the countenance anxious and de- pressed ; and they were very commonly irritable. There was from the first a stinging pain in the wound, which prevented sleep. So constant were these symptoms that the surgeon could predicate the outbreak of the disease in particular cases. Now what says Mr. Macleod ? ' In recording one case I relate all. During the night previous to death, the patient was restless, but did not complain of any particular uneasiness. At the • Surgery of the Crimean War, p. 168. t Olsenatmis on Phagedtsna gangrcenosa, by H. Home Blackadder, 1818. HOSPITAL GANGEENE. 167 morning visit, the expression seemed uuaccomitably anxious, and the pulse was slightly raised. The skin was moist and the tongue clean. By this time the stump felt, as the patient expressed it, heavy like lead, and a burning stinging pain had began to shoot through it. On removing the dressings, the stump was foimd slightly swollen and hard, and the discharge had become thin, gleety, coloured with blood, and having masses like gruel occasionally mixed with it. A few hours afterwards the limb would be greatly swollen, the skin tense and white, and marked along its edge by prominent blue veins. The cut edges of the stimap looked like pork. Acute pain was felt.' * Mr. Macleod here says, '■ the constitution bj^ this time had begun to sympathise.' Surely he has shown by his own words a sufficient amount already of serious general disturbance. The cold sweat which broke out over the body ; the irritable stomach ; and the weak, frequent, and failing pulse, were but indications of approaching dissolution. The respiration became short and hurried, giving evidence of the great oppression of which the patient so much complained. The heart's action gradually and surely got weaker, till, from fourteen to six- teen hours from the first bad symptom, death relieved him of his sufferings. Post-mortem examination, instituted shortly after death, showed the tissues of the limbs, and in many cases those of the internal organs also, to be filled with gas, and loaded with serous fluid. The vessels leading from the stump were • healthy, and in only one case had there been any actual mortification previous to death. After the taking of Sebastopol in September, the same form of disease again appeared, especially among the Russians who had been operated on, and was so deadly, that ' in no case, which I could hear of, did recovery follow.' t Dr. Hennen's account of hospital gangrene as it occurred in the Peninsida, during the war with the French, corresponds in all essential par- ticulars with the above. 'Let us suppose that our wounded have all been going on well for several days, when suddenly one of our most promising patients complains of severe pain in his head and eyes, a particular tightness about the forehead, loss of sleep, and want of appetite ; and that these feelings are accompanied with quickness of pulse and other symptoms of fever; his wound, which had been healthy and granulating, at once becomes tumid, drj^, and painful, losing its florid colour, and assuming a dry and glossy coat. This is a description of the first stage of our Bilboa hospital gangrene. If this incipient stage were overlooked, the febrile symptoms soon became aggravated ,• the skin around the sore assumed a higher florid colour, which shortly became darker, then bluish, and at last black, with a disposition to vesicate, whilst the rest of the limb betrayed a tendency to oedema. All these threatening appear- ances occm-red within twenty-four hours; and at this period the wound, what- ever might have been its original shape, soon assumed the circular form. The sore now acquired hard, prominent, rugged edges, giving it a cup-like appear- ance, with particular points of the lip of a dirt-yellow hue ; while the bottom of the cavity was lined with a flabby blackish slough. The discharge in this second stage became dark-coloured and fcetid, and the pain extremely poignant.' \ There is no reason to believe that the disease, as witnessed now, differs in any essential particulars from that recorded by * Op. cit. p. 170. t It»id. p. 171. X Principles of MiUtary Surgery, by John Ilennen, M.D. 1G3 GANGEENE. the sui'geons of tlie Peninsular vrav ; and a careful examination of facts shows, I think, conclnsiyelj that the causes which lead to its outbreak are general and not local, and in most instances preventible. A case came before my observation in which spreading gangrene of the character here described took place on the nates of a young married woman. She had been tra- velling outside a coach, and had got wet and excoriated, and she attributed the disease to this accident. But then one knew nothing of her habits or place of abode, and it may be inferred that she told as much of her history as she found convenient. Cases are not uncommon in which gangrene attacks one sore, leaving others on the same subject in their usual state ; and this fact has been urged as an argument in favour of the disease being primarily local. But in the course of a short time the same change will be observed, if the conditions remain un- altered, to spread from part to part., and that too in spite of the most rigorous attention to cleanliness. The treatment of hospital gangrene consists, firstly, in the entire destruction of the sloughing surface by the strongest procurable escharotic. Nitric acid is generally preferred. It should be applied by means of a small mop made of lint wound round a piece of wood of sufficient strength to admit of being pressed into every part of the wound. The eschar thus formed should be allowed to diy and form a hard and charred layer, ^^nder which granulation advances with great rapidity. No poultice nor wet lint is needed ; and there is no need of hurry in separating the eschar from the parts beneath. Chloroform should be administered, as the proceeding is very j)ainful ; then a full dose of opium should be given, and repeated if necessary'. A liberal allowance of wine, spirits, and other stimulants must be ordered, for patients take large quantities during this state of depression with impunity. Bark and quinine in these cases are frequently useful, and I have given the latter in large doses with success in cases where the application of the acid has failed. Should the sloughing process go on under the eschar, and the repetition of the caustic be impossible or injudicious, the Peru- vian balsam may be laid on freely, while the greatest attention is paid to keeping every part of the sm-face as dry as possible. But local treatment will frequently prove unavailing, so long as the patient remains exposed to the same influences. He should be removed from the ward or sick-room, and put into FROST-BITE. 169 anotlier building ; and when such a measure is impossible, the ventilation should be as free as possible, while disinfectants should be liberally spread about. No sponges should be allowed ; or, after having been used, they should be immediately burnt. Dressings and applications of all kinds should be simi- larly destroyed when of no further use. And, finally, the surgeon should feel that it were better for the sick to be unsheltered in the open plain, than to continue in the crowded wards of an hospital so affected. Frost-bite. The effect of cold in producing frost-bite was seen upon a large scale during the war in the Crimea by the surgeons attached to the British and French armies ; and there was a peculiar form of the disease affecting the hands and feet, very common during the first winter and spring, which Dr. Tholozan and some of the French surgeons were inclined to look upon as allied to a peculiar disease which aj)peared epidemically in France between the years 1828 and 1832, and was then termed acrodynia. Mr. Macleod, however, and with him, I believe, most English surgeons, is persuaded that it was the joint product of cold and scurvy. ' This affection,' he says, ' showed itself chiefly in the pulpy parts of the feet and hands, but especially in the ball of the toes, in the edges of the feet, and in the muscular ridge which runs across the sole of the foot at the roots of the toes. Its earliest symptom was a prickly sensation experienced when the patient stood on the foot, and was variously described by him as resembling the pricking of pins, or as if he walked on nails. There were lancinating pains in the calves of the legs, which parts felt hard and brawny, and were sometimes swollen and discoloured. There was weariness in the limbs, and a most distressing heat in the feet, especially at night, when the weight of the bed-clothes could not be borne. An erythematous redness was often observed along the edges of the feet or hands ; and the sensibility, though generally heightened, was occasionally diminished, so that patients sometimes said, in walking " they did not feel the ground." It was often localised in small patches, and not always accompanied by other scorbutic symptoms. It was often combined, too, with low fever or dysentery, and not unfi-equently followed by desquamation of the epidermis, and sometimes by local gangrene.' ^ Surtje)~y of the Crimean War, p. 79. 170 GANGEEISI]. This affection Avas intractable so long as the depressing influences on the general health continued ; and it was re- marked that dui'ing the first Avinter the frost-bites were much more severe and difficult to manage than during the second, when better preparations were made for the occupying forces. The French suffered more than the English. ' In their hospitals,' says Mr. Macleod, * a limb might be seen sphacelated half-way to the knee.' Any wounds from frost-bite are peculiarly difficult to heal ; and ' the removal of bone from the fingers or toes, however black and apparently dead, and though only attached by the most slender connection, was certain to cause a great amount of irritation, which sometimes became alarming.' '^ The same was noticed wherever the patient was situated, whether in the hospitals, in the camp before the city, on the heights above Balaclava, or in the warmer regions of Scutari, Eenkioi, or Smyrna. Surgeons gave up interfering in any way. The most soothing applications ; the greatest gentleness ; rest in the horizontal posture ; the administration of generous diet and stimulants in pro]3er quantities, were the chief measTires found of service. It mattered not whether or no chloroform were administered ; a surgical operation to divide even the smallest band was found to be fraught with danger ; and special in- junctions for non-interference in any way were therefore very properly impressed on the younger surgeons. We have in the Museum of St. Bartholomew's Hospital the feet of a girl aged nineteen which became frost-bitten during a cold night when she slept in the street. An attempt was made to restore cir- culation by putting the feet into warm water. Senile gangrene presents itself under tAvo forms — the dry and the moist. The former {gangrcena sicca) is due to the gradual decrease in the supply of blood to the part, and is slow in its progress; the latter, also dependent on deficient supply of blood, is more especially influenced by low inflammatory action consequent on irregularity in the circulation, and diminished nerve-power. In the first, the part slowly withers, and becomes dry. In the second, the part, feebly nom-ished, becomes in- flamed, and perishes. This disease, as its name imports,- attacks chiefly the old, or those whose constitutions have been injured by excess. Some surgeons have remarked that great eaters, rather * Op. cit. p. 173. SENILE GANGEENE. 171 than great drinkers, Jbave suffered from moist gangrene ; and as early as the days of Cowper, the ossification of the arteries of the legs was noticed in persons who had died of this disease in both forms.'^ A patient may be old from excess, and suffer from gangrene of the extremities at a comparatively early age. A man aged fifty-four was admitted into St. Bartho- lomew's Hospital, Feb. 22, 1839, with mortification of the third and fourth toes of the right foot ; oedema of both legs ; cough and expectoration of mucus tinged with blood. The coiinte- nance was of bluish aspect, as if there were obstruction in some part to the circulation. The extremities were cold, and the pulse feeble and at times scarcely perceptible. The man died the following day, and the body was removed without examina- tion. An instance of gangrene of the foot at a yet earlier age was under the care of Sir W. Lawrence in St. Bartholomew's Hospital in 1857. The patient, a young man aged 23, had a severe attack of acute rheumatism, accompanied with pericar- ditis ; effusion took place into the cavity of the serous mem- brane, and the circulation became so impeded that mortification of the foot ensued. Under proper treatment, the mortified parts separated and the stump of the foot healed ; but the patient suffered so much from the imperfect nature of the cica- trix, that he again presented himself for admission, being desirous of having the foot removed by amputation, which operation I accordingly performed. Inasmuch as the causes which produce this form of gangrene may come into operation at different ages, the term ' senile ' gangrene need not be used. The terms ' dry ' and ' moist ' express sufficiently the leading characteristics. Mr. James relates a case in which it happened to a woman aged forty -two."f" There cannot be a doubt that simple diminution of the heart's action will in some cases be followed by mortification of the lower extremities. We see such occui-rences after severe fever ; but granular degeneration of the contractile coat of the arteries will, by destroying the equalising power of these vessels over the circulation, lead to the same result. The action of the heart, however, is not in itself suJBficient to preserve the proper supply of blood to all the tissues of the body ; the stream is maintained by the contractility of the arteries, and, as recently shown by Mr. Wharton Jones, by that likewise of the veins. In Phil. Tra?is. vol. xxiii. p. 1195. f On Inflammation, pp. 545-552. 172 GANGRENE. old persons suffering from this form of gangrene the blood has been found thin and insusceptible of coagulation ; and in a case where amputation -was performed, difficulty was experienced in preventing secondary htemorrhage. Thus in cases of senile gangrene, many conditions may have been combined to lower the vitality, and to render parts prone to mortify from accident, injury, or diseases which under other circumstances would have been trivial in their results. The morbid change has been well described by Mr. Pott : — ' In some few instances it makes its appearance with little or no pain ; but in tlie majority of the cases the patients feel great uneasiness through the whole foot and joint of the ankle, particularly in the night, even before these parts show any mark of distemper, or before there is any other than a small discoloured spot on the end of one of the little toes. It generally makes its appearance on the inside, or at the extremit}^ of one of the smaller toes, by a small black or bluish spot; from this spot the cuticle is always found to be detached, and the skin under it to be of a dark- red colour. If the patient has lately cut his nails or corn, it is most frequently, though very unjustly, ascribed to such operation. In some patients it is slow aud long in passing from toe to toe, and from thence to the foot and ankle ; in others its progress is rapid and horridly painful ; it generally begins on the inside of each small toe, before it is visible either on its under or upper part ; and when it makes its attack on the foot, the upper part of it first shows its distempered state by timiefaction, change of colour, and sometimes by vesication ; but wherever it is, one of the first marks of it is a separation or detachment of the cuticle. Each sex is liable to it ; but for one female in whom I have met with it, I think I may say that I have seen it in at least twenty males. I think also that I have much more often found it in the rich and voluptuous than in the labouring poor — more often in great eaters than free drinkers. It frequently happens to persons advanced in life, but it is by no means peculiar to old age. It is not in general preceded or accompanied by apparent distemperature either of the part or of the habit. I do not know any p.irtieular kind of constitution which is more liable to it than another ; but as far as my observation goes, I think that I have most frequently ob- served it to attack those who have been subject to flying uncertain pains in their feet, which they have called gouty, and but seldom in those who have been accustomed to have the gout regularly and fairly.' Mr. Pott's belief that the idea of the disease proceeding from an ossified state of the arteries is a mere conjectm*e, has been sufficiently answered by the observations of Thomson and Hodgson. The treatment of senile gangrene must be conducted upon the usual hygienic princij)les. If we attempt to combat the disease by ' throwing in bark,' and by overloading the system with all sorts of stimulants and excess of food, we shall produce an increase of the local vascular excitement, which will be PHAGEDENA. 173 immediatelj followed by spread of tlie gangrene. I liave known patients over-persuaded to take nourishment against their appe- tite, but never has the transgression been done with impunity. In cases of humid gangrene, a light farinaceous diet is usually the most fit, and stimulants should be given with caution — port- wine mixed with water being that usually preferred. Opium must be given in doses sufficient to alleviate pain, and should be continued during the day as well as the night. The patient must be confined strictly to bed, the limb kept warm and slightly raised. Finally, let the surgeon beware of interfering with the separation of the slough ; nature will accomplish the task best when unaided. Indeed, surgical interference of any kind is, as a rule, dangerous. In cases of dry gangrene unattended by fever, especially in the aged, stimulants and tonics may be administered more freely, and animal food may occasionally be allowed. But even here excess is to be avoided ; the pulse must be consulted and the local disease watched. By care and prudence the life of a patient may be prolonged ; and though in general the disease ultimately gets the mastery, many years may be passed in comparative comfort. Phagedcena, derived from the word (f)dyo), to eat, is a term applied to a form of ulceration characterised by the gnawn look of its edges, and by the rapidity with which it, as it were, eats away the flesh. If we closely examine a phagedsenic ulcer, we notice that the edges are undermined, and that they have the appearance as if they had been nibbled away by the incisors of some small rodent animal. As was observed by Sir W. Lawrence, phagedajna may seem a superfluous addition to ulceration, which always implies loss of substance. It is, however, a convenient practical term to denote cases, not of infrequent occurrence, in which the destructive process is more rapid, considerable, and unequivocal than in simj)le ulceration. The various forms of phagedasna constitute an insensible transition from ulceration to mortification — being closely aUied to the former in their milder shape, and hardly distinguishable from the latter in their more violent form. Thus we speak of chronic and acute phagedsenic ulceration, which in their more active forms become sloughing phagedajna and hospital gan- grene. The present remarks are confined to phageda3nic ulceration, 174 GANGEEKE. or pliagedsena. The appearances are as follows. The edge is sharp, often ragged, with livid fragments apparently crumbling away; the margms are often red. The bottom is iiTegular, grayish, livid or tawny, sometimes with viscid and bloody discharge. In the acuter forms there is a sharp stinging pain, often considerable ; in the chronic form it is less marked, or indeed may be entirely absent. The frequency of phagedsena in the venereal wards of an hospital has long been generally noticed. Into this subject we do not propose to fenter, except by saying that it is engendered, from causes quite distinct from syi3hilis, in young, naturally healthy, yet often dehcate females, who lead a miserable life of prostitution in the worst parts of London, with little protec- tion from the coarseness and ill-usage of the lowest characters. Upon such constitutions exposure to cold and wet, the constant use of spirits, want of i)roper food, fatigue and broken rest, exert the worst of influences ; and any excoriation, aggravated by the effects of uncleanliness, is often followed by the most serious results. But phagedsena is met with in other regions than the organs of generation, and from other causes than those associated with either habits of prostitution or the depressing associations of syphilis. It is a fact that the severer forms of phage dsena are less common now at St. Bartholomew's Hospital than formerly, and those which are admitted come from the East End of London, where sailors of all nations and prostitutes make one motley throng. Field-lane and its tributaries are places of the past : air, light, and drainage have greatly changed the diseases of a class, whose habits, however, remain in most respects much the same. Hence we may infer that phagedsena may be induced by endemic causes affecting the general health. But may not this disease be generated by yet other causes ? If it be true that foul au', want of proper food, and other similar agencies suffice to create the spreading sore, how comes it that removal to the pure atmosphere of a well-founded hospital, with all its attendant comforts and the advantages of trained nursing and medical skill, does not at once arrest the morbid action ? To explain this we must suppose the presence of some septic material in the system, which has jDoisoned the blood, or in other words induced a state of septicaemia. Professor Panum {Arch. f. Path. Anat. xxv. 441) has arrived at the followmg PHAGEDENA. 175 results in respect to the nature of tlie putrid matters, after a series of experiments : — 1. The putrid ^^oison is not volatile, but fixed ; it does not pass over in distillation, but remains in the retort. 2. The putrid poison is not decomposed by boiling and eva- poration — not even when the boiling is continued for eleven hours, and the putrid matters are perfectly dried by means of a water-bath. 3. The putrid poison is insoluble in pure alcohol ; it is, how- ever, soluble in water, and is contained in the watery extract of the dried putrid substances after their previous treatment with alcohol. 4. The albuminous substances often contained in putrid fluids are not _2jer se poisonous, but only become so because they con- dense the poison on their surface ; they can be freed from it by careful washing. 5. The intensity of the putrid poison can only be compared with that of serpents, curara, and the vegetable alkaloids ; for after boiling, evaporation, and treatment with pure alcohol, 0*012 gramme of it almost suffices to kill a little dog. A great number of chemical processes are included in the popular idea of putrefaction ; many different products of com- positions are absorbed, and may be injurious ; and the circum- stances under which decomposing bodies act on the organism vary extremely. It makes a material difference whether a putrid matter pass from the stomach or intestinal canal, and thus acts on the portal vein and liver, or whether, infiltrated in the cellular tissue, it excites local irritation : whether it pos- sibly induces inflammation or coagulation in the veins and lymphatics, or whether, after the manner of other poisonous materials, it mixes with the blood, and so exerts both general and local injurious actions. Such cases as belong to Surgery are distributed under foui^ heads : — 1. Traumatic sepsis (primary traumatic sepsis). 2. Poisoning by putrid matter (secondar}^ infection, self- infection) . 3. Infection by the poison of dead human beings and similar matters (infected wounds). 4. The specific zymotic septic process, hospital gangrene, malignant pustule, noma, &c. It is to the fourth division that the subject of this article is to 176 GANGEENE. be refeiTed, whether the disease be called phagedena, noma, malig-nant pustule, or any of the other terms generally in use. Is phagedcena contagious ? To this I should reply in the negative, although hospital gangrene undoubtedly is so. But between these two we meet with a class of cases which indicates the necessity of answering with caution. In 18G8, a lad of about 18 was under my care in St, Bartholomew's Hospital, •with a circular foul pliagedcenic ulcer on tlie inner side of each aukle, covered by a perfectly black slough. That on the right leg measured full two inches' diameter, that on the left leg was somewhat less. The history was as follows : About a week previously a sheep which he was dragging from a pen, got one hoof between his leg and the boot ; the skin was a little bruised, but not abmded. In the course of twenty-four hours a pimple formed on some reddened skin ; this became a pustule, which rapidly passed into a spreading phagedaenic ulcer with sloughing surface. While lying in bed, he brought by accident the two legs together, and on the fourth day after the formation of the first sore, one precisely similar made its appearance in a corresponding situation on the left leg. While in his lodgings the ulceration spread in spite of the usual appli- cations with great rapidity ; but on his removal to the better air of the hospital, under similar treatment, the black scab separated, the phagedsenic action ceased, and the ulcers acquired a normal granulating aspect. Eoser affirms that he has seen cases which seem to show the possibility of a septic metastasis to the sacral region. He supposes that in septic poisoning of the blood, a local affection or metastasis is most liable to occur in such parts as are most dependent — which, in the mass of cases, is the sacral region. He is not disinclined to consider many cases of gangrenous bed- sore as metastatic affections. The treatment of j)haged8ena resolves itself under two heads — the general and the local ; and while in some cases the former seems sufficient at once to arrest the spread of the ulceration ; in others some marked local application, such as the destruction of the surface by strong nitric acid, seems needed, that the pro- cesses of repair may be re-established. General treatment. All sm'geons are, I think, agreed that in the general treatment the main features are, that, the strength should be kept up in every way and the nervous irritability allayed. Mr. Prescott Hewett is an advocate for rum and milk in the early morning — a remedy equally pleasant and useful. I usually order the concentrated essence of beef (i. e. four pounds of the meat yielding a pint of soup without water) : one or two ounces of this, or more, according to the patient's taste, to be given frequently. Good brandy with hot water, often with an PHAGEDENA. 177 egg and spice may be given. The rule is tlie same : stimulants should be administered until the patient is raised from the state of general depression which accompanies this disorder, and frequently very large quantities are required. Opiates are of the greatest use ; they may be freely adminis- tered, both for the purpose of checking the local pain and of giving rest at night time. Medicines do not seem in other re- spects to exert any marked effects in the acute stages^ but quinine or liq. cinchona?, combined with ammonia, may be administered with advantage. Above all things, the patient should be at once removed to some place where the surgeon knows that the air is pure and uncontaminated ; any change is better than to allow him to remain under the same circumstances as those which gene- rated the disease. I am no advocate for keeping the windows open day and night : the chill of the night wind may induce other complications. The state of the atmosphere may be better re- gulated by limiting the number of attendants, or in hospitals by exercising a proper supervision over the number of patients in the same ward, and the character of the diseases therein aggre- gated. So long as the appetite remains impaired it is of little good to order solid food ; but meat may be freely allowed when grateful to the patient, or a mixed diet, such as would be adapted to a person in usual health. It is also desirable to avoid any accumulation in the bowels, although, as a rule, purgative medicine should be administered with care. The local treatment of phagedaina is governed by clear and simple rules. The sharp stinging pain should be allayed by a lotion containing opium in sufficient quantity. A piece of lint thus saturated may be put on the part, and then covered with a bread-and-water poultice. In some cases a charcoal poultice cleanses the sore. Among recent applications carbolic acid in solution holds a j)rominent place. It corrects the foetor, pro- motes granulation, and is supposed to destroy the germs of the disease. Condy's fluid is another favourite application. In the more chronic cases, benefit may be derived from the use of black or yellow washes ; solutions of nitrate of silver ; nitric acid and opium ; solutions of alum ; ointments of various kinds, as the ung. hyd. nit. oxyd., the ung. hyd. nitratis, or the ung. rubrum, which contains the bisulphuret of mercur}^ and crea- sote. Pure creasote may also be applied. In other cases, the simplest applications are the best. In the more acute VOL. I. N 178 GANGEENE. forms, tlie surface of the sore may need disintegration by the action of strong nitric acid. This, however, should not be applied unless the rapidity of the destructive j)rocess be exces- sive, or parts of importance, such as a large artery, lie in imme- diate proximity. The surgeon should ever remember the im- portance of the preservation of the integument, inasmuch as after the subsequent cicatrisation, the neighbouring parts may suffer an unpleasant degree of traction. HOLMES COOTE. ULCEKS. THE chief interest of this subject, from the surgeon's point of view, is in the study of those forms of ulcer which appear in the integuments ; and to these, their diagnosis and treat- ment, the present essay will be almost entu-ely devoted. But, first, the general process of ulceration, though referred to in the appendix to the essay on Inflammation, may be briefly con- sidered. Ulceration is that part or effect of an inflammatory process in which the materials of inflamed tissues, liquefied or degene- rate, are cast off, in solution or very minute particles, from free surfaces, or, more rarely, are absorbed from the substance of the body. Not every such process of casting-ofp, however, is called ulceration; when the detached particles are only epithelial, though the process may be essentially the same, it is called desquamation, abrasion, or excoriation ; and the name of ulcer is not commonly applied to any result of inflammatory casting- ofP, unless the substance of a tissue deeper than the epithelial be exposed. Ulceration has very near afl&nity to gangrene ; the two pro- cesses, indeed, differ rather in degree than in kind. When the degenerate or dead substance is cast off in one or more portions visible to the naked eye, the process is usually called gangTene, or by some synonym of gangrene ; when the portions are not so visible, or are quite dissolved, it is called ulceration. More- over, the separation of a gangrenous or dead part is commonly effected by ulceration of the living, but inflamed and degenerate, part that bounds it ; and this separation is, indeed, the best example, and the most frequent beginning, of the formation of an ulcer. If the process be watched that follows the simple killing of a portion of the body (suppose, a piece of skin sud- denly crushed or burnt to death), inflammation is seen in aU its environs. After some time, the dead part being decomposed n2 180 ULCEES. and changed according to the merely chemical characters of its materials, the border of the living part next to it is seen in gradual process of removal. Often this border first loses its inflammatory redness, and looks like a pale-yellowish or white zone, or ' line of demarcation,' round the dead piece or ' slough ; ' but whether this change occur or not, the border of the living part nearest to the dead is first grooved, and then more and more deej)ly excavated, till the dead piece is wholly separated and detached from the living. The surface from which the dead piece is thus detached is an ulcer ; and the explanation of the process is, that the layer of living tissue next to the dead piece, being acutely inflamed, degenerates rapidly, is either liquefied or disintegrated, and is thus gradually separated, either in solution or in molecules suspended in the liquid in- flammatory product. An essentially similar removal of mflamed structures by ulceration, that is, by solution or molecular disintegration and ejection, may be seen in an}^ spreading ulcer of skin or mucous membrane, of bone or cartilage. Here, there may be no death of visible particles, no sloughs, but the inflamed and rapidly degenerating structures are cast out as by what some have called a molecular gangrene. It would be needless repetition to describe the minute changes which the degenerating inflamed structures undergo before being cast off: so far as they are known, they are described in the appendix to Inflammation. With them there is always discharged some liquid, in which they are suspended or dis- solved. The appearance and properties of this ' discharge,' or * ichor,' are various, according to the causes and characters of the ulcerative process. When the process is ver}^ active, the ichor is usually a thin, yellowish or grayish fluid, often tinged with blood, albuminous, not spontaneously coagulable, contain- ing abundant molecular matter, the debris of the ulcerating structures, and corpuscles like ill-formed pus-cells. From some ulcers, e.g. the primary syphilitic, it is contagious; from many it appears corrosive, not indeed as having a directly solvent power, but as exciting by its acridity, or by the * catalytic ' in- fluence of its own decomposition, inflammatory and degenera- tive changes in the tissues with which it is in contact. From many ulcers, again, the ichor or discharge is peculiarly ' foid,' i. e. it rapidl}' decomposes, yielding putrid or other offensive gases, or it contains putrid fragments of the ulcerating struc- CHIEF FORMS OF ULCEE. 181 tures, or of granulations wliicli die prematurely. Such is, commonly, the character of the discharge from the most rapidly destructive ulcers ; while, on the other hand, the more an ulcer tends towards healing, the more does its discharge become like * laudable ' pus. So long as an ulcer is in progress, the tissues next to it ar€ inflamed, and usually are in that state of inflammation which is understood as ' low,' being marked (at least, in the integu- ments) by a dusky redness, heat which feels to the patient burning and pungent, and with very little production of organi- sable matter. Commonly, the ulcerating surface is abrupt, looking jagged, or eroded, dusky, brownish or yellowish, mottled, without granulations, ready to bleed. The more active the progress of an ulcer, the more marked are these cha- racters in the structures around it ; and when its progress ceases and healing begins, these characters are exchanged for those of the healthy ' determination of blood,' which, without inflammation, attends the production and development of repa- rative granulations. The healing of an ulcer difiers in no material point from that of an open wound with less of substance. It is a healing by granulations ; and though the shape and other characters of the cicatrix often have peculiarities indicative of the disease that it has repaired, there is no known difference in the process of repair (see Wounds). What has now been said of the general process of ulceration is applicable for an explanation of the process by which all or any of the numerous forms of ulcers are produced ; we have no knowledge by which to explain the peculiar and characteristic forms that they severally present. Nevertheless, the diagnosis and import of these forms are of high interest in surgery. The chief forms of ulcers may be best named and arranged, in the first instance, according to the constitutional or specific diseases which they severally indicate or are derived from. For each constitutional disease in which ulcers are apt to occur may be said to express itself in them by the peculiarities of shape, size, and other qualities by which they are severally distinguished from a common ulcer, such as may exist in a healthy person after the separation of a slough from accidental violence. Another nomenclature and arrangement of ulcers, which has been very generally adopted, is derived from characters which 182 ULCERS. they present in certain local or accidental conditions. Thus ulcers are named irritable, chronic, sloughing, &c. But many of the characters implied by this nomenclature are transitory ; many are accidental ; some may belong equally to two or more kinds of ulcers that are essentially different and require different modes of treatment. The plan, then, that will be here followed is that of describ- ing, first, each of the chief varieties of ulcer, distinguished according to its constitutional or specific origin. The type with which to compare and contrast each of them is the simple ulcer, left at the separation of a slough, after injury, in a healthy person ; and the type of each distinct form or variety must be in the characters which it presents in its most frequent appearance, or in which it is prone to continue when not dis- turbed, for either good or harm, by any external circumstance. In a second section will be a description of the subordinate or accidental varieties of appearance which may be found in, or connected with, any of the chief forms of ulcer (though not with equal frequency in all), according to external circum- stances. A common, simple, or healthy ulcer, as already said, is such an one as is left after the separation of an accidental slough in a healthy person. In many of the points wherem other ulcers show some of their chief diagnostic marks, the characters of the simple ulcer are, of course, negative or accidental. Its locality, shape, size, and number, depend on the injury which it has followed. K only the skin has been destroyed, its base is level, slightly depressed (the less so, the more nearly its healing is completed), uniformly covered with small florid granulations, which feel soft, pliant, and elastic, and, though highly vascular, do not readily bleed and are not painfully sensitive. The edges of the common ulcer shelve gently down to its base, and feel scarcely harder than the adjacent healthy skin. At their junc- tion with that skin they are generally opaque-white, with a very slight thickening of epidermis ; Avithin this they have a pale purplish-blue tint, where the new-formed epidermis veils the colour of the healing granulations ; and yet within this the granulations have a deeper hue than those nearer to the centre of the ulcer, being most vascular where the cuticle is being actively developed. The pus from such an ulcer is ' healthy ' or ' laudable ' (see Abscess) ; the parts immediately beneath and around it are somewhat more vascular than is natural, but SIMPLE AND INFLAMMATORY ULCER. 183 are not otherwise changed. Such are the characters, by their deviations from which aU other ulcers are distinguished, and by their approaches to which they indicate their tendencies to healing. For the healing of a simple ulcer may be called spon- taneous, as that of a granulating wound may be ; and for both alike no other treatment is necessary than exclusion from injury. Inflammatory iilcers — that is, ulcers having their origin in an inflammation of low type, but not specific, or else in some con- stant irritation — are among those least different from the com- mon type. They usually have their origin in some slight injury, a scratch or blow, such as a 'broken shin,' which a healthy person migftit have suffered with impunity. Their most common seat is on the lower half of the leg, and they are commonly single ; they are usually less than an inch in any diameter, and of irregular shape ; their bases are generally level, very little depressed, ragged or flocculent, without granulations, ruddy, looking raw, or else ash-gray, or yellowish with adherent thin slough; their edges are abrupt, irregular, or shreddy; their pus, or ichor, is thin, watery, excoriating, not unfrequently blood-tinged. The skin round an inflammatory ulcer is usually full-red, bright or dusky according to the patient's general condition, hot and burning, and the whole seat and neigh- bourhood of the disease feel very painful, bm-ning and aching * down to the bone ;' not rarely, also, the surrounding tissues are oedematous or in patches excoriated. An inflammatory ulcer, unless it be due to some constant ex- ternal in-itation, always indicates general unhealthiness in the patient, but not always the same defect or error of the health. It may be found in the well-fed and plethoric of all classes, but is probably most frequent in the infirm and old, the ill-fed and overworked. There is, therefore, no specific or single method for its general treatment. This must be decided by the con- dition of each patient, just as that of any other active inflamma- tory disease must be. For local treatment the chief means are leeches, applied at a distance from the ulcer, e.g. near the knee or on the foot, if the ulcer be at or near the middle of the leg ; warm water-dressing, or lead-lotion applied warm, or poultices ; complete rest of the part, and (if it be the lower limb) recum- bency with elevation of the limb. Bandages, ointments, and plasters are usually to be avoided till the ulcer shows signs of healing. With less favourable changes, the inflammatory 184 ULCERS. ulcer is especially likely to be excessively painful (see neuralgic ulcer, p. 201), or to become cbrouic; mucli more rarely it assumes strumous, or syphilitic, or other specific characters derived from some constitutional disorder in the patient. Eczematous ulcers merit distinction from the preceding, although like them in many characters, especially in their most frequent seat, their usual shape and size, and characters of base and margin. They may have their origin in slight injuiy, the ulcers forming as in the last kind, and the sur- rounding inflammation assuming an eczematous instead of a common character, the skin becoming punctate or vesicular, or, in old persons, purpurous, or cracking and exuding an adhesive ichor with constant itching. But they are often spontaneous, the ulceration taking place in the middle of a patch of acute eczema. In either case, the general treatment must be guided by the character of the disease of the skin. The remedies for eczema must be used, regard being had especially to the gouty, stru- mous, or other constitutional disposition with which it is in each case connected. For local treatment it may be noted that such ulcers seldom tolerate ointments or dry bandages. In general, the best applications are water-dressing or wet linen- strapping ; if the skin around the ulcer exude profusely, it may be covered with daily-renewed pieces of blotting-paper, or dusted with starch, or, best of all, be occasionally washed with a strong solution of nitrate of silver, which is equally a good remedj' for the ulcer itself. It is probably these, more than any other ulcers, that have given rise to the question whether ulcers should always be cured if possible. There is sufficient reason to believe that the cessation or ciu-e of an established eczema has been attended with serious disease of the brain or other internal organ ; the same may happen with an ulcer of this, or probably some other kinds. The event is certainly very rare, but it may often be right to guard against it by making an issue in some place more convenient than the ulcer, or by renewing the cuta- neous disease with counter-irritants, especially by frictions with croton-oil liniment. Although eczematous ulcers alone are here named, yet it may be noted that ulcers may occur in several other forms of cutaneous eruption. They are, indeed, frequent in all the severer forms of the acute eruptions in patients that are cachectic : whether with intense struma, or syi)hilis, or through defective COLD ULCER. SENILE ULCER. 185 food, foul air, or other depressing influences. But at present it is siifficient only to mention tliese ulcers ; their diagnosis and treatment are to be determined by the eruptions with which they severally concur, and with the accounts of which they will be described hereafter. Cold idcers should be distmguished because of the peculiarity of constitution on which they depend, and which often has to be considered in the treatment of other ulcers of various kinds. They are like small inflammatory ulcers, occm'ring spontaneously in the extremities, especially at the ends of the fingers or toes, or at the roots of the nails. Li some cases they are preceded by severe pain and small gangrenous spots. They are in many respects like ulcerated chilblains, but they occur without any exposure to intense cold, in patients whose feet and hands are commonly, or even habitually, but little warmer than the atmosphere they live in. Such patients are among those who say they are never warm ; and the skin of their extremities, unless artificially heated, is to the touch like the surface of a cold-blooded animal. The blood must flow in these parts so slowly, that there is time for it to be cooled nearly to the temperature of the atmosphere ; probably it is often stagnant, or scarcely circulating."^ With this defect, which in its smaller degrees is very common, especially among women, the usual coincidents are a small feeble pulse, a dull or half-livid tint in the parts which in healthy people are ruddy, a weak digestion, constipated bowels, and scanty menstruation. The cure of the ulcers, and prevention of their recurrence, lie in the remedy of these defects. Many tonic medicines may be useful, but the most so is iron, in whatever doses the patient can take it. With it purgatives are generally necessary ; e. g. small doses of mercury and aloes, or of sulphate of magnesia. Full diet, also, is usually required ; exercise m the fresh air ; very warm clothing, especially of the lower half of the body; and wann bathing. Dry applications, or lotions with sulphate of zinc or of copper, are the best local means, and the part must be kept warm ; healing is always tardy or quite arrested at a tempera- ture far below the natural heat of the body. Senile ulcers present, usually, many of the characters of in- * Experiments are wanting to prove how deeply this coldness extends. The writer put a thermometer in a wound made in the division of a tendo Achillis in a cold-footed young woman, and it showed only 70° F., the atmosphere of the room bein g 65°. 186 ULCEES. flammatory ulcers of tlie lower type, but should be distinguisbed because of the peculiarity of tbeir origin and coincidents. They have no distinctive characters of shape or size, but are especially dry, secreting little even of ichor; and they have a kind of rusty-ruddy tint of their granulations, and are suiTOunded with a dusk}^-pink or red area. And these characters corre- spond with those of the tissues in which the senile ulcers are found, for they are most common in the dry withered limbs of those who are shrinking, as they grow old with either a timely or a premature degeneracy, and whose arteries are probably advanced in degeneracy. The surrounding skin is usually dry, thin, brownish, scaly ; it may be eczematous ; and its veins, especially those near or below the ulcer, are large or stellate. Often, also, some part of the border of the ulcer sloughs ; the slough, with a well-defined boundary, yellowish or grayish- white, extending into the adjacent skin. Thus, in some cases, the ulcer spreads at one i)art while it may be healing at another ;' extending with a kind of senile gangrene of the integu- ment, similar to that in which it may have had its origin. Such spreading is usually preceded or accompanied by aggravation of the pain with which the ulcer is associated, but which, except at such times, is seldom considerable. The general treatment appropriate for senile ulcers consists chiefly in giving such good food and wine as, under nearly all conditions, those who are withering require. Bark, also, is commonly useful, and the mineral acids ; and in cases attended with sloughing, opium often appears to be a very valuable remedy. For local treatment, stimulant ointments, or balsams, or these in combination, commonly do more good than stimu- lant lotions, which rather wither the granulations that may be forming ; or than water-dressings, which are apt to produce irritable eruptions about the sores. A very iiseful plan, when the disease is extensive, is to strap the limb daily with a mixture of resin-ointment and Peruvian balsam spread on strips of lint or linen. Strumous ulcers, most of which, it is probable, might be also called tuberculous, are most commonly seen as the consequences of strumous or scrofulous suppuration in the subcutaneous tissue or lymph-glands ; but they may appear without any such preceding disease. In this case, the usual stage previous to ulceration is that of slightly elevated, pale red or pink, circum- scribed thickenings of the skin, like cutaneous tubercles. These STEUMOUS ULCEE. 187 may appear singly or in groups ; and may, perhaps according to tlieir duration, be firm, or softish, or boggy, as -witli a soften- ing of tlieir substance. This last state, which is probably a kind of imperfect suppuration or softening of tuberculous matter under the skin, immediately precedes the ulceration. The ulcers, whether formed thus or after the wide opening of strumous abscesses in the lymph-glands or subcutaneous tissue, are most frequent in the neck, groins, cheeks, scalp, and the neighbourhood of the knee, ankle, wrist, and elbow. They are often multiple and clustered. They generally affect an oval shape, but by coalescence may be irregular and variously sinuous and of great extent, though singly they rarely attain an inch in diameter, and have little tendency to spread. The margins of strumous ulcers are commonly formed of undermined, over- hanging skin, which may be either thin or ii-regularly thickened, without induration, and either pale pink or purplish, according as the circulation is more or less free in them. The bases of the ulcers are usually unequal, soft, covered with large, soft, CBdematous granulations, which are often pale, and bleed on slight contact, and sometimes project exuberantly above the surrounding level. The pus of strumous ulcers is commonly thin, greenish-yellow, seldom irritant ; they are rarely very sensitive or painful. The parts around them may be healthy ; but when the ulcers have existed long, and especially Avhen they are connected with old strumous disease of bones or joints, all the adjacent textures are generally greatly enlarged with oedematous infiltration, and cloo-o-ed too^ether. By these characters strumous ulcers may, almost always, be recognised ; but the diagnosis is assisted by the coincidence of the known signs of the strumoiis constitution, or of similar disease in other parts or tissues. And these coincidences indi- cate the general treatment, of which the chief constituents must usually be either preparations of iron, especially the iodide or phosphate, cod-Hver oil, quinine, or iodide of potassium; occasional purgatives, or small doses of mercury; fresh air, especially by the sea, or on high hills ; free exercise ; bathing ; and scrupulous attention to the digestive organs, which are very commonly disposed to receive more and other food than they can make good use of. The local treatment of the ulcers (excluding the cases in which they are connected with diseases of the bones or other deep-seated parts) must generally be stimulant. For different cases, which it may be impossible to 188 ULCERS. define, the ointments witli iodine, or tlie iodides of potassium, lead, or mercury, may, any or all of them in succession, be found valuable. Or lotions of the iodides may be used, or of the astringent metallic salts, or of nitrate of silver. An excel- lent -way of applying these, when the ulcers are on the limbs, is with strips of linen or lint soaked in the lotion, and put on as firm strapping. Of numerous popular applications, the best, probably, is a poultice of bruised and warmed sea- weed. When the skin is very much undermined and burroAved, its destruction with potash, or some similarly acting caustic, is often very useful. Cases occur, though rarely, in which amputation is the only remedy for strumous ulcers. They are chiefly when the ulcers are about the ankle-joint, and attended with great oedema of the foot, or when they are deep enough to have involved some bone or joint ; but no general rules of treatment can be here laid down. The scars of strumous ulcers may be causes of ugliness and deformity, either by contraction or, more commonly, by over- growth, and the formation of bars raised in radiating lines, or networks, or tongues of skin. In such cases, excision of the scars may be necessary ; but in many instances a great part of the excess of scar may be removed by rej)eated slight blistering, and with time nearly the whole will level down. In superficial scrofulous ulcers on the hands and feet a peculiar appearance is sometimes produced by an excessive growth of the papillffi at the base or borders of the ulcer. In either, or in both situations, they give the ulcers a remarkably warty character — a character which is often maintained when the ulcers are healed — and leave a coarse, nodular, and warty patch of skin, with opaque, thick cuticle. At fii-st sight, such ulcers might be taken for papillary ejjithelial cancerous disease ; but the diagnosis is easy, through their being often multiple, having no hardness of granulations or of base, no sinuous or upraised border, no rapidity of progress. These warty strumous affections may be cm'ed with repeated paintings with tincture of iodine, or with the most stimulant of the iodine ointments. Scorbutic ulcers. Popularly, many kinds of ulcers are thus named ; especially the inflammatory, eczematous, and some of the strumous. But the name should be reserved exclusively for those that derive their peculiar characters from the existence SCOEBUTIC ULCER. GOUTY ULCER. 189 of scurvy. Mr. Busk, whose great experience on board the Dreadnought Hospital-ship has given him an unequalled knowledge of scurvy, has kindly supplied the writer with the following note : — ' Although scurvy in itself cannot be said to be attended with any peculiar form of ulceration, ulcers or sores of any kind already existing from other causes assume, in consequence of the scorbutic taint, a more or less peculiar character, and when thus modified have usually been termed " scorbutic ulcers." ' Scurvy essentially consists in an alteration in the constitu- tion of the blood, which leads to the efiusion into the various tissues of a fibrinous exudation, usually deeply coloured, and which has on that account been commonly regarded as a simple coagulum. That this effusion, however, can scarcely be re- garded in this light, is proved by several considerations, but more especially by the circumstance that it is, from the first, solid and capable of becoming imperfectly organised — that is to say, it is after a time permeated by newly-formed vascular channels. It is the presence of this effusion which causes the spongy swelling of the gums, the tumefaction and induration of the intermuscular tissue, the so-termed scorbutic nodes, and which, when poured out on the surface or in the substance of the corium, constitutes the vibices and petechise so characteristic of the disease. It is the efiusion also of the same semiplastic material on the free surface of sores or ulcers which gives them the peculiar aspect termed " scorbutic." * Ulcers of this kind are distinguished by their livid colour and irregular tumid border, around which no trace of cicatrisation is evident ; whilst the surface of the sore is covered with a spongy, dark-coloured, strongly adherent, foetid crust, whose removal is attended with free bleeding, and is followed by a rapid reproduction of the same material. This crust, in bad cases, as remarked by Lind, attains to a " monstrous size," and constitutes what has been appropriately termed by sailors "bullock's liver."' Gouty ulcers. Persons of gouty habit are among those most liable to inflammatory and eczematous ulcers ; but the form to which this name is specially given is that found in distinctly gouty parts, or over gouty deposits. Such ulcers are usually superficial ; and even when they occur on the ijalm or sole, and extend through thick cuticle, destroy only the surface of the cutis. They are circular, if of any definite sh;ipe, with low 190 ULCEES. shelvinsr borders, and witli bases tbat are either florid and without granulations, or covered with a thin yellowish or grayish layer, like a soft slough. They discharge a thin ichor, which commonly, as it dries, leaves a white chalky deposit ; and they are exceedingly slow in getting either better or worse. The parts around them are usually healthy, except in so far as they may be gouty. The general treatment of gouty ulcers must be determined by the general condition of each case. Locally they may be best palliated by the simplest applications, such as water- dressing or simple cerate ; or cured by washing with solutions of from five to ten grains of nitrate of silver to an ounce of water. Syphilitic ulcers. Those that are primary need no mention here, except to indicate the necessity of being on the watch for the diagnosis of such as occur on the lips, fingers, and other parts on which they are rarely seen, and more rarely suspected by the patients. And secondary diseases of the integuments are very seldom ulcerative, unless when pustular eruptions occur in the cachectic. Tertiary syphilitic ulcers, however, are so frequent, and their diagnosis from all others is so important, that, although it may involve repetition, they must be described here as well as elsewhere. They usually appear among the latest signs of syphilis, and are most severe in those who are most reduced, whether by the syphilitic poison abiding in them, or by mercury, or both, or by poverty, intemperance, or naturally unsound constitution. There is probably no form of ulcer in which the influence of all these evils is more intensely felt. Two principal forms of tertiary syphilitic ulcers may be dis- tinguished at, or near, the beginning of their formation; of which the one usually succeeds to rupia or some other ulcer- ating eruption, and the other follows subcutaneous indurations with circumscribed infiltration of the tissues {gummata, or syphilomata, as they are sometimes called). In their later stages, the two forms may be not distinguishable ; but they generally maintain the difference of being, the one superficial, the other deep ; the one extending through only the cutis, the other into or through the subcutaneous tissue. The more superficial tertiary syphilitic ulcers may be known, in many cases, by being commingled with well-marked eruption ; but when this is not the case, the signs most to be relied on are SYPHILITIC ULCEES. 191 as follows. They may occur on any part, but are most fre- quent on the trunk, as on the back, shoulders, nates, and, in next frequency, on the limbs. Their most frequent shapes are circular, annular, or crescentic, or horseshoe-like. The annular shape, in which a round or oval portion of healthy or scar-Hke skin is surrounded hj a ring of ulceration, which often extends at its outer border whUe healing at its inner, is almost certainly characteristic of syphilitic disease ; and equally so is the ulcer in the shape of the crescent or horseshoe, which commonly heals at its concave, even while extending at its convex border. Such ulcers may be single or multiple, and in the latter case may be grouped or arranged in a circle, or some other curvilinear figure. They may be of any size, from half an inch to five or six inches in diameter, and generally are smallest when they are most numerous. Their edges are usually abrupt, sharp-cut, or sometimes jagged ; not undermined, or elevated ; bounded by skin which appears little changed in texture, but may be ruddy, or highly vascular. Their bases are usually level, little depressed, uniform, dusky dark crimson, or more florid, with soft small granulations, if any. Their discharge very com- monly concretes into scabs, which may partially or completely cover them, and may be heaped up like those of typical rupia. Tertiary syphilitic ulcers of this kind are not usually asso- ciated with evident disease in the textures adjacent to them. They have themselves no induration, and, rarely penetrating beyond the cutis vera, they leave the subjacent tissues, as well as those round them, soft, pliant, and apt for rapid healing, with smooth and glistening scars that scarcely contract or adhere to parts under them. Generally, the ulcers of this kind are not associated with any other active form of syphilitic disease, though their diagnosis may often be assisted by the marks of such disease past-by. Neither have they any attendant constitutional disorder other than belongs to the several degi-ees of syphilitic cachexia ; and they are seldom very painful, unless when seated on the hands or feet. The deep tertiary syphilitic ulcers usually have their origin in circumscribed indurations, of a doughy, inelastic consistence, in the subcutaneous and sometimes in yet deeper tissues. Such indurations are at first painless, and scarcely involve the cutis ; it passes smooth over them, level, or but slightly upraised. But after the lapse of an uncertain time (it may be less than a 192 ULCEES. week, or more tlian a month), tlie central part of the indura- tion becomes soft, and feels boggy or rotten ; the cutis becomes adherent, red and thin, and all the diseased part more painful. Then the thin skin ulcerates, and at once the diagnostic cha- racters of this form of ulcer are established. Such ulcers are most frequent on the extremities, especially near the knee or the elbow or the shoulder ; but they may be found anywhere, and are not rare on the lips, forehead, alse of the nose, and other parts of the face, on the palate and the tongue. They are usually circular or oval, seldom less than a quarter of an inch or more than an inch in diameter. There are more often many than one at the same part, and not rarely several are found in different stages, or of different dates of formation. The edges of these ulcers are usually very sharp- cut, abrupt, sometimes going right down through the thick substance of the induration, as if a piece had been punched out of it. The edges are rarely either undermined, elevated, or everted ; and as they extend, the whole substance of the indu- ration is pretty uniformly destroyed. Their bases are not unfrequently covered with slough, due apparently to the degene- ration and death of the indurated substance in which the ulcer had its origin. Or, when not sloughing, the bases of the ulcers are commonly deeply excavated, without evident granulations, resting on the deeper subcutaneous tissue. Ulcers of this kind are seldom painful unless when acci- dentally inflamed, and are remarkably little affected by posture or those other external conditions which notably modify the characters of ulcers that are less evidently specific. The tissues adjacent to the induration which surrounds these ulcers are in the first instance little affected ; but as the disease extends, or has been from the first deep-seated, they may become even very deeply involved, e.g. to the deep fasciae, or muscles, or perios- teum. Very commonl}-, too, an area of dusky redness sm*rounds the ulcer, and the duskiness may be noted as one of the signs by which these tertiary syphilitic ulcers may be distinguished from certain strumous ulcers which are much like them, but have surrounding areas of a bright -pule pink. A well-marked, though not intense, cachexia is often (but far from always) associated with these ulcers, and periosteal or osteal pains may coexist. Yet more generally they are the only present signs of syphilis ; the disease seems to localise itself in them 5 and it is not very rare to find patients, who have con- SYPHILITIC ULCEE. LUPOUS ULCEE. 193 tinued for ten or more years subject to these tilcers, but to no other form of syphilis, and even ha\ing these ulcers on only one part, e.g. on one lower extremity. Little need be said here of the treatment of the tertiary syphilitic ulcers. It must be according to the general rules Avhich will be laid down in the essay on Syphilis ; yet a few rules may be mentioned. As with all specific ulcers, so with these : specific treatment is of little or no avail, but may be mischievous, while they are the seats of acute inflammation. This, ^though it be but an accidental complication, must be reduced by ordinary means before specifics can be profitably given. Iodide of potassium, in such doses as three grains twice a day, very rarely fails to cure any ulcers of either the super- ficial or the deep form ; but just as rarely is the cure perma- nent. Again and again after treatment with this medicine ulcers recur in or near the scars of their predecessors ; and the choice lies between repeating such temporary cures, till in time the disease as of itself ceases, or the employment of mercury. The local applications must generally be stimulant ; and among the best materials for dressings are the ointment of the nitric oxide of mercury and the black wash. If there be no acute inflammatory or other complication, either of these may be used till the ulcers are completely healed. In the event of such complications, the tertiary syphilitic ulcers are among those for which the plan of water-strapping is best adapted. In connection with the history of these tertiary ulcers, it should be mentioned that ulcers exactly like them may be found in young persons that have inherited syphilis ; that there is some reason to believe that they may be imitated by the effects of mercury given for other than syphilitic diseases ; and that when tertiary syphilis occurs in persons of strumous con- stitution, ulcers may appear of intermediate characters, in which it may be impossible to make a diagnosis, unless by the influence of iodide of potassium, which appears to be the greater in the same proportion as syphilis enters more largely into the constitution of the disease. Moreover, there are certain forms of ulceration prevalent in some tropical climates, and occurring among Europeans therein, which very closely resemble these tertiary syphilitic ulcers, and are like them curable with iodide of potassium. Lupous ulcers will be described with the Diseases of the VOL. I. 194 ULCEES. Skin, the tubercular condition of tlie cutis whicli usually precedes tlieni having given to ' lupus ' a claim to a place among cutaneous eruptions ; but their chief diagnostic cha- racters may be mentioned here. Occurring usually in persons of marked strumous constitution, they are most frequent on the face, especially on the tip or alse of the nose, and the upper lip or cheek. They are not very rare on the external female organs of generation. Often also they are seated on the boundaries of the skin and mucous membrane of the nose, extending on both ; or, with ulcers on these parts, others may be found perforating the septum of the nose or in the pharynx. A cu'cular ulcer perforating the lower and anterior part of the nasal septum, slow in progress, and generally healing when it is rather more than half an inch in diameter, is a very- characteristic form of lupus associated with tuberculous in- heritance. Luj)ous ulcers are commonly preceded by one or more flattened, slightly elevated, firm, oval or roundish, pink tubercles or thickenings of the cutis. These perish in the ulceration, and the extension of the ulcers is not usually preceded by thicken- ing of the cutis next to be invaded. The ulcers take the shape and number, and in the first instance the size, of the tubercles ; but they soon extend and coalesce, destroying in their progress not cutis alone, but the deeper textures, as the cartilages and bones of the nose, the mucous membranes, or any others that may stand in their course. And this progress is not with sloughing or any signs of active inflammation, but with con- stant and, it may be, slow ulcerative destruction of the borders of the ulcers. The borders are generally abrupt, irregular, ' eaten,' some- times sHghtly elevated or thickened and firm, very rarely under- mined. The bases may be nearly level, pale, and ahnost void of granulations, or they may be covered with coarse, dusky, prominent granulations raised highest at the centres. In either case the ulcers are very often scabbed over, by the drying and concretion of their discharge ; but the scabs do not facilitate scarring beneath them ; rather, they favour the progress of the ulcers. The ulcers are seldom pamful or prone to bleed, even when then- granulations are j)i'ominent, and the parts around them and beneath their bases are generally healthy. Coin- cident with them may be any form of strumous disease or of its con equeuces. EODENT ULCEE. 195 Lupous ulcers are the first to which can be ascribed that property of cancerous or mahgnant diseases which consists in their proneness to extend irrespective of tissues. But this character is not sufficient to prove that they have relationship to cancer ; their most evident affinities are with struma and tuberculosis. These indicate the most useful constitutional treatment, namely, that with cod-liver oil (which may need to be given in very large doses) or other remedies for struma. And it is to be observed that when tertiary syphilitic ulcers occurring on the face imitate many of the characters of lupus, these remedies are wholly useless for them, even more so than is iodide of potassium for the true lupous ulcers of strumous origin. But besides, local treatment is essential. A long course of very active stimulants, such as turpentine, may heal lupous ulcera- tion ; but such healing is insecure, and the disease is veiy apt to return in the scar. It is better to destroy the whole borders and base of the ulcer thoroughly with some escharotic, which may penetrate far enough to reach healthy structures. What escharotic should be chosen must be determined by the con- ditions of each case. Rodent ulcers (also often called lupoid, cancroid, &c.) have several characters in common with those last described; yet their difference is proved, among other distinctions, by their occurring as generally in the later half of life as the lupous do in the earlier ; and by their affinity with cancer, and not with struma. They usually originate in some tubercular or scaly spot of long duration on the face, on which repeated formations and off- castings of dry crusts and scales may have been observed. Their most frequent seats are the cheeks, eyelids, upper lip, nose, and scalp ; but ulcers of essentially the same characters may occur on the vulva, vagina, areola of the breast, by the anus, or per- haps many other parts. They are usually single, and not sym- metrical ; circular or oval in the first instance, but in their pro- gress becoming quite irregular in shape, extent, and depth. Their borders are seldom much elevated or distinctly nodular or lobed ; but are usually either abrupt or smoothly rounded, or with low tubercles in or near them, not undermined or everted. Both the borders and the base feel tough or hard, as if formed or bounded by a layer of indurated tissue from half a line to a line in thickness. Beyond this layer all the tissues adjacent to a rodent ulcer appear healthy. The surface of the base is gene- o2 196 ULCERS. rally smootli, and, it may be, level ; dull rcddisli yellow, looking lialf-dry and glossy, void of granulations, yielding very little discharge of any kind. It very rarely bleeds, or gives acute pain, or has any exuberant up-growth of granulations, or any warty or lobed structure, such as is so common a characteristic of the epithelial cancerous ulcers, to which, in some respects, the rodent bear a close resemblance. In very rare cases, a dis- tinct subcutaneous growth may be found at the border of a rodent ulcer. In such a case the writer found a firm, elastic, rounded mass, nearly an inch in diameter, pale-grayish, yielding- no cells or other structures like those of epithelial or any other form of cancer, but small corpuscles like those of ordinary STanulations. After the removal of the mass with the rodent ulcer, and the adjacent part of the ear by which it grew, the patient lived twelve years without recurrence of the disease, and then died with senile gangrene. The progress of a rodent ulcer is usually very slow, but if not checked by treatment, it is very sure, and at any time liable to be accelerated by accidental inflammation. It constantly ex- tends wider and deeper, destroying every tissue that it invades, yet maintaining throughout the same general characters of base and border, and the same usual absence of attendant growth. Such ulcers may destroy great portions of the face, and pene- trate so as to expose the pharynx or the nasal cavities, or the brain, or any deepest-seated part. Thus they may be fatal; but to the last, they have no associated similar disease in the lymphatics, or in any distant part, and no other cachexia than may be due to the feebleness which they cause. Indeed, it is often a subject of wonder when the contrast is observed between the horrible ravages of a huge rodent ulcer of the face, and the apparently undiminished general health and strength with which the patient bears it. In no other equally destructive disease is such a contrast seen. The treatment of rodent ulcers must be complete extermina- tion. The knife, or escharotics, may be used, according as the circumstances of each case may decide for one or the other : but generally escharotics are to be preferred, as being equally efficacious with excision, and attended with less risk. No general rule can be given for choice of escharotics ; but usually, for the smallest ulcers, arsenic is most convenient; for the larger and more superficial, the nitric acid, or acid nitrate of mercm-y ; for the larger and deeper, the Vienna paste, or pastes CANCEROUS ULCERS. 197 with chloride of zinc. After thorough extirpation of all the boundaries of the ulcer, and of whatever tissue near it may be indurated, there is, generally, no return of disease. If there be, similar treatment must be resumed ; and it may be con- tinued as long as there is any probability that the whole disease may be destroyed at once. Canceroiis ulcers vary according to the forms of cancerous gi'owth with which they are severally connected, and with tlie description of which they will be again referred to. But for then- diagnosis from other ulcers, two modes in which they occur should be noticed. In one, the ulceration begins in the skin over, and adherent to, a cancerous mass, into which it ex- tends as it deepens ; in the other, the first changes appear to be in the cancer itself, and the ulceration is by opening of the skin from within. The two modes may coincide, and their final results may be the same ; but the distinction between them is worth observing. In the ulceration from the surface inwards, the skin over a cancer becomes gradually thinner, adherent, tinged with blood, dusky-red or brownish ; then it cracks, or is excoriated, or scabs ; the excoriation widens and deepens, till the surface of the cancer is exposed. If, now, the cancer be prone to rapid increase (as medullary cancers usually are), it will generally protrude through the ulcerated opening in the skin, as a so- called fungous mass ; if less active, the ulcer generally deepens into it, and then may acquire slowly the characters of those that commence in the cancerous substance. In this manner of formation, the cancerous ulcer may have no characteristic shape, but may be known from any of the forms already described by the characters of the morbid growth beneath it ; and from ulcers over other than cancerous growths (at least in most cases) by its occurring, not through stretching or mere inflammation of the skin, but through the skin be- comino; constantlv thinner, and then in its residue cancerous, i. e. infiltrated with cancer. In the other manner of ulceration, degenerative changes usually first ensue in the cancerous mass, with softening, and, it may be, an ill-conditioned suppuration. The materials thus formed are discharged, with sloughing or ulceration, through the surface, leaving in the cancerous mass a cavity like that of a widely-open abscess walled-in with cancer. Then, with con- tinued ulceration of their internal surface, and at their open 108 ULCERS. margin, tlie cancerous boundaries of the cavity or ulcer still constantly increase by tbe addition of new cancerous matter ; so that, though the ulcer continually enlarges, it does not de- stroy the cancer ; rather, the growth extends more rapidly than the destruction, involving the adjacent structures more and more widely and deeply. The essentially distinctive character of these ulcers is the cancerous structure which bounds them, and in which, indeed, rather than in any natural tissue, they are found. To the growth of this structure, also, they owe chiefly their shape and other features. They are usually roundish or oval in their general outline. Their edges are generally raised and everted by the exuberant formation of cancer in and beneath the boundary of the skin ; and the raised margin, which may be also undermined, is usually hard, nodular or warty, and sinuous, imitating the structure of the cancerous mass. The base of a cancerous ulcer is similarly hard, nodular or warty, or covered with coarse granulations, uneven, deepest at its centre, not rarely bleeding without apparent cause. The discharge is usually a thin, acrid, strongly smelling ichor, which, in cases of superficial ulcers, and in old persons^ often concretes into a dry and almost horn-like scab. The structures beneath and around a cancerous ulcer being usually infiltrated with cancer, are hard or firm, through a layer from a line to an inch or more in thickness. The adjacent skin may be warty, with large papilla?. The lymph-glands in relation with the seat of the ulcer may be enlarged and hardened, and may thus give decisive evidence for diagnosis, if they main- tain their morbid condition, although there be no accidental irritation or inflammation in the ulcer. For, with such irrita- tion, any ulcer, as well as a cancerous one, may give rise to a corresponding enlargement of Ijanphatics. The treatment, and other matters relating to cancerous ulcers, wiU be considered elsewhere (Cancee). It remains to describe briefly those varieties in the characters of ulcers which depend on local or other non-essential condi- tions. Many of these, as already stated, have suggested names by which, as if they were specific distinctions, ulcers are often called and classified. These names may be respected if used in subordination to such as may imply the conditions on which, more essentially, the several forms of ulcers depend. VAEICOSE ULCER. 199 Varicose ulcers are sucli as are connected with an enlarged or varicose state of veins. They are found ahnost exclusively on the lower extremities, and especially on the lower half of the leg. The connection of ulcers with varicose veins is far from uniform. In some cases it is scarcely more than an accidental coincidence. A patient with varicose veins may have an ulcer of specific origin and form, and its characters and progress may be no farther affected by the disease of the veins than so far as that disease is a hindrance to the circulation. Generally, too, the more evidently specific the ulcer, the less is it modified by the disease of the veins. In other cases, an ulcer has its origin in inflammation of a varicose vein, beginning in a patch of skin which is inflamed, and suppurates over a varicose vein that is hardened, and probably filled with clot. And, in yet other cases, the defective movement of blood through varicose veins appears to favour greatly the occurrence and ill progress of that low inflammation of the integuments in which ulcers are most prone to form. This is especially the case in patients in whom the disease of the veins involves, not the larger subcutaneous trunks and branches, forming tortuous and convoluted thick- walled canals and clusters of veins, but the smaller cutaneous veins, which, in their dilated state, appear turgid and stellate near the very surface of the skin. Of the two forms of enlarge- ment of veins, often coincident, yet not rarely seen apart, this latter is by far the worst concomitant of ulcers of the integu- ments. It is through this, especially, that so many of the most painful inflammatory and eczematous ulcers at the ankles are described as beginning and always aggravated in pregnancies ; through this that such ulcers are apt to become chronic and callous ; and through this that, in advancing years, the healing of ulcers at or near the ankles is so slow and insecure. Although, as already stated, any ulcer may be complicated ■with varicose veins, yet they are most commonly found with the inflammatory and eczematous and chronic. And with all alike, the remedy of the defective circulation is essential tq a speedy and secure recovery. Constant recunibency, and elevation of the limb, are the simplest means to this end; but with many patients they are the least possible. Their best substitute, and that which is usually necessary for after-treatment, is regulated pressure, with bandages, strappings, elastic stockings, or the elastic sjoiral band ; the materials for the strapping, whether wet lint, plaster, ointment, or any other, being determined ac- 200 ULCEES. cording to the cliaracter of the ulcer. Special skill in bandaging may be rewarded with the greatest success in the treatment of varicose veins, and may often dispense with rest and recum- bency. The obliteration of the veins, by any of the means that will be described in the appropriate essay (Diseases of Veins), may also be advisable, especially in the case of chronic ulcers. And the complication of diseased veins increases, if possible, the necessity of improving defects of the general healtL ; every unnecessary hindrance to the circulation in any part should be removed, and every help given to insure a normal excretion, and full action of the heart. Among all medicines for this class of cases, iron appears to be the most effective ; there are comparatively few cases of ' varicose ulcers ' in which it is not beneficial, and it is most so when the smaller cutaneous veins are involved. Oxjium, also, is of value; most so when the ulcers are most chronic. Q^dematous, or wealc ulcers. These terms have been some- what vaguely used, but are best and most often employed for ulcers whose granulations are upraised, pale, translucent, soft, easily breaking, such as those usually are which are connected with scrofulous bones or joints. Except in connection with well-marked scrofula, or with disease of deeper textures, such ulcers of the integniments are not frequent. They may occur on an cedematous limb, the granulations partaking of the general serous infiltration ; but more commonly they owe their peculiarity to their granulations being constricted by surround- ing skin or scar. In the former case, the remedy, or rather the reduction of the ulcer to a more common form, depends on the curability of the general oedema ; in the latter, it may be effected by nitrate of silver, or astringents, as sulphate of zinc or of copper, or by dry pressure. Exuberant ulcers. Ulcers are sometimes seen, especially on the feet and hands, which, without any apparent cause, exhibit an excess of granulations. Their granulations rise prominent beyond the adjacent skin, and overhang it, and are not cede- matous, but as florid and compact as those of a healing ulcer. Escharotics, or pressure, or both, will cure this peculiarity. Till its origin be known, its chief interest may be in the likeness which it sometimes bears to the exuberance of ulcer- ated cancer. The diagnosis may rest chiefly on the feeling of the granulations : the cancerous are hard, or at any rate very firm, and fixed on a hard basis ; those that are merely INFLAMED ULCEES. 201 exuberant are not hard, bnt soft, fleshy, easily yielding to pressure. "When speaking of these ulcers with outgrowing granula- tions, it may be well to note that when an ulcer or fistulous canal opens into a sjaiovial cavity whose lining membrane is in the state of so-called pulpy degeneration, an exceedingly exuberant growth of granulations may ensue, with an appear- ance of eversion of the synovial membrane through the ulcer- ated opening. Hence the remarkable aspect of certain ulcers connected with diseases of joints and sheaths of tendons — fun- gous ulcers, as they are sometimes called. Hcemorrhagic ulcers constitute no distinct class, and their diagnosis and treatment must depend on other things than the mere bleeding. Some ulcers bleed, being vicariously cata- menial ; some through excessive venous fulness, or the burst- ing of a subjacent varicose vein; some, as phagedsenic or sloughing, through extending into some blood-vessel ; some, especially the cancerous, or those that are connected with ulcerated tumours of any form, through the giving-way of thin-walled new vessels ; some, because of the existence of scurvy or the hcemorrhagic diathesis. Neuralgic or irritable ulcers. The pain of some is so great and so disproportionate to all their other symptoms, that they may deserve one of these as a subordinate name. The pain of some examples of inflammatory and eczematous ulcers has been already mentioned, and is unexplained; so is that of many ulcers connected with small varicose veins ; but the type of ulcers, whose pain havmg no satisfactorily proved cause may be called neuralgic, is in those small, flat, oval, or circular ulcers that occur at the margin of the anus — the so-called irritable ulcers or fissures of the anus. These show well how very little power any sedatives, locally applied, have to subdue the pain of ulcers. The only remedy is in the cure of the ulcers, whether by section for those at the anus, or by what- ever means might be required for ulcers of the same kind not attended by unusual pain. Nitrate of silver, for example, will do more to assuage a neuralgic eczematous ulcer than any opiate application. It is, indeed, remarkable that when such ulcers are brought to healthy granulation they are scarcely painful, and their scars are not more sensitive than those of any other form. Inflamed ulcers. Any ulcer may become accidentally inflamed. 202 ULCEES. The signs of this event are, increased pain in and about it, a diffuse redness, or a brighter redness of all the adjacent skin, with more or less of oedema, a more copious discharge, thinner and often tinged with blood, and swelling of the granulations, with mottled, ruddj, and tawny colours, or with partial slough- ings of them. Commonly, too, the edges of the ulcer look more abrupt and jagged than they did, and extend more rapidly. The popular expression, ' angry looking,' figures very well the aspect of the inflamed ulcer. The remedy for this state is in some such treatment as the same patient might re- quire for any other inflammation. Rest, elevation of the seat of the ulcer, the removal of local irritants, water-dressing, poultices, generally suffice for local means, or leeches may be applied ; while the general ti'eatment is to be decided by the general condition of the patient. For at least one variety of ulcers — the chronic or callous — an active inflammation is often beneficial, inducing changes which are followed by a more rapid healing. The chronic, indolent, atonic, or callous ulcer has some of its chief characters told by these names. It is rare on every part except the leg, most frequent on its lower half; of uncertain size and shape, but most often oval, with its long axis parallel with that of the leg, or, when very large, encircling the leg. Its base usually lies deep, and is flat, pale, or tawny and dusky, with very minute or no visible granulations, compact and nearly hard, and adherent to the fascia beneath it. The margin is usually abrupt, or unequally shelving, and, in its most cha- racteristic form, ' callous,' thickly overlaid with opaque, white, dense epidermis, and having beneath this very enlarged pa- pillae. Both the margin and all the surrounding integuments, often for many inches distant, are thickened, hardened, ' cal- lous,' sodden, as with a kind of very firm oedema, and adherent to the subjacent fascia. The surrounding cuticle, also, is often shining and scaly, or dusky with pigment. The ulcer itself is generally almost painless, unless accidentally inflamed; its secretion is a thin ill-smelling pus ; its most frequent complica- tion is large varicose veins higher up on the limb. Any idcer of the leg may become thus chronic and callous when it exists very long ; and when a distinctly specific ulcer thus changes, it not only loses its specific characters, but ceases to be amenable to specific treatment. Thus, the more a ter- tiary syphilitic ulcer becomes like a chronic ulcer, the less is CHEONIC ULCEE. 203 tlie good influence of iodide of potassium upon it. But all ulcers are not equally liable to the change to ' callosity ; ' the strumous are much less so than the tertiary syphilitic, and the inflammatory and eczematous are more so than either. And although in general the peculiarities of the chronic ulcer may be due to a long-contmued slow inflammatory process, probably attended with production of lowly-organised, interstitial, new formation, yet in some cases the complete characters of the ulcer are attained in three or four weeks. This is most likely to happen in elderly people, ill-fed, or cachectic, or with firm oedema about the feet and ankles, in whom ulceration is excited by any ordinary cause. Through whatever course it may have passed, the chronic ulcer is usually amenable to treatment. It would be hard to enumerate all the means that have gained a reputation for curing it. Those which are certainly very good, and very rarely insufficient, are opium, regulated pressure, and blister- ing. Either of these, combined with rest, good food, and attention to the general health, will cure any but the very worst examples of chronic ulcer 5 and even in less advantageous cir- cumstances, they wiU seldom fail. The doses of opium usually found sufficient are a grain night and morning ; and the local treatment may be with stimulant ointments, such as that of the nitric oxide of mercury, or lotions of zinc or copper, or either of the following means. The regulated j)ressure is com- monly and effectually applied with calico bandages or straps of adhesive or lead j)laster on linen (on Baynton's plan), or, if the skin will not bear plaster, the strapping may be better done with linen wet with water or any appropriate lotion. Blister- ing should have for its design not only, if at all, the stimulating the ulcer itself, but the softening and thinning of its callous edges and adjacent tissues, which it seems to accomplish by causing absorption of part of the exudation with which they are infiltrated, and desquamation of the cuticle with which they are covered. With a similar view, a good auxiliary to any other mode of treatment is the scraping-off the thick epidermis from the margin of the ulcer. In the worst cases, when all these means fail, it is commonly because the base of the ulcer and the integuments surrounding it are so indurated and so adherent to the subjacent tissues, that they will neither stretch nor slide towards the centre of the ulcer, even when healthy granulations form on it and 204 ULCEES. would contract in developing into a scar. To remedy this hindrance of healing, it is sometimes useful to make incisions through the integuments, near and parallel to the margins of the ulcer, so that the gaping of the incisions may give oppor- tunity for the contraction of the granulations on the ulcer. Li similar cases, transplantation of an adjacent portion of healthy integument, sufficient to cover-in the ulcer, has cured it. In the Tvorst examples, and especiall}- in those in which a chronic ulcer forms a broad belt all round the leg, or in which such an ulcer over the tibia has excited thickening of j)eriosteum, and formation of new bone beneath its base, and is firmly adherent to the structures thus changed, the healing, even if it be achieved, is so unsound that amputation, if not too dangerous to life, is advisable ; and it should be done through healthy and mobile integuments ; otherwise, the result will be an un- sound stump. Phagedcenic and slougJiing ulcers. Nearly all the chief points of interest connected with the ulcers thus called will be con- sidered in the essays on Gangrene and Syphilis. Here it may suffice to say, that such rapidity of extension as may deserve to be named phagedfenic is verj' rarely seen in ulcers, except in connection with sy|)hilis, or hos2)ital gangrene, or some similar condition. In acute inflammation, any ulcer may enlarge quickly ; but the rapid destruction generally implied by phagedsena has a specific, and probably, also, an external source. Sloughing is a much more common complication of ulcers — sloughing, that is, not so much of their edges and adjacent parts as of their granulations. Thus, in inflammatory ulcers, the frequent appearance of a grayish or yello^vish base is generally due to sloughing of granulations; so in senile ulcers, sloughing is very common; and in any form, in old persons, senile gangrene of the integuments around the ulcers may ensue. So, again, the whole base of a great chronic ulcer may often be seen sloughing, through injury, or defective food, or exposure to hard weather. Such are the chief forms, principal and subordinate, of ulcers of the integuments, of which sufficiently numerous instances may be seen to allow of their being described in general terms. A closer and more express study of the subject would certainly lead to the discovery of many forms which are not here in- dicated, because they are kno^vn to the writer by ovUj a few VARIOUS FORMS. 205 instances, incompletely observed. The characters of ulcers, if more fully studied, both in well-marked and in modified and complicate examples, would be found as various, and, severally, at least as well-defined, as are those of cutaneous eruptions ; and with the better diagnosis that would be thus attained, there might follow a much better discrimination of the means of treatment appropriate for each. JAMES PAGET. EKYSIPELAS. A DIFFUSED, spreading mflammatioii of tlie skin, involv- ing more or less deeply the subcutaneous tissues, and pre- ceded and accompanied by febrile action. The term Erysipelas * has been applied to a variety of forms of inflammation which probably have no true connection with one another. On the other hand, distinctions have been made between forms of inflammation which are merely modifications of the same essential disease, erysipelas. The term is now, however, very properly restricted to a spreading inflammation, usually of an atonic character, the result of a peculiar morbid state of the blood. Of so specific a character is the disease, that in one of its forms at least, it has been considered as belonging to the order of contagious exanthemata. It resembles the true exanthemata, in its being sometimes infectious and sometimes epidemic, in its having its period of incubation, and a general tendency to definite duration. It differs from them chiefly in its liability to frequent recurrence. By Willan it has been placed amongst the vesicular eruptive diseases, from the disposition to the formation of bullae or vesi- cles. These, however, are only accidental. The term erysipelas, according to some, should be restricted to the diffuse inflammation of the head and face. Although this * Tlie derivation of this term lias occasioned some discussion : for the fol- lowing note on the subject I am indebted to Mr. Eobson, the printer of the first edition of this work: 'There seems to be no difficulty, etymologically, in deriving tpvrri-iXag from tpvOpoq red, and ttsXXo skin. The stem of tpv^>p6g is undoubtedly ipvB-, Lat. rub- in ruber, Germ, roth, Engl, rtid- in rudchj, red. With regard to the change of the 9 into a in some compounds, Benfey in his Gricchisches Wtirzellexikon, vol. ii. p. 125, says: "epvPlfiq rhodisch, wie ipvCi^ioi; zeigt, in der koivi) a = 9, tpraiiSi] : " which accounts for the a instead of 9 in ipvftiTriXac. And for -TrtXac from TriWn, Liddell and Scott {Lcxic. s. v.), compare uittXoc, to account for the single A.' VARIETIES. 207 may be taken as tlie type of true simple erysipelas, tlie restric- tion is hardly tenable. Looking to its causes, the disease may be divided into Symp- tomatic Erysipelas [E. consensuale) — the expression of some pre-existing constitutional disturbance ; Idiopathic Erysipelas — the result of general causes acting on the system from with- out, such as exposure, miasm, or epidemy;^ and Traumatic Erysipelas — where the uiflammation is directly excited by local iiTitation or inoculation. The classification into symptomatic and idiopathic is not perhaps practically important ; that into traumatic is more so, inasmuch as the severe forms of inflamma- tion of the subcutaneous tissues usually follow wounds and other local injuries. There are two principal varieties which are now universally distinguished : Simple Erysipelas {E. simplex, verum, legitimiim, superjiciale, fehris erysipelatosa), the cutaneous erysipelas of Mr. Nunneley, where the inflammation is more or less limited to the skin, the subcutaneous cellular tissue being only slightly or not at all affected ; Phlegmonous Erysipelas, or the cellulo-cutaneous of Nunneley {E. plilegmonodes, pseudo-erysipelas, plilegmon diffus.), in which the inflammation partakes somewhat of the character of phlegmon, aJffecting concurrently with the skin, the cellular and adipose tissues beneath, and generally running on to sup- puration. There is no real boundary between these two varieties. Simple erysipelas usually involves the cellular tissue to a certain extent, and may even be followed by suppuration in it. Phlegmonous erysipelas wiU often terminate in resolution. A thu-d variety is perhaps admissible — (Edematous Erysipelas {E. oedematodes) ; for although oedema is always present, more or less, in this disease, and largely so in situations where the skin is lax, as in the scro- tum or eyelids, yet in some states of system the cellular tissue is loaded with serum beyond what would be expected from the amount of cutaneous inflammation, which in these cases often does not present its usual bright colour. There is yet one form of inflammation which, although in it the primary affection of the skin is absent, is yet so identical with erysipelas in its causes * The terms ' idiopathic ' and ' symptomatic ' are often used in a reversed sense from that given in the text ; whicli is, however, more in accordance with the real meaning of the words, and has been adopted by Sir W. Lawrence and many of the best authorities. 208 EEYSIPELAS. and in most of its essential characters, tliat it cannot properly be dissociated from it, namely, diffuse cellular inflammation — the cellular erysipelas of Nunneley. These various forms of inflammation and their modifications must be regarded but as phases of one disease, which has its seat not merely in the part, but in the system. The form which the disease may take is determined by the state of system, the tem- perament, habits, &c. of the individual, or the external causes which produce it. In adopting this view of the nature of erysipelas, which is sup- ported by its infectious nature, by the occurrence of premonitory fever, and by its definite course, it is desirable to discontinue the application of the term erythema to its milder forms. The latter term has been applied to every form of simple local efflorescence of the skin, whether arising from internal causes or from exter- nal irritation merely. It is, perhaps, practically difficult to draw a line between them in all cases, though the real distinction is obvious. Erysipelas presupposes a specific determining cause ; but those forms of cutaneous diffuse inflammation which arise from external causes only, as stings, burning by chemical or other means, friclion {intert7'igo), or from, the irritation produced by the introduction of indigestible food into the stomach, are in no way allied to it, and may be properly classed under the head of erythema. Besides diffuse cellular inflammation, there are many diseases which do not produce the characteristic cutaneous inflammation of erysipelas, yet are probably closely allied to it, as e.g. phle- bitis both external and internal, inflamed absorbents, and puer- peral fever.* The same may be said of some forms of inflamma- tion of the mucous and serous membranes. For though the inflammation of the skin be absent, yet if the constitutional conditions be the same, they must be regarded as pathologically identical with erysipelas, however the expression of the condition may differ; just as in syphilis the same virus may produce simple chancre or phagedsenic sore, or various forms of cutaneous disease, or deep-seated inflammation. * Velpeaii, in liis clinical lecture on erysipelas {Leqons orcilcs, vol. iii. p. 205), classes together angeioleucitis, external phlebitis, diffuse phlegmon, and true eiTsipelas; though he maintains that they are widely different from one another. But he describes diffuse phlegmon as differing from what he considers true erysipelas {E. Wjitime) to as great an extent as angeioleucitis or external phlebitis do from either of them. VAEIETIES.— ERYTHEMA. 209 It has been objected by Sir W. Lawrence, who in this supports the yiews of Vogel and Hildebrand, that to justify the notion of the mucous or serous membranes being affected by erysipelas, it must be shown that the same phenomena are observable in them as are seen in the shin. If, however, the view generally received at the present day be correct, that erysipelas is the expression of a peculiar state of system, the result of some poison introduced mto or generated in the body, it is no longer necessary to find identity of charac- ter in the inflammations of the internal and external surfaces affected by it. Thus no one would deny to the sore throat of scarlet fever a special origin, though often the characters of the inflammation in no way differ from those of a simple non- contagious sore throat. Indeed, the argument of Sir W. Lawrence, founded on the state of the throat, is answered by what is seen in scarlet fever. He observes that the swelling and vesications of erysijDclas are not found in the inflammations of the throat attending erysipelas, ' which, on the other hand, are frequently attended with ulceration, with the formation of an ash-coloured or tawny substance adhering to the surface, and with superficial sloughing — occurrences either very unusual or not belonging at all to erysipelas.'^ Now in scarlet fever the skin-rash never goes beyond a mere efflorescence, with sometimes a slight vesicular eruption. But in the mucous membrane of the throat, ulcerations preceded by ashy or white exudation are common. The sore throat partakes, nevertheless, as much of the specific nature of the disease as the rash. And so in those cases where the recession of the inflammation of the skin has been immediately followed by deeper-seated inflamma- tion, there need be no special character to mark the nature of the disease, though the inflammation may really depend on special causes. Although erythema is regarded as differing from erysipelas in its essential character, yet from a certain similarity between the two, it may be well to give a short description of this affection. Erythema is a pale-red efflorescence invading only the superficial layers of the skin, though sometimes oedema is present, but rather as a cause than an effect of the inflammation. In general it is accompanied by only trifling swelling, which soon subsides. It appears in irregularly circumscribed patches * Medico,- Chirurg. Trans, vol. xiv. p. 22. VOL. I. P 210 EEYSIPELAS. — sometimes there may be but one, oftener there are many — which have not the tendency to sj)read widely, and join like those of erysij)elas ; they rarely exceed a few inches in extent, and in some forms are not more than a quarter of an inch in diameter. The patches may apj)ear on any part of the body ; theii' most usual seat is the chest and limbs, and they are generally confined to the part in which they first appear, though this is not invariably the case. The course of the disease is generally rapid, from four or five days to a fortnight in duration ; sometimes it is chronic, and it is said even to be intermittent. Usually the eruption is unaccompanied by fever, and in most forms is miattended with pain. Many varieties of this disease have been described, which seem to have little alliance with one another. Indeed erythema appears to be a symptom common to a variety of states of system and to mere local irritation. Symptomatic erythema appears in the course of other diseases, or arises from some transient constitutional dis- turbance, as from errors of diet, teething, or irregular men- struation. It occurs generally in persons of irritable lax habit, with delicate skin. In many persons the slightest causes induce an attack. Eugacious erythema {E. fugax) is frequently associated with other and more serious diseases, especially long-standing disease of the alimentary and other mucous membranes. But there are few internal afiections which may not at times be accom- panied by it ; and it is often an indication both of their presence and their severity. It may come on, however, simply from errors of diet, particular articles of food, as shell-fish, pork, &c., invariably producing it in some individuals. A case occurred to me in which the mere touch of laudanum would bring it on. It appears in the form of variously-sized difiiised patches, invading chiefly the upper parts of the body, and occurs most frequently in females. The peculiar character of this variety is its tendency to disappear suddenly at one part, to make its appearance again at another, this being repeated over and over again. There is a little heat, but no pain, and desquamation rarely follows its subsidence.* * The erythema often seen in persons who are inlialing chloroform, shows the dependence of these forms of rash on altered states of the vasi-motor nervous system. Dr. J. Murraj^, who for some time administered chloroform at the Middlesex Hospital, tells me that the rash appears chiefly in the form of VAEIETIES OF EEYTHEMA. 211 Erythema circinatum and marginatum are degrees of the same form. In E. circinatum a number of small round patches appear, which spread at their circumference while they fade in the centre, and by their intersections form a cluster of imperfect rings. Mr. Erasmus Wilson mentions a case in which the curves spread until the whole trunk and limbs had been occupied by them. E. marginatum differs principally in the deeper congestion of the spots and rings ; the colour approaches at times to purple, and the borders are more raised and defined. It is more frequently seen in elderly persons, and in connection with disease of the internal organs. E. papulatiim is distinguished by the small size of the patches, which are at first of bright-red colour and a little raised ; they become ultimately dark-coloured. A modification of this variety is E. tuberculatum, which is found more usually in debilitated persons, and is often ushered in by chills and fever ; the spots are more elevated and persistent than in the papular form. Erythema nodosum is usually seen in females of weakly and anaemic habit of body, and is not unfrequently associated with rheumatism. It appears in patches of tolerably uniform oval form, and sometimes two or three inches in diameter; the patches are elevated and have a tuberculated feel ; they are painful and often very tender. Like the former variety, they are at first bright, but become in the course of a few days dark- coloured and livid, and then gradually fade, and are followed by desquamation of the cuticle. The eruption is always preceded by febrile symptoms, sometimes severe, and derangement of the digestive organs; these symptoms disappear as the eruption comes out. The treatment of these varieties of symptomatic erythema, must be guided by the general condition of system under which they appear. Where they depend on mere casual derangement of the digestive organs, mild saline purgatives and a regulated diet, with the occasional use of the tepid bath, or simple sponging of the skin with tepid water, will be all that is neces- small patches about the chest — but is more general about the neck and face. It is often accompanied by evident enlargement of the thyroid gland. It appears previous to complete insensibility, and passes off during or shortly after an ordinarily prolonged state of anaesthesia. Dr. Murray says that it occurs in fully five per cent, of the cases of chloroform inhalation. P 2 212 ERYSIPELAS. sarj. Tonics are often called for, as generally tlie disease occurs in persons of weakly liabit or wlio are debilitated by disease. IdiojDatliic erythema may be produced by anything which irritates the skin, whether acting from within or without. Thus we have an erythematous state of skin from the distension of oedema in weak persons ; E. Iceve, oedematosum. Here the skin has a uniformly shining transparent red appearance ; this may continue long without change, and may then terminate in resolution, or ulceration, or even mortification may take place. A long-continued depending position may produce it ; and sometimes a similar inflammation may arise from internal derangement. The treatment consists in rest, position, cold lotion, and then gentle friction and the application of a wove bandage, with of course attention to the general state of the system. E. intertrigo arises from friction of one part of the skin against another, or from the dress, or from the irritation of discharges ; it is common in infants and in very fat persons. Chemical irritants, sun-bum, alternations of heat and cold, &c. will produce the same effect. Cleanliness, the removal of the cause, and weak lotions of lead, nitrate of silver, or corrosive sublimate, will generally suffice to remove it. Erythema sometimes presents itself in a chronic form, espe- cially on the face ; it is often obstinate, depending on internal derangements, to which the attention must be directed in order to remove the disease. As a general rule, symptomatic erythema springs entirely from causes operating within the system, while erysipelas for the most part implies the concurrence of external and special influences. We may now proceed with the consideration of the characters of erysipelas. The inflammation, being the manifestation of some contamina- tion of the fluids of the body, is, as would be expected, pre- ceded by more or less of constitutional disturbance. This is sometimes so slight as to be unnoticed by the patient, and hence it has been supposed that the inflammation may occur without the general symptoms. In many cases where this has been suj)posed to occur, the skin-affection has been one of simple erj'thema. The most usual j)remonitory, or accompany- ing constitutional symptoms are, a general feeling of indisposi- tion, languor and chilliness, amountmg at times to severe SYMPTOMS. 213 rigor. The skin is hot and dry ; there is loss of appetite and thirst, with precordial pain ; a bitter taste in the mouth, and eructations. The tongue from the first indicates the disorder of the digestive system. It is at first pale and fiabbj, and then becomes coated with a yellow creamy mucus. In the latter stages it usually becomes dry and brown and fissured, but sometimes it passes at once to brown, though there may have been little or no previous fever ; and this is frequently the case where dropsy is present. The bowels are almost always con- stipated, and when acted on, the motions are often black and offensive. Occasionally, however, diarrhoea sets in from the first, the motions being offensive ; and it is not unusual for relaxation of the bowels to occur towards the close in favourable cases. "V\Tiere these symptoms of derangement of the digestive system are especially marked, and the countenance assumes a yellow hue, the term ' bilious ' has been applied to the ery- sipelas. The state of the urine, which should always be looked to, varies with the intensity of the febrile symptoms ; some- times it is but little altered, often it is high-coloured and scanty, depositing abundantly the amorphous lithates. The application of heat will, as in many febrile diseases, often produce a slight cloudiness from coagulated albumen ; and in aggravated cases there may be a very considerable amount of it, the result of temporary congestion of the kidney. This is most usually seen towards the termination of the inflammation, where desquamation is taking place ; and at this time renal epithelium will often be found as well. But in a large number of cases there is no appearance of albumen in the urine. Dr. Begbie finds that albuminuria is more frequently present in symptomatic than in traumatic erysipelas. The urine is almost always acid, and abounds in urea, but with a diminution of the chlorides. The pulse is quickened ; sometimes it is full, soft, and compressible — sometimes, and especially in fatal cases, irregular and intermittent. When the disease has advanced, it may become rapid, small, and weak ; but often it remains large till the death of the patient, or the subsidence of the disease.lt h as been observed by Nunneley, and confirmed by Mr. Hinckes Bird and others, that if the pulse rise in frequency after the sixth or seventh day, it is a very bad sign ; this is generally true, though patients will often recover in whom the quickening of the pulse at this period has been noticed. The blood drawn during the early stages generally shows the 214 EEYSIPELAS. bufiy coat. The blood-corpuscles are diminished in number, according to Andi-al and Gavarret ; and Schonbein says that the serum is always tinged yellow by the colouring matter of the bile."^ In erysipelas of the head there is often bleeding from the nose diu-ing the acute stage. The nervous system sometimes shows no further disturbance than the lassitude attendant on febrile action. Often, however, and especially in erysipelas of the head, there is, even in the earlier stages, aching and oppression in the head, drowsiness, or excitement amounting to delirium. In the latter stages of the more formidable cases of the disease, low muttering delirium and subsultus are present. The delirium does not usually at any period present the characters of excitement, but rather the tjrpe seen in low fever.f Sometimes it resembles delirium tremens, the patient bemg readily recalled to con- sciousness when spoken to, but relapsing speedily into a wandering state. The excitement is, however, rarely so great as in delirium tremens. Generally, in the first instance, the wandering or delirium takes place only in the night, the mind during the day being unimpaired. During the early periods of the disease the temperature rises. The premonitory rigor is attended by an increase of 3° or 4°, and from this time so long as the inflammation is extending, the temperature will often range from 102° to lOS-o"^ ; being generally lower during the middle of the day than in the morning and evening, and lower in the morning than in the evening. Every fresh attack, or more active extension of the inflammation, is marked by an increase of temperature. Gene- rally the changes in temperatm-e coincide with changes in the pulse, becoming higher as the pulse rises in frequency ; but towards the end of the complaint the temperature often falls while the pulse remains quick. In favourable cases the tempe- rature usually falls to the natural standard on the sixth or seventh day of the eruption. * Simon's Animal Chemistry, Sydenham Soc. Translation, vol. i. p. 277. t Dr. Bastian brought before the Pathological Society, in January 1869, some observations on the state of the small arteries and capillaries of the gray matter of the brain in a fatal case of erysipelas of the head with delirium. These vessels were loaded with small aggi-egated masses of white corpuscles. The same condition was found in the capillaries of the liver and kidneys. To this embolism Dr. Bastian attributes the delirium and the albuminuria found in erysipelas, and some other febrile diseases. SYMPTOMS. 215 Frank has pointed out a symptom wliicli lie regards as of great value in determining the advent of erysipelas of the head and face. Whenever, he says, the x^atient has had severe febrile symptoms for some hours, attended with pain, tender- ness, and SAvelling of the lymphatic glands of the neck, he has no hesitation in determining that erysipelas is coming on. Chomel maintains the same view. It is denied by Velpeau, who regards the swelling as consequent upon, not as a pre- cursor to, the inflammation. There is no doubt, however, that the neighbouring glands are generally if not always tender be- fore erj^sipelas of a part sets in. Mr. Busk, indeed, tells me that, after close observation of a large number of cases, he is so convinced of the invariable occurrence of affection of the glands before erysipelas appears, as to consider it a pathogno- monic symptom ; and he believes that, although the blood be- comes affected, the actual primary seat of the local inflammation is in the absorbent system. Sometimes swelling and excessive tenderness of the glands precedes by many hours the appear- ance of a blush on the skin. If a wound or granulating surface exist, it takes on an altered action. The edges or surface become flabby, and covered with thin serum instead of healthy pus. Granulations become pale, and are absorbed ; parts tending to unite are dis- united. The seizure has been described as having in some cases been extremely sudden and violent. This has been noticed during the prevalence of violent epidemic erysipelas. It is reported of the late Sir George Beaumont, that he was at work after breakfast upon a picture, and fell down in a fainting-fit. Ery- sipelas presently showed itself on the head, and soon proved fatal. The severity of the premonitory symptoms is not necessarily an indication of the severity of the erysipelas. They may be very violent, and the inflammation slight, and vice versa. This seems to depend much on the temperament of the indi- vidual, and the greater or less tendency to constitutional reaction under partial derangement. The character of the symptoms, too, is modified by the same causes. One person will be restless and excited, another torpid ; in one there may be violent rigors, in another scarcely a feeling of chilliness, though the mflam- mation developed may be the same in situation and intensity. The period that may elapse between the attack of febrile symp- 216 EEYSIPELAS. toms and tlie development of the local inflammation, is far from being a fixed one. It may vary from a few hours to three or four days, and in rare cases to even a longer time. The local symptoms may be described under the principal forms of the disease in which they are developed, viz. of simple and phlegmonous erysipelas, and of diffuse cellular inflamma- tion. In its mildest form the inflammation resembles in all respects a simple erythema. The skin becomes of a diffused bright-red colour ; it retains its usual pliancy, and there is no swelling to be either seen or felt, neither is there any vesication. The patient experiences a sensation of tingling and slight burning in the part. The constitutional symptoms are usually very slight, and the inflammation terminates after a day or two in resolution, followed perhaps by some desquamation of the cuticle. In its severer forms, simple erysipelas presents more definite characters. The skin becomes red, tense, and shining ; frequently of a rose tint, whence the popular name ; but the colour may vary from a reddish yellow to a deep livid red. The appearance of swelling may be at first very slight, but on j)ass- ing the hand from the sound to the inflamed surface, a marked elevation of the latter will be noticed. The limits of the in- flammation are, in general, sharply defined — the redness not merging insensibly into the natural coloiu* of the skin, as is seen in j^hlegmon. A large portion of the skin may be attacked at once, and the inflammation has a tendency to spread widely in all directions ; or in one direction especially ; or it may be to break out in new patches, which extend and merge into one another, and into the part primarily affected. The parts newly invaded present the most characteristic appearances, as the disease is usually fading in those first attacked, while it is spreading to parts beyond. The redness disappears on pressure, and returns immediately on the pressure being removed. The skin has a more resisting feel than natural, and is hot to the touch. Very frequently miliar}^ vesicles, or large bullw, appear after the first few days, which burst and form incrustations ; hence the terms E. miliare and phlyctenodes. The vesicles are usually filled Avith a transparent serum, changing afterwards to a straw-colour and becoming often semipurulent ; in weakened states of the system, their contents have a deep purple colour. The pain is at first of a tingling and itching character, becom- ing afterwards more severe, burning and smarting. But it is SYMPTOMS. 217 not constant, nor is it ever of the throbbing, wearing kind which exists in ordinary phlegmon. Often there is an ahnost entire absence of pain ; but tenderness on pressure is always present. This is most marked while the inflammation is recent ; hence at the circumference there may be great tenderness, while in the central parts it may have disappeared. The inflammation, though chiefly afi'ecting the skin, is not limited to it. The areolar tissiie beneath is more or less infil- trated with serum ; so that, soon after the first invasion of the disease, considerable tumefaction takes place, and the skin becomes correspondingly tense and shining. When the face is the seat of the inflammation it becomes enormously swollen, so that the features are altogether obliterated. Suppuration and gangrene do not generally result from this form of erysipelas ; suppuration, however, occasionally takes place in small patches beneath the skin, especially in parts where the cellular tissue is lax ; and gangrene may occur in persons whose systems have previously been much debilitated. The more usual course is, that the inflammation extends and retains its activity for three or four days, and then gradually declines, the swelling decreasing from the absorption of the serum, and the skin getting a somewhat shrivelled look and a deeper red colour. The whole passes off in from seven to ten days. When the redness and tension persist for a much longer period, a deeper-seated inflammation, with suppuration, may be suspected. Desquamation of the cuticle almost always follows the subsidence of the inflammation. Simple erysipelas, unless it attack the head and face, or occur in persons already enfeebled by disease, is not of itself a formid- able complaint. In the head and face it is dangerous, from the tendency to affection of the deeper-seated organs. Thus the membranes of the brain are often much congested from the pressure made by the swollen tissues of the face and neck on the veins returning blood from the head, the membranes being already in a partially congested state from the febrile condition attending the disease. Occasionally cerebral excitement like that of delirium tremens takes place, and this even after the early and active state of the erj'sipelas of the head has subsided. This usually occurs in those who have habitually led irregular lives, and should be looked on perhaps as an accession of delirium tremens upon an attack of erysipelas. 218 ERYSIPELAS. Dr. Copland* mentions a case which occurred in the practice of Mr. Byam, and in which ' the cellular tissue of the throat and of the whole neck was so distended, that the integuments appeared girt around them with the utmost tension ; and in this instance the respiration and cough were as distinctly croupal as in idiopathic croup.' Severe inflammation of the membrane of the fauces, with affection of the larynx, is another source of danger. It sometimes gives rise to that most dangeroiis condition, oedema of the glottis. In one of the cases recorded by Mr. Arnott,t death ensued from ulceration and sloughing at the back of the larynx. Although erysipelas did not make its appearance externally in this case, yet the fact that two members of the family were seized with sore throat, accompanied by severe erysipelas, justifies the conclusion that this was a case of suppressed erysipelas ; of the same nature, pathologically, as the sore throat of suppressed scarlatina. The congested state of the lungs, which is occasionally found to exist in these cases, depends no doubt on the impeded re- spiration, produced by the swollen mucous membranes. These accidents occur most frequently in phlegmonous ery- sipelas ; but they may take place in the more aggravated forms of the simple variety. In oedematous erysipelas, the characters of the disease are considerably modified by the condition of the patient. It occurs in those of broken-down constitution, affected perhaps with serious organic disease, or reduced by previous illness. Instead of the usual bright rose-colour, the skin often presents a pale brownish or pale yellowish-red colour, and there is a strong disposition for it to run into gangrene. When this is imminent the pain is greatly aggravated and the skin assumes a livid dark appearance. The cellular tissue becomes loaded with serum, and the affected part presents much of the character of advanced anasarca. Such cases are serious, not so much from the severity of the erysipelas, as from the low state of the vital powers of those in whom it is usually seen. One or two forms under which the inflammation at times appears, may still be mentioned. The disposition to spread from the point originally invaded is one of the distinctive characters of erysipelas. But this tendency is sometimes so • Dictionary of Medicine, art. ' Erysipelas.' t Medical and Physical Journal, March 1827. EEEATIC EEYSIPELAS. 219 great that the inflammatioii will spread over considerable parts of the body, while those previously affected have returned to their natural state {E. amhidans). In a case recorded by La Motte,''^ the inflammation began in the head and extended down the neck and shoulders, and so continued spreading down- wards, the upper parts getting well, until no portion of the surface of the body had escaped, even down to the fingers and toes. M. Vidal t mentions another instance of rapid extension of the disease over the Avhole surface of the body. In other cases the inflammation will not spread continuously, but will invade distant parts, subsiding in one spot while it breaks out in another. To this form, which illustrates the alliance between erysipelas and the eruptive exanthemata, the term erratic {E. erraticnm) has been applied. J The severer forms of erysipelas, such as the phlegmonous and oedematous, are rarely erratic ; but this erratic tendency, though generally associated with the simj^le variety, often indicates organic disease of the secreting organs, or broken-down constitution. It is most frequently seen in connection with erysipelas of the trunk, and is very rarely attended with vesication. The inflammation may appear slight and partake more of the characters of a simple erythema ; but this form of the disease is never to be regarded without some apprehension. The metastatic erysipelas, which has been described by many authors, is probably allied to this erratic form. In these cases the inflammation suddenly recedes from the surface, and some internal organ, the lungs, or stomach, or intestines, are imme- diately affected. This occurrence is, however, much more rare than was at one time supposed. A few cases have certainly been recorded which seem to establish its possibility ; but it is so uncommon that many of the best observers, with the greatest opportunities, have never met with an instance of it. It is not so unusual to * See Cooper's Surgical Dictionary, art. ' Erj^sipelas.' t Medecine Operatoire, vol. i. p. 147. \ In reference to this erratic tendency in erysipelas, Hunter says : * There appear to me two ways of accounting; for this : one is, that the whole skin is very susceptible of such action, and readily goes on -with it by continued sym- pathy ; and the part having gone through the action, like the small-pox, &c., loses the disposition, and the action ceases. The other is, that the inflamma- tion is such as to contaminate while it spreads ; but when it has once acted, it is cured, as above observed.' See Hunter's Works, Palmer's edition, vol. iii. p. 315. 220 ERYSIPELAS. find the serous membranes affected coincidently -with tlie skin, or during the course of the disease, but without any disappear- ance of the erysij^elas. ' Universal erysipelas,' as it has been called, that is, where the whole surface of the body is attacked at once, not by spreading, must be extremely rare, if it ever occur. Mr. S. Cooper, in his Surgical Dictionary, mentions one such case, which was related to him by Mr. Maul of Southampton, but the details are not given. Another instance is related by M. Eenaudin,* but somewhat vaguely. It occuiTed in a woman fifty years of age. ' The entire skin of the trunk and limbs was slightly swollen, and was of an intense erysipelatous red colour ; the face alone seemed to be less affected.' It is possible that this may have been an instance of rapid erratic erysipelas. The other great variety of erysipelas, the phlegmonous, into which, however, the simple form merges insensibly, is of a far more serious character. Simple erysipelas attacks principally the cutis, and the areolar and adipose tissues are affected only in a secondary and comparatively trifling manner ; suppuration may indeed occur, but only in small patches and without death of the structures. But in phlegmonous erysipelas the sub- cutaneous tissues are involved as largely as the skin, and ex- tensive suppuration and death of the structures involved is the more frequent termination. As in the inflammation of the skin, so in that of the areolar tissue, there is no tendency to limitation and circumscription by lymj^h ; in this respect there is a striking contrast to true phlegmon. The skin itself, con- gested by the inflammation, and its nutrition interfered with by the destruction of the areolar tissue which supports and carries its vessels, falls largely into gangrene. The general constitu- tional symptoms which usher in and accompany the inflamma- tion are more severe. Phlegmonous erysipelas is generally the consequence of wounds jienetrating to the cellular tissue. It is in the head and in the extremities that the inflammation is seen in its most severe forms. In the former situation, how- ever, destruction of the skin is not frequent. The general symptoms are, as has been stated, of the same nature as those seen in connection with simple erysipelas, but they are usually of more aggravated character. Dupuytren has pointed out that the febrile symptoms, although continued, are Dicfionnaire des Sciences Medicales. PHLEGMONOUS ERYSIPELAS. 221 often marked by paroxysms and remissions, so that tliey have even been mistaken for those of intermittent fever. The signs of disorder of the digestive system are generally more promi- nent in phlegmonous than in simple erysipelas. Sometimes, however, the disease sets in mildly, both locally and generally, and gradually assumes a more serious character. The inflammation may at first present much the same ap- pearance as in the simple form, and there is often pain in the parts for some hours before the fever manifests itself. Generally, however, the redness is less vivid and has a dusky hue, and the colour is not uniform ; it is usually deeper at the centre than towards the circumference. The swelling is considerable, and pressure with the finger leaves a pit which does not immediately fill up, nor does the colour reapj^ear directly upon the removal of the pressure. After a time the skin becomes so tense and hard that pitting under pressm-e can no longer be produced : the redness becomes deeper and often assumes a violet hue ; small vesications and phlyctsense are frequently but not always present ; the pain is severe, burnmg, and often pulsating, and the general symptoms are aggravated ; the uriue is high- coloured and thick, its quantity is much diminished, and this amounts at times even to suppression ; the tongue is thickly coated and yellow. At this point, about the fifth or sixth day from the invasion of the inflammation, the symptoms often remain for a time stationary, or there may be a fallacious appearance of amend- ment. From having been hard and resisting, the skin becomes softer, it yields, and again pits under pressure. There is no sign of fluctuation, and the surgeon may be flattered with the hope that resolution is taking place. But the i^ersistence, and often the aggravation of the general symptoms, and, as not unfrequently happens, a fresh attack of rigor, indicate that so far from there being amendment, this is really the period at which the most serious changes are taking place. The cellular tissue has become the seat of suppuration and death. No fluctuation can be perceived, for the pus or purulent serum, when it first forms, is diffused through the areola?, or in thin layers, without any circumscribing boundary. Li some situa- tions, indeed, where the cellular tissue is abundant, as in the eyelids and face generally, the pus is found of good quality and in circumscribed cavities. Nor is the purulent secretion generally of an unhealthy character before sloughing of the 222 ERYSIPELAS. tissue takes place, except in tliose whose general powers are much reduced, when it will be found to be thin and sanious. If the disease be left to itself, the pus collects in larger quan- tities, separating the skin from its cellular membrane, and this from the fascia below, even throughout the entire limb, without forming a prominent swelling as in plilegmon, but buiTowing amongst the tissues. The skin, thinned and detached, becomes livid, and ulcerates or sloughs. The phljctsense which may have formed burst, and show a dead patch of skin beneath them. The pus which escapes is foetid, and shreds or layers of dead cellular tissue are found floating in it. From time to time large flakes of sloughy membrane, often many inches in length, and soaked in pus, are discharged. The destruction of the skin proceeds, parts which hitherto have retained sensibility and colour fall into gangrene, and, in extreme cases, an entire limb may be denuded. Generally, however, in the midst of the loosened skin and sloughy cellular tissue, small bands covered with granulations may be seen connecting the skin with the fascia beloAv. These, as Dupuytren has pointed out, should be carefully preserved ; they mark situations in which the vessels and nerves have escaped the general destruction, and they serve as starting-points for reparative action. In general the destructive action of the inflammation is limited by the fascia ; but this is not always the case. Where the disease has been very violent, the fascia, the intermuscular septa, the sheaths of the vessels and of the tendons, and the tendons themselves, may become involved. Even the joints may be penetrated and rapidly destroyed, and the bones may be denuded of their periosteum and become necrosed. Under these circumstances the limb will probably be permanently disabled, even if preserved ; and at the best it will be a very long time before the muscles can again be brought into use. Up to what may be called the third stage of the erysipelas, that, namely, in which the hard brawny state of the skin has not given way to the soft quaggy condition, resolution may take place under active treatment ; rarely, indeed, in the lower extremities, in which there is a strong disposition for the in- flammation to run on to suppuration. And when suppuration has occurred, the formidable destimction which has been de- scribed may, by treatment, be limited or arrested. The condition of the cellular tissue may often be seen in all its stages in fatal cases j for as the disease is jn-ogressive, some POST-MORTEM APPEAEANCES. 223 jiarts will be found in which only the earlier changes have taken place, while in others the destruction is complete. At first the tissue is congested and vascular, and its areolse contain serum, which is occasionally tinged with blood. The serum becomes thicker, and is replaced by a semi-fluid, whitish, or often deep yellow matter. This is still lodged in the areolse, and does not flow from them when cut into. By and by true pus appears, which, though still lodged in the cellules of the tissue, escapes when they are laid open. In the last stages the areolar tissue is found broken down, the pus is diffiised in layers, and contains the fi*agments and shreds of cellular membrane. The skin, where it has remained untouched by ulceration or mortification, loses after death its red colour, and appears shrivelled and brown. Its vascular tissue will be found congested, the veins especially being filled with dark thick blood. Pus and serum will be found in its areolse ; and exuda- tions of a plastic kind, such as exist in carbuncle, may be pre- sent. The cuticle readily peels off", and it seems as if a thin layer of serum lay between it and the corium. The internal organs, in fatal cases of erysipelas, do not present any special characters. Almost always there will be some disease of liver, spleen,"^ or kidneys ; often congestion of the mucous surfaces of the stomach and intestines ; in short, such appearances as might be expected in persons of broken constitution, especially when it is caused by habitual intemj)er- ance. The principal morbid characters are found in the blood. In the early stages of the disease, it has much the appearance of ordinary inflammatory blood; the fibrin is abundant, and forms a marked buffy coat, and the white corpuscles are very abundant. But when the disease has passed beyond the active stage, and symptoms of depression have come on, the blood loses the disposition to separate, and forms a thin loose eoagulum. Where death has occurred from the disease, the blood is sometimes thin and fluid, sometimes pitchy, often depositing a blackish powder. It stams the inner surface of the heart and great vessels, while the course of the superficial * The morbid states of spleen, so often found in connection -with erysipelas, are no doubt most frequently dependent on the altered condition of the blood in the later stages of the inflammation, and not on an}'- pre-existing- disease of the organ. The kidneys, too, will often be found congested in cases which present no evidence of previous disease of these organs. 224 ERYSIPELAS. veins is tracked out by transudation. The corpuscles are much altered, broken up, and irregular. There are, then, sufficient indications that, as in typhoid and allied diseases, the blood is the prmcipal seat of diseased action, which manifests itself in death and disintegration of the corpuscles. A very important fact has, however, been mentioned to me by Mr. Busk, viz. that in all the fatal cases "which he examined, the lungs were highly congested, and that on close inspection the smaller pulmonary vessels were always found to contain pas ; that, in fact, a minor degree of pyaemia was always present. He has observed the same thing in the small veins of the head where that part has been the seat of erysipelas. In those rarer cases in which the destruction of the fasciae and intermuscular cellular tissue has taken place, the muscles of the part are found black and soft. There is no evi- dence that they partake of the inflammatory action; their disorganisation probably depends on the destruction of the tissue which supports their vessels, which themselves are first blocked up and ultimately carried away in the general sloughing. Associated with erysipelas in its causation and in many of the phenomena attending it, is a form of disease which has attracted attention, in this country especially, under the name of ' diffuse cellular inflammation.' Although many cases of this disease had been described, its true nature was little recognised until the appearance of Dr. Andrew Duncan's paper in the first volume of the Edhiburgh Medical and Chirurgical Transactions. This form of inflammation, which, it may be stated, in its general characters is identical with the cellulitis of phlegmonous erysipelas, arises from manj^ causes. The cases to which Dr. Duncan drew attention were principally those caused by punctures made in venesection and in dissection ; but the inflammation may follow any form of injury or surgical operation, or it may even take place without recognised injury, from the general condition of the patient or of the atmosj^here. The disease is seen in its most intense form in those cases in which, as in dissection-womid, a septic poison is directly in- oculated. Such cases will be more fully treated of under the head of Animal Poisoxs. They must, however, be shortly noticed here in illustration of the general pathology of the erysipelatous affections. The diffuse inflammation of the cellular tissue is very fre- DIFFUSE CELLULAE INFLAMMATION. 225 quently seen in connection with absorbent inflammation and phlebitis, as well as with erysij)elas ; but it may occur inde- pendently of either. It may be supposed that they are in some degree allied in their nature, since they are so often seen to prevail at the same time and under similar circumstances. But there must be some condition of the system which modifies the action and determines the course which the inflammation shall take. After inoculation of the same morbid matter, one may be affected with diffuse cellulitis, another with inflamed absor- bents, while on a third nothing will be manifested, perhaps, beyond an irritable state of the punctured part. The general symptoms, when the disease takes place as a consequence of ordinary injury, are the same as are seen in erysipelas, and run ;the same course ; but the tendency to collapse comes on earlier, and the whole course of the disease is more rapid. In the cellulitis which follows the inoculation of septic matter this is especially the case, and death ensues more distinctly from the general poisoning of the system than from the extent and severity of the local affection. The early symptoms may come on insidiously or may set in with violence^ though even then there is usually a feeling of malaise preceding the attack. Profuse sweating is pretty constantly present. The prostration and excitement of the nervous system are more marked than in erysipelas ; there is usually great agitation, and the delirium is often very violent. Pain is not at first referred to the seat of the inflammation, but is felt severely in the limbs, or back, or head, and more especially in the prsecordium, and it may move from part to part. Pain in the chest, and hurried embarrassed breathing, are present in those cases where the cellular tissue of the pectoral region is affected, as is so usually the case in dissection- and bleeding-wounds. The pulse is rapid from the first. The symptoms are indeed very like those of pyaemia, to which the disease is closel}'' related. The course of the inflammation of the cellular tissue is the same in both classes of the disease. But while after ordinary injury it spreads like phlegmonous erysipelas, directly from the original seat of the injury, in cases of poisoned wound it attacks a remote part, between which and the puncture, in very many cases, no direct communication can be traced. In dissection- wound there is often inflammation of the absorbents and of the axillary glands ; but this does not appear to be a necessary antecedent ; it is often absent, or at any rate unnoticed, and is VOL. I. Q 226 ERYSIPELAS. usually transient wlien it does occur. The punctiu-e, too, may have entirely healed. The inflammation generally attacks the chest on the side which has received the wound, beginning in the neighbourhood of the axilla, and spreading over the back and chest and abdomen down to the ilium, but rarely passing to the opposite side. It may, however, begin on the opposite side ; or when it has commenced in the ordinary situation, may break out afresh in distant parts or spread across the chest. Often too in the course of the disease, patches of erysipelas or maculse, like those of typhus, may appear in various parts of the body. The extension of the inflammation to the plem-a, mediastinum, or pericardium, is not uncommon. The difference between phlegmonous erysipelas and diffuse cel- lular inflammation is, that whereas in the former either the skin and cellular tissue are attacked together, and from the same cause, or the affection of the cellular tissue is secondary to that of the skin, in the latter the cellular tissue is primarily involved, and the skin may be free entirely from or onl}^ secondarily affected with inflammation. The part is swollen and shining, very painful, and often exquisitely tender ; but the pain and tenderness are due to the tense condition of the skin, or to the nei'ves traversing the areolar tissue being involved in the inflammation, not to any inflammation in the skin itself. The swelling is diffused and uniform, not much elevated, and without a defined border. It is at first elastic and hard, but after a time becomes doughy. Occasionally there is crepitation, from the development of gases in the areolar tissue. These changes indicate that the inflamma- tion has run on to suppuration and sloughing. Although the skin does not participate in the primary inflammation, yet there is often an erythematous blush on it indicative of the disease below. The absence of cutaneous inflammation is most marked in those cases which arise from poisoned wound, followed by distant cellulitis. Where the inflammation follows local injury without inoculation, and spreads from the injured part, the skin is frequently affected. It assumes a pale-brownish, oedematous look, and towards the later stages may become livid, and be the seat of buUoe and vesications, and in some places even of spha- celation. It has been observed in some instances that the skin has been colder than natural; but this is by no means necessarily, nor is it perhaps even usually the case. Resolution may occur, but it is much less frequent than in phlegmonous erysipelas. In the less severe cases healthy abscess CAUSES. 227 may form ; but almost invariably the suppuration is diffused, and death of the cellular tissue ensues. The condition of the parts is the same as is seen in the sub- cutaneous tissue after phlegmonous erysipelas ; but there is in general a greater disposition to deep suppuration and destruction of fasciee, intermuscular aponeuroses, and sheaths of tendons. The deeper-seated layers of cellular tissue may become directly inflamed after injuries or operations. Operations on the sternum or neck are sometimes followed by diffuse inflammation in the mediastinum ; and lithotomy, or division of fistula, by inflam- mation of the pelvic fasciae or the areolar tissue about the rectum. The inflammation may extend from affections of the throat in malignant scarlet fever, and may supervene in other parts at the termination of low fevers, especially when complicated with disease of the intestinal mucous membranes. Death occurs in these cases, and especially after dissection or poisoned wound, more rapidly than from erysipelas. Some have terminated fatally as earl}^ as the fourth day from the receipt of the wound, and the eighth day seems to be about the average. In thus bringing together under one head cases of diffuse cellular inflammation arising from dissection-wound and from ordinary injury or operation, it is not assumed that the poison is the same in both instances. The symptoms are the same, but so are those in snake-bites, where the poison is apparently of a specific nature. But it is not improbable that in all these, in- cluding erysipelas, the condition of the fluids of the body is really the same ; and that though the morbid matters introduced may differ, they will produce a similar change in the blood. The in- tensity of the symptoms would depend on the degree of concen- tration of the poison, and the power of the system to resist its action. Chemico-pathology is more and more tending towards the old doctrine of fermentation, and indicates the rapidity with which albumen in certain states will induce changes in the animal fluids. And we have again abundant evidence of the rapid alteration which may take place in the whole mass of the blood under violent nervous impressions. Causes. The question as to the essential cause of erysipelas is still involved in much obscurity. There is now no doubt that the inflammation depends on some morbid state of the system, probably beginning in the blood ; which, as in the exanthemata and in typhoid fever, manifests itself in an altered local condition q2 228 ERYSIPELAS. and in a general febrile action. Dr. Robert Williams, -who ob- jects to the notion that a morbid poison can be developed in the system, supposes that an erysipelatous virus is always more or less present in the atmosphere, ready to act on those who are capable of receiving it in consequence of a pre-existing unhealthy state. It certainly cannot, like an ordinary inflammation, be produced at will by continued local irritation, however intense or prolonged, while in some the slightest local disturbance will excite it ; and in such persons, as was pointed out by Hunter, ' every inflammation, wherever it exists, mil probably be of this kind.' Be this as it may, there is no doubt that certain causes predispose to it ; and that when the system is thus predisposed, it may arise apparently spontaneously, or fi'om any local irrita- tion. The causes of erysipelas and of other similar constitutional disorders are usually divided into ' predisposing ' and ' exciting.* This division is not, however, sufficient to meet all the require- ments of the case ; and it is proposed here to distinguish them into predisposing, exciting, and efficient causes. The distinction between them may be thus illustrated. Two patients are ad- mitted into the wards of a well-ventilated hospital, each liavang received a similar incised wound. The one is in perfect health, the other is sujffering under derangement of the liver or kidneys. Supposing that no special cause of vitiation of the atmosphere is present, the wounds in both cases will heal ; the one perhaps by the first intention, the other probably more slowly and with unhealthy action; but in neither will erysij)elas be likely to occur. If, however, there be placed between these patients another, suffering under erj-sipelas, the first will probably still go on well, while the second will be attacked by the disease. Here the previous disease will predispose to the reception of the poison, and the wound will excite its action, while the emanation from the erj^sipelatous patient Avill be the efficient cause, without which neither of the two other states will be sufficient to induce the special inflammation. In the healthy subject, although an exciting and an efficient cause be present, the system will have strength enough to resist the influence of the miasm ; the pre- disposing cause is absent. Although in instances such as the foregoing the distinction between predisposing and efficient causes readily suggests itself, yet from our imperfect knowledge of the essential nature of erysipelas, it is not possible in a large number of cases to dis- CAUSES. 229 criminate between them. An atmosphere tainted by imperfect ventilation, or by noxious effluvia, may possibly generate the poison, or may merely predispose to its reception. With this reservation, we may consider bad ventilation, espe- cially where the atmosphere is impregnated with any impure exhalation, as among the most common predisposing causes of erysipelas. Hence the frequency and severity of the disease in hospitals a quarter of a century ago, as compared with the present time. A remarkable instance of the truth of this is furnished by the Middlesex Hospital. Previous to the alteration of the hospital in 1848, the ventilation of the wards, but more especially of the passages leading to them, was extremely deficient, and erysipelas, with its allied diseases, pyaemia and diffuse cellular inflammation, were very common. The wards, for the most part, remain unaltered in size, and the position of the wmdows is the same, but they are on a better construction. The approaches and passages have, however, undergone a com- plete alteration, and are now thoroughly ventilated. Erysipelas, from being common, has become extremely rare, not more than ten or twelve cases occurring in the hospital in the course of the year, nor does the disease appear disposed to spread when cases are admitted. There are few metropolitan hospitals which cannot afford the same kind of evidence. Yet it does not appear that all kinds of vitiation of the atmosphere, however intense, will predispose to the disease. The houses in the neighbourhood of the Thames, for example, during the summers when the ema- nations from it were most offensive, were not particularly visited by the disease. The Crimean army medical report affords us another remarkable instance. Low fever abounded in the camp and the hospitals, where numbers of wounded were lying ; the wounds took on various forms of unhealthy action, but erysipelas was almost entirely absent. Vitiated and unhealthy states of atmosj)here, then, even when conjoined with circumstances which are generally most favourable to the reception of the disease, are not of necessity sufficient to induce its appearance. On the other hand, the atmosphere may be vitiated by causes so slight as to escape observation, and yet be abundantly productive of ery- sipelas. An instructive example of this was seen in one of the male accident-wards of the Middlesex Hospital a few years ago. It was observed that erysipelas commonly attacked the pa-tients in two beds in particular, while it did not occur in any other patient in the ward or in the hospital generally. The constant 230 EEYSIPELAS. repetition of this occurrence led to tlie conclusion that some special cause of vitiation of the atmosphere was in operation in the neighbourhood of these beds, and it appeared probable that the presence of a dust-bin in the area below the window, on each side of which they were placed, must have had to do with the phenomenon. The dust-bin was cleansed and whitewashed, its door was kept closed, and directions were given that the window should not be allowed to remain open. The erysipelas at once disappeared. A couple of years afterwards, the disease was again found to attack the patients in the same beds. It appeared that the precautions had been neglected, the dust-bin had again be- come foul, and the door had been allowed to remain open. The adoption of the same measures again rendered the beds healthy, and they have since remained so. It may be remarked, that no unpleasant effluvium was detected in the neighbourhood of the window, which could lead to the impression that the atmosphere was in any way tainted. Here it cannot be determined whether the impure air merely predisposed the patients to take erysipelas, or whether the actual materies morhi was generated. The latter is, perhaps, the more probable view. Exposure to cold and wet, improper or insufficient diet and habitual intemperance, predispose to the disease, j)artly by their general debilitating effect, partly by their inducing disease of the abdominal viscera, especially of the liver and kidneys. Indeed, derangement of the digestive and excreting organs, particularly diabetes and Bright's disease, must be ranked as amongst the foremost of the predisposing causes. Women sujffering from amenorrhoea or dysmenorrhcea seem to be very liable to be attacked by it. Sometimes erysipelatous inflamma- tion takes place periodically at the menstrual period. M. Cos- tallat saw a woman who, during five menstrual periods, had erysipelas of the foot. The catamenia came on as soon as des- quamation began."^ This has been observed too by Hoffman. Patients recovering from dropsy and from fever are prone to it; but it is remarkable that those suffering from pulmonary disease are not very susceptible to its influence, and according to Dr. E,. Williams phthisical patients are rarely affected. Powerful mental emotions, whether temporary or continued, are un- doubted predisposing causes ; and none more so than protracted anxiety — perhaps fi-om its influence on the digestive organs. * Vidal, Mcdecine Operatoire, vol. i. p. 150. EXCITING CAUSES. 231 In some persons there seems to be a constitutional predisposi- tion to erysipelas, the slightest causes inducing- an attack of the inflammation. On what this state of system depends, is often obscure; it does not appear to be connected with the general health. The same proneness to special infection is seen in the case of many other diseases. It is observ^ed, however, that this proneness to the disease is often connected with the rheumatic and gouty diathesis. Exciting causes. Of the exciting causes the most frequent is local injury. Any kind of wound, even the simplest incised wound, any contusion, or fracture, or sprain, may excite the inflammation ; but lacerated wounds of the extremities, and scalp- wounds, are its most fruitful sources. Fatal erysipelas has followed the mere removal of an atheromatous tumour of the scalp. But while the inflammation may follow the simplest wounds where every proper attention is paid to them, they be- come far more decided causes of it if irritated by improper applications or by friction, or if thorough cleanliness be not observed. The retention of an unhealthy purulent discharge by compression or bandages is a common cause of erysipelas. That erysipelas should follow an ordinary clean incision, without inoculation of a morbid material, and which yet would not have occurred unless some local injury had been inflicted, in no way supports the view that it is a mere modification of an ordinary inflammation. The same thing is seen in other diseases ; in gout, for example, where an injury to a joint, or a contusion, or over-exertion, will often determine at once an attack in the part. A current of cold air will excite the disease in the head ; and it often follows the application of cold to the loins during men- struation, whereby the discharge is checked. A sudden cliiU will cause it. Over-exertion will determine its appearance. Generally, however, in such cases there are co-existing circum- stances favourable to the production of erysipelas ; as long exposure to cold or wet, insuflficient food, &c. This is often seen in the London hospitals in those Avho have walked from long distances in search of employment. But there is another and perhaps more decided cause in operation, namely, the vitia- tion of the blood itself by over-exertion. The observations of Duhamel, Haller, and Chaussier show that in over-driven animals the blood becomes disorganised, and capable of pro- ducing gangrenous pustules and malignant fever when inocu- 232 EEYSIPELAS. lated in healthy animals or in man."^ And yet, as is seen from the Crimean army report, the fatigue to which the men were exposed, even when followed by severe wounds and confinement in hospital, did not give rise to erysipelas. The scarification of parts affected with oedema, the legs and scrotum es^secially, is very apt to excite the disease, as are leech-bites and wounds made in venesection; and, when the predisposition is strong, even casual errors of diet. It is frequently seen in hospitals that patients who have received an injury which is going on favourably will be seized with sickness and shivering, and erysipelas will show itself. It will turn out that the mistaken kindness of friends has led them a day or two before to smuggle in some improper food, half-ripe fruit, or pastry. In short, it would seem that anything which produces a sudden derangement of the actions of a part, or of the whole system, may, under certain circumstances, determine an attack of erysipelas. In general, however, in order to induce phleg- monous erysipelas or diffuse cellular inflammation, the exciting cause must operate directly on the areolar tissue. Efficient causes. The efficient causes may be considered under the heads of (a) general atmospheric condition, or epi- demy ; and (6) infection or contagion. (a) It is a matter of common observation, that erj^sipelas is far more prevalent at one time than at another, and in one situation than in another. But this tendency has often been present to so groat an extent as to give to the disease the character of a severe epidemic. So far back as the time of Hippocrates this fact was observed. He has described an epidemic erysipelas, commencing in the spring and prolonged through the summer and autumn. In more recent times the records of such invasions have been very numerous. It does not appear that there is any one state of atmosj)here in par- ticular which tends to produce these epidemic forms. In some instances the season was cold and damp ; in many others great heat and drought prevailed. Winter and summer have alike seen them. Generally, however, other epidemics were prevalent at the same time ; and we may hence conclude that the atmosphere was unfitted to destroy the miasmata which were generated. (h) "While the existence of epidemic erysipelas is unques- tioned, the infectious nature of the disease is by no means * See on this subject Copland's Dictionar]/ , art. 'Blood,' p. 192. EFFICIENT CAUSES. 233 universally admitted. The Frencli wi-iters generally are opposed to sucli a notion, while it is received by most English autho- rities. The question is one of great practical importance. The possibility of producing the disease by direct inoculation from the vesicle may be put aside, resting as it does on the uncon- firmed experiment of Willan. All hospital surgeons, however, are aware of the risk attending the indiscriminate use of sponges when erysipelas is present in a ward. It is seen that if a wound be cleansed with a sponge which has been used on an erysipelatous patient, the disease is pretty sure to appear in it. In many hospitals sponges are not, on this account, allowed to be used, and tow or cotton-wool are substituted, and are at once thrown away. And this is a wise precaution. There is, indeed, no proof here that a specific vu-us is transferred from one patient to another. Those who deny the contagious nature of erysipelas not unreasonably assume that when the disease is prevalent it may be excited by any irritation, and especially by the application of impure animal matter to a wounded or ulcer- ating surface. In the same way, the mere fact of the exten- sion of erysipelas in a hospital, or other limited locality, without direct contact, is no evidence per se of infection. It may, and perhaps most frequently does, depend on peculiar atmospheric conditions, the result of imperfect ventilation or unwholesome exhalations, which generate possibly the efficient, possibly only the predisposing, causes of the disease. It must be admitted that the disposition to the propagation of erysipelas by infection is not so great as is seen in the case of many diseases. But take the instances of scarlet fever, typhus, and typhoid fevers. Of the infectious character of the first no one entertains a doubt. Of that of the two others the evidence is incontro- vertible, though it is denied by some ; but typhoid, though contagious, is infinitely less so than typhus. In erysipelas this character may be still less marked ; but its existence rests on observations too striking and numerous to be set aside without the adoption of explanations far more difficult to receive than the simple one which the facts themselves suggest. And if it can be shown that, in many cases, the evidence of infection is just as strong, and rests on precisely the same grounds as in scarlet fever or typhus, it would surely be irrational to reject that evidence because it militates against a preconceived opinion, or to assign to accidental coincidence sequences of events often recurrinir and in a re^rular order. 234 EEYSIPELAS. The cases recorded by Dr. Wells,* Dr. Stevenson,t Mr. ArnottjJ Sir W. Lawi'ence,§ Dr. Elliotson, Mr. Erichseu,|| and others, are too well known to require repetition here. They are too numerous and too striking to admit of any reasonable inter- pretation save that of the presence of disease of an infectious nature. Still it may be useful to put on record new and aii- thentic instances ; such as, amongst many others which have come to my knowledge, the two following. The first, which was under the observation of Dr. Rogers of Dean Street, resembles, save iii its final termination, the case which Dr. Elliotson has mentioned as having occurred to himself. ' A medical student went into the country, and was requested by his brother, a medical man, to visit an erysipelatous patient. Whilst leaning over her, he became conscious of a nauseous odour, which almost caused him to be sick. A few days after he was suddenly seized with shivering, followed by fever; erysipelas shortly came on in the head and face, and he died after a week's illness.' In the second instance, which has been communicated to me by Dr. Goodfellow, as having been witnessed in the Fever Hospital, there seems every reason to think that the disease spread from bed to bed by infection. ^ In the epidemic of typhus that prevailed in the autumn of 1838, more or less of erysipelas was constantly to be found in the wards ; and, as a general rule, it spread from bed to bed. On one occasion, however, this was more than usually striking. It occurred in the large fever-ward, containing thirteen beds, and well ventilated. Eiysipelas attacked a patient on that side on which were seven beds. She was in the bed next but one to the end ; the patient lying in the next bed, the third from the end, was next attacked, and then the patient at the end. The disease successively attacked all the patients in the order in which the beds were placed until it reached the lower end of the ward. It then attacked the patient lying at the same end of the ward, but on the opposite side, and spread from bed to bed until it reached the last on * Trans, of a Society for the Improvement of Med. and C'hir, Knoioledge, vol. ii. t Trans, of the 3Iedical and Chirurgical Soc. of Hdinburf/h, vol. ii. X London Medical and Physical Journal, March 1827. § Medico- Chirurgical Trans, vol. xiv. II Art and Scietice of Surgery, 5tli edition, vol. i. p. 495. DIAGNOSIS. 235 this side, tlie patient lying in whicli was the only one wlio escaped.' But the question of the identity in nature of erysipelas proper with many internal inflammations, which has been before alluded to, is one of even greater importance. At the present day, little doubt is entertained by British surgeons of the con- nection, if not the identity, of this disease with puerperal fever. They both arise under the same circumstances, and the instances of their co-existence in the same patient, and of the tendency which each seems to possess to excite the other, are so nume- rous, that it is next to impossible to resist the conclusion that puerperal fever is but an internal manifestation of erysipelas. And if so, the entire difficulty of receiving the view that other internal membranes may be the seats of the disease, is removed. That they are far less frequently so than the peritoneum after childbirth, is only what we should expect. They can rarely be exposed to influences so favourable to the production of the disease. Cases such as the following, reported by Dr. Gibson,* tend to this conclusion : ' An infant was attacked with ery- sipelas of one foot. The mother was soon afterwards seized with the disease in the head and face. The wet-nurse of the infant was taken with pneumonia, and was removed home, a distance of four miles. Her father, who had had an injury to the head, was soon afterwards seized with erysipelas of the scalp, and died ; her sister had low fever, with sore throat ; and two children in the same house were attacked with croup, and died.* Dr. Warrenf states broadly, ' I have seen numbers of patients perish a few days after operations, at the time that erysipelas prevailed in the hospital, without the slightest external ery- thema. In such mstances I have been in the habit of stating to you that these patients died of erysipelas as tnaly as if they had been covered with an erythematous eruption.' Careful observation is still requu'ed on this point, the importance of which in regard to treatment can hardly be over-estimated. Diagnosis. Erysipelas is Jittle likely to be mistaken for any other disease. Its limitation to one part of the body, and the uniform character of the redness and absence of punctation where it is invading fresh portions of skin, and the absence (save in erysipelas of the head and face) of sore throat, distin- * Trans, of Edinb. Med, and Chir. Soc. vol. iii. t On Txmow.t, p. 255. 236 EEYSIPELAS. guish it from scarlet fever. The first of Mr. Arnott's cases recorded in tlie Medical and Physical Journal might possibly, had it stood alone, have been mistaken for scarlatina maligna. In its severer forms, where there is oedema of the subcutaneous tissue, there is no sort of similarity between them. Erythema has a greater disjDOsition to appear in patches ; there is no swelling, and the general symptoms are usually milder. There is no doubt, however, that under the name of erythema are often included cases of mild erysipelas. It could hardly be mistaken for pemphigus, or any other true vesicular disease. From phlegmon, the whole character of the inflamma- tion and of the pain, its spreading character and the absence of prominent local swelling, the fever which ushers it in, and the absence of limitation, readily distinguish it. M. Vidal mentions a case in which malignant pustule was mistaken for ei-ysipelas : this complaint, however, is little known in England. Diffuse cellular inflammation is not always so readily distin- guished from other diseases. It most resembles those with which it is most frequently associated, such as ordinary internal phlebitis, phlegmasia dolens, or inflamed absorbents. Where, as in a limb, the hard and tender veins can be traced, and the swelling is principally limited to their track, the distinction may be readily made ; but when there is more diffused swellmg, and the course of the veins cannot be traced, there may be at first some difiiculty. In phlebitis, however, there is much less tendency to discoloration of the skin than even in cellulitis. The appearance of the limb and the early symptoms in intense absorbent inflammation sometimes resemble what is found in diffuse inflammation, and the two frequently co-exist ; but the red streaks and the extreme tenderness of the glands will point out the presence of the former. Extensive subfascial phleg- monous inflammation may produce rapid and general swelling of a limb, but the swelling soon becomes ?aiore localised and elevated ; and the character of the pain and the attendant fever are unlike those of diffuse cellulitis. Prognosis. So many attendant circumstances must be taken into account in estimating the probable results of an attack of erysipelas, that it is difficult to lay down any general rules for the guidance of the judgment. Each case will present its own special character. The season, and the general or local state of the atmosphere ; the age and constitution of the patient, his previous habits and PEOGNOSIS. 237 the co-existing diseases ; the exciting cause and mode of invasion, and the character and the situation of the inflammation, must be taken into account. The simple varieties uncomplicated with other disease will, if the patient be placed in a good atmosphere, run their course favourably, and terminate in re- solution in from six to ten days. But under other circumstances they may pass into more serious forms, or may of themselves be not unattended with danger. When the disease is epidemic or endemic, no attack, however slight at first, is quite free from peril ; and if at such times it supervene on wounds, the mor- tality is often great. In the very young and in the aged it is never without danger, nor in persons of cachectic habit, or whose constitution has been broken by previous disease or intemperance. When the disease attacks a dropsical limb, or comes on in the course of adynamic fever, it often proves fatal. In the former case, this depends rather on the cause of the dropsy than on the local condition ; for there are no circumstances under which erysipelas is more dangerous than when the liver or kidneys are diseased. In a large majority of fatal cases in adults, when the erysipelas is not epidemic, it will be found that there is cirrho- sis, or some other organic disease of the liver, or degeneration of the kidney. The presence of albumen in the urine, there- fore, in the early stages of the disease, and in unvarying amount, must always excite grave apprehension, as must its presence at any period when accompanied by a low specific gravity. In the desquamative stage, as has been stated, albumen is often present in greater or less quantity, but dis- appears as the disease declines. When diabetes is present, the erysipelas is serious, and often fatal ; and when the disease is erratic, or recurrent, or when itlingers on beyond the ordinary periods of resolution — the pulse, instead of becoming slower, remaining quick or becoming accelerated — a very guarded opinion should be given ; such forms are frequently associated ■with internal organic mischief. It is principally in the two former varieties that metastasis to deep-seated parts is said to occur. This is, however, not a common event in any form of erysipelas ; when it does take place, it is often fatal. The more severe forms of the disease, phlegmonous erysipelas and diifuse cellular inflammation, usually occur after wounds ; especially lacerated wounds, and those made in the gi-eat surgical operations. They are never unattended by danger, but the amount of danger will depend on the presence or 238 ERYSIPELAS. absence of the conditions which have been just noticed. It is in the head and in the limbs that injuries most tend to excite the inflammation. In the head it is more specially liable to occur, both symptomatically and idiopathicallj, and should never be regarded otherwise than as a serious disease, from the disposition which exists to congestion of the membranes of the brain, and to spreading inflammation in the fauces and air- passages. Apart from this, the danger of these forms of erysi- pelas will be, cceteris paribus, in proportion rather to the extent to which the areolar tissue is involved than to the severity of the inflammation ; the affection of a whole limb will be more dangerous than a more limited though more intense inflamma- tion. After all, it may be stated as a general proposition, that erysipelas is dangerous more from its association with other diseases than of itself. While erysipelas is sometimes a serious disease, it not unfre- quently has a salutary effect on a part or on the system. It often seems, like a fit of the gout, to clear away a long-stand- ing condition of general indisposition. When the disease has passed off, the patient will be found to have regained elasticity of mind and body. And in the same way, when a j^art long affected with some chronic intractable disorder has been at- tacked, the disease will have often disappeared or have been much ameliorated on the subsidence of the inflammation. Treatment. From the earliest times to the present day there have prevailed amongst practitioners two entirely opposite views with regard to the treatment of this disease in its earlier stages. According to the one, the disease, being essentially inflammatory in its character, should be treated according to the general rules laid down for the treatment of inflammation, by free bleeding and other antiphlogistic remedies. According to the other, the inflammation being the result of a lowered state of the system, a supporting and stimulating jjlan of treatment should at once be had recom-se to. Each of these views has found among its supporters men of the highest authority and of the most extended experience. At the present day, indeed, the question no longer possesses the same interest as formerly attached to it. In this country, at least, extensive bleeding has in all cases fallen greatly into disuse ; and in ery- sipelas especially, unless in very exceptional cases, is generally abandoned, though in France it has still its advocates. In investigating the records of this disease, one fact appears to be I TREATMENT. 239 established — that whatever plan of treatment was formerlj^ adopted, the inflammation ran a certain course with greater or less severity. What Sir T. Watson says of erysipelas of the head and face is applicable, so far as the treatment by any of the plans formerly recommended is concerned, to all forms of the complaint : * I think the more you see of this disease, the more convinced you will be that it is not to be cut short by any particular mode of treatment; that it will run a certain coui'se.' And Yelpeau and many others have expressed the same opinion. Although undoubtedly, the most satisfactory results have on the whole attended the treatment by support and stimulants, yet it can hardly be denied that the success of the opposite mode, even when carried to an extent which would now be con- sidered by practitioners in this country as highly improper and dangerous, has been such as to render intelligible, if not to justify, its adoption by those who still employ it. Some even of those who advocated a stimulating treatment, condemned the opposite plan only because the convalescence was thereby protracted ; and the experience of Larrey has led him to con- clude that it is safer in severe cases to treat on either plan than to leave the disease to run its own course. And it is not altogether correct to call erysipelas, as is often done, a disease of debility, in the sense that all who are attacked by it are in a weakened or low state. That the disease, by its contmuance, induces such a condition is undoubtedly true ; but persons whose general powers are unimjiaired may, from occasional and accidental causes, be placed in circumstances under which they may take the disease. In such cases the symptoms would run high, and the question might reasonably be entertained, whether a treatment calculated to diminish the intensity of the symptoms, and ward off the consequences which would follow their free development, would not be justifiable and even ap- propriate. From improved sanitary conditions, the efficient causes of erysipelas are not now so rife in this country as they formerl}^ were, and those attacked by it are generally, by habitual intemperance or by some continued j)i'6disposing cause, very susceptible to its influence ; their system is already below par. On the other hand, whatever may be at first the character of the symptoms, the disease sooner or later induces a state of system which demands support ; and a wise fore- thought would lead to the practice of husbanding the patient's strength as far as possible. It is admitted, moreover, on all 240 EEYSIPELAS. sides, that cases frequently arise in wliich depletion could not be thought of, and in which stimulants and support are re- quired from the first ; and such are the cases which now almost universally present themselves. There is one circumstance which should never be absent from the mind in considering the propriety of lowering the patient, and that is, the tendency which is often shown to sudden prostration. Whatever may be the mode of treatment adopted, there is one point which should never be neglected. Every means should be taken to ventilate the room pro]3erly ; the bed-curtains should be removed, and the air should be freely admitted around the bed. If two or more be affected in the same house or ward of a hospital, they should be separated. These pre- cautions should be taken, not only for the patient's sake, but to prevent as far as possible the risk of infection. If the erysipelas be in the head and face, of course it will be undesir- able to allow a draught of air to fall on the patient ; but it is equally, or even more important, that the air should not be stagnant about him. When many are attacked in a ward, it is always well to empty it as soon as possible, to have the walls and ceilings washed, and to ventilate it thoroughly. It is hardly necessary in a treatise like the present, to enter at large upon the various means of internal treatment which have been applied to this disease. The general principles of therapeutics, as applicable either to simjDle inflammation or to common or specific fevers, have of course been brought to bear upon it. It is clear that, apart from the question of the possi- bility of attacking the specific cause, no general rule can be laid down which shall apply to a disease which sometimes creates merely a transient febrile] condition, at others sets in with a violence almost equal to that of the plague ; which is at one time accompanied by high action, at another prostrates at once the vital powers. Each case must be treated to a certain extent according to the condition of the patient and the character of the attack. There are certain indications which should never be neglected. It has been seen that the bowels are generally torpid, though sometimes diarrhoea takes place. In either case the evacua- tions are unhealthy. AVhen there is constipation, and the bowels have been acted on by purgatives, the motions are usually pitchy and very offensive. When diarrhoea is present, the motions, though fluid, have otherwise much the same character, TREATMENT. 241 and are dark-coloured and offensive. In order to give full effect to any treatment, it is well that these states should be corrected ; and few cases occur in which the action of mercury in the first instance is not beneficial. In the more usual torpid states of the bowels, brisk purgation with calomel and jalap or scammony, followed up if necessary by a warm aperient draught, so that natural bilious motions may be obtained, will seldom fail to improve the state of the patient, and will always allow wine and tonics to be given with greater advantage. Even in more advanced cases, when the patient is in a state of prostration, with a dry tongue and weak pulse, if this point has not been previously attended to, his condition will be often found to improve under the action of the medicine, though of course wine and support should be given at the same time ; and where the disease sets in with diarrhoea, gray powder with soda three or four times a day will generally be found beneficial. The same medicine may be advantageously given when, after the bowels have been acted on by calomel, the motions still retain an unhealthy character. In the minor cases, saline medi- cines, with small doses of sulphate of magnesia, and in some very slight ones mere attention to diet, will be all that is needed. The condition of the bowels is disregarded by some surgeons ; and in many cases no doubt the disease will run its course, and the patient recover, where no attention is paid to this point. But it certainly seems consistent with reason, as I believe it is with experience, that the condition which is amongst the most frequent in predisposing to the disease, should as far as possible be removed. Many cases will of course occur in which the judgment of the practitioner will lead him to be more cautious in the use of calomel. Where the erysipelas, for example, appears at the termination of, or as- sociated with, other diseases, such as fever, or dropsy with organic affection of the liver or kidney, active purgation will not be well borne ; but even in such cases the use of the milder mercurial preparations will often be advantageous, while support and wine are allowed at the same time. When the derange- ment of the digestive system has been, as far as may be, re- moved, quinine, or cinchona, or calumba, wiU be found useful though before they may have had the effect of making the patient more feverish. With the exception perhaps of the tincture of the sesqui- chloride of iron, our chief trust should be in port wine or spirits VOL. I. R 242 ERYSIPELAS. and beef-tea. The quantity of wine which it may be desirable to allow must depend very much on the previous habit of the patient as well as on the character of the symptoms. Generally about six ounces a day, if this treatment has been commenced early, will suffice ; but in those habituated to free living, or when the supporting plan has not been resorted to until the symptoms of depression have come on, much more will be required. The effects of stimulants must be carefully watched. When they are found to produce dryness, and heat of skin, with increase of restlessness or torpor, it is a sign that they have been carried further than is good, and a longer interval should elapse before they are repeated. With regard to nourishment, a pint or two of beef-tea, and one or two cups of arrowroot or sago, will in general be all that is required. The stomach is not in a state to digest much, and care should be taken not to overload it. The sensations of the patient are valuable guides. If there be a loathing of food or a tendency to sickness, it is of no use, and will often do much harm, to force nourishment upon him. Wine rarely disagrees, and is as rarely objected to. Towards the later stages of the disease, if the patient be found in a state of low wandering, with a weak quick pulse, a rough dry tongue, and a cold skin, good bottled stout will be often the best medicine. Patients will be often seen to drink a tumbler or two of it with eagerness, when they have objected to other things, and then to fall into a tranquil sleep ; the skin will become warm, and bedewed with a comfortable moisture, and the symptoms on their awakening will be all ameliorated. Instead of wine or stout, it may be often better, in any stage, to give the stimulant to which the patient has been accustomed, especially if he show any marked preference for it. It is not a little remarkable that, among the nmnerous medicines which have been tried in erysipelas, that class alone which seems to exercise any really controlling power over the disease should not have had a recognised place till within the last fcAV years, viz. the preparations of iron. This is the more remarkable because Velpeau, so far back as the year 184-1, emphatically pointed out the advantage to be derived from their external use in simple erysipelas {E. legitime). In his Legons Orales, speaking of the failure of other remedies, he says that he was led to try the sulphate of iron, and adds : ' It modifies, it changes very positively the eiysipelatous inflammation. I do not say that it extinguishes it as soon as it is in contact with TREATMENT. 243 it ; but it is certain that it sensibly shortens its duration, and that an erysipelatous patch does not resist the application of the sulphate of iron for more than two or three days. Treated by this remedy, an ordinary erysipelas, where there is a suc- cession of patches of inflammation, never lasts more than three to six days, whereas the average duration of the disease is not less than twelve days.'^ The internal use of iron, in the form of the muriated tincture, had, however, been largely and successfully tried by Dr. G. Hamilton Bell for many years before this date ; but it was not until 1851 that the results of his experience were made public in a paper read before the Medico-Chirurgical Society of Edinburgh. The remedy is now in general use, and daily ex- perience shows that its value has hardly been overrated by Dr. Bell. The rationale of its action advanced by Dr. Bell is more questionable. He believes that the beneficial influence of the medicine is due to its controlling power over the tonicity of the capillaries of the inflamed part. That it is useful as a general tonic is very probable ; but its peculiar action on the disease, controlling and rapidly cutting it short in a manner effected by no other tonic, seems to indicate that it strikes more at the root of the disease itself, and that its principal effect is on the blood, as was suggested by Velpeau. The opinion given by Dr. Balfour is pretty generally borne out by the experience of those who have given the medicine a fair trial, ' that we now possess a certain and unfailing remedy, whether the erysipelas be infantile or adult, idiopathic or traumatic." f Cases may occur now and then in which the iron will appear to be inert. Indeed, I have met with some cases in which, although to all appearance very favourable for the use of the iron, it has had no marked effect in controlling the disease, which has run its usual course. It has appeared to me, never- theless, that in some of these the constitutional symptoms bore no proportion to the severity of the inflammation. But that given in full doses it will do, in the majority of cases, what no medicine of any other class has yet been found to do, namely, cut short the disease, no one, I believe, who has fairly tried it will deny. Less than a drachm and a half to two drachms a day will rarely in adults produce much effect. In severe cases, an ounce and a half to two ounces a day will often be required. Op. cit. p. 307. t Monthly Journal, 1853. R 2 244 EEYSIPELAS. The evidence of its effects rests on this : treated in the ordinary way, erysipelas, as a rule, runs a course of from seven to ten days at the least ; treated by the iron, it often subsides in from the second to the fourth day. It should, however, be given cautiously so long as the secretions of the liver and bowels are in the unhealthy state which almost always accompanies the early stages of erysipelas. In such cases the free administra- tion of calomel, followed by warm saline purgatives, is espe- cially called for ; nor need the advanced state of the disease, nor the lowness of the patient, interfere with this treatment, if it have not been previously adopted. Even when increased cerebral excitement attends the administration of the medicine, there is no need to discontinue its use, for it wiU be found that in general the disturbance will subside after a short time, as was pointed out by Dr. [BeR. The quantity of the tincture which may be required will depend on the severity of the symptoms. In advanced and serious cases, as much as half a drachm may be given every hour ; in slighter ones, fifteen to twenty minims every four hours will suffice. Of the symptoms which arise in the course of an attack of erysipelas, those which belong to affections of the nervous system are among the most important. They may proceed from vascular excitement, amounting to inflammation of the membranes of the brain, or from congestion, or from the circulation of an impure blood, or from exhaustion of the nervous system. Inflammation is rarely present, unless as a consequence of severe erysipelas of the head. But it must be regarded as itself of an ery- sipelatous nature, and its treatment must therefore be based on the same general principles as apply to the treatment of erysipelas. It is here, if anywhere, that bleeding may be properly resorted to. The tendency to effusion makes it highly important to lessen as early as possible the vascular action. Should it be thought necessary to take blood, it should be done early, and once for all. But it should be done cautiously, by leeches to the temples, or by small incisions into the inflamed pericranium ; and the bleeding should be arrested as soon as an effect has been produced on the pulse. It is only in the young and plethoric, however, and very rarely among the patients in a London hospital, that bleeding is called for. Free purgation, and the use of turpentine enemata, will be in most cases useful. And when the liver and bowels have been largely unloaded, the iron may be safely given, and will act as I TEEATMENT. 245 in other states of the disease. Wine, too, may be allowed, but its effects must be very carefully watched. When coma has come on after marked inflammatory symptoms, with a rapid pulse and thickly-coated, black, dry tongue, the case is one of the most serious character. Dr. Copland says, that he has seen the most marked benefit from the use of calomel, in a full dose, with camphor, followed by turpentine and castor-oil in the form of an electuary, to be placed on the back of the tongue, and repeated until the bowels begin to act, when its operation may be pro- moted by enemata, blisters being applied to the nape of the neck or insides of the thighs. Copious offensive black motions are generally brought away, with marked amelioration of the symptoms. This mode of treatment, followed by the free use of the tincture of iron and of wine, will, I believe, be effective in aj)parently hopeless cases. In the other forms of affection of the nervous system bleeding is never admissible. The general treatment which has been re- commended will, in most cases, be all that is required to allay the nervous symptoms. Sometimes, however, they demand special attention. For example, we not unfrequently see cases in which the nervous excitement and restless wakefulness are greatly in excess of the general symptoms of the erysipelas, and tend to exhaust the patient. This has been observed often in connec- tion with erratic, and it is said with metastatic, erysipelas. In such cases morphia or henbane are often of great use ; but they should be given very cautiously if there be evidence of the existence of organic disease of the liver or kidneys. As a general rule, indeed, narcotics are not well borne in erysipelas, and tend to cause a dry tongue and congestion of the brain. Under no circumstances should they be given until the bowels have been freely relieved. Camphor, on the other hand, whether wandering or torpor be present, seems to act favour- ably ; and may be freely given when nei-vous symptoms, and especially those which occur in the later stages of the disease, are marked. Another and a valuable remedy is ammonia. The cases to which it seems most appropriate are those also in which nervous prostration or excitement is especially x^rominent; where, for example, the inflammation being of the simple kind, the skin remains soft and not burning, or is perhaps cold ; where the tongue is moist and flabby, and the pulse quick, large, and weak, while there is great restlessness, or transient delirium, or nervous prostration. But where the tongue is hard, and dry, 246 EEYSIPELAS. and fissured, and the skin is hot and dry, ammonia does not appear to me to agree so well. With regard to the general treatment of diffuse cellular in- flammation arising from injmy or operation, with or without the inoculation of a morbid poison, there is now little difference anion o"st surgeons. On all hands the depleting treatment is condeimied, and the free and early use of tonics and stimulants recommended. Our chief dependence must be on wine, spirits, or stout, with camphor and henbane, or perhaps opium, to allay the irritable condition of the nervous system and diminish the pain. It may be presumed that the iron remedy will act favourably in such cases, as they are in their nature the same as erysipelas. 1 have not, however, had any personal experience of its effects. The local treatment of simple er3sipelas and of the early periods of phlegmonous erysipelas must be considered with reference to its effect on the local inflammation and on the disease generally. The suggestion of Hunter, that the inflammation contaminates while it spreads, is one which has perhaps not received all the attention which it deserves. The inflammation is the expres- sion of a diseased state of the fluids ; of what nature, is still a question. It may be the elimination of a poison, or a result of altered nutiition or of altered nervous action. One thing is clear, that the products of the inflammation are of a morbid nature, capable of producing the disease in those who are pre- disposed to it, and at the part at which they are introduced. Hence may arise the disposition, so remarkable in erysipelas, to spread from the point first invaded. But opposed to this disposition there is the tendency to elimination which exists in the exanthemata, and indeed in disease generally, if the system be sustained in a state of vigour sufficient to enable it throw off the disease. To a certain extent, then, the local inflammation may be regarded as reacting on the general disease, and any thing which would check the local action would so far tend to the removal of the disease generally ; just as in small-pox the severity of the attack is greatly modified by rendering the pustules abortive. It is only on some such assumption that the apparently con- tradictory facts can be reconciled, viz. that the disease itself is general, the inflammation being only its external manifestation, and that the removal of that external manifestation will aid in curing the disease. The observations by Velpeau on the effect of the local appli- TEEATMENT. 247 cation of the sulphate of iron have been verified by others. Mr. Luke informs me that, according to his experience, the collodion treatment often cuts short the disease ; nay, even mere position has some influence in arresting its course. But though these and other measures are beneficial, and at times perhaps effectual in removing the disease, yet cases con- stantly occur in which they exercise no actual control over it ; the disease has too great a hold, or the vital powers are too low, to allow of its arrest by such measures. Nor should they under any circumstances be trusted to alone, valuable as they are when combined with other treatment. The sulphate of iron, either in a lotion or ointment, produces, as has been said, a decided effect on the inflammation, and tends to shorten the disease. In lotion, a drachm of the salt to a pint of water ; in ointment, a scruple to an ounce of lard, may be used. Its effect is very speedy and marked ; the redness and tension subsiding, and, if freely applied, the disposition to spread being in some measure checked. But it is an incon- venient remedy, from its soiling the linen with which it comes it contact. The efiicacy of collodion in arresting erysipelas is not fully determined. That it is a most useful application is admitted by all. It was, I believe, first used in this affection by Mr. Busk, and is now extensively employed both here and abroad. By Mr. Luke, whose opportunities of testing its efficacy in the London Hospital were very extensive, it is regarded as having an arresting influence over the disease. In a communication which he was good enough to make to me, Mr. Luke informed me that he had abundant reason for believing that the course of the disease might be cut short by the careful and free use of collodion. Mr. Busk, however, attributes to it only a palliative influence. There is no doubt whatever that it forms an uniform and unirritating protection to the sensitive skin. Besides this, it is probable that it acts directly on the inflammation, emptying by its contraction the congested vessels ; and there is no doubt that, as in other inflammations, uniform pressure is a most valuable means of relief. But even when the collodion has been applied well beyond the limits of the redness, and the parts beneath it have been rendered pale, the inflammation is often found to continue its spread and pass beyond. By checking the intensity of the local inflammation, however, it no doubt tends to check the severity of the general disorder. Another agent for which the property of controlling the 248 ERYSIPELAS. disease has been claimed, is tincture of iodine, which was recommended by Mr. Norris,* who believes that the effect is not merely local, but that ' it exhibits a marked control over the constitutional symptoms.' I do not know whether this remedy has been employed by others. If it really exercises any influence over the local and general symptoms, it would be well to try the effect of iodised collodion, which is at times benefically employed in strumous affections. An application frequently used is the nitrate of silver, first recommended by Mr. Higginbottom of Nottingham.f His directions are that 'the affected part should be well washed with soap and water, then with water alone, to remove every particle of soap, as the soap would decompose the nitrate of silver ; then to be wiped dry with a soft towel. The concen- trated solution of four scruples of the nitrate of silver to four drachms of distilled water is then to be applied two or three times on the inflamed surface and beyond it, on the healthy skin, to the extent of two or three inches.' Care must betaken that every part be effectually touched, and if the inflammation spread the application must be repeated. Another mode of applying the lunar caustic, especially in erysipelas of the limbs, is the formation of a line a few inches above the inflamed part, completely surrounding the limb. Care must be taken that no part of the circle be left untouched. The inflammation will come up to this line, and there in many cases stop ; or if the ring be imperfect, wiU insinuate itself through the opening, and then spread beyond. In a large number of cases this treatment has appeared to me inoperative, the inflammation passing the line of demarcation, and sometimes even a second and a third line. At other times, however, the inflammation has been arrested. The plan is so simple that it might be weU to adopt it in any case, in conjunction with the collodion, or iron, or other application to the inflamed part. Whatever the application to the inflamed part, strict atten- tion should be paid to position. If the inflammation be in the limbs, they should be elevated ; the leg, for example, should be kept in the j)Osition which was formerly maintained in fractured patella. This alone will often give marked relief, diminishing action and relieving congestion. T^ • Medical Ti7nes and Gazette, Dec. 1852. t An essay on tlie Use of Nitrate of Silver in the Cure of Inflammation, Wounds, and Ulcers. TREATMENT OF DIFFUSE INFLAMMATION. 249 There are not many things which are more comfortable to the patient than a thick layer of cotton-wool placed over the part, to which powder or collodion has been applied. Generally it is more soothing than fomentations, and requires far less attention and exposure. Fomentations, however, when the inflammatory action runs very high, are often desirable, and chamomile or hops will add to their efiicacy. Cold lotions should never be employed ; they may indeed check the local action, but with a tendency to invasion of the disease in other situations. The application of leeches in the early stage, of blisters, of the actual cautery, and of mercurial ointment, has been recom- mended, and they have all been largely tried. There is no evidence that they have any real effect on the disease, and they are generally abandoned in this country, though still used in France. The objection which exists against general bleeding may be urged against any such amount of local bleeding as would really diminish the action of the part ; and unless they are freely aj)plied, they only irritate. Counter-irritation, by blisters or the hot iron, does not appear to shoi^en the duration of the disease ; nor is there evidence that it has been productive of any other benefit. The same remark applies to mercurial oint- ment, which has the disadvantage that it generally salivates profusely. The local treatment of phlegmonous erysipelas does not differ in its earliest stages from that of the simple forms. The advocates for depletion of course recommend that more decided antiphlogistic means should be used, and that blood should be taken freely from the part by leeches, cupping, or incision. The two former methods are now little employed, and are rarely productive of any good. The practice of making incisions is one of long standing ; and considering the high vascular action and great tension which are present, is one which it might be supposed would naturally suggest itself to the surgeon. According to Velpeau, they have long been practised in Russia, and amongst the peasants in Brittany. Modern surgery is indebted, however, to Dr. Copland Hutchison * for their intro- duction to the notice of the profession. The plan, which from the year 1814 Dr. Hutchison had adopted largely in naval practice, consisted in making incisions of from an inch to an inch and a half in length, and two or three inches apart, in a longitudinal direction, through the affected limb. Their depth * Med.-Chir, Ti-aiis. vol. v. 250 ERYSIPELAS. varied according to the nature of the inflammation. In general they reached the fascia, but extended through it when the inflammation extended to the deeper tissues. From fifteen to twenty ounces of blood were usually lost from the overloaded vessels. The haemorrhage was controlled as far as is possible ; a little pressure, with attention to position, generally effected this ; the limb was then fomented. The obvious effect of these incisions is to relieve the tension of the skin, to allow of the escape of the accumulated serum and pus where it is formed, and hence to diminish the risk of sloughing of the cellular tissue, and of extension of the suppuration. As phlegmonous erysipelas will often, under proper treatment, end in resolution, it is not necessary to resort at once to incisions ; but when the skin is becoming brawny, and it is clear that suppuration is threatened, they should be made at once. Still more important is it to have recourse to them, when that softening occurs which has been before described as indicating that the cellular tissue has fallen into suppuration. Instead of these small incisions. Sir W. Lawrence recommended one long incision extending longitudinally through the whole length of the inflamed part, and thus at times reaching from one end of a limb, to the other. This plan is now, however, generally abandoned ; the amount of haemorrhage was in some cases so great as to prove fatal. Nor is the relief afforded to the con- gested tissues greater than when the safer and milder treatment by multiple incision is adopted. The practice of scarification, recommended by many of the older surgeons, was again brought into notice by Sir Richard Dobson,"^ who used it in all forms of erysipelas. It consists in making numerous punctures, varying in number according to the extent of the disease, from ten to fifty, and in size from one to two-fifths of an inch. They were repeated twice a day in moderate cases, and three or four times a day in severe ones. According to Sir E. Dobson, only two cases were lost out of many hundreds treated in this way. If used early, these punctures often prove highly beneficial ; but if the indications of commencing suppuration be present, it is better at once to have recourse to the small incisions. When the boggy feel in the part indicates that suppuration has advanced to destruction of tissue, incisions must be freely * Med.-Chir, Trans, vol xiv. TREATMENT OF DIFFUSE INFLAMMATION. 251 made, and collections of matter must be at once let out. The suppuration will be abundant, and the dressings must be often changed and the parts cleansed. The matter is always more or less putrid, and it is extremely useful to syringe out the subcutaneous tissue with solutions of carbolic acid or Condy's fluid, or hyposulphite of soda, or with even the undiluted solution of sulphurous acid. I prefer the hypo- sulphite, using a solution of from twenty to thirty grains to the ounce. The parts should be washed out each time of dress- ing. If the discharge be very offensive, a solution of chloride of zinc (fifteen grains to the ounce) will be found more efficient than any of the above. Shreds and flakes of sloughy membrane should be gently drawn away, and it will save time if the skin, which is thinned and blue, and evidently unfit to take on healthy action, is at once removed ; but every point of skin or subcu- taneous tissue which retains its proper vitality should be care- fully husbanded. It is better to avoid poulticing, which tends to keep up a profuse suppuration. The part should be supported with per- forated lint or linen, outside which should be a layer of cotton- wool, and the whole surrounded with a bandage. When the action of the part begins to flag, stimulant washes may be used, or the lint covered with the basilicon ointment. Where the granulating surface is very extensive, the cicatrisation will go on well to a certain point, and then the process may become arrested, and the modes of treatment required in indolent ulcers must be put in force. It is well to protect the edges with col- lodion and oil. The patient's strength must be freely supported, and every- thing done which will tend to the improvement of his general health. Nothing can be more contradictory than the statements which have been made with respect to the effect of compression in erysipelas. It was employed by the older surgeons, as Pare, with success ; but had fallen into oblivion when Velpeau, in 1826, again brought it into notice. At first he employed it in all forms of the disease, but ultimately he came to the conclusion that, while if employed at the right time and in the proper manner, it was almost a certain means of arresting* phlegmonous erysipelas, it had no effect on the simple forms. He says ^ that when the phlegmonous erysipelas is only * Leqons Orales de Clinique Chirurgicale, vol. iii. p. 271. 252 ERYSIPELAS. of three days' duration, compression will almost always produce resolution ; and that it is still useful even when pus has formed and the cellular tissue has become mortified. Perhaps the compressive bandage has not been so well applied by others, but certain it is that it has not been generally found so efficient as to bring it into general use. The roller should be so applied as to produce moderate but uniform pressure, and should be reapplied every twenty-four hours or less, according to the effect it has in diminishing the swelling. The pressure produced by collodion is more uniform and suf- ficiently firm ; any benefit, then, which can be derived from compression will be more easily obtained by its use than by that of the bandage. Generally, then, it may be stated, that in the early stages of phlegmonous erysipelas, in the course of the first two or three days, attempts may be made to arrest the course of the inflam- mation by the means which are found most effective in the simple forms, — such as the use of collodion, of iron, or of the compressive bandage. Should these not be found of any avail in checking it, incisions should be at once resorted to freely and decisively; and they should be resoi-ted to afterwards wherever it may be found that pus is lodged, or that the cellular tissue has been destroyed in parts removed from the neighbour- hood of those previously made. The treatment of diffuse cellular inflammation is much the same as that of phlegmonous erysipelas, but it must be more prompt. The chances of resolution are far less, and we have no guide in the skin as to the state of the parts beneath. It is well, so soon as there is evidence that the disease exists, to make incisions at once ; but of course heemorrhage must be carefully checked. The after-treatment must be the same as in the phlegmonous form. Care must be taken that, while the dead tissue has free exit, those parts in which vitality still remains are carefully preserved. Perforated lint spread with basilicon ointment should then be laid over the limb, and surrounded and supported by cotton-wool and bandage, which must be changed as often as the amount of suppuration calls for it. CAMPBELL DE MORGAN. PYEMIA. PYEMIA first attracted considerable attention in connection witli a condition of veins known as phlebitis, but the expres- sion has now obtained general usage, as conveniently indicating certain effects produced in the system by the action of animal products. For a time, many observers associated it with other changes. Some, following Desault, ascribed it to a distm'bance of the nervous centres ; others considered it as primarily an affection of the lymphatic system ; whilst some have written of its occurrence as dependent upon occult atmo- spheric causes. Two conditions may be considered under the name of pyaemia or systemic infection : one the primary or direct consequence of a poison, in which fluid elements are, it is probable, chiefly con- cerned ; the other a series of affections secondary to the primary disease, or dependent upon other and distinct causes. By regarding the two as necessarily interdependent authors have differed much in their explanation of the secondary affec- tions to which the term 'pyaemia is most appropriately applied. Animal or septic poison, introduced into the system, is the exciting cause of the primary disease, systemic infection. In no case, however, is its nature detected, far less the cause of its peculiar action, any more than of the virus of small-pox, syphilis, and other affections propagated by inoculation. There is reason to believe that it is connected in some subtle manner with a vitiated condition of the blood, and that it causes changes closely resembling those diseases in their characters. It is possible that such poison may be absorbed through the lungs, or from the alimentary canal ; but the cases here to be considered ai'e rather those in which the mischief commences in a diseased or injured part, as an ulcer or a wound ; to which surfaces, putrid or other animal matters are unfoi'tunately apt to be frequently applied. It signifies little whence these matters are derived — whether from decomposing pus, unhealthy secretions, decom- 254 PYiEMIA. posing hides, dead bodies, vegetable putrefactions,* or from animals suffering from acrid discharges, as in glanders ; since the influence of all such, regulated by the intensity of the poison, for they vary in this respect, and by predisposing causes presently to be mentioned, may be conveniently described under two modifications. In the first of these the action is general. The poison is rapidly absorbed and diffused throughout the system, either iii the veins or by the lymphatics and their associated glands. Within twenty-four hours, in acute cases, there are rigors, vertigo, and general uneasiness. Then follow heat, perspiration, and in- creased rapidity of pulse. The seat of inoculation is dusky, indurated, often pustular, or if it had been before secreting pus the discharge ceases. Radiating from this centre, the integument is distending with a serous effusion, presently to be mingled with thin sanious pus. The swelling, generally somewhat elastic, is hard and tense over enlarging and painful glands. The blood, deranging the heart's action, is circulated violently and rapidly through the system ; exuding from its vessels, as in purpura, it stains the surrounding tissues, forms ecchymoses in internal organs, or is poured out upon mucous surfaces, and is then chiefl}" removed with purging or vomiting. In another twenty-four hours, the patient — flushed, anxious, restless, even delirious — is in a hopeless condition, with prostration and rapid sinking. In other instances the affection is less acute in its progress, the poison causes a less disturbance, and the symptoms are in- sidiously developed. They then simulate those of typhoid fever, to which disease this form of systemic infection bears a close resemblance, and may be recognised as a common cause of death after surgical operations, the j)atient sinking gradually with symptoms of a low febrile character. If the blood even- tually rights itself and the j^atient recovers, convalescence is slow, owing to the feeble condition of the system — a condition caused by direct disturbance from the poison, and by the fluxes of one kind or other which ensue, and aid, perhaps, in elimina- ting the virus. In this chronic pysemia, as it has been called, successive suppurations may invade the joints or subcutaneous tissues, and the progress of any case may be marked by frequent relapses.'t * Gaspard, Journal de Physiologie, torn. ii. p. 14. t Paget, St. BaHhol. Hosp. Reports, vol. i. p. 2. ; also Braidwood on Pyeemia, p. 130. PEEDISPOSING CAUSES. 255 In the second modification the action of the animal poison is local, is often er recovered from, and, if fatal, the result is due to predisposing causes, or to changes which depend upon secondary complications. In these cases of systemic infeciion predisposing causes may be recognised in the habits and constitution of the patient, or in the conditions by which he is surrounded. Predisposing causes intensify the general effect, converting a comparatively trivial local mischief into the worst form of systemic infection, or by their absence render of no effect the most virulent animal poison. Various as they are, they may be grouped under cer- tain well-known conditions, (a) Previous illness, either of a chronic character, or especially connected with blood-disease, from which the patient is slowly and with difficulty recovering, as pneumonia, dysentery, or scarlet fever. (&) Extreme prostration of the system from organic disease, as phthisis of the lungs, degeneration of the kidneys — conditions often associated with the desponding state of mind noticed in this malady, and by some accounted its cause. (c) Exhaustion consequent upon surgical complaints with the eventual shock of an operation, as in diseases of joints,^ severe fractures of bone, cancer of the breast, ending in amputation, (d) Parturition, difficult and pro- tracted, or overtaking women in feeble health, more especially if symptoms arise in the treatment of which depletion is em- ployed, or if in this, or in the previous conditions, diarrhoea or vomiting should interpose, (e) Effect of unhealthy occupations and of exposure, as during the war in the Crimea, of which Mounier states, that no pysemia was noted among the first two thousand amputations, whilst afterwards it became of quite ordinary occurrence, associated with gangrene, scurvy, and typhoid fever. (/) Over-indulgence in food or in spirituous drinks ; sudden abstinence from such indulgences ; and, lastly, certain conditions which would seem to be hereditary. * Pyaemia was the cause of death after amputations in — Bryant's cases. Callender's cases. per cent. per cent. All amputations . 10 Primary amputations Amputations of expediency . 70 Secondary amputations . . 15-3 Primary amputations . . 43 All traumatic amputations . 7-1 Secondary amputations . 25 Amputations for disease . . 39-1 Pathological amputations . . 43 — Bryant, Med.-Chir. Trans., vol. xlii. p. 88. Callender, Med.-Chir. Trmis. vol. xlvii. p. 75. 256 PYEMIA. In a word, such circumstances and habits as engender a feeble and unsound state, in which slight injuries produce effects which would never arise in a healthy constitution. Impure air, such as results from crowding of patients, neglect of their wounds and of decomposing animal matters discharging from them, also enfeebles, nay prostrates, the sick man ; though it by no means gives a special character to the disease, merely reducing him to a condition favourable to the development of pyaemia, erysipelas, gangrene, and other allied disorders. Ex- cept as regards ventilation, heat and cold, and their relative effect in the decomposition of animal matter, little stress need be laid upon atmos]3heric influences. Mental depression is undoubtedly associated with this disease, and its influence may materially aid the development of systemic infection, and pysemia, when acting in concert with more directly predisposing causes. Age does not seem to exert any predisposing influence, for infants alike with the old are apt to suffer from this disease, whilst, as might be expected, figures show that the large pro- portion of cases belongs to the middle period of life, to that in which people are most exposed to the hurts and changes out of which pysemia is developed."^ The most important change which results from the various predisposing causes is a modification of the blood. Constituents are probably left in it, unused or unremoved, from defective secretion or embarrassed excretion, some of which are ready, on the least disturbance, to undergo decomposition. Chemistry fails to give us conclusive evidence of these conditions. It is found by many, indeed, that fibrine is deficient — hypinosis — in scarlatina, in cases of exhaustion, of starvation, and in most of those which come under the denomination of cachexia, whilst by others the very contrary is asserted to be the case.f Alcohol, taken habitually in excess diminishes the fibrine; | and • For tables of ages, see Braidwood, op. cit. p. 210. t Vogel, PatMogical Anato7mj of the Human Bodij, English Trans., p. 69. Bouchut, Memoire sur la Coagulation du Sang veineux, kc, in Gazette Medicale d^ Paris, 1845, p. 2G0. Becquerel and Rodier, Pathological Chemistry, Eng- lish Trans, p. 56. X Huss, Alcoholismus chroniciis, Stockholm u. Leipzic, 1852. Peters On the Pathological Effects of Alcohol, in Neio York Journal of Medicine, vol. iii. No. 9. SECONDAET AFFECTIONS. 257 in this, as in most other instances of deficiency of fibrine, the albumen and the fatty principles are relatively increased. Clots when formed within the vessels are soft and infiltrated with serum, forming a gelatinous-looking mass, a tissue of fibrine containing between its fibres a large proportion of fluid serum. They lack contractile power. Lymph, when effused, is laden with corpuscular and granular matter, and soon acquires the character of pus. The blood, when removed from the body, as by haemorrhage, forms in about the usual time a soft <3oagulum, buffed and slightly cupped, in which the white cor- puscles are found in great excess, as in the blood of women shortly after delivery ; it seems in other respects impoverished, and its fibrine is deficient in contractility, as well as modified in actual quantity. Materials, too, in process of absorption may have entered more or less directly into the blood, as after chronic pneumonia, or may be present in excess during some natural process. Lactic acid in the blood of women after parturition is one of these; and Mackenzie holds that it is capable of producing, when introduced into the blood artificially, the phenomena of some forms of puerperal pysemia.'^ Whatever the morbid con- dition may be, the blood in these cases, as noticed by Bouillaud,t has a tendency to coagulate in its vessels during life on the least provocation, and then to enter upon other changes. Systemic infection, then, is caused by some animal poison, and influenced by predisposing causes may become a general disease, more or less rapid in its progress, with symptoms allied to those of typhoid fever, or may be limited to a local action more or less diffused. Secondary affections may follow the general or the local disease, and were originally more especially referred to under ihe nsime ' pycemia.^ In many of these cases consequent upon general systemic infection, the blood is so altered from its natural state that it simply exudes from its vessels, and diffuses its colouring matter, the rapid progress of the disease leaving no time for further changes. In more chronic cases, local * Mackenzie, Med.-Chir. Trans, vol. xxxvi. p. 210. t Bouillaud, Archives ffeneralcs de Medecinc, 1823, torn. ii. p. 189. Boucliut op. cit. VOL. I. S 258 PYEMIA. suppurations may be establislied, chiefly of a pustular character ; and in these there is a resemblance to small-pox or scarlatina, blood-diseases, as they are termed, in which pustules or ab- scesses follow the introduction of a virus, or result from ex- treme debility. The secondary complications which may follow the local dis- ease (but are often dependent upon conditions different from any of the preceding) are marked by sjTnptoms sufficiently characteristic. The patient, weak and enfeebled by previous disease, or influenced by other predispositions already described, complains suddenly of cold, and is presently attacked with rigors. In nearly all surgical instances — for example, in twenty-eight out of thii-ty-three of Arnott's'^ reported cases — the patient is described as going on well when the symptoms first become declared. If a wound is suppurating at the time, the discharge often ceases, its surface becomes diy, and the surrounding integument acquires a dusky hue. The rigors, of varying severity, are repeated at brief intervals ; or, though this is the exception, a day or two may elapse before they recur, no symptoms arising in the interval. Perspirations, sometimes profuse and causing considerable exhaustion, sometimes scanty, succeed the rigors. The skin soon becomes dry and harsh, but towards the close of the case, if it terminate fatally, there breaks out a clammy sweat. The temperature fluctuates, but rarely reaches above 104°. The pulse, rising rapidly to one hundred or one hundred and thirty beats in the minute, is feeble, sometimes intermitting, and though jerking, is easily compressed. The tongue, at first but little altered from its condition prior to the attack, soon grows dry on the dorsum, and is covered with a brownish fur. At the same'time there is a remarkable sense of depression. The countenance is anxious and oppressed, the eyes sunken. There is often pain about the head; the patient, restless and irritable, fails to obtain accustomed sleep, and becomes rapidly emaciated. With these symptoms there exists a tawny discoloration of the integument almost characteristic of the disease, requiring, however, to be distmguished from the jaundice tinge with which it is sometimes complicated. Without the' mtercurrence of other symptoms, the patient may pass quickly into a typhoid state, and thus, in a few days, the disease may terminate * Med.-Chir. Trans, vol, xv. SYMPTOMS. 259 fatally, or, less rapid in its progress, may tend to gradual sink- ing, the patient lingering* for several weeks. When any one organ is especially involved, new symptoms arise. Delirium, rarely of a violent character, with pain about the head, the patient growing heavy and drowsy, answering only when roused, and then with hesitation and indistinctness, points to the nervous centres as chiefly implicated. Hurried respiration, dyspnoea, slight cough, sense of weight about the heart, or pleuritic pains, point to the thorax and its contents. Sickness and vomiting, or diarrhoea with bloody stools, con- taining shreds of fibrine, mucus, and pus, point to the intesti- nal canal, and recall the fact that this disease is sometimes associated with dysentery. Diarrhoea with copious bilious evacuations points to the liver, as also do stools consisting of crude food without any bile, especially when combined with jaundice ; and this is confirmed by pain in the hepatic region. The bladder and kidneys are seldom affected. These local symptoms show where the stress of the* disease is borne ; the main symptoms, those of depression and prostration, advance the while. In the extreme exhaustion at the close of this malady, it is not unusual to observe discharges from various surfaces, as from the nostrils, from the ears, or from the uterus in the female, or to meet with effusions into serous or synovial sacs. For the patient, with a sudden complaint of pain, will often draw attention to a joint, swollen and rapidly distending, or several articulations may be found painlessly im- plicated in the disease. Nor is it unusual to see on the integu- ment patches of dusky discoloration, as though local deaths were commencing before dissolution, or to notice pustular erup- tions, or the rapid development of boils. It is unnecessary to describe the muttering delirium, the parched tongue, the lips discoloured with sordes, which prelude the fatal termination. The symptoms are the same as those of low tj^hoid fever. Few recoveries from the acute secondary complications are recorded ; and even in these the symptoms mark an early stage, when the existence of this disease has been suspected rather * After operations the symptoms of pyaemia have commenced any time from the second day to the third or fourth week. After parturition they usually commence within the first ten days. The patients have sometimes lingered for two or even three months. s2 260 PYEMIA. than proved. In isolated cases, patients liave recovered after severe rigors, followed by some of the local symptoms, as dyspnoea. Expectoration of puriform mucus from the lungs, the passage of bloody and copious stools observed in these recoveries, have been regarded as eliminating processes by Avhich the system is relieved of the morbid material influencing the blood. Many 'pathological changes are found in the dissection of fatal cases. Some of these are referable to a primary disease, others to the secondary complication. Amongst primary affections may be observed diffused sup- puration, as that which accompanies the second modification of systemic infection. Pus, or pus mingled with serum, is then seen infiltrated through the tissues, more especially the cellular, or limited to the course of the arteries, the veins, or the lymphatics. Such suppuration may have extended from a wound, as after an operation, or it may start from a frac- tured bone, or may-be from inflammation of internal parts, as of the pleurae, of the lungs, or of hydatid tumours, whilst in other cases, the process may have commenced about ul- cers, as of the integument, or of the mucous membrane, as in dysentery. In the midst of these suppurative changes, the veins are found filled with clots, and these clots undergoing various changes. It must here sufiice to state,* that, at first of a deep red tint, they become brown, or of a rust colour ; the red cor- puscles diffuse their contents and lose their shape ; the clots then soften, and presently become diffluent, so that, after a short time, varying from a few days to a week or more, they form a yellowish fluid resembling pus, or have a sanious a,ppearance from being mingled with colouring matter of a deeper tint. Gulliver f first drew attention to these changes, and they have been since examined by Bristowe, Virchow, and others. These conditions, it is tiTie, can be demonstrated only in veins of considerable calibre, but it is reasonable to believe that they occur in the smallest branches, as at the base of an extending ulcer, or around a suj^purating tissue. Haemorrhage is chiefly prevented by the closing of such vessels with coagula. * For further consideration of the disease of veins referred to, see the article Diseases of Veins. t Med.-Chir. Trans, vol. xxii. p. 1G6. PATHOLOGICAL CHANGES. 261 without wliicli they would of necessity bleed when their walls break down in the progress of the disease. The clots once formed, changes ensue (the predisposition being the same) similar to those in other veins ; only, as a rule, the larger the vessel and the greater the extent of softening coagulum, the more serious and rapid are the secondary effects. Although the tissues around such veins, and even the outer wall of these vessels, may be the seat of diffused inflammation, it cannot be too strongly urged that ordinary pus is never found in their interior on dissection, except when an abscess bui-sts into their canal; and there is no evidence that their lining mem- brane inflames, although it may be involved in gangrenous pro- cesses. In other cases there are conditions of even more common occurrence than the preceding, which occasion the formation of the clots. Small vessels, ruptured in contusions and causing ecchymoses, are often closed by coagula, conservative against hsemorrhage, but sometimes dangerous from their insidious ex- tension''^ and subsequent disintegration. Their presence is recognised in some cases of failure in the union of bones broken near the medullary foramen. The}'' may extend from ecchy- moses of the surrounding tissue into a femoral or other prin- cipal vein, and to the sinuses of the brain after injuries of the scalp. The case of a man, aged sixty-two, illustrates this mode of formation and extension of coagula. Whilst following his ordinary employment he fell heavily on his left hip, and sustained a fracture at the neck of the femur. He sank four months after the accident from chronic bronchitis. The rectus muscle and the adductors were greatly ecchymosed, and there was a considerable ecchymosis by the side of the femoral vein as it lay upon the adductor longus. The superficial veins were unaffected, but many of the more deeply-seated were filled with coagula softening at the centre. These veins were found entirely upon the inner side of the thigh, in the vicinity of the ecchymoses. They opened directly into the femoral, which was filled by a decolorised clot, about two inches in length, terminating at the junction of the external circumflex, just * In these and other cases it has long been known that no serous infiltration of the part necessarily follows the occlusion of even the principal venous trunks. See Bouillaud, op. cit. p. 19G. 262 PYEMIA. Fig. 1. below the profunda, fig. 1, h. This clot was soft, and disinte- grated at its centre so as to resemble pus, fig. 1, a.* The inner coat of the vein was natural, and there was no suspicion during life of the existence of the coagulum. Another man, also sixtj-two years of age, was brought into St. Bartholomew's Hospital suffering from symptoms of concussion, which followed a fall on the vertex, with laceration of the scalp. He quickly recovered from the immediate effects of the accident, but died on the twenty- sixth day with symptoms of pyaemia. The veins opening into the superior longitudinal sinus were dis- tended with disintegrating coagula, and the sinus was filled from end to end in the same manner. Its walls were na- tural, and the adjacent membranes of the brain were free from inflammation, nor was there any fracture of the skull, but in the immediate vicinity of the smaller veins there existed several slight ecchymoses. The lungs were filled with secondary deposits. Many such cases might be referred to, if necessary ; but the above are sufficient to illustrate the fact. Similar clots, extend- ing from the placental surface of the uterus, assist in explaining cases of puerj)eral phlebitis not due to diffused inflammation of the cellular tissue around the pelvic veins. The jirobable connection between these clot-formations and the secondary abscesses will be subsequently considered. The post-mortem appearances which belong to the secondary affections accompany some one or more of the preceding con- ditions. The following table of thirty-one cases, taken in se- quence from the report-books of St. Bartholomew's Hospital, shows their more frequent situations, and the relation of each to'jL primary disease. * Museum of St. Bartholomew's Hospital, series xiii. POST-MOETEM APPEAEANCES. 263 Cases of PycBmia. Situation of the second- No. of Eeferences to the casea Nature of the primary affections ary compli- cations Cases in the first colmnn 1 . Phlegmonous inflam. of scalp Lungs 23 1, 2, 3, 4, 5, 8, 10, 11, 2. ,, „ mediastinum 12,13,14,17,18,19, 3. „ „ leg 20,21,24,25,26,27, 4. Diffused infl. of pelvis after lithotomy 28, 29, 30 5. Pelvic cellulitis Brain 8 1,6,17,20,23,28,30, 6. Wound of scalp 31 7. Gun-shot wound of ilium Liver 7 4,12,15,19,22,28,29 8. Compound fracture of femur 9. „ ,, femur Kidneys 7 9,13,14,17,19,29,30 10. Amputation of thigh In joints 2 Around „ 4 11. „ thigh 6 7, 16, 24, 25, 29, 30 12. Empyema 13. Empyema Muscles 4 7, 18, 24, 30 14. Empyema 15. Typhoid ulceration of small intestine Heart 4 1, 13, 29, 30 16. Dysentery 17. „ with rheumatism Spleen 2 14, 20 1 8. Eroding ulcer of .spleen 19. Suppurating hydatid in omentum Skin 2 24, 30 20. Abscess in lungs 21. „ liver Bones 2 18, 27 22. „ uterine wall 23. „ orbit Intestine 30 24. ,, neck 25. „ sterno-mastoid muscle Prostate 1 26. „ axilla 27. „ around diseased hip-joint Uterus 31 28. „ in thigh 29. „ over left radius Trachea 2 30. „ „ right tibia 31. Cancer of uterus Testis 17 Although the capillaries of the lungs, coming first in the order of the circulation with reference to the primary disease, are most frequently involved, the above table, which fairly repre- sents the results to be obtained from the cases reported by various observers, shows that the secondary affections are by no means limited to the first set of capillaries, but implicate with much irregularity various parts of the body. They present the following appearances. When present in the lungs, the secondary disease involves more frequently the left than the right viscus ; it occupies the lobes indiscriminately, and lies beneath the pleural surface or deeper in the pulmonary tissue. When superficial, the serous covering is usually inflamed ; and soft lymph smeared over its surface, and yellowish shreds hanging from it, at once point out the situation of the deposits. Sometimes the pleural sac is even filled with pus, which is usually thin and laden vsdth lymph- 2C4 PYiEMIA. masses. The deposits are easily detected by touch, hard, resisting, and isolated amidst crepitant lung-tissue. When cut across, they present, according to the progress each has made, some such conditions as the following. In those just formed there are small ecchymosed spots, caused by stasis of the blood in some of the capillaries of a lobule. This red consolidation extends until the whole lobule is involved, and then stoj)s, pro- bably where the artery branches off before entering it. Unless two adjacent lobules happen to be simultaneously affected, these changes are at first limited to one, and this explains their tolerably uniform size in this their commencement.^ The ll vessels are simply filled with coagula ; for the lobule, though solid, is not gorged with blood, nor does it bulge and so com- press those which lie around. After a short time the parts first consolidated begin to acquire a rusty tinge, then a lighter brown, at the same time softening and presently becoming diffluent ; minute yellow specks appear and extend, or sometimes the brown or sanious colour persists, surrounded by the red ring of as yet unaltered coagula, and if now examined tmder the microscope, they are found to consist of fatty granules, amor- phous debris, and altered blood-globules. These changes are quickly succeeded by others. Irritation is kindled in the parts around, which become red, congested, and this time with effusion or rapid cell-growth, so that when the lobule first affected is thoroughly disorganised, it is infiltrated with materials which reach it from the surrounding inflammation, and its contents are mingled with ordinary pus-cells. This advanced condition constitutes the abscess as usually observed, and described as a collection of pus surrounded by congested pulmonary tissue of a deep crimson colour. These abscesses now vary greatly in size, so that the same lung contains some no larger than a pea, and others which form masses of considerable extent. No satis- factory evidence has been offered to show that their progress is ever arrested, and repair or cicatrisation commenced. Their contents are never found thickened, drying up as it were, with puckering and shrivelling of the surroundmg tissue. The ex- pectoration of fribrine-like matter from the lungs, in cases of supposed recovery, has, however, induced the suggestion that such changes may in rare instances ensue. Liver. Secondary deposits commence in this organ by the fill- • See Lee on PMehitis, p. 29. SECONDARY DEPOSITS. 265 ing here and there of portal capillaries and associated veins with coloured clots, so that they are distinctly majDped out upon a cut surface of hepatic tissue. The subsequent and surround- ing congestion is less intense than in the lungs, owing to the coarser character of 'the capillary network, but the change in colour, fig. 2, and the Fig. 2.* softening take place ^.^f^^^S^^^M^^^ as rapidly. At this ^'^'^mM^SIS^^^f^m^^^ stage the microscope jf^^^jfmKlS^^^^StiS^^^^^^ enables us to detect /^:':v..j|HM^|^^^^^^^H^^^^^^^ amorphous material, yJKj^^mBMS^^^^^^^^^^^t^^^^^ fat granules, and a ^""■"■■■■^^^^^■^^^^^^^^^^^^ sprinkling of hepatic cells, but no pus-corpuscles. There ensues an exudation into the neighbouring tissues, which are soon in- filtrated with lymph and serum. This softens, and, in the un- healthy condition of the system, is quickly mingled with pus, and so an abscess is formed. But as yet before the abscess is confirmed a very characteristic appearance is presented. A number of firm nodules of a yellowish colour are conspicuous ; these are the occluded vessels, representing the outer part of the lobules ; around them is a pale -gray, jelly-like network enclos- ing them as it were, and this is the surrounding effusion of lymph and serum. Even after the softening of the fibrine and the for- mation of pus, the abscess retains some trace of its origin ; for when the pus is washed away, a mass of tough tissue remains, in which can still be traced the skeleton of the lobules. As surrounding parts are involved, they pass through similar changes, so that in the same liver may be seen fibrinous plugs, lobules with lymph effused around, and abscesses of varying size, in their turn bordered by exudation-materials, for no distinct wall invests them, and in their general characters forcibly calling to mind the diffuse suppuration of subcutaneous tissue as distinguished from a simple abscess. If from any circum- stances the diffusion is arrested, the diseased lobules are soon bounded by organisable lymph, and in some cases the wall thus formed becomes thick and membranous, after the fashion of that which lines a chronic abscess. At the same time the con- tents thicken and begin to dry up, as though a curative process was commencing; further changes are, however, usually prevented * From a drawing in the Museum of St. Bartholomew's Hospital, No. 271, showing part of a liver with the portal capillaries and associated veins of many lobules filled with decolorised coagula. 266 PYiEMIA. by the death, of the patient, so that there remains a doubt whether these abscesses are ever completely cured in cases reported to have recovered after symptoms indicative of their presence. Skin. Lee has recorded "^ three conditions of the integument as observable in these cases, which seem to be modifications of one another. First, a pustular eruption resembling that of small-pox ; secondly, irregular spots of congestion of a dusky colour ; and thirdly, congested patches darkest in their centres, rapidly passing into mortification, usually with extension of the congestion to j)arts around, though sometimes limited by a line 'of demarcation. These patches are apt to form at points sub- jected to pressure. Changes similar to those in the lungs and liver occur in other organs with immaterial variations.t The situation of the secondary deposits is capricious, not merely as to the organ which they involve, but as to the part of each organ implicated. The more vascular tissues are of all most prone to be affected, but it is in the least vascular that the subsequent changes are most rapid, as, from the more complete cutting-off of blood supply, gangrene most constantly ensues. Wherever secondary deposits are developed, they may in turn, if the patient's life be sufficiently prolonged, become the source of others, which pass through similar changes, and may be termed for distinction tertiary. Other secondary affections. Effusions into serous or synovial sacs, commonly into those of joints and of the pleurae, rarely into the ventricles of the brain, constitute another class of changes. The ordinary secretion may be increased, becoming in the case of joints less viscid than natural ; or there may be an effusion of serum, or lymph, or an accumulation of pus, or of pus stained with blood. In some cases, the cause of these changes may be traced to irritation from a collection of pus somewhere close at hand, as beneath the pleura, or in the tissues which immediately sun'ound joints. The effusions occur without material congestion, and generally towards the close of fatal cases. In considering the causes of the secondary complications — it may be remarked that the frequent occurrence of these • Op. cit. p. 53. t For r^8um6 of brain-mischief, see Braidwood, op. cit. p. 168. THEOEIES OF EXCITING CAUSES. 267 secondary abscesses after surgical operations lias induced many observers to offer explanations of their origin. From the mass of writings upon the subject, it is necessary to select the views which have received the greatest amount of credit, and to relate the arguments by which they have been supported. It is generally admitted that secondary complications (ab- scesses) may result from mere poisoning of the system in con- nection with any of the causes of systemic purulent infection ; but without doubt a large number of cases exist in which those secondary affections are dependent upon local diseases, and are due to mechanical obstructions in the smaller vessels, affections occurring when the blood is ill nourished and the patient exhausted, but affections which are not necessarily dependent upon a general poisoning of the system, but are connected rather with its prostration and the end-coming of its life. It is to such cases that the following observations especially apply. (a) Pus introduced into the Mood. Of aU exciting causes none has been more generally insisted upon than this, and many arguments have been brought forward in its favour. The connection of the secondary complications with a primary local suppuration; the presence of pus-cells in the blood; the characters of the secondary affections, and the results of experiments, are its principal props. These must be severally examined. Connection of secondary complications with a primary local sup- puration. When phlebitis was attracting general attention, it was observed to be frequently followed by secondary deposits. On further examination, phlebitis was found to exist in most cases of pyaemia, and nothing was more natural than to look upon the two as closely connected. Attention had been already drawn by Boerhaave, Morgagni, and Desault * to the presence of secondary abscesses after ulcers and after suppuration, in- volving more especially the brain, and they had been ascribed by the latter to some nervous influence : but, although Tessier supported the doctrine of a purulent diathesis,t most writers * See Morgagni, De Sedibus et Ccnisis 3Iorborum, lib. iv, epist. 51, art. 17, 18, 19, 20. Riber, Recherches sur la Phlebite, in Reime Medicak, torn. iii. Quesnay, Memoircs de VAcademie Ronnie de Chinmjie. Paris, 1819. t Tessier, Expose et Exainen critique des Doctrines de la Phlebite, <^-c. Paris, 1838. 268 PYEMIA. including Rose, Dance, and Arnott,"^ inclined to tlie view of their dependence upon the introduction of pus into the blood. So long, then, as phlebitis was believed to give rise to suppuration within the veins, the coexistence of these secondary affections was easily accounted for. Either from breaking down of the clot which should have limited the suppuration, or from absence of such clot owing to a degenerate condition of the blood, the pus, it was argued, directly or through some collateral branch found its way into the general circulation. But cases coming under notice in which no phlebitis could be demonstrated, it was observed of these that they accompanied some form of suppuration, such as that in wounds after opera- tions, that of diffused inflammation of internal parts, as the mediastina, or abscesses in bone, and other structures, as, for example, the prostate gland. The idea of the absorption of entire pus-globules through the walls of veins was speedily abandoned ; and although some maintained that putrid serosity alone found its way into the circulation, and so excited the diseased action, the belief gained ground that the pus passed into the open orifices of veins — a supposition strengthened by the frequency with which, as noticed by Cruveilhier, the secondarj'^ affection followed injuries and operations upon bone, in which tissue the veins, it is well known, neither collapse after division, nor contract upon the clots which form and afterwards shrink within them. In other cases, it was urged, the opening in the vessels might result from ulceration and sloughing of their walls ; and the irritation of a surrounding suppuration was supposed to reopen even those veins which had been closed in the healing of wounds. On the other hand, it was noticed how often pus might get into the blood and yet no symptoms of pyeemia ensue, and how many secondary affections occur before any local suppm-ation has been established. It is now known that the lining mem- brane of veins rarely presents evidences of inflammation ; that it probably never secretes pus, and that the appearance of sup- puration noticed in these vessels is in truth'caused by softening clots. t The above views are, therefore, in part imtenable. The presence of p^is-cells in the blood. Healthy pus applied to • Rose, Med.-Chir. Tram. vol. xiv. p. 251. Dxace, Archives g^nirales de Medecine, torn, xviii. p. 473 ; xix. 5, 161. Amott, op. cit. t See article on Diseases of Veins. THEORIES OF EXCITING CAUSES. 269 blood as it flows from a vein hastens coagulation simply as a mechanical agent. It does not mingle with that fluid, but coagula form around in from two to three minutes, and the coagulation is slowly diffused. Serous pus and the serum of decomposing pus cause more general coagulation ; for as they incline to mingle with the blood, they present a greater number of centres for coagula to surround. And it should be observed of the experiments from which these results were obtained, that the pus was simply dropped into the blood, and not stirred up with it, whereby undue artificial mingling was avoided."^ After injection of small quantities of pus into the veins of living and healthy animals, none of it can be found in the allied venous trunks ; but, traced beyond these, it is recognised as arrested in the first set of capillaries in the course of the circu- lation, so that its corpuscles undoubtedly circulate with the blood, though it is reasonable to infer, from their action upon that fluid out of the body, that they become capsulated with fibrine as they flow onward, and that by the same process their size is modified. Now, many observers go so far as to afl&rm that, in the disease in question, they can recognise pus-cells in the human blood, scattered amongst the red discs (when viewed with the aid of the microscope), the latter retaining their usual appearance, except when the pus is present in large quantities. Under such circumstances, Gendrm states that blood-corpuscles are converted into pus-globules ; and mingling pus and blood in the proportion of one to eight, he proves that, after twenty- four hours, none but pus-corpuscles can be detected. But Gluge and Vogel have shown that pus, acting like water, simply dissolves the capsule of the corpuscles, and that this is the cause of the modification noticed. All, however, agree that pus-cells, when present in small quantity, do not interfere with the red discs, from which they are easily distinguished. It is from their resemblance to the white corpuscles that their detec- tion is rendered difficult and doubtful. Granting they have entered the circulation, can then the pus-globule be distin- guished from the white blood-corpuscle ? Sedillot,t who has carefully considered this question, is confident in the distinction to be drawn between the two. ' The pus-globule,' he says, ' is • See Mackenzie, op. cit. p. 196 ; Lee, op. cit. p. 26. t De V Infection purulente, p. 262, note by Lebert, Paris, 1849. 270 PYEMIA. To"" ^^ sV ^^ ^ millimetre in diameter, whilst the white globule is _|- to -j^, a sixth or a fifth smaller. The pus-globule is slightly yellowish, the other is a dead white. The pus-globule is spherical, the white one flattened,^being at most lenticular but never spherical ; its surface is smooth and indistinct, whilst that of the pus-globule is roughened or granular. The nuclei, when shown by means of acetic acid, are found larger, -3 J^-^ to -^-J-^ of a millimetre in diameter in pus- cells, and exhibit in their interior a regular, well-defined cavity ; while white corpuscles contain nuclei much smaller {-^^ to -4^), resembling nucleoli or rather fatty granules. The white,' he adds, ' when present are less numerous than the others.' How far these differences are available for diagnosis, those can well judge who are in the habit of examining such cells under the microscope. If present, the pus-globules may disorganise the blood in some subtle manner, causing its fibrine to separate and coagulate here and there in the capillaries, or they may determine secondary ab- scesses by their mechanical arrest and by the changes which then ensue. Dance and other observers,^ however, are unable to detect these pus-globules, or altogether deny their presence in blood. Some explain their absence by suggesting that they are me- chanically compressed, and so no longer recognised, just as they entirely lose their character when mingled in small quantity with blood out of the body, and entangled in contracting fibrine. The experience of many observers shows, in opposition to the opinion of Sedillot, that the white globules are greatly in excess in all these cases, even in those in which no source of pus-cells has existed ; that their number is naturally very variable ; that it increases rapidly after certain processes, as digestion; and that they are abundant durmg pregnancy, and for some time after delivery. Whilst, then, uncertain of oui' ability to distinguish between the two, the differences being trivial and difiicult to detect, even as described by those most favourable to their recognition, the fact of our having under many, perhaps under all, circumstances favouring pyaemia, an excess of white corpuscles, prevents the evidence in favom- of the presence of pus-globules in the blood from being accepted as conclusive.t * Donn6, Cours de Micrographie, p. 82. Paris, 1844. t On the points of resemblance between pyaemia and leucocytliemia, see Dr. Hughes Bennett, quoted by Braidwood, op. cit. p. 227. EXPERIMENTS ON ANIMALS. 271 Character of the secondary abscesses. These having been ex- amined when completed, to the exclusion of the preliminary changes, and being found laden with pus, were naturally adduced in favour of the theory of their purulent origin. It is now cer- tain that no pus-cells are found in them at their commencement. Results of experiments. It has been proved at various times, by the injection of pus into the veins of living animals, that veins inflame ; that veins do not inflame ; that local coagulation immediately results, or, as Majendie states, that coagulability of the blood is destroyed ; that the injection is followed by fib- rinous deposits ; that it is followed by purulent deposits ; that pus-globules, when mingled with their serum, cause most rapidly the secondary affections ; and, on the contrary, that pus-cor- puscles, when separated from their serum, produce them most certainly : * but these different results are intelligible enough if the difficulties which beset experiments of this nature, and the extent to which observers are always biassed by the doctrines of the day, are duly considered. Repetition of the most important leaves no doubt that the more recent experiments have been accurately observed, though great allowances must be made in drawing deductions to be applied from them to the human subject, if only on account of the healthy condition of most animals operated upon, and the slowness with which they take up diseased actions, especially of a suppurative character. The results obtained may be briefly shown in a series of typical cases. (1) After single injections of pus, animals, if previously healthy, usually recover ; so that four to twenty grammes were often in- jected by SediUot without causing inconvenience ; but that this is not invaribly the result, is shown by the following experiment. f One half drachm of recent pus, injected into the right femoral vein of a dog caused immediate death. The femoral and allied veins, as far as the right am-icle, that cavity, the commencement of the vena cava superior, and the right ventricle, were filled with a continuous dark-coloured coagulum, in various parts of which portions of the pus were sequestered. The blood was fluid * Reumert, De Symtomatibiis Injlammationis Venee Cavee, Diss, inaxig., Havn. 1840 ; Gendrin, Ilistoire anatomiquc des Inflcwi. vol. ii. pp. 13, 14 j Mackenzie- op. cit. ; Gaspard, op. cit. ; Lee, op. cit. ; Sedillot, op. cit. t The experiments here narrated, originally described by various authors, have been repeated by the author to corroborate their accuracy, and those thus repeated ai'e here cited, as they agree in the main with the originals. 272 PYEMIA. in the veins of the opposite side, in those of the head, and in the left cavities of the heart. (2) Simple inoculation with pus of the tissue surrounding a vein is followed by slight local suppuration, the blood remaining unaffected in the adjacent vessel ; and no change results from the application of pus to the edges of wounds in venous trunks, although in these experiments some pus-globules probably pass into the circulation. The wounded veins are repaired in the usual manner. (3) Injections of small quantities of pus are usually followed by secondary deposits. About eight drops of pus were injected into the right femoral vein of a small dog. The animal, on re- covering from the chloroform, refused food, and after twenty- four hours began to snuflfle. It was killed, by division of the spinal cord, at the forty-eighth hour. The vein was natural from the ligature upwards. The lungs were irregularly studded with spots of a red colour, averaging a line or two in diameter. These consisted of minute vessels gorged with blood, probably coagulated, for it could not be removed by pressure. Their uni- form appearance depended upon their limitation to single lobules.* Examined under the miscroscope, they were found to consist of ordinary constituents of blood mingled with granular ceUs. (4) If the animal is in a healthy condition, the secondary ap- pearances pass off. At the same time as the last experiment was performed, about twenty drops of the same pus were introduced into the right femoral vein of another dog, and the animal was killed at the ninety-eighth hour. The veins were healthy through- out. In the left lung only one, in the right two small ecchymoses still existed, similar to, only rather darker than, those noticed in the preceding experiment. The other organs were natural. These examples are taken from amongst many, and are easy of repetition : they serve to iUustrate the fact that pus is arrested in the first set of capillaries, and that the blood-stasis which ensues presently rights itself and eventually clears off. (5) The secondary abscesses are obtained by Sedillotf and others by injections repeated at intervals, in animals consequently enfeebled by disease. Similar results may be obtained in dogs which are let blood before introduction of the pus, three or four * Museum of St. Bartholomew's Hospital, series xiii. t Sedillot, op. cit., p. 128. EXPERIMENTS ON ANIMALS. 273 days being allowed to elapse before the abscesses are looked for. (6) Similar or allied results follow the injection of many other substances ; thus, decomposing serum mingled with pus-debris causes even more diffused effects than pus, and, acting more after the manner of the poisons alluded to as causing systemic infection, gives rise to local gangrenous lesions, with considerable extravasation of blood into the surrounding tissues. Experi- ments have been recorded by Cruveilhier and Gaspard showing . some of the substances besides pus which are arrested in the capillaries ; thus the latter writes : ' les corps trop grossiers, tels que le mercure, I'huile, le sediment de I'extrait d'opium, etc., ne peuvent pas outrepasser les petits vaisseaux intermediaires aux arteres et aux veines ; ' and both describe the formation of the secondary abscesses. Gaspard's * experiments also prove that similar substances, carried rapidly through arteries, produce violent local irritation in those parts only to which the branches of the injected artery are distributed. (7) It happens sometimes that pus — and it is only of pus the fact has been recorded — slips by one set of capillaries, as in a case narrated by Sedillot,t in which, the mesenteric veins being in- jected, the liver remained unaltered, whilst the lungs became the seat of secondary abscesses. This cannot be ascribed to any difference in the size of the two sets of capillaries ; but it has led to the suggestion that pus-globules are only arrested in their course when they become aggregated, or increased in bulk by the addition of materials from the blood. Thus, although the secondary complications seem to follow upon the introduction of various substances J into the blood, of which pus is one, and probably depend upon their mechanical arrest in vessels intermediate between the arteries and veins, yet, on applying the results of these experiments to the human subject, they are met by the facts that pus-globules are not of a certainty found in the blood ; that the secondary abscesses are often unconnected with any primary local suppuration ; and that they are not in the first instance purulent. With the exception of decomposing serum and other fluids of * Gaspard, op. cit. torn. v. p. 319 ; Loe, op. cit. p. 39. t St^dillot, op. cit., dix-huitieme experience, p. 101. X Amongst these fibrine should be enumerated. See Sedillot. op. cit., onzieme expt^rience, p. 8G 5 also p. 110. VOL. I. T 274 PYEMIA. an allied character, wliicli can only excite the complications by setting up some vital or chemical action, there is but one material other than pus by which to explain the mechanical origin of the secondary changes ; but this material is so generally present in this class of cases of pysemia, that it requires separate con- sideration. Before entering upon its consideration, however, a few words may dispose of the theory of a purulent diathesis, which, indeed, proposed in times long past,'^ refers to what is now regarded as the unsound condition induced by predisposing causes, in which the system is prone to suffer from suppurative or typhoid diseases. In the same way may be dismissed such theories as presuppose that fibrine about to be eliminated into pus undergoes a re- trograde metamorphosis, is can'ied on in the circulation, and causes like actions to go on in the accompanying fluid ; also the older, but less far-fetched idea, of the influence of a nervous ac- tion; a view entertained inconsequence of observations byDesault on secondary affections connected with injuries to the skull and its contents. With these may be classed absorption by the lymj^hatics, which of late years has been, by most observers, discarded as a cause of the secondary complications. The cases which are quoted in its favour are found, on inquiry, of a doubtful character ; some are incorrectly reported, as can easily be seen, now that more is known of the subject ; for example, Dumas narrates several in which the lymphatics about the uterus (mistaken, doubtless, for the veins) were filled with pus, which, however, could not be detected in the associated glands, where it was consequentlj^ supposed to be in some way elabo- rated.f Other cases have been examples of diffused inflammation in the course of the lymphatics, or have been connected with changes independent of the absorbent system. J An ingenious idea, applicable more especially to cases in which pyeemia follows surgical operations, as after excision of a testis, or amputation of an extremity, has been originated by the suggestion that materials, harmless to those organs and textures to which they should have been applied, when unused or unremoved from the blood, act as local irritants to other structures, and so engender secondary mischief, such as effusion * De Haen, Ratio Medendi, torn. i. p. 102 et seq., Paris, 1761 ; also Tessier, op. cit. t Dumas, op. cit. p. 106. J Lee, op. cit., case xxix. THEOEIES. CLOT-SOFTENING. 275 of puriform fluid into joints. These materials may liave affinity witli cliemical substances, but they do not admit of recognition by physical means.* Chevers lays great stress upon previous abdominal complications, observing, ' It is highly probable that, in most of the individuals who thus perish, even if they had never become the subjects of any wound or injury, some other vicissitude would, by bringing the renal or hepatic mischief into active operation, have equally determined the occurrence of fatal cerebral, thoracic, or abdominal inflammation.' f (b) Disorganised fibrine introduced into the hlood. As is more folly detailed in describing diseases of veins, J coagula are formed in these vessels, with inflammatory changes of adjacent tissues and of the outer wall of a vein itself, or in veins ruptured by violence. When a predisposition exists, very little is sufficient to cause their deposit. Bouillaud § writes of them as often noticed in the cachectic from simple pressure, in the veins of the pelvis from compression by cancer of the ovaries, and in the internal iliac from distension of the sigmoid flexure with hardened faeces ; and, as bearing upon their connection with pyscmia, Tweedie mentions a case in which this disease followed a contusion of the thigh ; Lee, one after a blow uj^on the patella. These coagula, when formed in a small vein, are limited in either direction by the first collateral current, though they may extend past one or more of these into larger vessels involving at last important canals, if aided by predisposing circumstances, and by a blood-condition thereon dependent. Disregarding the in- fluence of any surrounding inflammation, and looking at them as hindered in their extension by the action of the blood as it sweeps past them, they may at first encroach upon and in time pass these currents by the addition to their surface of irregular plates of fibrine, as shown in the accompanying woodcut (fig. 3, a) ; an encroachment which may be prevented if the greater force and capacity of the collateral stream be sufficient, even * Finger, Prdger Vierteljahrschrift, No. iv., 1847. t See Simpson, Med. Titnes and Gazette, vol. i. 1859; Chevers, op. cit. p. 94. X See article on Diseases of Veins. § Bouillaud, op. cit. ; Bouchut, op. cit. p. 244 ; Lee, op. cit., Ccase vi. j Humphry On the Coagrdatimi of the Blood in the Venous System during Life. Cambridge MacnaiUan and Co. T 2 276 PYAEMIA. Fig. 3. under adverse predisposing circumstances, to keep clear its channel. Once arrested in their progress, particles may be loosened and carried off from tlieir surface, where washed by the flowing blood, and then pass on through the veins and heart (fig. 3, h), each forming an embolon or plug, entering pulmonary arteries of a smaller and lessening diameter, until they at length lodge, usually at a bifurcation, where, as after the application of a ligature, new clots form upon them. These detached portions undergo various changes, and, if cutting off any considerable supply of blood, may cause even gangrene of the part involved. They are of interest, in connection with clot-softening and disintegra- tion, as showing how smaller particles when circulating with the blood, produce even more noticeable effects. Wliatever may be the cause of this softening of clots, the fact is undoubted, and has been carefully studied in connection with the clots, or polypi, as they were formerly termed, which are found mider certain circumstances in the cavities of the heart, and in the venous canals. It is probably associated with that unhealthy condition of fibrine, whereby it is wanting in con- tractilit}^ and retains in its meshes an undue quantity of serum. The disintegration commences in the oldest portion of each coagulum, so that it may affect one side, one extremity, or the middle of a clot, as the case may be ; it is accompanied by the changes in colour already described, and, fi'om their often acquiring the appearance of ordinary j)us, the earlier ^■=1 o , observers were led to con- 7j\if°' sider these clots as true i purulent collections. When •j§ examined under the mi- croscope, they are found to contain (fig. 4, a) blood- cells variously modified ; ^***' '^ some mere shreds, others serrated and puckered ; some, probably white corj)uscles, being pale and transparent when acted on by acetic acid. These are entangled amidst a quantity of granular matter and globules, " = €b ©0' Fig. 4. i THEOEIES. CLOT-SOFTENING. 277 composed, perhaps entirely, of oil soluble in setlier (fig. 4, h) ; here and there many of these granules and globules form masses of very variable size, irregular in their outline, though sometimes having a surrounding cell- wall (fig. 4, c), which how- ever can seldom be demonstrated. These also are soluble in sether. Lastly may be noticed irregular masses of varying size — portions, perhaps, of fibrine as yet unreduced to a granular condition. Such is the material which is prepared in many cases of pyaemia to enter the current of the circulation, and which is supposed to excite the secondary complications by mechanical obstruction of the caj^illaries, setting up local irritation and imjjeding function, and so causmg actions of an ordinary inflam- matory character to become established. Three points here require a brief notice, (a) Do disintegra- ting clots acquire the characters of true pus ? There is no proof that they do. They sometimes contain simple cells which have been regarded as inflammatory products ; but pus-cells are not detected, so at least say recent observers. Their statement, however, must be received as offered under the existing views of 13us-formation, of which much might be said for which the present is scarcely the place, though attention may be drawn to the revival in some sort of the doctrine, descended from Hunter, and so much insisted upon by Gendrin, that pus-cells are not changed blood-corpuscles, but cells re-formed from the disinte- grated blood-constituents. (6) How does the softened clot- debris find its way into the cu'culation ? Eirst, through some collateral branch connected with the vein where closed by the softening mass ; secondly, by rupture of the clot-wall which separates the debris from the circulating blood (fig. 5), either at its distal extremity, opening into the nearest branch, the clots entangled about the valves preventing their perfect closure, or at its proximal end, the further formation of a clot to confine the debris being usually prevented by the presence of a strong anastom- osing blood current, (c) Are these softening- clots found in all cases of secondary complication ? Sometimes * Museum of St. Bartholomew's Hospital, series xiii. Clot from a pul- monary artery, its softened contents discharged through its distal extremity. 278 PYEMIA. their presence is easy of proof, sometimes it may be infen'ed from the existence of a morbid change with which they are usually associated. Their presence is certainly more constant than that of any other condition with which the secondary affec- tions can reasonably be connected, but it is very apt to be overlooked. A female, for instance, died from pyaemia which followed disease of the knee-joint ; the vessels of the limb were examined and were healthy, and it was assumed that some other cause must be sought in explanation of the pysemic symp- toms. There existed, however, a bed-sore over the sacral region, and about this, and also in many of the vessels leading to the internal iliac vein, numerous softening clots were discovered, and were, without doubt, the soiu'ce of the secondary affections. Bristowe and Savory have pointed out that the embolic theory does not explain cases in which the capillaries of the lungs escape whilst other organs are affected, although in the course of the circulation they should have first been blocked ; and this objection is not answered by the suggestion that the fragments may have slipped by the first set of vessels. These cases class rather with those of systemic infection. As it stands at present the term pya?mia clearly includes, (1) cases in which animal products, such as septic fluids, poison the blood, causing mischief of a typhoid or pyogenic kind, and producing often, but not necessarily, what are known as second- ary abscesses ; (2) other so-called secondary affections (abscesses) in which the debris of softened clots, and detached portions of fibrine, find their way into the blood, and give rise to mechanical obstruction, and both are modified by predisposing causes in individual cases.'^ It is to be regretted that surgeons have not limited the term pysemia to the class of secondary deposits traceable to mechanical causes. !N^ow that the term is held to include all cases of septic or puriform infection arising in the * Savoiy arrives at the following conclusions : — ' The causes of the local congestions and suppurations in pyremia may therefore be thus classified : — ' Stasis due to mechanical action. 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THIS disease is generally described as a •powerful and painful spasm of the voluntary muscles, ivMch is long -continued and uicontrollahle. The spasm of the muscles is that of rigid con- traction, and from its constancy and non-intermitting character it has been termed tonic. These spasms continue without any interval of complete and perfect relaxation, except in the last stage of the disease previous to death ; and although violently increased from time to time by sudden and most severe par- ' ixysms, yet they are never for an instant discontinued altogether, ' long as the complaint can fairly be said to exist. The spasms are not to be mistaken for those of convulsions, which consist in alternate spasms and relaxations, remitting and intermitting, and often receive the appellation of clonic. Tetanus has been regarded as consisting of several forms and varieties, based uj)on some peculiarity in its mode of develop- ment and subsequent course. In former years it used to be subdivided into classes, according to the predominant affection of certain muscles, and thus varieties have been described — Trismus, Opisthotonos, Emprosthotonos, and Pleurosthotonos ; afterwards it was considered more advisable to arrange it, accord- ing to the probable cause, into traumatic, where it arises from injury, and idiopathic, where no external or visible cause is ap- parent. Again, tetanus has been classed according to its inten- sity, rapidity, and duration, under the denominations of acute, subacute, and chronic tetanus. For practical purposes we may re- gard the disease in two forms, recollecting at the same time that both are one and the same affection, modified in intensity and in its effects by some peculiar condition : 1st, the acute form, which is generally met with after injuries, but may also exist, though more rarely, in the idioj)athic variety, and is for the most part fatal ; 2d, the chronic form, the usual type of idiopa- thic tetanus, yet occun'ing in the traumatic variety : this is the 310 TETANUS. form which raises the hopes of the Sui-geon and Physician, as recovery may take place by judicious treatment. We shall, however, confine ourselves to one description of the disease, viz. the acute form, and reserve for separate considera- tion such modifications and deviations from the typical affection as offer any special peculiarities. Premonitory symptoms. — Although there can be no doubt that, in many instances, there may be certain signs which usher in this complaint, yet these do not differ from the ordinary pre- monitory symptoms of other diseases, and do not lead us to anticipate its onset : thus we may find an uneasy sensation in the wound, or an additional pain thereof, or the wound may become inflamed and initable : there may be febrile symptoms and rest- lessness, languor and debility, loss of appetite, headache, con- stipation, &c. ; still not one of these symptoms is in any way peculiarly and especially associated with the approach of this terrible disease. The first evidence of tetanus unfortunately and but too truly portrays the unmistakable nature of the disease ; the con- dition of the muscles of the jaw, or the aspect of the patient, at once announces the victim. Mr. Morgan * lias given a very grapMc, although in parts some-what exag- gerated, description of the onset, progress, and termination of this disease in its acute foiin ; and as it is generally quoted, we have thought it better to tran- scribe the account given by him, instead of adding another description to the already overstocked number. He writes ; ' The first decided symptoms will almost invariably be an uneasy sensation and stiffness in the muscles of the lower jaw aud tongue, which does not, however, in Xke Jirst instance, amount to actual pain, imless the pai-ts are a good deal moved about, and generally about the same time diffness is ohserved in the hack of the neck. Thus the first complaint of your patient will often be, " that he has taken a cold, and is suf- fering from a sore throat and stiff neck;" and therefore, unless the friends and attendants are made acquainted with the importance of keeping a strict watch for the occurrence of these symptoms, and the necessity for an immediate application of remedies, they wiU be attributed to a wrong cause ; and thus the disease will be gradually gaining gi-ound till the only hope of safety is gone, for the sole chance of recoveiy from the use of remedies depends upon their early application. Some have complained of a violent pain imder the sternum as a concomitant symptom. ' As the disease proceeds in its course, the patient complains of dlfficidty and pain in masticating and sivalloning his food; the lower jaw soon becomes com- pletely fixed and closed, and with every effort to open the mouth, the pain, which is now continued and severe, is increased to agony. In this early stage • A Lecture on Tetanus, 1833. SYMPTOMS. 311 you will usually find that the muscles coimecting the head and neck with the body are affected, and that the concomitant symptoms are languor, debility, and either complete or incomplete bending of the body backwards. ' The next symptoms will be a convulsive cramp ui all the affected muscles, brought on by any attempt to swallow ; and the very idea of beiug obliged to make such an effort excites an expression of horror and distress in the counte- nance. Sometimes in the early, and more rarely in the advanced, stage of tetanus, the stomach wiU be sympathetically affected, and, in consequence of this, nausea and vomiting will occasionally occur. ' The next constant symptom will be a sudden, violmt, and continued pain, increased at short intervals by spasm extending from the scrohiculns cordis to the spine, in the situation of the diaphragm, * Shortly after this symptom has shown itself, the abdominal muscles will be constricted and hardened by tetanic cramp ; and the contraction of these parts is so permanent and violent, that, on pressing upon the abdomen, the muscular fibres convey to the hand the sensation of a hard board beneath the skin, rather than that of living animal matter. ' In the course of time all the volimtary muscles partake more or less in the disease. The head is thrown back and fixed by the powerful contraction of the extensor muscles of the neck. The extremities likewise become fixed and rigid. The shoulders are di-awn forward by the pectoral and deltoid muscles ; and the arms are either stretched out or fixed in a parallel line with the trunk, or drawn across the abdomen. The lower extremities are almost invariably in a straight position, and consequently in a line with the body. But notwith- standing the continued and powerful contraction of muscular fibre in the limbs, it will be found that the wrists and fingers are but little affected ; the ankles and toes, however, suffer occasionally from the effects of the disease. * At this period of the complaint the countenance is pale, anxious, and con- tracted,* and is disfigured by the perverted action of the muscles, producing what is termed " the tetanic grin " (Risus sardonicus). The spasms now become more violent and more frequent, and during their continuance and immediately after them the respiration is hurried and laborious ; but in exceptional cases it may be easy and performed by the abdominal muscles. While the spasmodic paroxysm lasts the pulse is generally quick, small, fluttering, and irregular ; but during the intervals both the pulse and respiration are comparatively tranquil. * In some cases the spasm becomes so violent that the assistance of an atten- dant is necessary, during the paroxysm of cramp, to prevent the patient from being projected out of his bed. In other cases, again, the spasms are less sudden, though equally strong and painful, and consequently, instead of that jerking contraction of the muscles, the body is more gradually raised from the bed, and if the muscles at the back of the neck and trurdj and those of the lower extremities are the parts most powerfully affected, then it often happens that the body at intervals is drawn into the form of a bow, and in the recumbent position the occiput and heels rest solely on the bed, whilst the lower limbs and trunk curve upwards to form a complete arch. * An aged expression of the face. The disfigurement may remain permanent after recovery from the disease ; in a case under the author's care, it was still well marked, after a lapse of eleven years. 312 TETAmJS. ■■ 'It ■will frequently happen that, in consequence of the continued contraction of the sphincter muscles of the bladder, retention of urine takes place, and priapism -svill occasionally occur as a concomitant symptom. (This latter symptom is unusual.) * The hoicch are in most cases obstinately constipated, and the large intestines loaded with offensive scybalous matter. * The secretion of urine vai-ies, but it is rarely very profuse. * Towards the termination of the disease, the torture of the last attack of spasm, and the apprehension of the near approach of another paroxysm, produce an expression of dreadful mental distress and anguish in the countenance. The sufferings are only to be soothed by perfect rest and quietude ; the slightest attempt at motion immediately brings on a new attack of spasm ; the opening of a door, or the waving of the bed-curtains, will throw the patient into con- vulsions ; and even the sound of that voice which, on other occasions, might have soothed and smoothed the path of anguish and of sorrow to the grave, will now only add increased agony to intense suffering. Every sound, every moving object in the room is fuel added to the fire which is consuming the life of the tortured victim. ' At the close of life the whole face becomes distorted and disfigured, and the larynx forcibly drawn upwards ; * the spasm in the muscles, depressing the lower jaw, now and then alternates for a moment iu severity with that by which their antagonists are affected, and thus for a moment an aperture is left between the jaws through which the tongue is instantly pushed and as instantly crushed and lacerated by the sudden closure of the teeth upon it. If a large portion of the organ should be thus wounded and strangulated, h.'Bmorrhage will immediately follow, and the countenance and even the bed-clothes will be bathed in blood, thus giving additional horror to a scene in which the extremes of mental agony and intense bodily suffering appeared indeed to have done almost their utmost beforehand. ("Wound of the cheek or tongue is rare.) * In some cases the last moments will be comparatively tranquil, for exhaus- tion and delirium occasionally render the patient alike insensible to pain and to all that mental distress which was previously excited by apprehension and despair; but, in the majority of instances, the torture of a paroxysm of spasm terminates at once the sufferings and the life of a tetanic patient. ' The intellectual faculties remain unimpaired even to the last, and the senses are perfect, but sometimes rendered morbidly acute.' Febrile excitement is not essential, but if present is second- ary. Dr. O'Beirne states that he witnessed about 200 cases ; but he never saw one accompanied by fever. Profuse perspira- tion is often observed, and esjoecially during the sj)asms. Sleej) rarely occurs in acute traumatic tetanus, and then only during a few minutes, or in the intervals between the exacerba- tions, or when the continued contractions in these intervals are not attended by much pain. In the subacute cases, however, sleep is more frequent, and a more complete relaxation of the • Feebleness of voice often occurs, and is said to be due to the spasmodic interference with the action of the chest, and to the tight shutting of the jaws. VAEIETIES. 313 muscular contractions takes place ; but upon the jpatient being wakened the full tension of the muscles returns. The foUoAvmg varieties have been noticed in the characters of the muscular spasms : 1. Trismus, or clenching of the teeth from spasm of the muscles of mastication. This is so constant an occurrence in tetanus that the disease has received the special appellation of locJced-jaw. We must recollect, however, that this is not the sole symptom of the disease, but only one local sign, and may be met with in other affections ; this will again be referred to when alluding to the diagnosis of the disease. Towards the decline of tetanus, and where it is attended with extreme exhaustion and prostration, the spasm of these muscles gives way, and the jaw becomes relaxed and drops open. 2. OpistJiotonos, when the body is bent backwards. This is the most common variety, and is generally noticed in the ordi- nary descriptions. 3. Emprostliotonos is when the body is bent forwards. This is very rare, and has been seldom witnessed. Aretseus has mentioned it, and Larrey has recorded several cases.^ The muscles on the anterior part of the body are said to be so contracted as to bend the head upon the chest, to curve the spine anteriorly, and to draw the thighs towards the belly. In very severe cases, the head is brought into contact with the knees, so that the body presents the shape of a ball rather than that of a bow, according to the remark of Aretseus. 4. PleurostJioto7ios indicates that the body is bent laterally. This is also very rare. It has been observed in acute cases, but more frequently in the chronic forms. In the case of a female, aged twenty-four, at Guy's Hospital, it was observed to attack the right side more especially : it was fatal in this instance. Sir G. Blane has published two cases. Trismus nascentium, tetanus infantum.' — New-born infants are subject to tetanus, and offer the same symptoms as are observed in adults. It usually makes its appearance about seven or nine days after birth, but may occur up to the fourteenth day. The progress is, however, more rapid in some, death taking place in ten or thirty hours : the disease is then called acute. In * Larrey, va. his Memoircs de Chir. Militaire, torn, i., observed that if the ■wound happened to be in the anterior part of the trunk, and tetanus followed, it was generally in the shape of emprosthotonos. It was actually the most common form in the army of Egypt. 314 TETANUS. others, life may be prolonged to eight or nine days, and it is then termed subacute. It has been attributed to division of the umbilical cord, and hence considered traumatic ; and it has been traced to exposure to currents of air, bad ventilation, and unwholesome nutriment, and hence denominated idiopathic. It is frequent among the Negro races, and has been stated to be the chief cause of depopulation of the Negro infants in the West India isles. At one period, the infants born in the Dublin Lying-in Hospital died of tetanus, within the first fortnight, at a rate of 17 per cent. ; but when a better ventilation became established, the mortality was reduced to 5 per cent. Puerperal tetanus is generally of the acute kind."^ There are still some other varieties in the s}Tnptoms which require to be considered ; but these must be regarded as ex- ceptions to the general rule. Sjpasms 'primarily attacking the muscles of the part injured instead of the muscles of the jaw. — Mr. Morgan relates two cases : a sailor, a patient of Guy's Hospital, received a lacerated wound of the fleshy part of the thumb, occasioned by a splinter of teak- wood, which had transfixed the part. This was forcibly extracted at the time, and the wound healed perfectly. The first symptom of the disease occurred about two months after the accident, and consisted of a painful neuralgic affection of the muscles of the ball of the thumb, without any appearance of inflammation in the part. He died, and on dissection two pieces of splintered teak were found imbedded in the abductor muscle, and resting upon a branch of the radial nerve. A scholar received a blow of a schoolmaster's cane on the hand. In this mstance both pain and spasm commenced in the injured part, and the first true symptom of tetanus was a gradual spasmodic contraction of the flexor muscles of the hand, by which the fingers were drawn into the palm. The cramp subsequently extended to the arm and other parts, and eventu- ally terminated fatally. Absence of pain. — Sir Gr. Blane mentions a curious case in which the spasmodic affections were unattended by pain even to the last moment of existence. In this instance, the cramps were accompanied by a tingling and agreeable sensation. The ac- cesses were attended by feelings of pleasure, and a strong ten- dency to laughter. * For cases of puerperal tetanus, see Duh. Quart. Jonni. 1865 ; British Med. Jouni., June and September, 18G5 ; Med. Tiines and Gaz. 1865, COMPLICATIONS. 315 Special affection of the muscles of the face and eye. — Of sevent j- two cases of tetanus occurring in Guy's Hospital, three are men- tioned to have been so attacked, and in two of these the spasm in- volved the orbicularis palpebrarum, inducing closure of the lids, and simulating ptosis. The muscles of the eye are sometimes but not generally affected ; when this occurs, the eyeball is fixed and drawn slightly inwards, the patient being unable to direct it towards particular objects. The pupil of the eye varies, being sometimes contracted, and at other times dilated. Cerebral coviplications are very rare in tetanus, but may be met with in isolated instances ; thus there occurred six cases out of seventy-two admitted into Guy's Hospital : in three cases there was delirium, in two of which it came on towards the close of the disease ; but, in the third case, was present before the attack supervened, and entirely subsided directly the tetanus made its appearance : in one there was coma ; but this was considered to be owing to the large doses of morphia ad- ministered. Epilepsy may form a complication ; thus at Guy's Hospital a female, the subject of epilepsy, was attacked with tetanus a few days previous to its expected occurrence ; there were screaming and convulsions, and these partook of the character of the periodic epileptic seizures. Convulsions and screaming were observed in a young female who died of acute tetanus on the sixth day of the attack, following an incision into an inflamed bursa over the knee. Loss of poiver over the extremities occurred in two of the Guy's Hospital cases. Miscellaneous complications. — Tetanus has attacked those la- bouring under bronchitis and laryngitis, and a fatal issue has resulted ; and it has also been complicated with erysipelas, and with fatal effects. In the case of a man aged sixty-two, the skin of the abdomen was found to be peculiarly shrivelled. In one case the symptoms continued severe until the ninth day, and on the eleventh day a miliary eruption appeared over the whole body, accompanied with succession of spasms and intervals of repose. On the sixteenth day exhaustion and rambling supervened ; but on the twenty-second day subsidence of the symptoms took place, and a protracted recovery ensued. Remission of the symptoms. — This is extremely rare, yet it has been noticed in several instances. Of sixty cases observed in Guy's Hospital, four had this peculiarity : in two of these there 316 TETANUS. was evident relief of the symptoms for tliirteen days, althougli death ultimately ensued from exhaustion ; in the other two remission only took place for a very short period, viz., a few days, and was succeeded by more intense symptoms ending fatally. Dupuytren mentions a case in which the disease subsided for twenty-eight days, and then returned after an exposure to cold. M. Duval mentions some curious cases in which the disease assumed the form of anomalous ague, in one of which it was remarked that both sides of the body were never affected by the paroxysm, but regularly alternated in successive fits. Death, may take place in several ways : During a paroxysm of spasm and convulsions of the heart and muscles of the larynx. — It is not correct, as some affirm, that death in tetanus is due to the extension of spasm to the heart. Mr. Howship thought so, and records a case in point where the heart was found firmly contracted eleven hours after death. In only one out of sixteen cases, observed at Guy's Hospital, was this condition found. In some instances sudden death has occurred whilst being raised in bed; in another during the administration of an enema ; in another whilst drinking ; and again, in another, immediately after the extraction of a tooth for the purpose of feeding : it has also been observed during efforts at stool. In these cases the deaths were probably due to spasm of the laryn- geal muscles. Duringan attach of asphyxia and sitfocation. — This occurs gene- rally from the foregoing circumstance, viz., spasm of the muscles of respiration. Of forty-six cases in Guy's Hospital, in which the mode of death was noticed, in thirty-two it arose from the two foregoing conditions. From exhaustion. — This is less frequently observed, although it was noticed in twelve of the forty-six cases at Guy's Hospital. From accidental circumstances, such as erysipelas, coma from over-dose of morphia, &c. The causes of tetanus may be arranged under two heads : 1st, the probably immediate and exciting causes j and 2ndly, the remote or predisposing causes. I. The exciting causes comprise : A. Wounds and injiirics. Traumatic tetanus. — There is scarcely a single lesion which maybe said to be exempt from its attack, from the simple blow or contusion to the most severe compound fracture and laceration. It would be a waste of space to enumerate every form of lesion in which it has been I CAUSES. TRAUMATIC TETANUS. 317 found to occur ; we shall, however, classify them in the follow- ing order : 1, contusions and strains without wound, such as blows bj a cane across the nape of the neck or on the palm of the hand, &c.; 2, wounds of the soft parts, embracing simple abrasion of surface, incised, punctured, lacerated and gunshot woimds ; 3, burns and frostbite ; 4, fractures and dislocations, simple and compound ; 5, minor operations, such as extraction of teeth, cupping, seton, ligature of j)Lles, the accidental inclu- sion of a nerve in a ligature, incision into an inflamed bursa ; 6, major surgical operations, as amputation, castration, excision of the mamma ; 7, surgical diseases, such as gangrene, ulcers of the leg, fistula in ano, presence of guinea-worm under the in- tegument, caries of the tibia ; 8, incidents in obstetric practice, such as abortion, retained placenta, &c. The degree of the local injury bears no relation to the severity of the symptoms ; thus, a slight contusion may be followed by the most acute tetanus ; and, on the other hand, a patient with severe compound fracture may be seized with a mild attack and recover. The following relative proportions, which the occurrence of tetanus bears to the several surgical lesions, are taken from cases of admission observed at Guy's Hospital during a period of seven years. There were of Major and minor operations . 1,364 cases : tetanus occurred in 1 Wounds of all varieties . . . 594 „ „ ,, 9 Injuries and contusions . . . 856 „ „ „ 1 Bums and scalds 456 „ „ „ 3 Compound fractures .... 398 „ „ „ 9 3,668 23 Among the large number of total admissions of surgical disease, independent of direct accident, during the above jjeriod, only one case was attacked with tetanus ; thus showing beyond doubt that its occurrence is rare in the several forms of surgical disease, and that it is most frequently met with in the more severe varieties of injury and accident, such as compound frac- tures, burns, and injuries to the fingers and toes. The situation of the injury has been especially noticed as a source of frequency by some authors. Others, again, declare that the locality of the wound must be considered as almost a matter of indifference. Hennen observed it oftener after wounds of the elbow and knee ; others, again, more frequently from in- juries of the thumb and great toe. The extremities, however. 318 TETANUS. are mucli more exposed and liable to injiirj ; hence perhaps the frequency of tetanus from injuries in sucli situations. As to the state of the wound at the time when tetanus sets in : some observers, amongst whom is Larrej, attribute the tetanus to a sudden suppression of the discharge of a sujDpurating sur- face, the wound presenting a dry surface, or being covered over only with thin serous exudation. Others, agam, are of opinion that cicatrisation is mostly complete on the accession of tetanus ; thus, Travers goes so far as to offer an explanation of this cir- cumstance in the following terms : ' In flesh-wounds the jjeriod of commencing cicatrisation, after the mundifying process is completed, seems to be the most liable to the attack of spasms. It is difficult to disconnect the phenomena of the incipient spasm with the altered condition of the nervous and muscular structure in the healmg or newly-cicatrised part. Cicatrisation is adhesion and the fastening of parts before free and movable on each other, and its effects would be equivalent to their stran- gulation or confinement by pressure of any kind, the interruption to their function being the same.' Others maintain that it occurs most frequently in recent wounds ; thus John Hunter expresses his opinion : ' tetanus arises also from slight womids before either inflammation or sup- puration comes on ; they are generally the most frequent. It is from iiTitation.' But he further on remarks : ^ Wlien I have seen it from considerable wounds, it was after the inflammatory stage, and when good suppuration was come on.' Tetanus, however, is found to set in at any j)eriod and in any state of wound, and there are no grounds for assuming that any one condition is more favourable to the production of tetanus than another. The interval between the receipt of the injury and the first symptoms of tetanus is termed by some the period of accession or incubation. This varies from a few hours to many days, and must of itself depend, in a great measure, upon a variet}'" of con- comitant circumstances, which will be more appropriately considered under the j)redisposing causes, such as age, con- stitution, climate and sex. It is asserted and generally maintained to be correct, that tetanus, occm-rmg over twenty-two days after the injury has been inflicted, is more likely to be recovered from ; and that the more sudden the onset after receipt of the injury, the more surely will the result be fatal ; but, at the same time, we must bear in CAUSES OF IDIOPATHIC TETANUS. 319 mind that some of tlie severest and most rapid cases liave occurred wliere an interval of ten days lias elapsed. Of 277 cases, there were, Previous to the lOtli day . . . 130 cases, of whom 101 died. From the 10th to the 22nd day . 126 „ „ 65 „ Ahove 22 days 21 „ „ 8 „ B. Tetanus arising from causes unconnected with any injury or lesion of surface, commonly known as idiopathic tetanus. — This forms the second variety of the exciting causes, and includes exposure to damp and cold, humidity, irritation of worms, terror, sudden suppression of natural discharges, and acute diseases, &c. Exposure to damp and cold, however, seems to be the main cause of this idiopathic variety ; hut there cannot he the least doubt that in a great many of the traumatic cases this cause has played an essential part in inducing the disease, and although the majority of such cases are enumerated as traumatic, yet they should constitute an intermediate variet}'. Among the vicissitudes of temperature as a cause, the following are worthy of note : plunging into a warm bath whilst heated ; falling into a river in a state of perspiration, and during the flow of catamenia ; sudden change from the heated atmosphere of a baU-room to the external air ; in hot countries exposure to the chilly night-air and dew ; also exposure to the cold and moist breezes from the sea : sleeping in the open air all night in a fit of intoxication ; sleeping on the ground after fatiguing marches under a broiling sun ; sleeping in confined and iU- ven- tilated apartments ; breathing a contaminated or miasmatous at- mosj)here. Hennen lays less stress on the agency of cold than on that of air in motion, for all the cases that fell under his own ob- servation had been exposed to a stream of air either hot or cold. Irritation of worms. — Worms have undoubtedly been dis- covered in persons dying of tetanus ; thus a case is recorded among those occurring at Guy's Hospital. Dr. O'Beirne, in the ' Dublin Hospital Repoi'ts,' seems to regard their presence as of considerable effect in the production of the disease ; but, long- before him, Laurent of Strasburg went so far as to assert, that even in wounded subjects the real cause was the presence of worms in some part of the alimentary canal. It is probably a very remote and exceptional cause of the disease. Foreign hodies in the intestines. — Heurteloup relates a case m which the attack was apparently brought on by an accumula- tion of cherry-stones in the intestines. 320 TETANUS. Terror. — Dr. Hennen is an authority as to terror being the im- mediate antecedent of the disease. Intense anxiety of mind is quoted by Willan as a cause. Siidden suppression of the secretions and excretions has been mentioned. Fournier Pascay relates the ease of a woman who, ■while labouring under a gastric fever and in a state of perspira- tion, exposed herself at an open casement to the north wind, causing sudden supj^ression of the perspiration. The suppression of the lochia, and the suppression of acute dis- eases, such as variola, typhus, and gastric inflammation, have also been enumerated. II. The predisposing causes, although remote, must neces- sarily be taken into consideration. Age. — Tetanus occurs at every period of life. The peculiar affection in young infants termed trismus nascen- Uum has been already alluded to. It is principally seen in the tropics, but has been occasionally met with in Europe. It occurs within the first two weeks after birth, and is supposed to depend upon irritation of the primsB vise by meconium, worms, unnatural secretion, &c., or on a morbid condition of the um- bilical fossa. This has been mentioned before, and will not <3ome under the present consideration. Of regular tetanus, the youngest case on record is twenty- two months, and the oldest seventy-five years of age. Of 449 cases, there were Under 10 years of age .... 29 cases Between 10 and 30 years of age . 261 „ nearly 60 per cent. „ 30 and 50 „ „ . 122 „ Over 50 years of age .... 37 „ 8ex. — The ancients considered females to be more frequently affected, but less severely, than males. This does not accord with the experience derived from the returns at Guy's Hospital : for out of 72 cases of this disease, 12 occurred in females, being 16-66 per cent., and aU were fatal; 60 attacked males, bearing an avera<]re of 5 of the latter to one of the former. Taking a more extensive general average, deduced from 449 collected cases, it appears that males are more frequently at- tacked in a ratio of about 7^ to one female. Constitution, habits, previous health, &c. — Is there any pecu- liarity in the state of the constitution ? Hunter seemed to think so ; he says : ' But every thing relative to locked-jaw does not arise from irritation of the wound itself, neither from inflamma- PREDISPOSING CAUSES. 321 tion nor symptomatic fever ; for in such states tlie constitution is not disposed to it. It arises from an irritable habit, which may be increased or produced by irritation, but not such as is capable of producing inflammation. There must be a dis- position for the disease ; thus, madness is produced from the slightest causes when the mind is predisposed; so it is in agues and fevers, the constitution being particularly predis- posed at the time to such diseases.' Sufficient attention has not been paid to this subject to insure any satisfactory conclusion ; it aj)pears that the very quiet and cheerful, the very irritable and excitable, the strumous and fair, are alike equally liable, and in each is the disease alike equally fatal. Condition of hody. — Tetanus likewise attacks the healthy as well as the unhealthy, the emaciated as well as the robust and well-developed, the spare as well as the muscular. This does not correspond with John Hunter's remarks, viz. ' That those most susceptible to the disease are of sickly and weak frames, and of suspicious minds, and not of strong and robust ones.' Habits of life. — There is much difficulty in arriving at any definite conclusion concerning this point ; it has, however, attacked the temperate as well as the intemperate, and the dissipated as well as those who have lived low. Of sixteen cases recorded at Guy's, seven were temj^erate, and seven intemperate and dissipated, and both bore an equal ratio, as in both there were two recoveries and five deaths. These returns are, however, too meagre for any general conclusion. Hygienic causes. — Dr. Dickson^ remarks : ^' I trust I am, therefore, justified in inferring that to the improvements in the medical and surgical treatment of wounds, in cleanliness and ventilation, avoiding at the same time exposure to currents of cold air, or sudden changes of temperature ; in fine, to superior diet and accommodation, but particularly to the greater attention paid to the state of the bowels, may be attributed the great infrequency of tetanus of late in the West Indies, when com- pared with former wars.' Races and climate. — Europeans are said to be peculiarly ex- empt from the disease, whether in their own country or in India. There is much greater liability of the Negro race to every form of tetanus or trismus than of the white race. Mr. Peat, in his essay on tetanus in the East Indies, gives the following percent- * Med.-Chir. Trans, vol. vii. p. 4G5. VOL. I. Y 322 TETAOTJS. age of its occurrence among the various castes, viz. : Hindoos 1*63 per cent., Mussulmans 1 -09 per cent., Parsees 1*005 per cent., and Christians 0*75 per cent. Natives of warm climates are greatly susceptible. ' Is this,' Mr. Travers observes, ' owing to their being of a more relaxed fibre and greater susceptibility of impression both external and internal ; or, in other words, that less resistance is opposed to morbid action, and that in them the disease runs its course with greater vehemence and rapid- ity than those of temperate regions ? ' John Hunter remarks, ' that climate seems the first of the predisposing causes, and that which can probably produce it without any other causes. In warm climates it is most frequent. The cramp is most frequent in warm climates, and also in bed ; fits also are more frequent in bed, for warmth seems to have a peculiar effect in producing a particular disposition in the nerves ; and when there is an immediate slight cause, such diseases readily take place ; nay, some are disposed to such action without any imme- diate cause, which probably arises from climate, joined with a very strong natural predisposition. ' Influence of season in the productio^i of tetanus. — Respecting the separate months of the year in which it occurs, little can be gathered : it seems to be as frequent in one month as another ; so also in respect to the seasons of the year, for it is found to be developed in the cold, temperate, and warm months in an equal ratio. The same results are observed in the cases occiu-- ring in the East Indies. The influence of the seasons has no effect on the mortality in tetanus."^ Occurrence of tetanus after naval and military engagements. — Space will not allow us to enter into this question, as it will be duly considered under military surgery. Diagnosis. — There occurs sometimes a peculiar affection about the neighbourhood of the muscles of the lower jaw, which is attended with sj)asms, and causes contraction of those mus- cles resembling very much that of locked-jaw. "We must not, however, mistake these purely local diseases, inducing trismus, for the actual disease itself ; in all the spurious forms the con- traction of the muscular fibre, although constant, is never increased by painful and distressing paroxysms of spasm ; and generally, if the exciting cause be removed at an early period, the complaint will disappear. This is often observed in diseases of the alveoli from carious teeth, in ulceration of the gums and • For an extensive investigation of this point, see Guy^s Hospital Reports. Ser. iii. vol. iii. DIAGNOSIS. 323 mucous membrane of the mouth, &c. ; also in children during the period of dentition. Tetanus may be mistaken for hydrophobia, in consequence of the spasms in tetanus now and then affecting the muscles of deglutition, inducing a fear of swallowing from its exciting spasmodic action, and giving rise to a dread of fluids. We will offer the leading symptoms of the two diseases in contrast with each other in the following somewhat artificial table :^ Tetanus. Spasm of muscles more con- tinued ; less remitting, and never intermitting. Constant rigidity of the muscles of the jaw, becoming gradually fixed and closed ; tonic spasm. The cause is exposure to cold or wound, rarely from the bite of an animal, and it generally occurs soon after the injury. The bite of a tetanic animal does not produce tetanus. Countenance, tetanic; drawing up of the nose ; wrinkling of the forehead; angles of the mouth drawn towards the cheek-bone, presenting a frightful risus sar- donicus. There is an expression of pain, but the eyes are natural. No great thii-st, and in general no great aversion to fluids adminis- tered in small quantities j rarely any discharge of saliva. Vomiting and gastric pains rare. Mind generally clear to the last. Recovery in idiopathic forms. HrDEOPHOBIA. Spasm of muscles of brief dura- tion ; if not voluntary, at least tem- porary, and will cease to exist dur- ing intervals of rest and quietude, the jaw being relaxed, and opening and shutting readily. The spasms are clonic. Cause, the bite of a rabid animal, and it rarely appears before the thirtieth day. The bite of hydrophobic animals must have communicated the dis- ease when it exists. ■ Countenance, hydrophobic ; an expression of excitement, fearful distress, and peculiar restlessness, never to be forgotten ; occasionally frightfully convulsed ; eyes bright and glistening, but at times suf- fused. Thirst and aversion to fluids cha- racteristic ; even the sight or noise of fluids induces paroxysms ; with frequent and viscid discharges of saliva; efibrts to disengage it in- ducing barking and vomiting. Vomiting and gastric pains gene- ral. Mind subject to rabid impulses and numberless deviations, passing to delirium. No authentic case of recovery. Intolerant sensibility of sui'face and origans of sense. In Dr, Ogle's collection of cases of tetanus, occurring at St, George's Hoa- T 2 324 TETANUS. Idiopathic tetanus has been mistaken for rheumatism, and treated accordingly. Both affections have as their exciting cause exposure to cold and moisture upon the body of a person previously heated, perspiring, and fatigued; and although the symptoms in both, at first, are those of stiffness of the muscles of the back of the neck and other parts of the body, yet they differ in that the one consists of a chronic and slow affection of the muscular, tendinous, and ligamentous "structures, while the other confines itself to a spasmodic affection of the muscular system, influenced probably through the medium of the nervous system. However, in two of the Guy's Hospital cases, previous to admission the tetanic symptoms were treated for, and supposed to be, rheumatism. In a temperate climate, a sudden accession of tetanic symp- toms of great severity and running their course rapidly, in a person who has received no local injury, nor been exposed to cold and damp, would create a strong suspicion of poisoning. Thus there are some vegetable poisons which produce almost every symptom of tetanus, as observed either in animals ino- culated therewith, or in persons who have unfortunately swal- lowed the poisons. Chetik, a poison prepared from the juice of a large twining shrub, a species of strychnos, produces artificial tetanus. Strychnia, however, is the poison with which we are most fami- liarly acquainted, as bearing the closest analogy in its symptoms and effects with those of tetanus. The symptoms produced in animals are general uneasiness, convulsions of a tetanic kind, muscular rigidity, arching back of the head and neck, violent stretching of the legs, and spasms brought on by the slight- est touch like a galvanic shock. The symptoms, as it affects pital, lie mentions ' Case 5 as one of combined tetanus and hydrophobia.' See British and For. Med. Hevietv, October 1868, p. 485. He remarks : * This case is one which seems, to a certain degree, to link together all the three forms of disease — hydrophobia, tetanus, and epilepsy — under one common patho- logical classification. Given, excessive irritability of the common spinal centre, arising from agents acting either centrally or peripherally through the cen- tripetal nerves, we have resulting from the application of any suitable exciting stimulus an irritation, motor action, or spasm, which may either be of the general muscular system, as in epilepsy ; or of particular regions, as those of the jaw, neck, throat or back, as in tetanus; or more especially of the throat and pharynx, as in the present case of hydrophobia, the spinal derangement being attended by cerebral disturbance, as in the present instance, with mental delu- sions and even mania.' DIAGNOSIS. 325 man, are agitation, trembling, tetanic convulsions, spine and neck bowed, arms stretcbed out, bands clencbed ; tbe stiflEiiess wben once set in never entirely disappearing ; recurrence of first paroxysms and reappearance of jerking rigidity ; retraction of muscles of moutb and face; tbe countenance suffused and red, and tbe pupils dilated. Tbe patient can open tbe moutb and swallow ; tbere is no locked-jaw, but spasm of tbe respiratory muscles ; teiTor of suffocation ; larjmgismus early, sudden, and intense ; consciousness retained to tbe last ; senses unnaturally acute ; calmness. Tbe time of acting is, in small doses, balf an bour to an bour; in large doses, about ten minutes. In large doses, deatb ensues in a quarter of an bour ; in small doses, from balf an bour to an bour. In tbe celebrated trial of Palmer for poisoning a man named Cook by means of strycbnia, it was argued by tbe defence tbat tbe deceased Cook died of tetanus from natural causes, and not from any poisoning by strycbnia, and bence arose a question as to tbe diagnosis of tbe symptoms of tetanus from tbose of strycbnia.* Tbe following are tbe facts of Cook's case : He was com- paratively well up to a certain nigbt, wben about eleven o'clock be took some pills, and in tbree bours be was seized witb great agony, and sbrieked dreadfully, calling out ' murder.' He bad rigid and cold extremities ; tbe eyes starting, and tbe wbole body convulsed : be was gasping for breatb, but was perfectly conscious. Tbere was a gradual subsidence of tbese symptoms, and be fell into a state of repose and sleep, tbe attack baving lasted tbree bours. On tbe following day be was comfortable and conversed rationally, and was improving, baving got up and sat in bis cbair and laugbed and joked. At eleven o'clock tbat nigbt be again took pills, and in an bour afterwards be com- plained of stiffness of tbe muscles of tbe neck ; tbe bead and neck became unnaturally bent back, and be screamed and became dreadfully convulsed, crying out, ' liaise me up ; I sball be suffocated.' Tbe convulsions lasted from five to ten minutes, and affected tbe wbole body, so tbat it was boAved back. It was impossible to raise bim on account of tbe extreme rigid- ity. He was quite sensible ; tbe action of tbe beart slowly weakened and ceased gradually. Tbe second attack lasted not * For a full detail of the trial and the diagnosis of poisoning by strychnia, see Dr. Taylor's Essay in the Guy's Hospital Jiqjorts for 1856. Series iii. vol. ii. p. 269, et scq. 326 TETANUS. more tlian fifteen minutes from its commencement to the ter- mination in death. It was argued that the disease was not tetanus, for in the latter affection the symptoms commence in a mild form and then become stronger; it is gradual, continuous, and always pro- gressive, and there is never a total subsidence of symptoms. Again, tetanus rarely runs its course in less than two or three days, oftener longer ; and it never lasts for a few minutes and then subsides, to come on again in twenty-four hours. In tetanus from poisoning there are remissions or intervals of relaxation. How far these arguments hold good may be judged of by the perusal of the foregoing details of the varieties in the symptoms of tetanus."^ Hysteria, combined with spasm, called hysterical tetanus, occurs in females. There is no instance of a fatal termination of this affection. The representation is often so faithful, that many instances of reputed examples of successful treatment of tetanus have been merely conquest over hysterical spasms. Dr. Copland remarks : * In females trismus or subacute teta- nus may assume an hysterical character, or hysterical symptoms may be associated with the tetanic, the disease being really tetanus and occasioned by an injmy. Of this association I had a very remarkable instance many years ago in a cook in my own family. In hysteria, the spasms and convulsions are seldom accompanied with unconsciousness, or if they be so attended, the loss of sensation is incomplete and supervenes gradually ; again, the spasmodic or muscular contractions are subordinate phenomena, and of comparatively short duration.' Epileptic convulsions are attended always with entire loss of consciousness, and hence are distinct from the convulsions of tetanus. This symptom often precedes the spasmodic attack ; the muscles of respiration are early affected, and cerebral con- gestion and imperfect oxygenation of the blood result. Apoplexy never produces tetanic convulsions. However, Dr. Copland remarks one form, ' convulsive apoplexy,' where the membranes have become involved, giving rise to tetanic rigidity of the muscles, more particularly those of the neck or limbs, with various convulsive movements. * An interesting case of poisoning by strychnia is reported in the Guy's Hospital Reports for 1868, p. 265. In this case the diagnosis -was mainly due to the intermittent paroxysms of spasm, and the lad crying out before each spasmodic convulsion, ' It is coming on ! It is coming on ! ' PROGNOSIS. 327 Morphia sometimes produces convulsions ; but these are of an epileptic character, and long in their development. The advantage to be gained by dividing tetanus into acute or traumatic, and chronic or idiopathic, has been much dwelt upon as assisting in guiding us in our prognosis ; this may be illus- trated from the following quotations : Dr. O'Beirne witnessed 200 cases of traumatic tetanus in the Peninsula, not one of which recovered. Hennen confesses that he never saw a case of ' acute symptomatic tetanus ' recover. Dr. Dickson found all curative measures followed by unqualified disappointment. Mr. Morgan says, ' I have never seen or heard of an instance of recovery from acute tetanus.' A writer in the Edinhurgh Journal, vol. xv., says, ' that the idiopathic disease is a far milder and more tractable affection ; and this is a fact well known to every planter in the West Indies, who never considers his Negroes as safe when the disease super- venes on a wound, but is frequently successful in alleviating the idiopathic species.' Some author observes, that if within forty-eight hours the disease runs a rapid course, it will be fatal ; but if it be not fully developed until the ninth or tenth day, there may be a favourable termination. Parry attempted to found a prognosis upon the state of the pulse ; he says : ' If in an adult the pulse, by the fourth or fifth day, does not reach 100 or perhaps 110 beats in a min- ute, I believe the patient almost always recovers ; if, on the other hand, the pulse on the first day is 120 or more in a minute, few instances will, I apprehend, be found in which he will not die.' Larrey formed an opinion, that perspirations in certain j)arts, as the chest and abdomen, were critical, while those beginning on the head and extremities were symptomatic only. Recorded cases are not to be taken as evidence, inasmuch as often only successful cases are mentioned, and deaths passed by as a matter of course. In acute traumatic cases the prognosis is most unfavourable, and there is scarcely a well-authenticated instance of recovery on record. In subacute cases of the traumatic variety recovery does some- times take place, and especially when there is a long interval between the injury and its accession, and where the symptoms set in mild and pursue a slow course, gradually advancing in extent and severity. 328 TETANUS. In the idiopathic variety, wliere it does not assume an acute and rapid form, the prognosis is for the most part favourable, and we may always hope for a chance of recovery. Taking all forms together, in a fair average number of cases the proportion seems to be 7i deaths to one recovery. The dm'ation of the disease will be gathered from the follow- ingr record of 327 fatal cases : Within 2 days . . 79 cases fatal. From 10 to 22 days . 43 cases fatal From 2 to 5 days . lOi „ „ Above 22 days . . 11 » „ „ 5 to 10 „ . 90 „ „ Thus the mortality up to the fifth day is equal to, or even higher than, all the remaining cases included. The most rapid death has been in from four to five hours, and the longest duration on record, in a fatal case, is thirty-nine days. This return will considerably modify the statement generally made, viz., that if tetanus continue over a period of twenty-two days, a favourable issue is to be expected, and recovery almost certain. The post-mortem appearances are vague and unsatisfactory in the extreme, and it is difiicult to decide whether the actual condition observed is virtually a morbid lesion essential to the disease, or an alteration due to other circumstances, such as the mode of dying, or a mere cadaveric alteration. The late Mr. Wilkinson King, of Guy's Hospital, used to remark at the post- mortem table, whenever there was an examination of a case of death from tetanus : ' Gentlemen, we will now proceed to give you a demonstration of a case of healthy anatomy, for there will be no visible morbid appearance, otherwise than congestion of the organs in various degrees, which are owing to accidental circumstances.' We shall, however, cursorily survey the more prominent con- ditions that are met with : The body is usually found rigid, and the muscles firm and contracted, and^ occasionally ruptured, but in some there is no rigidity at all. The nerves at the seat of the wound may be found inflamed, injected, irritated, lacerated or punctured ; yet in other cases perfectly healthy and uninjured ; and in one case the divided nerve had reunited and was not inflamed. The brain has been found to be healthy, firm, congested, darker than natural, pinkish, &c. PATHOLOGICAL ANATOMY. 329 The medulla oblongata has been likewise found in a liealtby or congested state ; but some observers have noticed a change in the density and specific gravity of different portions of the spinal cord. The specific gravity was found increased through- out, and generally about the region of the cord which was in immediate communication with the nerves of the wounded parts. In the idiopathic variety this change was found through- out the whole cord. Dr. Copland is rather in favour of post- mortem evidences of morbid change in the spinal cord, medulla oblongata, and membranes. He says : ' These changes are rarely altogether absent when the inspection is made twenty- four hours after death; and in no inspection which I have witnessed have inflammatory appearances in one or other of these parts been wanting.' Lockhart Clarke, in his communication ' On the Pathology of Tetanus,' in vol. xlviii. of the MecUco-Chir. Trans., observes that ' in six cases the spinal cord exhibited lesions of structure of different kinds, and frequently of surprising extent. It seems to consist precisely of disintegration and softening of a portion of the grey substance of the cord, which appeared in certain parts to be in a state of solution. The fluid thus formed, however, is at first more or less granular, holding in suspension the fragments and particles of the disintegrated tissue, but in many places it is perfectly pellucid.' He asks whether the structural lesions and disintegration of tissue are the effects of the functional excitement of the cord manifested in the tetanic spasm ? or are they the cause of the spasms ? He negatives the former question, and as to the latter he states that they are not the direct or sole cause, since in those cases of paralysis in which similar lesions exist they do not give rise to tetanic spasms or convulsions. He believes that the lesions depend on the conjoint operation of injury of the peripheral nerves with hypera3mia and a morbid state of the bloodvessels of the cord, and the resulting exuda- tions and disintegrations. Dr. Dickinson, in vol. li. of the Med.-Cliir. Trans, p. 265 et seq., has given a very accurate description of the spinal cord in a case of traumatic tetanus in a man a3t. 25, who died in 18^ hours : ' The cord presented three remarkable enlargements, one in the cervical and two in the lumbar region. The morbid changes were : 1. A general intense injection of the cord, with dilatation of the bloodvessels in the grey matter more than the 330 TETAMJS. white, and in the left posterior horn more than in the rest of the grey matter ; 2. A structureless transparent exudation had been poured out around the bloodvessels in many situations, and by its forcible intrusion into the tissue had torn the cord in many situations, and had been the chief cause of the extended swellings by the displacement it occasioned ; 3. There were certain circumscribed changes in the white columns.' The figures on the accompanying Plate show fully the appear- ances enumerated in the above remarks. The sympathetic system has been thoroughly examined ; in some it was found healthy, and in others slightly injected. Dr. Copland, in 1822, suggested it to be the seat or pathological cause of tetanus ; but, as he says, ' it must not be overlooked that the ganglia are often very vascular even in health.' The blood is generally foimd uncoagulated ; but in other in- stances the blood in the heart has been found firmly coagulated, the coagula extending up the arteries and decolorised. There has been no satisfactory examination of the state of the blood, either pathologically or chemically. Much stress has been laid on the state of the heart, as a means of diagnosis of death from tetanus ; but it may assume every possible condition, and is generally only an indication of the mode of death of the individual. In one case, that of a boy, set. 11, who died of acute tetanus, the voluntary muscular fibre under the microscope was foundyery granular, resembling that of the heart undergoing degenera- tion ; otherwise, in the majority of cases, no change has been found in the muscles. The lungs, larynx, and alimentary canal present no other appearances but what are due to accidental causes and the modes of dying. From the foregoing remarks on the morbid anatomy, it must be understood that the pathology is still involved in great obscurity. Some affirm tetanus to be an irritation of a peculiar kind, and affecting the excito-motoiy apparatus ; that the irritating cause may be eccentric at the extremity of, or in the course of the afferent spinal nerve, or it may be centric within the spinal canal itself. Some consider it to be an exaltation of the polarity of the cord and medulla. Others, again, maintain it to be identical with inflammation of the spinal cord and medulla oblongata, and adduce cases of inflammation of such structures as inducing symptoms of tetanus. It has been suggested that it is due to a morbid condition of the blood, inas- much as it resembles in some respects those diseases which are produced by poisonous agents, as strychnine, hydrophobia, the poison of woorara, &c. Dr. B. Eichardson, in the Trans, of the Epidem. Soc. of London, vol. i. p. 28, Rgl. PL.l /" N, / / c;^ Central ^ray matter reduced to a state of fluid .^ granular disintegration a Eztravasationm posterior white columnSj &■ posterior horn, the latter broken into two parts,& the lateral part of the cord displaced outwards h. Colourless exudation m ^ - ^^- _ _ 3 posterior horn. TuffeB"West scxdpadiial ^ WWesl imp 1 Anterior horn of graj matter. 2 Posterior horn cf graj matter 3. Posterior white column 4 Antero -lateral columns 5 Anterior median fissure displaced. TEEATMENT. 331 on the theory of zymosis, refers to the question of tetanus, as belonging to the zymotici. ' In this disease, the poison, in my opinion, is first developed in the wound as a result of decomposition. Thence carried into the circulation, the new substance, without any necessaiy increase of its own parts, excites a zymosis, ending in the production of an alkaloidal or alkaline body, which has all the power of exciting the symptoms of spasm as much as strychnine itself.' The reviewer of the article ' Tetanus ' in Reynolds's System of Medicine, in the JBritish and Foreign Med.-Chir. Heview, vol. xlii. p. 297, says : ' The author does not attempt to trace any connection between the acknowledged causes, cold and damp and Wounds, and the production of such a fearful consequence in only a few cases.' * With regard to its relations to hydrophobia and analogy of the latter to that of snake bites, may not the connecting link between chilled wounds and spasmodic paroxysms be an animal poison generated in the wound during the process of healing ? And being an animal poison, therefore poisonous in extremely minute doses ? And being an animal poison therefore latent in the system for long periods ? And being an animal poison, therefore specially fatal to the nervous system ? The greater tendency of punctured and closed wounds to cause tetanus is very suggestive of the needle-like serpent's fang, and the frequent triviality of the dog's bite, which are the more deadly the less blood flows.' Dr. Copland justly observes : * ' If tlie difficulty of ascertain- ing pathological conditions, upon wliicli all rational indications of cure should be based, be so great in this malady as not to have hitherto been overcome, can it be a matter of surprise that the means which have been resorted to, both by physicians and by surgeons, in its treatment, hare been most opposite in their effects, the most different in their natures, and in every respect most empirical and uncertain ? In this state of our knowledge, it would be better to leave nature to her unaided efforts, to observe closely and accurately what is the true procession of changes and of their manifestations, and to ascertain the seats and the extent of lesion, as soon after death as may be attempted with propriety.' It will be well, however, shortly to enumerate the several methods of ti'eatment that have been adopted and recommended. Each and all have had their advocates, inasmuch as recovery has taken place after their use, and the disease has been con- sidered to be checked in consequence. It is questionable in the extreme, as to the agency and potency of remedies successfully employed in isolated and rare instances, when these same are utterly powerless in the majority of other cases so treated. Of the local treatment which has been had recourse to, the following Art. ' Tetanus,' Diet. Pract, Med. 332 TETANUS. may be eniuQerated : Incising and laying open the original ■wound, and removing all extraneous and ii-ritating substances ; amputation of the limb ; division of the nerves at or about the seat of the wound ; the local application of numerous counter- irritants,^ sedatives, anti-spasmodics, mercurials, &c. ; the application of leeches, cold, aconitina, belladonna, &c., to the spine ; various topical remedies to the abdomen and region of the diaphragm ; wai*m, cold, and shower baths ; electricity and galvanism. The constitutional treatment. — Almost every internal remedy has been successively tried, and no one individual medicine has been singled out as an appropriate means of cure : thus anti- j)lilogistics, including blood-letting, purgatives, calomel, anti- mony, colchicum, &c. have been extensively used ; alteratives in the shape of the varied preparations of mercuiy, large doses of :fixed alkalies, solutions of arsenic, &c. ; diuretics, in the form of tincture of cantharides, oil or spirits of turpentine, given in frequent and large doses, so as to irritate the urinary passages or to occasion bloody urine ; sedatives, such as digitalis, tobacco, uicotina, hydrocyanic acid, aconitina ;t anodynes and narcotics, as opium, morphia, belladonna, colchicum, cannabis indica, €ther and chloroform internally and by inhalation ; stimulants and antispasmodics, including musk, ammoniacum, camphor, turpentine, assafoetida, castor, wine and other stimulants; tonics, such as quinine, bark, strychnia, iron, zinc, &c. ; hygie- nics and dietetics, as support, milk-diet, &c. ; injections into the veins of solutions of opium, stramonium, &c. ; tracheotomy and laryngotomy. The Calabar bean in sufficient doses to para- lyse the voluntary muscles has been attended with great suc- cess, J although it has, on the other hand, failed very frequently. Although there is no specific remedy that can be relied upon, yet inasmuch as some remarkable recoveries have taken place from the use of certain medicines, we should at once select one of these well-recognised agents and fully carry out the treat- ment with energy, whether it be the use of chloroform, the administration of the tincture of aconite, the Calabar bean, * The application of blisters to excite a renevral of the discharge in the wound. Subcutaneous injections of atropine and other powerful remedies have "been tried and found useful. t See cases of recovery by Fleming's tincture of aconite, Brit, and For. Med.-Chir. lievieu; 1859, vol. xxiii. p. 48G. t See Remarks and Cases by Dr. E. Watson, Lancet, March 2, 1867. TEEATMENT. 333 qiiinme, morpliia, &c., the hypodermic injection, or the applica- tion of curara. We do not intend to offer any remarks on the foregoing reme- dies, but merely add that we can hardly call the above medicines administered, even although attended with recovery, ' remedies ;* they appear, for the most part, to have little or no specific action in the control of the disease. Those remedies which have had a more direct influence have been such as have rendered the paroxysms less severe, and more enabled the pa- tient to resist the exhaustion caused by spasmodic action. We must recollect that tetanus runs a certain course ; it has its period of accession, its height and intense activity, and its gra- dual decline. It often kiUs by exhaustion during its decline. Nothing seems to check its regular course ; there is no control in its unvarying and too often fatal career : it will have its sway. All we can do is to enable our patient to weather out the storm by giving him as much strength as possible, and not adding fael to the fire by all sorts of applications and internal remedies which have over and over again signally failed. If we can help our patient on one day after another, we gain much ; constant watching and constant attention are required, by night as well as by day ; an unflinching perseverance on the part of the sufferer in carrying out these views ; besides the avoidance of all causes of excitement, and more especially the cold air or winds ; taking care to preserve an uniform tempera- ture as much as j)ossible The following apposite opinions are here quoted : John Hunter thus sums up his views on the treatment of te- tanus :* * AU the antispasmodics have been given, but without apparent success ; opium has kept its ground the longest, but with little reason, as it only quiets ; but from some patients having got well under its use, its name has been raised; I have tried it, both m large and small doses, though always unsuccessfully. I think medicines have no power without they produce some visible effect. Opium never removes the cause, though it will prevent the effects ; it cures spasms and removes pain, but it does not remove the cause. It often does good, by not allowing the symptoms to do harm to the constitution. The first appearance of a cure is a recovery of strength, as weakness is a predisposing cause ; and the first indication * Hxinter's Works, by Palmer, vol. i. p. 688. 334 TETAlSrcrS. should be to strengthen the system. I know of no internal medicine.' Again he remarks, when treating of constitutional diseases from local irritation :* ' As these diseases which I have brought into this class are of such various kinds, each must be taken up apart, and treated accordingly ; but they are such as yield very little to medicine, for in some the constitutional disease is formed, and does not require the presence of the local disease to keep it up, as in the tetanus ; and in others, the local disease being still in force, it is not to be expected that the constitutional affection is to be entirely relieved, although in some degree it may. In those which form a regular constitutional disease, such as an ague, although the locaV disease may still exist in full force, yet some relief may be expected ; the bark is to be administered, although not with a view to cure, as the immediate cause still exists ; but bark will in some lessen that susceptibility in the constitution, and may cure, at least for a time, as I have seen in agues arising from fistula in perineo.' Travers observes rf ' Now the treatment of tetanus admits of the employment of two classes of remedies, relaxants and tonics. They are in no degree incompatible, but common sense would lead us to endeavour first to calm a wrong action, and having succeeded in calming it, then to apply our tonic for the restitu- tion and preservation of the right one. Perhaps the tonic may be the calming power we ought to employ in a case so rapidly destructive to life as the really acute tetanus ; but our limited experience does not warrant the conclusion.' We cannot finish this article without adverting to the recent attempts at cure by means of the woorara poison. Mr. Morgan, in his work on tetanus, offered the following suggestion as a means of cure in this disease. He vsrites : ' There is a close analogy between tetanus and some other spasmodic affections produced by the inoculation of poisons. Almost every symptom of tetanus may be produced in animals by a poisoned womid from chetik, a species of strychnos. It occurred to me, that if I could obtain an equally active poison which produced diametri- cally opposite effects, I might be able to control the effects of the one by the operation of the other {contraria conb-ariis) . The ticunas or wouraU was found to have this effect, and I could * Hunter's Worls, by Palmer, vol. iii. p. 437. t See Travera on CotistUtitional Irritaiion. TREATMENT. 335 readily control the severity of tlie spasms and prolong life by the subsequent inoculation therewith. In more than one case I have perfectly restored the animal to health by bringing this antidote into operation as soon as the first effects of the che- tik were observed, and regulating its after-consequences by partially or altogether cutting off from time to time, by means of a ligature, all nervous communication between the wound into which it was inserted and the brain. In all cases I took care to insert a quantity of tetanic poison more than sufficient to destroy life, provided no remedies had been used.' But it is only within the last two years that this plan has been carried into effect. An Italian surgeon was the first to use woorara : he employed it in three instances, applying the poison in solu- tion to the wounded part, and, Avhere no wound was present, to a raw surface artificially produced by blisters. In two of his cases the tetanus was acute and traumatic, but both died ; in the third case the disease was chronic, and recovery ensued. In Paris, likewise, three cases have been experimented on, and with the same result. So also in London, two acute, and one chronic or subacute case, have been treated by woorara, and recovery only effected in the latter case. Thus, of nine cases in which woorara has been employed, six were acute, and terminated fatally, and three were chronic or subacute cases, which recovered. Now this is not at all satisfactory; for chronic or subacute tetanus is a recoverable disease ; not so acute tetanus, and it is here that a remedy is anxiously sought for. Woorara has at present not fulfilled its purpose. Curara as a cure has been thoroughly investigated, and cases of recovery recorded by Demme."^ Dr. Harley attributes its value to its peculiar power of paralysing the motory much sooner than the sensory nerves. Its action in tetanus is to allay the spasm ; to keep the spasms from killing the patient by their violence, until the morbid state calling them into play has exhausted itself. ALFRED POLAND. # Schweiz. Zeitschnft fur Heilk. i. p. 356, 1863.] DELIRIUM TREMENS. THE name ' Delirium Tremens,' wliicli, like so many otliers used in medicine, has been objected to on account of its want of scientific accuracy, is, perhaps, on this very account, the best that can be adoj^ted to characterise a disease with the real pathology of which we are as yet so little acquainted. Like many other affections of the nervous system, it is marked by symptoms so well defined as to leave us in no doubt as to its reality, while they also sei've to distinguish it from other forms of disease with which at first sight it might be supposed to be closely allied. Half a century has scarcely elapsed since it was first discriminated from the delirium caused by inflam- mation of the brain ; and since that time, though much has been written on the subject, so little light has been thrown on its true causation, that the most opposite modes of treatment have been recommended for its cure. The first distinct notice of the complaint is contained in a pamphlet published by Dr. Pearson of Newcastle in 1801, reprinted in the Edinburgh Medical and Surgical Joiirnal in ISl'S,"^ soon after the appearance in that periodical of papers on the same subject from the pen of Dr. Armstrong. f In the same year the attention of the profession was more generally attracted by the publication of Dr. Sutton's treatise,| who strongly advocates the same views as those enunciated by Dr. Pearson. The practice then commenced has been more or less followed by the majority ever since, and the successful issue of cases treated on a wholly different plan, serves only as an illustration * Observations on Brain-fever, by Samuel Burton Pearson, M.D. ; Ed. Med. and Surg. Journal, vol. ix. p. 326. t Ibid. pp. 58, 146. \ Tracts on Delirium Tremens, on Peritonitis, and on the Goid, by Tliomas Sutton, M.D. PATHOLOGY. 337 of the principle which ought never to be lost sight of in weigh- ing the merits of opposing views, viz. that in a large number of instances disease has a tendency to run a natural course and to terminate in recovery ; and that consequently the so- called ' cure ' takes place, not because of the treatment adopted, but either quite independently of it, or even in spite of its being unsuited to the particular case to which it has been applied. Another source of error in drawing conclusions from the result of particular cases, which is too often overlooked in the eager desire to establish a favourite or original mode of treatment, is to be found in the different degrees of intensity and severity exhibited by a succession of cases ; among some a fatal issue is no uncommon occurrence, while others have scarcely presented an unfavourable symptom. This may be verified by the very great difference in the mortality at any of our public hospitals at different periods, although the treatment may remain practically the same. Pathology. — The real nature of the affection has by no means been made out by morbid anatomy. The post-mortem ap- pearances only reveal to us the mode in which the fatal termination arrived ; they throw no light on the origin of the disease, or the morbid conditions on which it is dependent. We know not in what way the nerve-structure is altered by continued habits of dissipation ; or how the blood, contaminated by the frequent introduction of alcohol into its current, serves to excite in the deteriorated brain that peculiar delirium, tremor, and insomnia, which so distmctly mark the disease at the bedside of the patient. The condition is one to which we are almost disposed to apply the term of ' disordered function,' because the evidence of the disturbed action of the organ is so much more distinct than that of the change of structure which no doubt goes along with it. This is more or less the case at present with all diseases of the nervous system, in the minute investigation of which so little progress has been made. Still, the information derived from anatomical research is worthy of study, because, as it tells how death is actually brought about, it offers suggestions as to how the fatal event may be prevented or warded off. The striking appearance is that of excessive serosity, whether contained in the ventricles, or under the arachnoid, or pervading the whole tissue of the brain, so as to give rise to the term so commonly in use of ' wet brain.' Occasionally turgidity of vessels is observed ; but VOL. I. z S38 DELIEIUM TEEMENS. this is nrncb. more rare as a pathological fact in cases of simple delirium tremens, and may, not without reason, be alleged to have been produced by injudicious treatment. Congestion of the brain is the invariable result of opium-poisoning, and here too we occasionally meet with serous effusion. This circum- stance it is which gives importance to the objections raised against its administration in delirium tremens ; but it may be remarked that the turgidity of vessels and the effusion of serum stand to each other in an inverse ratio in the two cases ; in the one congestion often occurs without effusion, in the other effusion without congestion, even when opium has been given freely. Another cause of congestion sometimes comes into operation, viz. the employment of means of restraint. The struggles of the patient to be free from an impediment which he cannot understand, hurry the hea.rt's action and interrupt his respi- ration, and thus very materially promote venous congestion. It is therefore the duty of the practitioner to watch very closely the effects of such measures where he is under the necessity of having recourse to them. The livid hue which sometimes pervades the face and neck and ears of the body after death, due in some degree no doubt to altered blood, betokens a condition closely akin to strangulation, and is only seen in those cases in which great violence on the part of the patient has been met by undue restraint. Clinical study alone furnishes us with data on which we can rely in forming any notion of the true nature of the disease ; and there seems no reason why, with caution, correct inferences may not be drawn from this source when anatomy fails as a guide. First, it is to be remembered that the disorder is not brought about by a first debauch ; that a necessary element in its causation is the hahit of dissipation. This habit is not to be measured by the actual quantity of stimulants taken : a patient in whom the nervous centres are easily acted on becomes excited and tremulous, * nervous ' as it is often called, by very small quantities taken daily at unsuitable times ; while in some remarkable cases two or three bottles of ardent sjjirits have been consumed every day for months, or even years, before the disease has been developed. Occasionally cases are seen in which the habit having been for a time restrained by circum- stances, delirium supervenes immediately on excessive intoxi- cation ; and while these present many analogies to true CLINICAL HISTORY. 339 delirium tremens, they differ from it not only in the more marked features of the attack, but also in this important fact, that the delirium is excited by the intoxication. Most writers have pointed out the necessity of such a distinction with refer- ence to treatment, and this form of delirium has been not inaptly called the delirium ehriosorum. This class of cases is that to which alone the view is applicable that alcohol acts as a direct poison, like belladonna or stramonium; and that the delirium is in the one case, just as in the other, due to the presence of a material poison introduced into the circulation from without. But even in such instances the antecedent is still essential ; the habit, though restrained by circumstances, must have existed ; in the first instance the abuse of alcoholic stimulants may produce a condition of nearly complete stupor, but it never gives rise to delirium. Delirium is unmistakable evidence of a prior change in the nerves or the blood, or more probably in both together. Secondly, we have to take into account the exciting cause of the attack. Sometimes it commences in a person habitually intemperate, after a recent debauch during which little solid food has been taken, the appetite being lost, and the stomach in a state scarcely capable of performing the function of di- gestion; and we are led to the conclusion that the want of healthy nourishment is the main cause of the disorder. But it is very usual to find in such cases that there has been also some great mental anxiety, which has very probably led to the excess in the vain hope of ' drowning care ; ' and this mental condition is not without its influence in producing the result, even without any very unusual amount of dissipation; the sleeplessness produced by mental anxiety, and the exaggeration of that nervous depression under which drunkards in their sober moments so constantly labour, are of themselves sufficient to hurry on an attack of delirium when the patient is already prepared for it. Next in frequency are those cases in which delirium tremens follows on an accident or injury attended with nervous shock, or supervenes during the continuance of low forms of erysipelatous fever, and that unhealthy character which the reparative process in wounds so constantly assumes in persons of intemperate habits. In other instances, again, the disease arises under circumstances in which the usual amount of stimulus has not been obtained ; and it has been too hastily concluded that its sudden withdrawal had brought z 2 340 DELIEIUM TREMENS. on the attack ; an opinion which seemed to be supported by the apparent benefit obtained from free stimulation during its con- tinuance. The records of our various prisons, in which so many committals occur among habitual drunkards, would seem to negative such an idea ; and we are constrained to look rather to the circumstances to which the forced abstinence is due, such as privation or illness with their accompanying mental depression and want of food, as more probable causes, than to any diminution in the quantity of stimulants taken by the individual. Thirdly, the clinical investigation of the disease has clearly led to the conclusion that it is one of depressed, and not ex- alted, vitality. The softness of the pulse, the muscular tremor, and the copious perspirations, are all so many proofs that there is no inflammatory action going on. In former days, when the presence of delirium led to its being classed among inflamma- tions of the brain, and antijihlogistic treatment was conse- quently adopted, the mortality was frightful ; and many of the older writers have spoken both of sweating and tremor as being of the worst omen in phrenitis, wholly unaware that these were symptoms of a different disease. For them they were only indications that antiphlogistic remedies would be ill-borne, and that, if already adopted, they must be abandoned. With the knowledge obtained by post-mortem examinations in more modern times, any idea of an inflammatory origin has been wholly abandoned ; the wet brain of the drunkard is no longer regarded as a ' very dangerous modification of meningitis,' which exhibits none ' of the actual results of inflammation.' ^ We are warranted by these observations in assuming — 1. That the disease is one of exhaustion, in which, whatever be the change which has actually passed on the nervous system, the first indication for the practitioner is to guard against the approach of death by sinking, or by coma in consequence of passive efPusion into the brain. 2. That it is not a direct form of poisoning, in which after a few hours of waiting and watch- ing the poison will be eliminated by some secreting organ or other, and the patient will be restored to health, as happens in opium-poisoning or in intoxication (alcohol-poisoning); but that some obscure structural change has been wrought, and whether alcohol be present in the blood or not, there must have been Abercrombie, Diseases of the Brain, Part I. sect. iv. § 8. DIAGNOSIS. 341 some additional cause which has produced the delirium, and this generally of a depressing kind. 3. That, so far as the nervous system is concerned, the condition is such as we might expect to be generated by depressing causes, and treatment ought therefore to coiTCspond rather to those forms of insanity accompanied by depression than to those which are charac- terised by excitement. Diagnosis. — With reference to diagnosis, it is to be remembered that the history of the case is very often defective in the most material point — the indulgence of evil habit. Neither the patient nor his friends are quite willing to confess to that of which their better feelings make them ashamed ; but while the knowledge of habitual excess gives certainty to the diagnosis, the disease may no less be developed in persons who may be thought by their friends to be very moderate in the use of fermented liquors, and yet who have taken more than their nervous system could tolerate. Yery often the trade or occupa- tion of the patient supplies this link in the chain of evidence by showing that he has been placed in circumstances of temp- tation ; and if loss of appetite be at the same time complained of, the inference will generally be correct that the temptation has not been successfully resisted. It has been alleged that delirium tremens may be brought on by the habitual use of opium; and Sir Thomas Watson, in his admirable lectures, speaks of a medical gentleman of temperate habits who was on the verge of delirium tremens from mental excitement and anxiety. It has also been asserted that the opium eater is liable to attacks of delirium tremens. Of the action of opium on the nervous system, in its habitual abuse, we fortunately know little in this country, and whether the one habit can produce the very same condition of the nervous system as the other, it would be idle to speculate ; certainly the change in the character of the blood which we know to result from the abuse of alcohol cannot be excited by opium. It does seem unwise to employ this name to designate any form of delirium accompanied by muscular tremor, occurring in persons of known temperance. Such a condition may be seen in cases of severe typhus ; indeed, in rare examples, so close is the resemblance that a superficial observer may be readily deceived before the patient is put to bed and the mulberry rash discovered. Not unfrequently the delirium of erysipelas or of rheumatic fever presents features closely resembhng delirium tremens ; but it is only in the intern- 342 DELIRIUM TREMENS. perate that the gemiine disease is developed. This view may be regarded as an over-refinement ; but in our ignorance of its real mode of causation, we cannot class under the very same category cases which are dissimilar in this important antecedent ; and it is safer to speak of them as analogous than as identical, especially when a closer scrutiny very generally discovers also some dissimilarity in the symptoms present. We would there- fore restrict the term absolutely to those cases in which habits of excess have existed. Next in the order of events comes the exciting cause, which may act either primarily on the mind or on the nervous system, as the organised structure through which mind reveals itself; just as in the analogy of other forms of disease we see acute mania brought on by mental excitement, and delirium in phrenitis or in fever produced by actual change in the brain or in the blood with which it is supplied. The character of the exciting cause has but little importance in the diagnosis of the disease ; it is always one of a depressing kind, and consequently has an important bearing on treatment. The actual attack is usually ushered in by sleepless nights and restless days, and there is almost always more or less of febrile disturbance. Exceptions to this rule more especially occur in surgical practice ; and sometimes when everything seems to be going on favourably, delu-ium suddenly commences almost without warning. In all cases of severe injury in persons of intemperate habits, the surgeon must be prepared for such an event, and must guard against its invasion by husbanding the powers of his patient, and sustaining his strength from the first by suitable nourishment and the judicious employ- ment of stimulants when necessary. The features of the disorder are so striking, that very little experience is sufficient to render its discrimination by no means difficult. The chief points to be observed, in addition to those derived from the history of the case, are the following : 1. The character of the delirium itself. — This is especially marked by the presence of one dominant idea, which has gene- rally something of unpleasantness mixed up with it, and ex- cites the individual to constant activity. It is, as denominated by Sir T. Watson, essentially a ' busy delirium.' The patient is either harassed by some worry connected with business, or he is alarmed by the presence of some loathsome or horrible object, and he is in constant agitation to get this business-matter SPECIAL CHAEACTERS. 343 arranged, or to rid himself of tlie object of liis alarm. He is perpetually jabbering on this one subject, and getting out of bed, or pulling his bed-clothes about, under the influence of the same predominant idea, which from time to time changes from one thing to another. But there is no violence or maniacal ex- citement ; he has no tendency to injure himself or others, and his only risk is that of getting out of the window by mistake, or rushing out of doors in his night-shii-t in pursuance of the idea which rules him for the time being. Still he is generally managed with comparative ease by anyone who combines firmness with gentleness, and only frets and rebels against un- necessary restraint or harshness. During the earlier periods of the attack he will generally put out his tongue, answer questions put to him, and do as he is directed, and there is none of the incoherent rambling and muttering of words with- out meaning and connection seen in other forms of delirium ; it is only when the brain begins to be oppressed by serous exudation that such symptoms are seen. 2. The existence of tremor along with the delirium. — This feature is so marked that it has given its name to the disease. It is not quite like that seen in the weakness and utter prostration of fever when there is delirium and subsultus ; it is more allied to the nervous trembling of a very excitable person under the influence of some mental impression, which for want of a better name we call ' nervousness,' strangely modified, however, by the peculiar restlessness of the delirium which it accompanies. The patient is constantly on the move, and every movement is made in the same tremulous, unsteady manner. Even before the de- lirium has actually commenced, or during convalescence, there is a peculiar hurry and agitation about his actions ; he puts out his tongue, or thrusts forward his arm for his pulse to be felt with a jerk, or he rises up in bed with a bound : there is a want of steadiness and deliberation in everything that he does. This combination of hurry and unsteadiness is one of the most de- cided evidences of the approach of the disorder, before anything like delirium is seen. 3. Restlessness and want of sleep. — These, though not peculiar to this form of delirium, are its invariable concomitants. The predominant idea keeps the patient in a constant state of imaginary employment ; he is no sooner persuaded to lie down than he is up again, or, if he remain in bed, he is perpetually pulling about or arranging his bed-clothes with the same object. 344 DELIEIUM TREMENS. Sleep, under such circumstances, is wholly impossible ; but no doubt there is more than this, for sleeplessness generally pre- cedes the delirium ; and it is only in exceptional cases that this indication is wanting. In other forms of delirium, insomnia generally follows the existence of delusion, whereas in delirium tremens it very often precedes it for several days. 4. A condition of general depression of the vital powers. — This is perhaps the most important point in the consideration of the disease, because, while it gives certainty to the diagnosis, it also indicates the true line of treatment. Its importance, as one of the sources of our knowledge of the pathology of delirium tremens, has been already pointed out, and this knowledge be- comes in its turn the only basis of sound and rational treatment. It is not enough to determine that an habitual drunkard is suffering from delirium with some amount of tremor, and go on to adopt a certain routine practice ; for his condition may be the direct effect of a recent debauch, while the blood is still poisoned by a large quantity of alcohol, which is producing irritation of the brain and congestion of the liver ; it may, in short, be the delirium ebriosorum, and not true delirium tremens, and the treatment suited for the one may be useless or injurious to the other. We must go a step farther, and enquire into the con- dition of the pulse, skin, and tongue ; whether they indicate febrile action of an inflammatory or, at least, congestive kind, or whether they prove that the condition is one to which these names are wholly inapplicable. The pulse probably will be, as in most conditions of debility, more frequent than in health, but the skin is not dry or bui-ning ; it is usually covered with moisture, and the perspiration occasionally becomes very pro- fuse. The tongue at the same time is seldom dry or brown ; sometimes it is tolerably clean, more commonly coated with a moist whitish or creamy fur, and having a flabby or oedematous aspect. Dryness of the tongue or redness at its tip and edges, with a roughish fur on its dorsum, may be regarded as pointing rather to the delirium of over-stimulation than to the genuine type of the disease. The absence of heat of head, the freedom from local pain and uneasiness, and the dilatation of the pupil, all serve as so many distinct indications that the disorder is nowise related to plirenitis, with which there is now hardly any excuse for its being confounded. The conjunctiva3 are very often suffused just as they are in typhus, a disease, like it, of a TEEATMENT. 345 depressing kind, the analogy to whicli has been already referred to, and did not escape the observation of Dr. Pearson."^ Treatment. — The opposite views of the treatment of delirium tremens taken by various writers are at first sight very unaccount- able. The explanation, however, is to be found in the absence of any pathological data as to the exact nature of the disease, and in the empirical nature of our practice. It may indeed be to a certain extent called a rational empiricism, inasmuch as we know both the usual causes of a fatal result, and the invariable mode of recovery by sleep. To avoid the one, and to aid in the production of the other, is the rational aim of the medical practitioner, and the discrepancy of opinion has in great measure arisen from too exclusive regard being paid to one or other of these parts of treatment. Some years ago a patient under the care of Mr. Jones of Jersey,! having by mistake swallowed one ounce of tincture of digitalis when almost in articulo mortis, made such a rapid recovery without any unfavourable symptoms that Mr. Jones was induced to employ it extensively in the treatment of the disease. His conclusion was that it very generally succeeded in pro- ducing sleep when administered in large doses. In other hands the result has not been quite so satisfactory, and most prac- titioners shrink from the responsibility of giving the remedy in such poisonous doses as we are assured can alone prove success- ful. Various other remedies have been tried with the somewhat mistaken view that sleep will not be procured except by power- ful agents employed in heroic doses. Such a doctrine cannot be too strongly reprobated. The evidence of the older writers is clear and distinct on one point, viz. that when delirium tremens was mistaken for phreni- tis,and treated by depletion and antiphlogistic remedies, the mor- tality was very much greater than when the distinction had been made and the treatment by opium introduced. It is not possible to trace the causes which led to this change in treatment. Dr. Sutton attributes the discovery to accident ; he offers no theory to account for its success, but claims for it the same confidence among the profession generally with which its success had inspired himself. The reaction which, to a certain extent, has taken place, may be ascribed to the indiscriminate manner in which the drug has been subsequently administered, as compared Op. cit. t M^'id- Times and Gazette, September 18G0. 346 DELIEnJM TEEMENS. with the caution used by its earlier advocates. The cases fur- nished by the opponents of the treatment by opium prove clearly that in many instances simple attention to the functions of digestion and elimination, with good management, is sufficient to insure recover}'^, and that opium may sometimes at least be dispensed with.'^ In the earlier stages of the affection, when the case is only marked by anorexia, disorder of stomach and troubled sleep, its further progress may very generally be arrested by remedies calculated to restore the functions of the stomach and liver, and to evacuate the morbid matters which we know must have accumulated in the blood by long habits of dissipation. At the same time the strength of the patient must be sustained by pro- per nutriment, and powerful cathartics must be avoided. A patient threatened with delirium tremens cannot bear any decidedly lowering treatment ; for, as has been already shown, the exciting cause of the attack is most frequently of a de- pressing kind, and abstinence from food generally plays a very prominent part in its development. These indications are perhaps best fulfilled by the adminis- tration of small doses of blue-pill, followed by a warm and mild aperient ; nitric acid in combination with bitter infusion, with the adjunct of some stimulant diuretic, is often highly beneficial ; sometimes even more powerful tonics may be usefull}- adminis- tered, such as quinine and sulphuric acid. ^Vhen the red edge of the tongue and tendency to vomit indicate a more irritable state of the stomach, such as is likely to be produced by the direct action of the stimulant on its mucous membrane, effervescing draughts with an excess of ammonia are to be preferred to reme- dies more decidedly tonic ; while the irritability is soothed by the application of a sinapism to the epigastrium. The great object of treatment is to enable the patient to take and to assimilate a sufficient quantity of proper nourishment ; without this the dis- order will get worse. And here perhaps lies the greatest difficulty. Solid food is absolutely refused ; even soup or beef-tea may cause such a loathing that the patient cannot be persuaded to take them, or they may be rejected by the stomach. In such circum- * See especially Clinical inustrations of the Pathology and Treatment of Deli- rium Tremens, by Prof. Laycock, Ed. Med. Journal, vol. iv. p. 289, 1858-9, But it may be remarked that few of the instances there recorded present such a degree of severity as very often marks the disease in this metropolis. Per- haps something is due to the diflerent stimulant in common use in Edinburgh. TEEATMENT. 347 stances, tlie feeling of prostration causes him to have recourse to some stimulant as the ' only thing which will stay down,' and this again increases the anorexia. Sometimes, indeed, the medical attendant feels the same necessity ; and then good ale or porter, or even wine, are to be preferred to spirits, as con- taining some amount of nutriment ; and it should be made a sine qua non, in granting the indulgence, that solid food even in the smallest quantity is taken with the beer, which should be given only at stated intervals, and not taken as fancy directs. Along with these measures, the nervous agitation is decidedly calmed and the exhaustion of want of sleep may be avoided, by giving a morphia draught at bedtime. When delirium has fairly set in, we ought to ascertain, if possible, how long it has lasted, because it is almost vain to hope for the immediate occurrence of sleep, however large the dose of opium may be. The same quantity of opium which has failed the first day may be completely successful the second. If no treatment has been previously adopted, it is wise to commence with a dose of calomel, wliich should be accompanied by a grain and a half or two grains of opium, followed after some hours by a purgative. Congestion of the liver is so common with drunk- ards that the function of this organ demands our first attention ; but caution must be exercised that the patient is not too much depressed by the remedies. An effervescing saline with excess of ammonia, and a few drops of laudanum, may be given every second or third hour, with a view to calm nervous excitement and moderate the restlessness of the patient. Whatever food can be taken is to be allowed ; and according to the state of the pulse, more or less of some stimulant may be given from time to time. In these matters the attendant must be very much guided by the whim of the patient, the object being to sustain his strength ; this must be done in the best way that the cir- cumstances of the case will admit of, but over- stimulation must be carefully avoided. The idea that stimulants can cure the disease has no warrant in experience ; and theoretically we may assume that if they do not prevent its occurrence in a man whose habits are those of constant indulgence, and who has been but lately under no restraint, they cannot cure the complaint when the same person is brought into the wards of the hospital. Still I think one cannot fail to be struck with the remarkable manner in which a tongue covered at first with a thick creamy for becomes perfectly clean while stimulants are being given in 348 DELIRIUM TEEMENS. such quantity as tlie exigencies of the case seem to require. No more complete justification can be offered for their administra- tion, and when this effect does not follow, the practitioner is hound to reconsider his judgment and reflect whether they are really called for, and to what extent the needs of the system demand their continuance. An opiate of some sort should be administered at bedtime and repeated once or twice, even when we do not expect to induce sleep, for the purpose of calming the delirium which is always aggravated at night. The dose should be full, but in the first instance not unreasonably large until the idiosyncrasy of the patient is known. It may be repeated at intervals durmg the night, and should be entii-ely suspended during the day. If it be the great aim of the practitioner to procure sleep, he must not be tempted to give more opium than his patient will bear, and so complicate the case by superadding narcotic poisoning to the state of delirium tremens. It is always wise to interpose an interval of complete rest in the course of each twenty -four hours, and defer the administration of the opiate until night, when other circumstances tend to favour its opera- tion. Caution is especially called for if there be contraction of the pupils, which, as it is not a usual condition in delirium tremens, points either to an excess of narcotic action or to already commencing effusion on the brain ; and in neither case can large doses of opium be beneficial. Not unfrequently death occurs under circumstances very similar to the effects of narcotic poisoning, and it is not alwaj'^s easy to satisfy the friends that the medicine had nothing to do with the development of the symp- toms. In a scientific point of view, it can never be regarded as judicious treatment to push the action of a remedy which, in its operation on the brain, gives rise to a somewhat analogous train of phenomena. The real function of the medical atten- dant is to obviate the tendency to death, in whatever mode it is most likely to occur, and by those who oppose the use of opium it is alleged that want of sleep is not to be reckoned among the causes of a fatal issue. It is no doubt true that in health a man cannot die from want of sleep as he may from want of food ; but delirium tremens is not, surely, the only disease in which prolonged wakefulness may terminate in exliaustion of brain and coma, and in which the artificial induction of sleep may restore its normal functions, and arrest the morbid action which might lead to such a result. TREATMENT. 349 But -anquestionably tlie moral management of the patient is the point of most importance in practice. Coercive measures are always prejudicial, and are only justifiable under the most unavoidable necessity. The patient may almost always be controlled by firmness combined with a soothing and gentle manner, if his fancies be humoured and not contradicted. Much stress is justly laid by the older writers on this part of the treatment, and it has been unfortunately too much lost sight of in modern practice. Opium and the strait-waistcoat have been sanctioned, from the difficulty of treating such cases in hospital with a limited staff of nurses. It is to be feared that sometimes a fatal termination might, not without reason, be charged against such treatment, a,nd the opium has borne the blame when the forcible restraint was really more in fault. Dr. Pearson's notes on this subject are quaint and instructive, although few would be disposed to follow out to the letter the various injunctions laid down. Perhaps the arguments against the treatment by opium would have found fewer supporters but for the neglect of such an important element of success. Whatever doubts may have been entertained in regard to the rules of practice now laid down as applied to the more ordinary forms of delirium tremens, all are agreed that when it super- venes on an accident or injury, or in the course of an attack of erysipelas, the safety of the patient depends upon free stimula- tion and the exhibition of opium. In very many cases it is vain to talk of what may be the most scientific mode of treatment, because the patient cannot be persuaded to submit to it ; but he may be induced to take some form of stimulant, such for example as a draught of porter, in which we may disguise a dose of laudanum to calm his wild excitement ; and if it do no more, it at least helps to ward off fatal syncope, and gives nature time to do her own work in her own way. Recently, attention has been called to the possibility of intro- ducing narcotic substances into the cellular tissue, by what is called the ' hypodermic method,' in cases in which they have seemed to fail in producing their effect when taken into the stomach. In delirium tremens it is well to bear in mind that the assimilating powers of the stomach are always much inter- fered with, and that consequently, while the remedy itself is very likely to escape absorption, its presence in the stomach is apt to increase the anorexia and inability to assimilate proper nutriment, which stands so much in the way of successful 350 DELIEIUM TEEMENS. treatment. Sometimes, too, the resistance of tlie patient pre- vents the administration of an opiate in the ordinary way ; and in either case the injection of a few drops of solution of mor- phia under the skin may be practised with perfect safety, if due caution be exercised. In this mode of treatment more than any other is there a danger of pushing the narcotism too far. The immediate risk attending the repetition of an opiate before we can be certain that it has been absorbed is obviated ; and if sufficient time be allowed to pass before a second or any subsequent injection is practised, and sleep is still not induced, there is a great tendency to go on with the treatment, forgetting that in such cases the brain may be ultimately poisoned by opium, and yet sleep be as far off as ever. Sleep, not narcotism, is natiu'e's method of cure in delirium tremens. When there is extreme prostration and the skin is bathed in prespiration, it is not unreasonable to expect benefit from the exhibition of tonics and astringents ; personal experience, per- haps rather limited, has seemed to confirm this view. Quinine and acid in full doses, during the intervals of the opium treat- ment, have certainly been well borne and apparently have done good in such cases. To sum up : the natural mode of recovery is by sleep, which occurs in the milder cases spontaneously ; the object of treatment in the severer cases is to bring about this result by the judicious administration of opiates. Full doses are to be repeated at short intervals for a limited time, and to be again resorted to after the lapse of some hours, if at first misuccessful. The functions of the stomach and liver at the same time claim special atten- tion, because they are almost always disordered in drunkards, and the consequent non-assimilation of food is one of the essential elements in the causation of the disease ; the strength must therefore be supported by such nourishment as the stomach can bear, and, when necessary, by the administration of stimulants, while all needless coercion is to be carefully avoided. The great error in the treatment of the present day seems to be the regarding opium and stimulants almost in the lio-ht of specifics, while neglecting other important measures ; it consists in the endeavour to ' cure ' by heroic means, in place of resting satisfied with aiding in bringing about the ' recovery ' of the patient. ANDREW WHYTE BAECLAY, M.D. SCROFULA. SCROFULA is, in one respect at least, an unfortunate word, for it is not clearly defined. On the contrary, very different significations are attached to it. It has certainly become a vugue term, so that wherever met with, it is necessary to refer to the context to obtain an idea of the sense in which it is employed. For example, by some it is applied to a certain state of the constitution, and by others to the disease which results from it. Again, it is often applied to all the diseases which, arising in a certain state of the constitution, possess some general features in common ; while it is sometimes limited to the absolute deposit of tubercle, being simply synonymous with the more modern phrase tuberculosis. Finally, the confusion reaches its climax by the introduction of the adjective scro- fulous, which is, and perhaps ought to be, if used at all, em- ployed in the same sense as the substantive, but is applied more frequently, at least in conversation, as a less definite term to doubtful cases, when the features are obscure and the diagnosis uncertain. Some great authorities, indeed, draw a distinction between the tuberculous and scrofulous diathesis, attributmg to the latter leading pathological tendencies other than the formation of tuber- cle — such as attacks of what may be called low or chronic inflam- mation, in certain parts — and consider the two classes marked respectively by the characters enumerated on page 363. But although there may be, and no doubt is, difference in the degree to which a tendency to the formation of tubercle exists in the two cases, it appears to me that there is nothing sufli- cient to warrant the pathological distinction which it is now the fashion to make between scrofula and tubercle. It is necessary to state, then, that in these pages by the term scrofula is understood a certain disease or defect of the con- stitution in which there is a tendency to produce and accumu- late a substance called tubercle in various tissues and organs. 352 SCROFULA. Tubercle may therefore be said to be the essential element of scrofula. But it does not follow from this definition that a formation of tubercle must necessarily occur in every case of scrofula. That depends upon the extent of the affection, and is determined by various circumstances. The use of the word in this comparatively restricted sense possesses at least this merit : it gives precision to the term and renders it definite. But it may be said, Then why not make it at once synonymous with tubercle ? that would be yet simpler. Tnie ; but then some term would still be required to express the state of the system, and none, as matters at present stand, would be so convenient as scrofula. Scrofula, or struma (which is a synonymous term), is there- fore generally identical with tuberculosis; the use of the latter term, however, being often restricted to the case in which tubercle actually exists. Wliat, then, is tubercle the essential element of the disease ? Its characters, as generally recognised, may be thus described : Tubercle in its strict sense is a substance not vascular, or at least possessing no bloodvessels proper to itself. It has ex- tremely little, if any, inherent power of growth, but beyond all other structures, perhaps, tends to early degeneration. It is either produced in distinct masses of very small size, which may remain separate or rapidly coalesce, or it is infiltrated through various tissues. Tubercle is usually described as occurring in two principal forms. It is perhaps more frequently seen as an opaque substance of a dull pale-yellow colour ; sometimes tolerably firm, yet friable like cheese ; at others, softer, like putty, readily yielding to pressure and smearing the surface on which it is pressed ; either accumulated into a distinct mass varying in size from a pin's head to a small orange, or else occurring as an infiltration. But very often it appears in the form of small granular bodies, varying in size from a mere speck to that of a millet- seed, or occasionally larger; of a pale-gray tint, translucent, and glistening. The more transparent ones sometimes reflect or refract the tint of the surrounding tissues. To a superfi- cial inspection they appear spheroidal, but when more closely examined, they are seen to possess sharp angles ; the circum- ference is more or less irregular, with short branching pro- TUBERCLE. 353 cesses. Thus intimately connected witli the adjacent tissues, they cannot be distinctly isolated. They are always firm, and sometimes hard ; the cut surface has very much the appearance of cai'tilage ; they yield little or no fluid when crushed ; they tend to accumulate in groups. The first of these forms is distinguished as the yellow, and the last as the gray, or from its ordinary size as the miliary, tubercle. Between these two cardinal forms any intermediate variety may occur. The shape which a mass of tubercle assumes is doubtless due to the influence of the parts around. Its name is derived from the fact that it often possesses a tuberiform shape, although Dr. Carswell has shown that this is less common than had pre- viously been supposed. It is seen most frequently in the brain, and also in the cellular tissue. But it may occur in layers, as in serous membranes, or ramiform, as in the bronchi. In short, its shape is determined by the mould in which it is cast. In truth, tubercle is most frequently infiltrated into the natural tissues ; and although the term infiltration is commonly applied to the diffuse form alone, even the circumscribed masses with definite though generally irregular outlines are, as Paget says, equally infiltrated among the natural tissues, only in these the mfiltration occupies a defined area. Hence the reason Avhy a mass of tubercle, although in itself strictly homogeneous, yet often appears otherwise to close observation. Distinct lines and streaks are frequently visible throughout its substance. These are due to some of the tissues of the organ which become enclosed by the deposit of tubercle as it accumulates. In this way blood vessels and aU kinds of structures may be found in a mass of tubercle ; and the tissues thus enclosed sooner or later degenerate or undergo other morbid changes. As a general rule, it may be stated that tubercles which are most regular in shape, spheroidal or tuberiform, as tubercles in the brain, are most uniform in aspect and structure. A large and irregular mass of tubercle may arise either from continued deposition around a single centre, or by the coales- cence into one of several distinct masses. Tubercles in the lung especially illustrate the latter mode, when of any consider- able size. It has been disputed whether tubercle is ever encysted. With reference to this question Walshe says : ' We have our- VOL. I. A A 354 SCROFULA. selves never seen encysted tubercle in any structure of the body, if by tlie term be understood tubercle contained within a cyst, which has acted as its formative organ. But we have seen in very rare instances in the lung, and, comparatively speaking, somewhat more frequently in bone, tuberculous matter sur- rounded by a more or less complete membrane, strongly assimilable in properties to the pyogenic membrane of abscesses, and, like it, obviously formed consecutively to some at least of the matter it invested. Such we believe to be the key to the comprehension of " encysted tubercle." ' The minute stmcture of both forms of tubercle is essentially the same. They diifer principally in the condition and the relative proportion of the different elements. To the microscope tubercle exhibits various forms. These may be separated into those that are proper to the tubercle itself, and those which are incidental or accidental and derived from the surrounding parts. As the elements proper to tubercle may be recognised : Shapeless fragments ; flakes or shreds of a substance which is sometimes, as in gray tubercle, transj^arent and almost homo- geneous or delicately fibrous ; sometimes, as in yellow tubercle, obscurely granular. It swells and becomes more transparent when treated with weak acids or alkalies : Innumerable and extremely minute molecules and granules, especially abundant in the yellow tubercle, and in it ming]ed with oil-globules of various size ; these are soluble in, and may be abstracted by, ether, and recovered by evaporation : Corpuscles or cytoblasts of various shapes and contents, but almost all distinguished by being more or less irregular in form. They are for the most part shrunken, wrinkled, withered, and appear like defectively-developed, aborted or degenerate exu- dation-cells. Their contents are generally granular, and now and then something like nucleoli may be discerned in their interior. These corpuscles occur in both kinds of tubercle, but those in the yellow variety are much more deformed and distorted, and their contents are more granular. In addition to these there are found incidentally : ill-formed epithelial cells in all stages of development and degeneration ; masses of pigment ; crystals and plates of cholestearine ; rem- nants of enclosed and disintegrating tissue, as, for instance, in the lung fragments of elastic fibre, and rarely small bloodvessels in a state of fatty degeneration. TUBEECLE. 355 Tubercle has of course been subjected to chemical analysis, and in some instances with very elaborate results. Amongst other substances, it yields, as would be expected, oil, nitro- genous principles, cholestearine, chloride of sodium, phosphate and sulphate of soda, phosphate and carbonate of lime, mag- nesia, &c. As already indicated, tubercle possesses very little or no inherent power of growth. It increases simply by the addition of new matter upon its exterior, or by the gradual coalescence of distinct deposits. Tubercle when deposited may ^^ndergo various changes. In the first place, can tubercle, when once deposited, be simply reabsorbed ? This question would be doubtless very generally answered in the negative. Walshe, however, says that his belief in the occurrence of such reabsorption is firm ; and Yirchow believes there are rare cases in which tubercles, in con- sequence of undergoing complete fatty metamorphosis, become capable of absorption : but, although there is assuredly no reason for denying its possibilty, the evidence advanced in its favour is yet far from conclusive. Yellow tubercle, after it has remained firm for a variable period — the crude tubercle, as it is called — has a strong ten- dency to soften. This, in the majority of cases sooner or later occurs. The process of softening may commence in any part of the mass, and may be either of intrinsic or extrinsic origin. There appears to be no doubt now that the change is sometimes, perhaps usually, intrinsic — a form of natural degeneration, such as may occur in lymph, and by which the softening of fibrinous clots within the heart and veins is effected. Indeed, as excep- tional cases, tuberculous coagula sometimes form within the bloodvessels. This process of spontaneous softening usually commences at or near the centre of the mass, ' in the part of it which, we may believe,' says Paget, ' being most remote from the blood, is least able to maintain itself in even such low development as it may have reached.' When a tubercle under- going this change is divided, the softened portion glutmous, tenacious, fatty, is readily distinguished. It may be pressed out from the firmer portions. As the change proceeds, softened caseiform flocculent fragments float in a thin, yellowish, turbid fluid. By and by the whole may become liquid. In the liquefied matter corpuscles may still be detected in advanced stages of degeneration, amidst an abundance of mole- A A 2 35G SCEOFULA. cules and globules of oil. Under these circumstances the large granule-cells appear. The principal changes are, the disinte- o-ration and destruction of the corpuscles and the abundant increase of oil-globules. It is fatty degeneration. But the softening may be of extrinsic origin, and, as it were, accidental. In this case it is due to ' the mingling of liquid products of inflammation in the adjacent tissues.' Softening from this cause usually commences at the periphery, but some- times in the central portions, when the natural textures are there enclosed. Pus then becomes mixed with fragments of tubercle. The liquid thus produced is usually discharged by ulceration of the investing tissues, or it may be retained. The fluid por- tion is then slowly absorbed, and it dwindles into a putty-like mass, which still further shrinks and hardens. When the disintegrated tubercle is discharged, either an ulcer or a cavity is produced. In this way vomicae in the lungs are commonly formed. And these may be extended ' through communications formed with softening tubercle on their con- fines.' It is stated that tuberculous matter is sometimes, though rarely, exuded from the surface of certain mucous membranes without any breach of texture. Yellow tubercle may undergo what is termed calcareous degeneration, and this even after it has begun to soften. The corpuscles shrivel and wither. The organic matters gradually disappear by absorption, until scarcely a trace remains, and nothing but a cretaceous mass composed of inorganic salts is left behind ; and this may be, but is not often, finally expelled. Such cretaceous fragments are sometimes expectorated. The gray tubercle may also undergo a peculiar degeneration or withering. Rokitansky thus describes it : ' After abiding in the primitive crude condition before described, it becomes transformed, with the loss of its moisture — with condensation — to a hard nodule, and shrivels into a tough, amorphous or indistinctly fibrous, hornlike mass — in a word, cornifies. This determines a complete wasting and death of the tubercle, subversive of aU further change. Occasionally this i)rocess is associated with bony deposition, the tubercle becoming a partly cornified, partly ossified nodule.' He adds : ' this tubercle does not undergo any other metamorphosis independ- ently.' TUBERCLE. 357 But it is now generally accepted that the two forms of tubercle, the gray and the yellow, represent different stages or degrees of the same disease. The gray is regarded as an earlier condition of the yellow tubercle. This opinion is based upon the following evidence. As already described, they exhibit essentially the same structure. It is true that the difterent elements vary in their relative proportion in the two forms, the corpuscles predomina- ting in the gray, and appearing more normal in character, less degenerate ; and the granular and molecular matter being much more abundant in the yellow : but this is a question of degree merely, not of kind, and when considered, constitutes a strong argument in favour of the view. The gray and the yellow tubercle are often found mingled together. And further, the yellow tubercle often a23pears in the substance of the gray, and is believed gradually to take its place ; and this transformation may be seen in all degrees of progress. Even Rokitansky admits ' the combination of the two cardinal tubercle-blastemata in different proportions, and their manifold grades of co-ordination and of blending,' Speaking of the degeneration of the gray into the yellow tubercle, Williams says : ' Generally the change begins in the centre of the mass, apparently because, there being no per- meatmg vessels, the centre is the furthest removed from the vivifying influence of the blood.' This explanation has been also applied, as previously mentioned, to the central softening — the further degeneration of yellow tubercle. But it does not follow from this that the deposit of yellow tubercle is always, as some maintain, preceded by the gray. On the contrar}', in some organs the gray is very rarely seen ; in the brain, Walshe says, never. And sometimes yellow tubercles are discovered of the minutest possible size, without any trace of gray substance. Virchow and others, however, regard the gray miliary granule as the typical form of tubercle, and the yellow as the same in a state of fatty degeneration. With regard to the relative frequency of tubercle in the various textures and organs, I will quote Rokitansky, for his statistics are unrivalled. He gives the following scale : In adults : lungs ; intestinal canal ; lymphatic glands, more particularly the abdominal and bronchial; larynx; serous membranes, especially the peritoneal and pleural ; pia mater ; brain ; spleen ; kidneys ; liver ; bones and periosteum ; uterus 358 SCROFULA. and Fallopian tubes ; testicles (including the epididj'mis), with prostate gland and seminal vesicles ; spinal cord ; striated muscles. In children : the lymphatic glands, together with the spleen, would take the lead, folloAved by the lungs, with the bronchial mucous membrane, the brain, the serous membranes, &c. But this list includes all formations, whether primary or secondary. A more important question still remains to be answered. In what organs is the primary deposit of tubercle most frequent? Where is tubercle most likely to be deposited in the first instance ? I refer again to Rokitansky. ' If, which is most important, we consider tuberculoses individually, ac- cording to their primitive or to their secondary appearance, an entirely different scale is set up. The lungs and lymphatic glands, it is true, retain their uppermost rank, but are im- mediately followed by tuberculoses which stand very low in the foregoing scale, namely, of the urinary system, of the female sexual mucous membrane, of the bones, of the testicles, with the prostate gland and the seminal vesicles. Meanwhile tuber- culoses of the intestine, of the larynx and trachea, of the serous membranes, of the spleen and liver, take a very subordinate position in the new scale, seeing that they seldom, if ever, become the primary seat of tubercle. Tuberculosis almost invariably attacks several determinate organs concurrently at the outset, or at a very early period.' With regard to the tissue in which tubercle is deposited, he says : ' The seat of tubercle, as exudate, is, at any point of any texture, extraneous to the bloodvessels. Wherever there is a capillary range, a deposition of tubercle is possible. The seat of tubercle is without doubt precisely, or at least in close proximity to, the spot of its exudation, its blastema being in the highest degree coagulable. It is most probable, for this reason, that it does not affect textures nourished from a distance by a slow imbibition of their substance with plasma, for example, cartilage. We can ourselves testify to the occurrence, both in the larger bloodvessels and in the ca- pillaries (as depots or metastases), of coagula obviously of a tuberculous nature.' It is worthy of note that tubercle has generally in every organ some favourite part, some portion especially disposed to the deposit. For example, in the lungs it usually commences at the apex ; in bones, in the spongy ones, or in the cancellous TUBERCLE. 359 texture of others. In some of the cases it is perhaps possible to account for the selection. What is the nature of tubercle ? This great question, second to none within the whole range of pathology, so often asked, so often replied to, yet remains a doubtful one. The highest and best authorities are still at issue concerning the nature of tubercle. Is it a specific product, and should it be classed with the same order of diseases as cancer ? Is it the product of inflammation ? Is it composed merely of the elements of dead tissue ? Is it a peculiar transformation of tissue-elements co-ordinate with fatty and the allied degenerations ? Has it always an origin from the cellular elements of connective tissue ? Is it ever formed by the increase and metamorphosis of epithelial cells analogous to the process of glandular secretion, or rather as a morbid de- squamation ? Is it simply a degraded condition of the nutritive material? These questions might be multiplied. The grand argument in support of the opinion, that tubercle is a form of degraded plasm.a, or, more specifically, degenerate lymph, which assumes the hitherto generally received doctrine concerning exudation to be the true one, is similar to that on which the relation of gray to yellow tubercle, jireviously referred to, is founded, viz. that all forms and conditions of lymph are met with, from that which is most plastic and susceptible of organisation, to that which is most degenerate — the gray and yellow tubercle — and that between these extremes all interme- diate gradations are found, so that it becomes impossible tc draw a line, which is not an arbitrary and artificial one, at any point, and say that it separates lymph from tubercle. Nay, more ; this gradual transition may be seen even in a single deposit. Rokitansky says, 'just as tubercle -blastemata combine with one another, so, in like manner, does organisable blastema enter occasionally into combination with tubercle.' And, further, as would be expected, ' the combinatioii of gray tubercle with organisable fibrine is more susceptible of proof. The instances are not rare in which, hard by pure gray tubercle, granulations are found, in which one portion of their blastema is in progress of organisation to a fibrous texture, whilst the other abides in its primitive condition, and eventually falls into decadence — comities.' Again, Schroedervan der Kolk says rudimentary filaments of newly-formed tissue are sometimes seen amons the cells of tubercle. 360 SCEOFULA. This holds good even for their minute stracture and the elements of which they are composed ; as in the two forms of tubercle, it is a question of degree onl}^ ; the plastic elements predominating in the higher, and the products of degeneration in the lower forms. Paget says : ' There are, I believe, no signs by which degenerate lymph or pus may be, in all cases, distinguished from ordinary tuberculous matter. A distinction of degenerate lymph from tubercle may be impossible.' The same statement also applies to the charges which the deposits subsequently undergo. Rokitansky and Paget, when speaking of the degenerations of tubercle, frequently compare them to the degenerations of lymph. Indeed, so far as we know, the process is the same. But on this account tubercle is not to be regarded, as it sometimes is said to be, as an event of inflammation. It does not follow from this that inflammation must necessarily precede its exudation. It may be, and doubtless is, often an exciting cause ; but tubercles are fi'equently deposited without any evidence, either direct or indirect, of inflammation. If the question be asked, What, then, determines the exudation or deposition of tubercle? the answer may be — supported as it is by the authority of Rokitansk}' — Tubercle, ' like other blastemata,' may exude insensibly as in the act of nutrition, or as a result of congestion, or as a consequence of inflam- mation. But the occasional or frequent connection which exists between inflammation and tuberculous deposit is another fact in favour of the relation of tubercle to lymph. In certain forms of pneumonia the efPused matter which produces consolidation of the lung may have in one portion all the characters of ordinary lymph, and in another the characters of tubercle ; and in some of these cases the matter, which cannot be distinguished in any way from tubercle, evidently consists of degenerated portions of the lymph. In different j)arts this process of degeneration may be traced. A similar condition is frequently witnessed elsewhere. On the other hand, tubercle has no inherent independent power of growth such as tumours jjossess. Moreover, tubercle has in its structure no characteristic element which defines it from all other structures. Although Lebert and others have described corpuscles supposed to be distinctive as ' tubercle-cells,' yet by the great majority of ob- servers these cannot be distinguished from degenerate and TUBERCLE. 361 deformed exudation-corpuscles, such as are commonly seen, under certain cii'cumstances, in effused lymph. We may there- fore speak of tubercle as composed of degenerate and decaying elements. Dr. C. J. B. Williams — who has for many years regarded tubercle as ' a deo-raded condition of the nutritive material from which old textures are renewed and new ones formed, and that in its origin it differs from the normal plasma or coagulable lymph, not in kind, but in degree, of vitality and capacity of organisation ' — divides deposits into three classes. The eu- plastic ; healthy organisable lymph. The cacoplastic ; defective in organisability, represented by the indurated tissue which characterises cirrhosis of the liver and that which occasions the opaque tough thickening of the valves of the heart, and seen again often in the dense cicatrices of scrofulous sores. Into the lowest extreme of this class comes the gray transj)arent tubercle. The aplastic; which includes all the more common forms of tubercle. These divisions, and the terms employed to express them, are convenient and useful ; only it must always be borne in mind that they are in one sense artificial, inasmuch as their limits are not naturally defined. For, as Williams says, ' every gradation may be found between euplastic and aplastic deposits.' This view of the pathology of tubercle — its affinity to lymj)li — which is a very old one, and received many years since the support of Alison, enables us very clearly to comprehend the relation of the gray to the yellow deposit, and to understand how, by a process of still further degeneration, the transforma- tion ensues ; and how it happens that so often the yellow form is at once, in the first instance, deposited, the change in this case preceding the exudation. But by Yirchow and his school a very different view of the nature and affinities of tubercle has been set forth. The mode of formation of tubercle has indeed been chosen by Yirchow as the chief illustration of his great doctrine which is now well known by the name of cellu- lar pathology. According to this view, which utterly rejects the old doctrine of exudation, the essential elements of tubercle — the cells — are the offspring of the cells of connective tissue. This is affirmed of all morbid growths, even of the so-called deposits. Like tubercle, they all arise in connective tissue, and the cells of which they are essentially composed are the de- scendants, degenerated or variously perverted, of the original 362 SCEOFULA. connective tissue corpuscles. Thus it can never be right to speak of a deposition in a part, but always of a new growth from a part. Perhaps, however, after all, the contradiction involved in these two great doctrines is more apparent than real ; or rather it may be said, that while either view fails to expose the whole truth, each reveals an important part of it which the other ignores. The old doctrine takes no heed, or at least offers no explanation, of the changes which the so-called deposit under- goes, while the new doctrine looks no farther than the part in which these new formations are found to explain tlieii' origin.* Are there anj- signs by which that state of the constitution which tends to the production of tubercle can be recognised ? Does scrofula manifest itself by any other symptoms than the deposit of tubercle ? Often, very often ; but not always. As a general rule, but subject to numerous exceptions, it may be said that the symptoms of scrofula are the symptoms of debility. * Within the last few years much attenlion has been given to the question, "Whether tubercle can be transmitted by inoculation ? The attempt to propagate the disease by this means is not a new one, but of late numerous experiments have been made on animals, and from these the conclusion has been drawn that tubercle may be thus produced. In 18G5 and 180(3 M. ^ illemin laid before the French Academy of Medicine two series of experiments, to show that tubercle can be transmitted from man to animals by inoculation {Bull. Acad. Med. xxxi., xxxii.). In the latter year Lebert related experiments confirming this result {loc. cit. xxxii.). It was also in the main confirmed by a committee appointed to report on the subject. Similar experiments were performed by MM. Herard, Comil, Hofl'man, and Genondet, and by Mr. Simon and Dr. Marcet, the latter gentleman proposing to use the sputa of patients as a means of diagnosis of tubercular disease {Med.-Chir. Transactions, ly()7). Jjut then Dr. Andrew Clark found that he could succeed in producing similar results by inoculating animals with other non-tuberculous morbid products. Dr. Sanderson, from numerous experiments, came to the conclusion that moibid changes in internal organs, of the same nature as those resulting from the inocu- lation of tubercle, could be produced by any irritation of the requisite degree of intensity applied to the subcutaneous tissue, and that experiment aff'orded no ground for believing in the existence of a tuberculous virus (British Med. Jour., April 18, 18(J8). About the same time, and quite independently, Dr. Wilson Fox fovmd that non-tubercular substances introduced under the skin of guinea- pigs and rabbits were followed by the production of a disease which he consi- dered tuberculous {Op. cit. May 23, 30, and June G, 18G8). These experiments, then, afford no support to the doctrine that tubercle is a specific disease in the sense in which that tenn is commonly employed, but tend rather to confirm the opinion which has been advanced in the text. SCEOFULOTJS DIATHESIS. 363 Those wlio have written on the subject have, for the most part, described at length certain characters of body and mind, by which they affirm those j)ersons to be distinguished in whom the disease is Hkely to be developed : and usually two varieties are depicted. In the first, distinguished as the sanguine or serous, there is a general want of muscular development ; for although the figure may be sometimes plump and full, the limbs are soft and flabby ; the skin is fair and thin, showing the blue veins beneath it ; the features are very delicate, often a brilliant transparent rosy colour of the cheeks contrasts strongly and strikingly with tlie surrounding pallor ; the eyes, gray or blue, are large and humid, with sluggish pupils, sheltered by long silken lashes ; hair fine, blond, auburn, or red ; teeth white, and often brittle ; there is frequently a fulness of the upper lip and alse nasi; the ends of the fingers are commonly broad, with convex nails bent over their extremities. Such persons usually possess much energy and sensibility, with elasticity and buoyancy of spirits ; they often possess, too, considerable beauty. In this variety, with the same delicacy, the skin and eyes are sometimes dark. In the second, distinguished as the phlegmatic or melancholic, the skin, pale or dark, is thick, muddy, and often harsh ; the general aspect dull and heavy ; hair dark and coarse ; the mind is often, but not always, slow and sluggish. Children especially, in whom the diathesis is strongly marked, are often distinguished by the narrow and prominent chest, the tumid and prominent abdomen, and the paste-like complexion ; the limbs are wasted ; the circulation languid ; chilblains are common on the extremities ; the mucous membranes particularly, and, above aU of them, the digestive, are liable to morbid action ; the breath is often sour and foetid ; the tongue is furred, and the papillae towards the apex red and prominent; the bowels act irregularly, and the evacuations are unusually offensive ; the digestion weak ; the appetite variable and capri- cious. In Dr. Todd's opinion, the ' strumous dyspepsia presents a more characteristic feature of this habit of body than any physiognomical portrait which has yet been drawn of it.' The relation of disorder of the digestive organs — the subject upon which Abernethy was so wont to insist — to scrofula, was many years ago particularly dwelt upon by Lloyd. There is often a singular assumption of age both in character and appearance ; in mind and manners they are prematurely old. 364 SCEOrULA. Moreover, j)ersons, and especially children, possessing tliis diathesis, are very subject to certain affections which are regarded by many as manifestations of scrofula. Such, for in- stance, as various eruptions frequently seen behind the ears ; chronic inflammation of the eyelids and conjunctivse ; a certain form of ophthalmia, described as stinimous ; chi-onic ulcers of the cornea, &c. Now although it is quite true that those who are thus distin- guished are especially prone to the production of tubercle, yet it is equally certain that it frequently occurs in others who do not at all correspond to either of these descriptions. In fact, we know of no description of persons in whom we could venture to say that tubercle will not appear, for it belongs to all tempera- ments. The utmost we can assert is, that in those in whom the characters previously detailed are most strongly marked, tubercle is most liable to occur. Moreover, some of the characters detailed are so common, that it may be reasonably questioned whether their connection with tubercle is not merely accidental ; while of others more decided it may be doubted whether they are not rather the effects of, than antecedent to, scrofula. Scrofula is a disease of early life. Its manifestations are very common before, and comparatively rare after, the middle period. Certain persons, then, are more liable than others to a dej^osit of tubercle, although it is by no means always possible to dis- tinguish such beforehand. Persons in whom there exists this tendency to the formation of tubercle are said to possess the scrofulous or strumous diathesis. Now the great cause of this predisposition is undoubtedly hereditary. It is transmitted from parent to offspring. Scrofula is, perhaps, more frequently transmitted hereditarily than all other diseases together. It does not follow that the parent must have tubercle in order to transmit the diathesis to the offspring, any more than it follows that the disposition or tendency so transmitted must necessarily lead to the development of tubercle. Indeed, many maintain, with Sir James Clark, that ' a state of tuberciilous cachexia is not the only morbid condition of the parent which entails the tuberculous predisposition on the children ; there are several diseases which have this effect : in short, a deteriorated state of health in the j)arent, from any cause, to a degree sufficient to pi'oduce a state of cachexia, may give rise to the scrofulous constitution in the offspring.' CAUSES. 365 Can tlie diatliesis, if not liereditarj, be acquired under any possible circumstances ? To this very important question it is, from the nature of the subject, almost impossible to give an un- equivocal answer. The causes of disease are conveniently and naturally divided into predisposing and exciting or determining, and the development of disease depends upon the extent to which these causes act in combination. For example, by way of illustration merely, let it be assumed that any given disease cannot be produced unless the sum of the causes reaches a certain figure — say a hundred. Now, so long as this number can be attained by the causes conjointly, it matters not what their relative share in it may be. The predisposing cause may equal seventy, and the exciting cause thirty, or vice versa. From this it follows, as is well known, that when the predisposition to disease is strongly marked, the most trivial exciting cause may suffice to develope it ; it may be ninety-nine to one. On the other hand, if the exciting cause or causes be sufficiently in- tense and prolonged, the disease may be produced when there is only the faintest predisposition. Now the difficulty of answering the question just proposed lies in this. It can never be said of any person that he has no predisposition whatever, that he is proof against the occurrence of tubercle ; for tubercle has again and again appeared in those seemingly the most im- mune from it. Or again, supposing the subject of tubercle to be born of apparently healthy parents, we do not know that the diathesis was not lurking latently in them, wanting only a sufficient amount of exciting causes for its outbreak. For it is commonly believed that a predisposition may lie latent in a generation or two, and appear in the next ; moreover, other diseases of debility than scrofula in the parent may probably develope the scrofulous diathesis in the offspring. In short, the question cannot be answered, because it can never be said of any one that he is proof against tubercle ; and when tubercle does appear in any one in whom from his constitution and history we should least have expected it, we cannot be sure that he has not inherited the disposition from an ancestor, immediate or remote, in whom nevertheless it may have been latent. ' For there is hardly a family,' says Dr. Latham, ' into which con- sumption, sooner or later, does not enter.' Practically speaking, however, there are no grounds for denying the fact that the disposition to tubercle may be, when not hereditary, acquired ; on the contrary, both reason and experience are in favour of 366 SCROFULA. the belief : and even were the evidence less convincing than it is, even were the case more doubtful, it would be wisest to act upon the assumption of its possibility. Of this, however, there is no doubt, that the tendency to the production of tubercle exists in diiEFerent degrees in various persons ; it may be so strong that no skill or care can avert its development; it may be so slight as only to appear under a combination of the most unfavourable exciting causes. What are these ? ' They may all be ranked together,' as Alison says, * as causes of debility ; ' many of them may be regarded, not as exciting causes merely, but as predisposing ones. The chief are — Insufficient food and improper diet. Watson, speaking of this cause, remarks : ' There is one fact which has always struck me as ver}"- instructive and convincing on this point. Infants at the breast, supplied with good milk, and with plenty of it, sel- dom show any signs of scrofulous disorder ; whereas as soon as they are weaned they become subject to various complaints of a strumous kind. When an unweaned child is brought to us with ophthalmia, we expect almost always to discover inflammation of the common and acute kind — the purulent eye ; in nme children out of ten Avho come after weaning, we look for and find some form of scrofulous inflammation, such as pustular ophthalmia.' On the other hand, intemperance and excess. Impure air, whether simply from want of ventilation, bemg deteriorated by respiration, &c., or impregnated with deleterious gases and noxious vapours. Exposure to wet and cold, and to sudden changes of tem- perature. The utmost importance is to be attached to climate. The climate of Great Britain is prejudicial in this respect, perhaps rather on account of its variableness and vicissitudes than from its low temperature, when compared with those regions where scrofula is less common. The influence of climate is shown not only in the improvement which many persons experience when they migrate to warmer and more equable ones, but also in the frequent development of tubercles in the inhabitants of those latitudes when they come hither. Mental depression. Few causes can rival for mischief anxiety, when intense and prolonged. Of course these causes are more potent when combined. Certain occupations are mischievous, on account of the cir- TUBERCLE IN THE LYMPHATIC GLANDS. 367 cumstances to wliicli those who follow them are exposed. Such, for instance, as working for the greater portion of the twenty- four hours in close and ill-ventilated rooms lighted bj gas ; exposure to noxious fumes and vapours, or to the dust of stone or metal, or to the night-air at all seasons and in all states of the weather, or to great and sudden transitions of temperature ; excessive and continued fatigue, whether mental or bodily; poverty, of course, with all the evils following in its train. Knowing that the causes of debility favour the formation of tubercle, we can understand its frequent supervention when the powers are depressed by some other disease. Where we have any reason to suspect a predisposition to tubercle, we anxiously watch during the period of convalescence from iUness of any kind. As illustrating the course and local treatment of tubercle, when deposited, the cervical lymphatic glands may be con- veniently selected ; for of all pai-ts liable to the deposition of tubercle within reach of the surgeon, they hold the first place. In the adult, as we have seen, the lymphatic glands rank next to the lungs and intestinal canal in order of frequency, and in children of all organs they stand first. Now these glands are sometimes the seat of common inflam- mation and suppuration, and this may occur even in those who possess the scrofulous diathesis. But this is a rare exception to a very general rule ; for when these glands inflame and suppurate, it is usually as the result of a previous deposition of tubercle. I believe that the vast majority of those cases which are spoken of as ordinary inflammation of the cervical lymphatic glands modified by the scrofulous diathesis are really due to some deposit of tubercle in the first instance. And i3erhaps the view which has been taken in this article of the pathology of tubercle enables us to understand and reconcile the con- tradictory statements which appear on this point. Eor instance, the substance found in the lymj)hatic glands that one patho- logist calls tubercle, another says is only degenerate lymph ; while those most conversant with the subject admit that there are certain forms of deposit seen in the lymphatic glands and elsewhere, in which the distinction of degenerate lymph from tubercle is impossible. There is certainly, as Virchow remarks, a close correspondence between the cells of the gray granule and the corpuscles of the lymphatic glands ; a corresjjondence, he adds, which is neither accidental nor unimportant. As 368 SCROFULA. there are, in fact, all degrees between the most plastic lymph and the most degenerate tubercle, it is clearly impossible, even pathologically, and much more impracticable surgically, to distinguish by any definition the cases which should be called tuberculous from those which are not. Extreme cases are sufficiently clear : it is concerning the intermediate ones that the doubt occurs ; and the difficulty is often evaded by describ- ing them as inflammation of the glands occurring in a scrofulous constitution, and modified accordingly. It is a characteristic feature of tubercle that it is deposited insidiously. Generally it is not preceded by any symptoms which we are able to recognise. We have no warning of the event ; no local disturbance in the first instance ; no pain at the commencement, and comparatively little at any time. It is often curious to witness the great and singular disproportion between the pain and the local mischief. The first symptom which attracts attention to the cervical glands is their enlarge- ment. Their position is manifested by their induration and prominence. Before they become apparent to ordinary obser- vation, a careful examination of the region they occupy will often detect them slightly enlarged and indurated as distinct and movable kernels along the borders of the sterno-mastoid muscle. At this time the slight change is perhaps due to in- creased vascularity, which may be antecedent to, or coincident with, the deposition of tubercle ; for they will often at this time, under more favourable circumstances, subside and disappear ; a liappy event, which is by no means a common one when tubercle is once unequivocally deposited. When tubercle, then, is once deposited, it may either remain, j)erhaps for a long time, quiescent, or it may continue simply to increase. The adjacent glands, under these circumstances, partially blend together, and sometimes form very considerable and ugly masses in the neck, looking and feeling like small l^otatoes beneath the surface. Or, after a while, it may undergo calcareous degeneration, as previously described ; the organic matter being absorbed, until by and by nothing is left but a small cretaceous fragment in the substance of the gland. Or, lastly, as its usual tendency is, sooner or later it may soften, and so give rise to more active symptoms. Even after the mass has softened, it may still be, and often is to some extent, absorbed ; but usually the liquefaction is followed by its discharge. The surromiding parts inflame, and pus becomes mixed with the SCROFULOUS ULCEES. 369 softened tubercle ; the integuments over it become thinner, and * point,' and at last give way. This process only differs in de- gree from the course of an ordinary abscess in the vigour of its action and the rate of its progress. It is altogether more indolent. The inflammation is less intense, and its symptoms much milder. The ' pointing ' is less concentrated. The matter discharged usually consists of curdy flakes in a thin, turbid, yellowish liquid. Dr. Latham, in his well-known lectures on Clinical Medicine, has graphically described this process of softening and expulsion of tubercle in the cervical glands as an obvious illustration of what so often occurs elsewhere in parts hidden from our view. He divides such cases into two principal classes. In the first there is only a necessary amount of inflammation excited, just sufficient to accomplish the result, and which subsides as soon as that is effected. This, he says, is called the ' specific limit ' of the disease. ' By this is meant the limit proper to its local morbid action, which, for any purpose it has to accomplish, it never need to transgress.' In the second case the inflammation may spread beyond its specific limit, and become much more severe and extensive than is needed for the mere elimmation of the tuberculous matter. It may extend widely and deeply. This distinction is of great importance, especially with reference to treatment. It sometimes haj)pens that after the tuberculous matter has been discharged, very intractable ulcers are left behind, and similar ulcers of the integument are often seen, which we reasonably conclude to have resulted from the deposition and discharge of tubercle. They are often preceded by ill-defined deposits in, or indurated patches of, the integuments and sub- jacent tissue. These, after a while, inflame and soften, and discharge a thin turbid pus. Often the mischief extends more deeply, as in the neighbourhood of joints ; but the same course is followed : first, the deposit and the induration ; then the lique- faction and inflammation ; at length the abscess with its serous and curdy pus ; and finally, but too often the indolent and intractable ulcer. These ulcers assume all sorts of shapes, but are almost invariably irregular in outline. The surface is uneven with large, pale, and flabby granulations ; the edges rounded, thickened, and often undermined. There is generally in the less chronic forms some surromiding redness, but it is of a dusky and VOL. I. B B 370 SCEOFULA. livid hue. They are usually remarkably passive, torpid, and stationary. When these abscesses or ulcers heal, generally a very obvious scar results. The cicatrix is dense and thick, and frequently dee^jly coloured, from passive congestion. Often it is consider- ably depressed ; sometimes the surface is raised into ridges. Its continued contraction often causes considerable j)uckering of the integuments around. When tubercle is deposited, in addition to the consti- tutional treatment to be spoken of presently, what can be done locally ? So long as active symptoms are absent, perhaps the less that is done the better. The great object is, to prevent inflamma- tion ; and this is best averted by protecting the tumour from aU sources of irritation, and keeping the parts in as quiet a con- dition as is possible. Frequent handling is particularly mis- chievous. While it remains passive, any kind of interference is more likely to do harm than good, by exciting active symptoms either in the tumour or in the parts around. Of course, if there be any tendency to absorption, if the tumour should at aU diminish, the indication for doing nothing is still stronger. If, after the lapse of some considerable time, weeks or months, the tumour should still remain passive and stationary, it may become proper to employ, cautiously, some means with the view of stimulating absorption. Gentle and uniform pressure, if the situation will admit of it, or some mild stimulating application, such as a weak solution or the ointment of iodine, or oil gently rubbed over the surface with or without the addition of camphor or ammonia — these and similar applications sometimes appear to be beneficial ; but their effect must be closely watched, and discontinued if any symptom of vascular excitement should present itself. But supposing, as is sometimes the case, that, in s^^ite of these or even still stronger applications, the tumour remain indolent and stationary, should any other measure be adopted ? Should it be removed by operation ? Hardly ever. Such a case may occur — cases have occurred in which tubercu- lous glands have been successfully removed by the knife, but far more frequently the operation has been followed by very uncomfortable results. Enlarged absorbent glands, whether from tubercle or other causes, especially in the neck, are very deceptive. When examined through the integuments, the mass LOCAL TREATMENT. 371 may appear to be well defined, isolated, entirely superficial, and freely movable upon the subjacent parts ; but when exposed in an operation, a small portion of it perhaps is found to creep under the sterno-mastoid muscle, or into some deeper portion of the neck. This leads to, and is connected with, another gland, also enlarged and diseased, but which lay too deep for detection before it was exposed. This, of course, must not be left ; but the attempt to remove it discovers that it is in the same way connected with several others affected like itself; and so the surgeon finds himself at the commencement of the chain of glands very appropriately called ' concatenatse,' and what is worse, in the midst of structures which prudence declines to dissect. So the operation must be completed with this very unpleasant result — a small part of the disease removed, and the greater portion left behind. The operation can be justified only when the tuberculous gland has remained for a very long time stationary in spite of all local measures and constitutional treat- ment ; when from its size or situation it is either seriously in- convenient, or an unsightly deformity ; and when, so far as a careful examination can discover, it is not connected with diseased glands more deeply situated. Wlien tubercle in a gland or elsewhere begins to soften, the object of the surgeon is to conduct it to its issue with the least possible amount of disturbance to the surrounding parts, to keep the inflammation within its specific limit. Water- dressing with warm fomentations is usually most comfortable. Poultices, generally speaking, do not agree very well; but occasionally a light bread poultice, made according to Aber- nethy's prescription, proves very grateful. I venture to question the propriety of the recommendation to open these abscesses early. The grounds for this practice do not appear to me to be valid ones. So far as I have been able to observe, when the inflammation is not unduly extensive, after suppura- tion has occurred, and the central portion of the mass has become soft and fluctuating — and as the integuments over it become thinner, there is generally a sensible diminution of the surrounding disturbance — the area of inflammation contracts. Moreover, in these cases, just at the period when an ordinary abscess would point and discharge its contents, these often recede, not spreading into the parts around, but apparently by absorption. There is less tension of the integuments. They become relaxed, sometimes appearing slightly shrivelled, and 372 SCROFULA. the blusli of inflammation is less vivid and extended. I believe tliat these salutary changes are often prevented by too hasty interference. In these cases, as a rule, the symptoms of sup- pui'ation are not of that urgent character which renders an earlv evacuation desirable. The pain is seldom severe. The constitution is not often disturbed. Of course when the inflam- mation is disproportionately severe and extensive, the question is entirely different ; measures more prompt and active then become necessary. Sometimes the abscess will disappear altogether without opening, but an artificial aperture is gene- rally advisable when a natural one appears inevitable. This should be very moderate in size ; extending only through that portion of the integument which appears unlikely to survive. The puncture should not be followed by jDressure. It can do no good to force out violently that which will flow out naturally. Unnecessary pain is inflicted, and still more important mischief is often effected, by bruising parts which are not able to resist, but very prone to resent, such an injury. The mischievous effects of pressure may not be, and are not always, obvious ; but I believe the balance to be, even then, on the side of evil. These abscesses too often degenerate into those troublesome and obstinate ulcers previously described. The best local applications are those which are gently stimulant, such as Peruvian balsam, the tincture of benzoin, the red oxide of mercury, a weak solution of nitrate of silver, &c. Sometimes the surface may be touched with nitrate of silver or sulphate of copper with advantage ; and when the edges are spongy and livid, it may be proper to destroy them -with caustic, or to remove them with the knife. The question is often raised, whether, supposing we were able to do so, it is desirable, in certain cases, to heal these ulcers. It is believed that they may act as natural outlets for an exu- dation which might otherwise be deposited in more important parts. The fact is, until the state of the constitution is improved and the tendency to the deposit counteracted, there is not much chance of healing them ; and, when the general health is restored, they will spontaneously close without risk. That they heal, may be generally accepted as a proof that the source of danger is removed. This question becomes more doubtful when raised with respect to the performance of a capital operation, such, for instance, as the removal of a portion of a limb for what is usually termed CONSTITUTIONAL TREATMENT. 373 scrofulous disease. In sucli a case tlie decision must depend on the state of the constitution ; the condition of the more impor- tant organs, as the lungs ; and the effect which the disease, whose removal is contemplated, has upon the system. Have all other means failed ? Is the patient able to bear the opera- tion ; that is, is there power sufficient to accomplish the process of repair ? If there be extensive or active disease in the lungs, the operation can only hasten the catastrophe. Can the disease in the extremity be so conclusively connected with the constitu- tional symptoms, the hectic fever, as cause and effect, to render it fairly probable that they wiU subside when that is removed ? This question is one of the most difficult that the surgeon is ever called upon to answer. A sound decision in any case can be founded only upon careful and continued observation."^ But in the treatment of deposits of tubercle local means are worthless in comparison with constitutional measures. It can avail but little to encounter the effect alone, while the cause is still in operation. The grand indication is to arrest, if possible, the tendency to the formation of tubercle. The treatment of the deposit is comparatively of little moment. Amongst drugs, those most esteemed in the treatment of this disease are, iodine and iron, bark, the alkalies and mineral acids, and, above all, cod-liver oil. Before a course of any medicine is commenced, the condition of the digestive apparatus should be carefully scrutinised, and any disorder of it should be, so far as it is praticable, rectified. While those symptoms previously enumerated exist, matters are only made worse by the exhibition of tonics. A disordered state of the digestive organs is most commonly seen in children, and is best treated by strict attention to the diet, and the regular use of some mild aperient for a few days or longer. A few grains of rhubarb and soda for some nights in succession, occasionally combined with a little gra^^ powder, and then followed by a dose of castor oil the next morning, in order to clear out the canal, usually succeed very well. But it is need- less to enter into detail. The principle of treatment is the point to be insisted on. Concerning the method of carrying it out, almost everyone has some especial fancy of his own. Assuming, then, this difficulty to be absent or to be overcome, the way is clear for the employment of tonics. * See elsewhere for the special description of tubercle in the bones and other local deposits. 374 SCEOFULA. The preparations of iodine are most likely to prove serviceable in the absence of all fever and vascular excitement. If these are present, they often only increase the mischief. They may usually be prescribed with advantage in simple but concentrated decoction of sarsaparilla. Iron, as might be exjjected, is sometimes eminently beneficial. Its use is especially indicated when the symptoms of anaemia predominate ; when the blood seems poor in red cells ; still more if this be combined, as it commonly is, with a feeble cir- culation and a general want of tone. Among the milder pre- parations are the ammonio-tartrate and citrate, and the potassio- tartrate. The last is especially useful for children, and has the additional advantage of being compatible with the alkalies. The vinuni ferri, too, is a mild and simple preparation, and very often a most valuable one. But the sulphate of iron, when it can be borne, is sometimes much more efficacious, and the tincture of the perchloride is perhaps the most powerful of all. But iron will not suit the system in all cases of mere debility. When the lips and conjunctivae are florid it is least likely to agree. Iron and iodine may be often very profitably prescribed in combination. The syrup of the iodide of iron is a very con- venient form. Bark, and its preparations generally, are particularly useful, during the period of suppuration, in supporting the system and averting hectic fever. It is curious to observe what effect it sometimes exerts upon this process. It tends to bring matters to a crisis. Doubtful symptoms of activity in and around the deposits wiU often subside ; and a slow, languid, imperfect sup- puration is often pushed forward into a more healthy action. When the flesh is flabby, when there is great debility, when the appetite is bad and the excretions tolerably healthy, then bark is indicated. Iron and quinine combined are often emi- nently useful. In suck a case the mineral acids also are generally given vdth advantage. They are deemed especially useful in checking the profuse perspiration of hectic fever. The alkalies and their carbonates are often very useful in the treatment of stramous dysjDcpsia. They are more particularly indicated when the urine is highly acid, and contains an excess of the lithates, or still more, any free lithic acid. Tor children, lime-water, either in milk or sarsaparilla, is often serviceable, CONSTITUTIONAL TEEATMENT. 375 or the carbonate of magnesia held in solution by excess of car- bonic acid. When there is much local disttu'bance about a tuberculous deposit ; when the inflammation appears to be independent of any change in the mass itself; and more especially if this be combined with any gastric disturbance, the operation of an emetic will often be followed by signal improvement. Aperients and purgatives are perhaps too often employed in mere routine. During a course of tonic medicine they are generally required from time to time, and always when the state of the tongue and the excretions indicate a loaded con- dition of the intestinal canal, or the presence of morbid matter, such as imperfectly digested food, or depraved secre- tions. But of all medicinal remedies for scrofula none at present enjoys so high and well-founded a reputation as cod-liver oil. The fixed oils, as a class, are often beneficial ; and it is curious to note, in connection with this fact, when considered in its relation to nutrition, that some have observed very often in cases of scrofula a peculiar dislike to fat ; but for its efficacy cod-liver oil surpasses every other. Some have sought for the cause of this superiority in the iodine, bromine, phosphorus, and other of its constituents. But the proportion in which these exist is too minute to render it probable that they have any considerable share in such important results ; and, more- over, these elements have been used in various other combina- tions without benefit at all comparable with that which is obtained from the oil. Perhaps its excellence may be more closely connected with its disposition to form an emulsion more readily than other oils, for it is peculiar in saponifying with the carbonates of the alkalies. This may possibly in some measure explain its more ready absorption from the intestinal canal. It has been suggested also that it is more easily digested than other oils, because it contains, to some extent, the principles of the bile. The beneficial effects of the oil are very general throughout the body. But the most remarkable, although probably by no means the most important, is the increased accumulation of fat. When it first came into general use, people were surprised at the rapidity and extent of its action in this respect. Great difference of opinion stiU prevails as to the particular kind of cases in 376 SCEOFULA. which it is most serviceable. It is assuredly more or less so in the vast majority. But that the best effects may be obtained from its use, it must be taken for a very long time. Want of perseverance here is attended with its usual result — disapi^ointment. It is not a question of days only, but often of months, or even years. It should therefore be regarded as an article of diet rather than as a medicine, and usuall}', after a while, the dislike to it ceases. A table- spoonful may be considered a full dose for an adult ; but this quantity should be gradually arrived at, commencing with a teaspoonful. It may be taken twice or thrice daily, and immediately after a meal ; for at that time it is least likely to create nausea, and, moreover, it does not then interfere with the appetite. It may be taken upon a small quantity of some other fluid, such as a little wine or a bitter infusion. When the stomach is weak and there is a tendency to nausea, a solution containing the fortieth or thirtieth of a grain of strychnia, acidulated with nitric acid, often proves a most useful vehicle. This I first learned from Dr. Williams. Some people, and especially children, can take the oil alone without any discom- fort. Again, some persons can take it for any length of time with impunity ; but in the majority, after a while, it is apt to create nausea, and produce other symptoms called bilious. I think the best way of avoiding this is to suspend its administra- tion for a day or two, now and then, and if necessary, at that time to give an aperient. Of course it is much less likely to disagree when the digestion is good, and it can be taken much more comfortably by those who are able at the same time to use exercise. As might be expected from its composition, it can, as a rule, be taken in larger quantities, and for a longer period, in cold than in warm weather. Probably the lightest and clearest oil is the best. It has never been shown that the darker oils possess any additional advantage, and they are much less likely to be borne. In cold weather the oil should be slightly warmed before it is taken, for it is thus rendered less tenacious, and is more readily swallowed. These details should not be despised. In almost all cases it is of the utmost importance that the oil should be taken, and by due attention to such details as those just alluded to, this may generally be accomj^lished. But, after all, mediciaes, even cod-liver oil, should be only accessory to hygienics. Sometimes, perhaps often, in the HYGIENICS. 377 earnest application of some particular remedy in tlie treatment of disease, we are apt to neglect tlie adoption of those more general means bj wliich diseases are averted and the health is preserved. With regard to scrofula, whether tubercle be already formed or not, all the causes previously mentioned should, so far as they can, be avoided. AH causes of debility should be carefuUy shunned, and the system should be raised as nearly as possible to the level of perfect health. The food should be nutritious and sufficiently abundant, and should contain a fair amount of proteine principles. Stimulants, if needful, should be taken in moderation, never in excess. A mother with scrofula should not suckle her children, for this is prejudicial both to her and them ; but a healthy wet-nurse should be obtained : and Sir James Clark recommends that the child should not be weaned until the period of * teething ' has passed. The due warmth of the body, not neglecting the extremities, should be secured by adequate clothing, and flannel should always be worn next the skin. Constant residence in pure and dry air, and regular exercise proportioned to the strength should be recommended. If proper exercise cannot be taken daily, friction of the surface with a flesh-brush may be substituted. Tepid or cold bathing is useful, especially in salt water, if it can be borne and is followed by perfect reaction. The mind should be cheerfully occupied, but not unduly tasked. This last point is especially important in regard to children. Too often, in the natural anxiety to educate, the state of the health is overlooked or forgotten. Unfortunately, the scrofulous diathesis is fre- quently accompanied by unusual activity of mind, which is apt to be encouraged, but needs to be restrained. It has been already stated that the climate of Great Britain is not the most congenial for those who possess the scrofulous dia- thesis. Yet there are some situations free from the most important objections ; where the atmospheric changes are less frequent and sudden, and the winter comparatively mild. When the diathesis is more strongly marked, it often becomes neces- sary, in order to avert its further development, to seek abroad a> milder and more equable climate. But it is surely a mistake to suppose that a warm climate is the one best adapted to all cases of scrofula. It is so doubtless in the great majority in which the disease is far advanced ; but in many cases, at an earlier stage, its further development is 378 SCEOFULA. more satisfactorily arrested and tlie general health improved by a more bracing air. Children with tuberculous glands, but whose health appears otherwise tolerably good, would perhaps profit less by transportation to Madeira or Egypt than by resi- dence on the south or west coast of England. DeHcacy of con- stitution is sometimes increased and mischief encouraged by dread of exposure. Of course, on all these subjects relating to hygienics, there are many matters, other than those with which we are concerned, to be taken into consideration. All depends upon the person's position in life and the cu'cumstances by which he is surrounded. It is often only a choice of difficulties involving more than one vital question. WILLIAM SCOVELL SAVORY. HYSTERIA. HYSTEEIA would be mucli less interesting and impoi-tant if its phenomena were confined to its occasional paroxysms, and its 'other characteristic and distinctive symptoms. An hysterical fit seldom presents any difiiculty of diagnosis, for its nature is usually sufiiciently apjDarent ; and the same statement ■will prove true, although, perhaps, a little further enquiry will be sometimes needed, for many other of its less striking but not less decisive manifestations, such as the globus hystericus, and other milder forms of the attack. But hysteria does not always assume this regular and characteristic form ; on the contrary, it frequently occurs strangely disguised, and its essential features concealed in the garb of some other disease whose characters it assumes and whose symptoms it mimics. This it is which especially gives interest and importance to hysteria ; which so often renders ib a stumbling-block in the way of a correct diagnosis, sometimes masking by its prominent symptoms the existence of a graver malady, but far more frequently by the similarity of its symptoms leading to the opposite error of mistaking a simulated for a real disease. And this form of hysteria has been aptly termed protean ; for there are few diseases, the symptoms of which are not at times more or less mimicked by this singular affection. The hysterical fit in its common forms is not likely to be mis- taken. However much it may vary in duration and severity, its general characters are sufiiciently obvious and well known whether it consist merely in a violent and uncontrolled display of emotion or appear fully developed. The deep and hurried inspirations at the commencement, followed by occasional sighs or sobs or screams — the sense of choking, leading to agitated movements of the hands about the neck, as if to remove some oppression there — the irregular muscular movements generally, such as struggling like a person contending, beating the breast, or tearing the hair — the withdrawal, more or less complete, of the power to balance and sustain the body — and with aU this, 380 HYSTEEIA. seldom loss of consciousness, althoiigli sometimes sensorial dis- turbance — the flushed, but calm and not distorted, countenance — the closed and perhaps trembling lid, with the eye bright and natural beneath — the hot skin, excited circulation, vehement action of the heart, which, however, subsides as the fit declines — the whole terminating either in violent laughter, with a, copious secretion of pale urine, or in tears, or in a combination of the two, or in sleep more or less profound — these symp- toms are not to be misinterpreted. By the consciousness not being wholly lost, especially at the commencement ; by the absence of well-marked and decided convulsions, limited to one side or to some portion of the body, the muscular movements being rather strugglmg and capricious ; by the absence of all lividity, particularly of the face, and distortion of the counte- nance ; in a word, by the absence of all signs of impeded respi- ration, which on the contrary is deep and sighing ; and finally, by the subjects of the attack being almost always women at that period of their lives when the uterine functions are active, the hysterical fit is distinguished from every other. The duration of the fit may vary from a few minutes to several hours. Occasionally such paroxysms succeed each other at frequent intervals, the person remaining in the mean while in a drowsy state. In this way the attack may be extended over some days. In its slight and transient forms many of these symptoms do not appear. A very common variety is limited to what is termed the globus hystericus. A sense of uneasiness or discomfort is felt in some portion of the abdomen, usually in one of the iliac regions — and it is said to occur more frequently in the left — as of a ball or some solid bod}-. This is described as rolling about, and then rising upward until it reaches the throat, when a sudden and alarming sensation of choking is experienced, but often attended with frequent attempts to swallow. This usually ends in a similar manner to the more fully developed attack. Although the characters previously enumerated, when fairly developed, are peculiar, and sufficiently distinguish the hysteri- cal from all other fits — for instance, from epilepsy, both by positive and negative symj^toms — yet it occasionally happens that cases occur presenting features which may almost be said to be intermediate between these for the most part widely- separated affections. Many of the symptoms of hysteria may be united with others which are ominous of epilepsy. This is SYMPTOMS. 381 what might be naturally expected. It is only one instance out of so many in which diseases distinct enough in their typical forms are prone to blend with others which trespass on their confines. Perhaps the principal cause of neglect of the study of hysteria is the generally accepted fact that its attacks are hardly ever of a dangerous character. This, however, requires some quali- fication. Certainly death, either as a direct or indirect result, is exceedingly rare, although it appears that even this fatal effect has been induced in some instances by exhaustion. But an evil worse than death occasionally waits upon hysteria. It is not difiicult to understand that the mind rather than the body may at length succumb to violent and oft-repeated attacks. The mental faculties being thus weakened and dis- ordered, hysteria sometimes leads to insanity. To enumerate all the diseases which are liable to be simulated by hysteria would be to furnish an almost complete nosological table. ' This disease,' Sydenham wrote, ' is not more remark- able for its frequency than for the numerous forms under which it appears, resembling most of the distempers wherewith man- kind are afilicted. For in whatever part of the body it be seated, it immediately produces such symptoms as are peculiar thereto.' Leaving out of consideration here those which fall to the lot of the physician, such as peritonitis and paralysis, we may glance at the more prominent ones, the care of which devolves upon the surgeon. These will sufiiciently illustrate others. Disease of the spine. — A young woman will complain of pain in the back, with weakness of, and perhaps pain in, the lower extremities. Often there is a sense of constriction in some portion of the trunk, with occasional spasms. There may be even paralysis, accompanied with a difficulty of voiding the urine. Wlien the spine is examined, it will be found to be acutely tender. A more careful examination, however, will probably discover that the pain is not confined to one portion of the spine, but extends to different regions, and is inclined to vary in position. Moreover, the tenderness is excessive and superficial, so that the patient flinches and complains more when the skin is pinched than when the vertebrae are pressed. And it should be borne in mind that most persons, more especially women and children, will start or shrink Avhen sudden, although comparatively slight, pressure is made for the first time in the lumbar region of the spine ; and this flinching, as Skey points 382 HYSTEEIA. out, is much more considerable if at the time of the examination the body be unsupported in front. Then, although the disease may have existed some time, there is no corresponding constitu- tional disturbance. Tlie normal condition of the body is main- tained. There is no wasting ; no defect of nutrition. All this occurring in a young -woman, in whom probably the circulation is weak, with some disorder of the uterine or other functions, stamps the disease as hysterical. Disease of the joints. — A girl will complain of severe pain and tenderness in the knee. The joint is fixed and immovable, and any attempt to move it elicits loud cries. But the tenderness, as in the last case, is excessive and superficial, so that she complains more when the skin is touched than when the heel is pressed upwards. There is frequently, too, a tendency to spasm ; but this is different from the painful and involuntary startings of the limb at night in the real disease. Often also the leg is fixed in the extended position, whereas in real disease of the joint it is usually bent. However, to this rule there are abun- dant exceptions. The joint does not undergo any material alteration in size and shape, although there is often some degree of fulness — a puffy swelling. In some cases the enlargement may be considerable ; but when this occm-s, it is due to some local applications which have been previously employed. The joint, and indeed the whole limb, is very subject to frequent variations of temperature. 'Thus, in the morning the limb may be cold, and of a pale or purple colour, as if there were scarcely any circulation of blood in it ; while towards the after- noon it becomes warm, and in the evening is actually hot to the touch, with the vessels turgid and the skin shining.' Moreover, there is always a sense of weakness in the limb, which, after a while, is partially due to the condition of the muscles consequent on their inaction. Then there is the absence of constitutional symptoms. Although the sleep may be disturbed, and the j)atient watchful, there is not that almost entire absence of it which is so serious a feature in destructive disease of the joint. There is here a sufficient proportion of sleep for the necessities of the system. AU this having existed without any material alteration for some time, with perhaps evidence of general debility or some local disturbance, proves the affection to be hysterical. Or the hip-joint may be affected. There is pain in the hip and knee, aggravated by pressure and motion, and the patient SYMPTOMS. 383 lies fixed in one position. But liere again tlie pain is diffused and superficial. Then time effects no real alteration in the condition of the limb. The investing muscles do not waste. There is no flattening of the nates. There may be unusual fulness about the joint, leading for a time to a suspicion of abscess. Sir B. Brodie observes that it is not uncommon to find much alteration in the figui-e of the parts. The pelvis may project posteriorly at the same time that it is elevated towards the affected side, so as to make an acute angle with the column of the vertebrae. Under these circumstances the limb is appa- rently shortened, so that when the patient stands erect the heel does not touch the ground. This strange distortion, due to the predominant action of certain muscles, assisted by the long- continued unnatural position, must not be confounded with dis- location. These affections of the joints sometimes terrainate in remarkably sudden recovery. Disease of the mammary gland. — The breast of a young* woman is very painful and tender, and there is probably an unnatural fulness and tension of the entire gland, obvious when contrasted with the opposite one. The skin may have a glossy aspect, but the surface is very pale ; or perhaps here and there ill-defined portions of the gland appear somewhat more indu- rated than the rest. These symptoms, especially the last mentioned, are very much aggravated by repeated handling, to which, unfortunately in these cases, the breast is continually subjected,, so that often the suspicion of some tumour is ex- cited, by which matters are made infinitely worse, inasmuch as it leads to rej)eated and prolonged examination. In these cases the true diagnosis is usually confirmed by the condition and history of the patient. There is commonly clear evidence of a feeble circulation and general debility, very frequently associated with some irregularity or other disorder of the uterine functions. Often, too, there have been previously some decided sjonptoms of hysteria. Retention of urine. — A patient declares that she is unable to void her urine ; that she has no power over her bladder. The bladder may be distended even to an abnormal extent, and yet the urine is retained. The absence of all local causes; the healthy condition of the urine ; and the character and history of the patient, generally remove all doubt of the natm'e of the case. If the bladder be artificially relieved, the evil may be indefinitely prolonged. On the other hand, continued retention 384 HYSTEEIA. may lead to chronic inflammation or paralj^sis. These un- toward results are, however, comparatively very rare. The patient, if left to her own resources, usually discovers before very long that the power has returned. Local imin. — Pains of every kind and degree of severity affecting any and, in succession, every part of the body are common enough in hysteria. One of the most frequent and familiarly recognised has been called clavus hystericus. This is a pain in some one point of the head, %vhich has been likened to the supposed effect of driving a nail into the part ; hence the name. Its usual seat is immediately above one eyebrow. It is frequently more or less intermittent, and sometimes when the paroxysms occur at regular intervals, it closely imitates the affection called brow-ague. Another very common seat of pain is the side below the mamma, usuall}- the left. It is generally accompanied with acute tenderness, so that the person is unable to lie upon it. It is sometimes described as a stitch in the side. It is often remarkably persistent. Complaint of pain in the hypogastric region is very common. In fact, ^ the processes of ordinar}^ life, which in health are unfelt, are sensible and some- times painfully so, to the hysterical patient.' The character of the patient and her history generally declare the nature of the case. These and various other pains, more especially those in the head, are commonly described as amounting to ex- cessive agony, and the subjects of them are very seldom at unj loss in their description. Their imagination usually fur- nishes abundant similes and illustrations. It is not uncom- mon after a time to perceive in the part complained of a full and puffy condition of the integuments, accomj)anied with increased heat and perhaj^s some trifling vascularity. This immediately leads to the suspicion of abscess, and that after all the diagnosis was wrong. In truth, many of these cases are for a while exceedingly perplexing, and sometimes it is im- possible to establish at once a clear and satisfactory diagnosis. Chronic abscesses are often very insidious in their progress, and, at their commencement especially, most obscure. On the other hand, these local hysterical affections sometimes occur in those in whom they would be least expected to arise ; in whom, perhaps, no other evidence of hysteria is, for the time, apparent. The diagnosis of these pains is sometimes still further com- plicated by the fact that they may have supervened upon some injury, which perhaps was trivial, but which may be described as severe. DIAGNOSIS. 885 But, instead of being thus unduly exalted, tlie natural sen- sibility of a part may be variously perverted or completely lost. And these disorders are not limited to ordinary sensation, but affect the special senses also. Inequality and local variation in temperature are not un- common. And the same remark may be extended to the affections of voluntary motion. Every variety occurs, from violent convul- sion or spasmodic contraction of a limb or muscle to complete paralysis. And often two or even more of these disorders co- exist, so that it is easier to imagine than to describe the innumerable forms and varieties of local hysterical affections. It may be well to review for a moment the chief points which should be borne in mind in the diagnosis of hysterical affections. In the first place, the subject is generally a young woman, in whom, perhaps, the functions of the uterus or of some other organ have been for some time and are disordered, and in whom hysteria may have been already manifested in some of its more regular forms. Yet it would be a grave error to suppose that local hysterical affections do not occur in subjects who present none of these conditions. They are incidental to women even in advanced periods of life, and in whom no error of function can be elsewhere discovered. Nay, they are sometimes wit- nessed in the opposite sex, and I venture to think more fre- quently than is commonly imagined. Young men, the subjects of excessive mental or bodily fatigue and prostration, not un- frequently exhibit local affections which cannot in any way be distinguished pathologically from those which are called hysterical. Every form of disease and infirmity is, in turn, supposed to exist, and abundant evidence is furnished of the accuracy of Aristotle's observation, that melancholy persons are most ingenious. Such cases are often termed hypochondriacal ; but when hypochondriasis is employed in this sense, it appears to me to become synonymous with hysteria. Indeed, Sydenham and others have considered hypochondriasis as a modification only of hysteria, the difference dej)ending merely upon sex. Certainly they are connected by all their main features, and it is more than difficult to say in what essential points they differ. Nor are local hysterical affections always preceded by hysterical paroxysms. To assume this would be as grave an error as to suppose that these local forms are always cases of volmitary VOL. I. c c S86 HYSTEEIA. deception. No doubt, in the majority of cases, careful enquiry and examination will elicit some other evidence of hysteria either past or present. But to this rule there are many ex- ceptions, and the surgeon who relied upon it in his diagnosis would be led too often seriously astray. Then, although the aflfection may have existed — and it usually will last — for a considerable time, there is no commensurate impairment of the general health and strength, such as is pro- duced by organic disease. The contrast between the local symptoms and the general mischief always furnishes most im- portant evidence. A careful cross-examination of the local symptoms will gene- rally elicit some contradiction or inconsistency. For instance : the pain and other symptoms are often remittent or inter- mittent, not steady and abiding. The pain is often superficial ; in fact, integumental, and very prone to be widely diffused beyond the supj)osed seat of mischief. Moreover, although after a time there may be some slight alteration in the size and shape of the part, there is never that decided and peculiar change which is, sooner or later, the inevitable result of certain local diseases. Chloroform is often of invaluable assistance in the diagnosis of hysterical affections ; for instance, in a case of contraction of a limb. When the patient is fairly under its influence, she can neither complain nor resist ; and the ease with which the limb can be then extended, its perfect mobihty and natural condition, proves the affection to be simply a fault of volition. But the difficulty of diagnosis is incalculably increased when hysteria supervenes upon some real disease. Ordinary symp- toms then become exaggerated, and the cause of their origin is apt to be overlooked in their obvious association with hys- teria. Close and continued observation will at length resolve the doubt. In some of these cases chloroform will remove the difficulty. But such a combination is comparatively rare. Hysteria generally disappears before real disease. Finally, hysteria is far more frequently mistaken for real disease than real disease for hysteria, not only because it appears so curiously disguised and is so prone to simulate other diseases, but also because it so commonly occurs. Sydenham affirmed that hysterical disorders ' constitute one moiety of chronic distempers ;' and this statement is endorsed by ConoUy. Brodie says : ' I do not hesitate to declare that PATHOLOGY. 387 among the higher classes of society, at least four-fifths of the female patients, who are commonly supposed to labour under diseases of the joints, labour under hysteria, and nothing else.' So variable in aspect, so inconsistent in character, hysteria mocks all attempts to define it, and seems to defy every en- deavour to explain its pathology. Yet thus much appears clear and certain — it is essentially an afiection of the nervous system. It is well known that the common office of the nerve-centres is that of variously disposing of the several impressions that reach them through their afferent nerve-fibres. Thus, if com- municated to motor fibres, reflex movements are produced ; and the reflection may be confined to a single nerve, or it may radiate amongst several. In the one case, the result may be the con- traction of a single muscle ; in the other, the whole body may be agitated. Or an impression conveyed to a certain portion of a nerve- centre may be transferred to other parts. Thus, what have been called sympathetic pains arise. For examples : pain in the knee in disease of the hip ; pain in the shoulder in affec- tions of the liver. But, like reflection, this transference may be limited or diffused. In the latter case a local irritation may produce widely extended effects. A familiar example is pre- sented in toothache ; the pain sometimes spreads over both jaws and the face. On the other hand, impressions producing like results may be transmitted from the braiii to the other nerve-centres. As the iTile, in health, the effect produced varies : 1. As the intensity of the impression. This is commonl}-- obvious, and it is strikingly illustrated in the ganglia of the sympathetic. For instance, the ordinary stimulus of food in the intestines conveyed to the ganglia is simply reflected and produces contraction of the canal. But if, from the character of the food or otherwise, the stimulus be increased, the stronger impression is conducted from the nearer to the more distant ganglia, and more widely-diffused and vigorous contractions result. Or the irritation being yet greater, the impression may reach the cerebro-spinal centres, and radiating thence, produce various pains and contractions, such as cramp. 2. According to the condition of the nerve-centres. Thus the same impression will produce very different effects in dif- ferent persons. Irrespective of the power of endurance, one person feels pain more acutely than another, and even in the c c 2 388 HYSTEEIA. same person the susceptibility varies at different periods of life. This is shown b}^ the comparative facility with which con- vulsions are excited in children. An amount of irritation which in the adult would fail to produce any visible effect, will often in the very young, in this way, prove fatal. A familiar example is seen in the effects of ' teething.' If, then, from any cause the irritability — that is, the suscep- tibility to impressions — of the nerve-centres be in any way affected, it follows that the effect of any impression conveyed to them will vary proportionately. So, according to the condition of the nerve-centres, the effect of any impression may be exalted or diminished, or otherwise perverted. This, it may be rea- sonably assumed, is the key to the interpretation of the patho- logy of many affections of the nervous system, and amongst them of hysteria. The particular form which the morbid action will acquire depends, doubtless, upon the seat and nature of the change. No wonder that this change is generally too subtle for our scrutiny, seeing that it may be due simply to the quantity or quality of the blood in the part or to the rapidity of its cir- culation. Nothing is positively known of the exact condition of the nerve-centres which predisposes to the production of hysteria. It may be sometimes due to a defect in their original construc- tion, but probably they are far more frequently enfeebled sub- sequently. It is, almost as a rule, associated with some form of debility of the system, or defect in the general health ; and this, connected with its variable manifestations ; its sudden access and disappearance, often as the result of some forcible impres- sion on the nervous system ; its cure by means which improve the health and strength ; and the absence of any discoverable lesion or defect after death, dissection affording only negative evidence — seem to connect the affection with the quantity and quality of the blood supplied to the nerve-centres, in a word, to their nutrition. That a defective condition of the blood or its circulation should be primarily manifested in these organs, is the result of the fact that no other organs are so immediately dependent on a healthy supply. The nerve-centres being thus predisposed, a veiy trivial im- pression will be sufficient to excite the local or general pheno- mena of hysteria. The exciting cause may be either some abnormal state of any organ producing irritation, or the disease PATHOLOGY. 389 may have its origin in a nerve-centre. In this way the emotions may be supposed to act. Thus the exciting cause of hysteria may be either of centric or eccentric origin. In the latter case there may be, as in epilepsy, an aura hysterica. Brodie relates the following cases : * An unmarried lady, thirty-two years of age, consulted me on account of her being liable to some very distressing paroxysms, in which she experienced a difficulty of respiration, attended with a sense of constriction of the chest, and great general excitement and agitation. These paroxysms often continued for ten or fifteen minutes, recurring at irregular intervals ; sometimes without any evident cause ; while at other times they might be traced to some sudden emotion of the mind. So far the case did not differ from many other ca^es of hysteria ; but the peculiarity of it, and the circumstances which led to my being consulted, was as follows : There was a particular spot near the ensiform cartilage, which she believed to be in some way or another connected with her complaint. Nothing could be discovered in this part different from what is usual, by the most strict examination ; but the pressure of the finger on it never failed to induce one of the paroxysms which I have just described. When these paroxysms were most severe, they were always attended with an abundant flow of limpid urine. These symptoms had existed in a greater or less degree for ten or twelve years, and had supervened on a state of exhaustion occasioned by an attack of typhus fever. * A young married lady, who was liable to ordinary attacks of hysteria, complained of a tender spot on the anterior part of the abdomen, a little below the ensiform cartilage. The slightest pressure of the finger on it caused excessive pain, and was fol- lowed by violent agitation of the whole person, bearing a more near resemblance to the convulsive motions of chorea than to anything else and continuing for several minutes.' Viewing hysteria in this light, it is easy to understand its common association with disorders of the uterine functions ; an association so frequent, that by many it has been, and is still believed to be, constant, as the derivation of the word implies. That the local irritation should be so frequently connected with the generative organs is what would be naturally expected from a consideration of the nature of their relation to other organs through the nervous system — their extensive ' sympathies ; ' 390 HYSTERIA. the powerfal and active causes of excitement, and nmnerous distiirbances to which they are subjected. But there is ample evidence to show that the exciting cause may be elsewhere, as for instance, in the intestinal canal, and act quite independently of the generative organs. For the same reason it can be understood why hysteria so commonly occurs in women, seeing that the organs of genera- tion, from their nature and influence, are so liable to prove an exciting cause, and that the system generally of women is, as a rule, so much more impressible than that of men. But, as would be expected in this view of it, hysteria does sometimes, though comparatively seldom, occur in men; al- though in them the general symptoms of hysteria rarely become paroxysmal. They usually assume the features of hypochondriasis, which, if not identical with hysteria, is yet so closely allied to it, that the one passes by insensible degrees into the other. Nor is it difficult to understand how hysteria may supervene upon some local disease which may act as its exciting cause. Thus hysteria may be set up by a wound or tumour.'^ On the other hand, but more rarely and obscurely, a local hysterical affection may lay the foundation of organic disease. The influence of the mind upon the body is a subject well worthy of the most attentive consideration. If everyone were familiar with the striking effects which may be produced by a steady and continued concentration of the attention upon a part of the body, we should hear less of the frauds and follies attributed to ' animal magnetism ' and of some other deceptions. Hysteria remarkably illustrates the powerful influence of emo- tions upon both body and mind ; and more especially when it occurs, as it sometimes does, in imitation as it were of a paroxysm witnessed in another. It has been often remarked that one hysterical patient in a ward wiU sometimes produce many more. It is worthy of note, that in hysteria, more especially in its local forms, the effect produced, leading at length to some change or disturbance in the part, may react upon the susceptible nerve- centres, and thus aggravate materially the existing mischief. It is said that the liability to the hysteric paroxysm bears an exact ratio to its past frequency. * On this * Keflex Hysteria/ see the essay on Diseases of Nekves. TREATMENT. 391 It is sometimes very difficult, if not impossible, to diagnose between hysterical and neuralgic affections on the one hand, and hysterical and feigned diseases on the other. And although in its typical and more common forms hysteria is sufficiently distinct from either neuralgia or voluntary simulation of disease, yet extreme cases are met Avith by which it appears to merge into one or the other. As a distinctive character between hysteria and neuralgia, it may be said that in the latter the cause of the mischief is always somewhere in the nerve or nerves between the seat of pain and the centre inclusive. Although contrary to the opinion of some, I venture to think that cases of voluntary deception should be separated from hysteria. In practice this may not be always possible, but pathologically the distinction appears to be clear ; and to include them under a common term can lead only to confusion. Still more difficult is oftentimes the diagnosis between hys- terical and what are called sympathetic pains ; for in either case the cause is perhaps some local u-ritation acting through a nerve- centre. After all, the chief means of distinction here must lie in the proportion between local cause and effect. Can it be assumed that the local mischief or disturbance, whatever it may be, is in itself adequate to account for the result ? If not, is there then, so far as can be ascertained, any additional evidence of undue irritability or increased susceptibility of the nerve- centres which will explain the exaggerated effects ? The management of a person in a fit of hysteria is a very simple matter. Beyond placing her out of the way of mischief, on a bed or a couch, perhaps the less that is done the better. Many of the plans of treatment which have been recommended are certainly injurious. It is doubtful if any of them are bene- ficial. Above all, no restraint should be imposed upon the patient, excepting such as appears to be absolutely necessary for her safety. It seldom happens that she seriously injures herself. Of this there is much less real than apparent danger. The subsequent exhaustion is generally very trifling ; there is apparently a curious disproportion between this and the violence of the paroxysm. In the treatment of hysteria, besides those general measures which are calculated to correct the morbid disposition of the system, special remedies are usually needed to remove the exciting cause. This, in a cursory enquiry, is very likely to be overlooked, as it is often subtle and obscure. It is especially 392 HYSTERIA. liable to escape notice because commonly connected witb some disorder of those functions which, being in more immediate relation with the gang-lia of the sympathetic system, are fre- quently not revealed by direct and obvious symptoms. Yet it is always very important, and often essential, that the exciting cause be detected, and this a close and careful investigation will usually disclose. Then, beyond regarding the condition of the system generally, the state of every function should be particu- larly examined, more especially those of the uterus, the disorders of which prove to be so fi-equently the immediate exciting cause ; and whatever is discovered to be wrong, either here or elsewhere, must be treated accordingly. In investigating the nature of any local affection, with the view of determining its relation to hysteria, the condition of the part affected should be carefully examined in the first place — and this, if necessary, with the aid of chloroform — in order to discover if there exist any equivalent cause for the evil com- plained of. Failing in this, the investigation should be carried along the course of its nerves to their centre ; and no evidence being obtained of anything unnatural, the state of all the organs should be successively examined. Then the condition of the systein generally in regard to the health and strength, not of the body alone, but of the mind also. And lastly, the previous history and present habits of the patient. Certain applications are often beneficial in temporarily reliev- ing local j)ain, such as lotions or ointments of aconite, bella- donna, or opium, or injections of morphia. But there is one grand objection to all of them. They become the means of continually directing attention to the part and of magnifying the importance of its symptoms. The temporary relief of pain frequently fails to counterbalance these evil effects. This objection, however, does not apply so forcibly to the application of plasters ; and it is often an excellent plan to cover completely the part with some plaster spread on leather or moleskin, and not to allow it to be exposed or touched so long as the plaster will adhere. Thus the great evil of repeated examination is prevented. In hysterical affections of the breast, for instance, this kind of local treatment is eminently serviceable. In the case of muscidar rigidity or contraction — as, for example, when the leg is drawn up towards the thigh — when with the aid of chloroform relaxation has been effected, and the part has been restored to its usual position, it sometimes proves i TEEATMENT. 393 useful to retain it so by means of a splint or otherwise, so that when the patient recovers we are able to appeal to the fact as an unanswerable confirmation of the truth of our conviction respecting the nature of the case. If this plan be not adopted, it is curious to witness the gradual return of the part to its previous condition so soon as the effects of chloroform begin to subside. And even after the artificial restraint has been con- tinued for several days, as a rule, the same relapse immediately follows its removal. But these obstinate and enduring local affections can be satisfactorily treated only by general measures. The difficulty of effecting a cure sometimes appears to be almost insuperable ; and this not so much from failure of the means employed, as from the extreme difficulty in many cases of enforcing their application. And this difficulty is complicated when the ex- citing cause has its origin in centric disturbances, as mental emotions. For in this case it is too often placed beyond our control. Nevertheless, this we must endeavour to reach if possible ; but failing, the attempt should be made to direct the discharge or expenditure of emotion through another and more natural channel ; as, for example, in active exercise. This is more practicable than attempting in the first instance to suppress its effects, for in a mind unaccustomed to discipline this is not easily accomplished. The worst fits are those which supervene upon intense efforts to suppress strong emotions. Carter says, ' it may be taken as an invariable rule, that the paroxysm will be violent in exact proportion to the length of time during which the feelings giving rise to it have been con- cealed.' . In these cases, certain of the nerve-centres may be fairly described as in a state of extreme tension, and the dis- charge of nerve force through one or other of the various channels by which reflex actions are ordinarily manifested, seems in numerous instances to afford natural and safe relief. As previously stated, when the affection is voluntary on the part of the patient, when it is a case of wilful simulation, then it passes beyond hysteria. But there are some cases — and these are the most perplexing — in which, from long-continued disuse and want of effort, the will has lost its due control over the emotional influences. The most common cases are * those in which the occurrence of the fit, although not volitional, is yet a matter of surrender, and might be prevented under the pressure of an adequate motive.' 394 HYSTEEIA. Besides the adoption of all those hygienic measures which are adapted to improve health and increase strength — and it must not be forgotten that debility diminishes resistance to emotional as well as to other influences — a vigorous and perse- vering attempt must be made to erase all vicious habits and to remove all baneful influences. In order to succeed, the surgeon will need the aid of those whose consistent co-operation it is often most difficult to secure. Friends frequently fail to perceive the necessity of a plan of treatment which otherwise appears to be harsh and cruel. Matters are very often made worse by yielding to that desire for sympathy which is so urgent and universal. As the rule, hysteria will be found to be engrafted upon some form of debility, and this, in many cases, is the result of the kind of life which these patients have led. Hysteria is one of the many penalties imposed upon idleness. It will be too often found upon inquiry, that while the functions of neither the mind nor the body are ever exerted or even fairly exercised, the emotions uncontrolled are continually subjected to unwholsome excitement. WILLIAM SCOYELL SAVORY. SYPHILIS. ' La syphilis devrait servir de clef a toiite la pathologie.' — Axdral. CHAPTEE I. INTRODUCTION. WHEN syphilitic matter is applied to the surface of the human body, no appreciable effect in general results ; but when the poison comes in contact with the thin skin in those situa- tions where it joins the mucous membrane, or when applied to the mucous membrane itself, or to the skin in places where the epithelium has been removed, then inoculation may take place. As observed in practice, the results of inoculation afford con- siderable variety; when artificially performed, they are much more uniform. Four distinct and well-marked morbid processes may follow syphilitic inoculation : 1st. The inoculated part may become affected with the * ad- hesive form of inflammation,' in which lymph is poured out either in the substance or on the surface of the part. 2nd. The absorbents may assume an active share in the morbid process, taking up some of the infected parts, and with them portions of the syphilitic poison. This process will, m the following pages, be called ' lymphatic absorption.' 3rd. The inoculated part may, within a few days of the application of the poison, be affected with suppurative inflam- mation ; and 4th. The morbid action may terminate in mortification. Of this there are two practical subdivisions : (a) Death of the whole infected part, which is then thrown off as a slough ; and (b) Dissolution and death of a part only of the contaminated structure, leaving a part still infected. 396 SYPHILIS. These four kinds of morbid processes, essentially distinct when once developed, usually maintain their original character until the termination of the disease. Thus the specific adhesive inflammation may be recognised by its characteristic induration often long after the sore (which usually accompanies it) has permanently healed. But it will, nevertheless, occasionally hapj)en that the action will become changed, and this altered condition (if careful attention be not paid to it) will lead to an error in the diagnosis. A sore affected with adhesive inflam- mation, upon the application of some fresh irritant, may become a suppurating sore. The superinduced action may perhaps modify, but will not prevent, the specific results of the original disease; or again, a sore that has presented for a time the characters of the suppurative inflammation may alter its appear- ance and assume those of the adhesive form. In such a case, the first disease will not prevent the constitutional effects of the second. Both these forms of action will constantly be accompanied by ' lymphatic absorption ;' and the disease in the lymphatic glands will be of the same nature as that from whence the absorbed product was derived. It will also sometimes happen that the specific adhesive inflammation may terminate in mortification, or that a part superficially mortified may become affected with specific adhesive inflammation. In either case, the mortifica- tion may be superficial or extend to the whole of the infected tissues ; but if the specific adhesive inflammation has once taken place, its effects upon the constitution will subsequently appear. The above four kinds of diseased action, resulting directly from the application of the syphilitic poison to the surface of the body, may be clearly traced both after artificial inoculation and by attentively observing the natural course of the disease in different instances. It must always be borne in mind that the character of a sore at one time is no certain indication of what it may previously have been, or of what it may ultimately become. In the mode in which the disease is usually com- municated, a part may be subjected to infiuences which would have a tendency to produce more than one morbid action. Such influences may be applied either at the same or at dif- ferent times. When applied at the same time, a twofold ino- culation may occur on the same spot ; and if the consequent respective actions require different times for their develoi^ment. PATHOLOGY. 397 one disease may first iiin its course, and be subsequently- followed by the otber, whicli will then go through its different stages, modified perhaps, but not altered, in its essential charac- ters, by the first. The number of poisons which may produce morbid actions in a part scarcely admits of demonstration. Two different poisons may sometimes produce the same action. Thus, the secretion produced by the puncture of a foul lancet, and that arising from an injury to a portion of cancellous structure of bone, may both give rise to erysipelas ; or, on the other hand, the same poison may, under different circumstances, give rise to more than one kind of morbid action. It does not, then, follow that because we can distinctly trace so many morbid processes, that there are the like number of morbid poisons. The diseased a.ctions we can trace with great precision, and can predict the circumstances under which they will occur, and define distinctly the laws by which they are regulated and controlled. It is, therefore, more in accordance with strict inductive science, simply to describe the different modes of action which occur after impure contact, than to ascribe each different action to a different poison. Hunter believed that gonorrhoea was always produced from the same virus as syphilis, and nearly all the practitioners who followed him were of the same opinion. Swediaur, however, remarks that the happiness and tranquillity of many families, not less than the fatal effects arising from the improper treatment of this disease, seem to demand the most careful researches upon the subject. He had convinced himself, from well-authen- ticated experiments, and numerous cases attended with the greatest care, that those who maintained that gonorrhoea and syphilis were always the effect of the same poison, and those who held an opposite opinion, were both wrong in generalizing too much, and in speaking so positively and so lightly on a point of so much importance to the physician and the patient. He had, as he believed, proved to demonstration that blenor- rhagia of the genitals of the two sexes owed its origin some- times to the venereal or syphilitic virus properly so called, and sometimes to some other acrimony applied to the urethra or the vagina. Several cases are related which go to prove that a discharge may be syphilitic or produced by the syj)hilitic virus ; and, on the other hand, cases are given to show that blenor- rhagia is generally very different in its origin and nature from 398 SYPHILIS. the disease produced by the syphDitic virus. It will easily be conceived, he remarks, of what importance this distinction is in practice, when, on the one hand, we see practitioners treating all gonorrhoeas as venereal (syphilitic) with mercurials ; and, on the other, by an ill-founded theory suffering the syphilitic virus to be communicated, and the disorder propagated through whole families, without giving themselves any trouble as to the un- fortunate results. This, in a few words, gives perhaps the best account of the theories of the nature and treatment of sj^hilis extant in 1821. In 1838, Ricord's Traite pratique siir les Maladies veneriennes appeared, and this must always remain a most important epoch in the history of syphilis. Ricord professed to demonstrate the truth of his views by experiment, and offered his experimental illustrations to all who might wish to witness them. With triumphant success, and to the satisfaction of his admiring pupils, Ricord demonstrated daily the great fact, that when pus was taken from the urethra in a case of gonorrhoea, and inocu- lated upon the patient, no result followed; whereas when pus was taken from a suppm'ating sore, and inoculated with the point of the lancet, a suppurating chancre was always produced. A great triumph had here been achieved. Science had vindi- cated her right, not only to distinguish between different morbid processes, originating apparently in the same way, but also to reproduce some of these actions, and experimentally to trace them through their various stages. With the light thus derived from experiment, the following conclusions were arrived at by M. Ricord : I. A chancre is known for certain, neither because it has appeared after a suspicious contact, nor on account of its situa- tion, nor because it has an indurated base, nor on account of its colour, its shape, the character of its edges, nor by the red areola by which it is surrounded, but by its being inoculable so as to reproduce exactly the same disease again upon the same patient an indefinite number of times. All the other conditions may vary ; this alone always remains the same, and affords the same experimental results. II. The pus of a chancre can alone produce a chancre. III. The best way to produce a chancre is to inoculate some of the secretion from its surface upon another part of the same patient's body. IV. Beyond the contact of the pus introduced beneath the ^PATHOLOGY. 399 cuticle, no other action is necessary to produce a well-developed chancre. V. The inoculation never fails when the pus is taken under the necessary circumstances, and is properly applied. VI. The pus taken from an inoculated pustule will reproduce a chancre of the same kind originating in the same way, and thus the propagation may extend from pustule to pustule. VII. Wlien several inoculations are made from the same suppurating chancre, each one gives rise to a separate pustule, which subsequently becomes a chancre. If three punctures are made, we do not see one succeed and another fail. The number accurately corresponds with, and is never more nor less than, the number of the inoculations properly made. VIII. The pustule, and the chancre which succeeds it, are always developed upon the precise spot where the inoculation is made, and never upon any other part. IX. Whatever different forms the suppurating chancre may ultimately assume, its coiu-se, in its origin, is always the same. The appearance of the pustule is absent only when the part has been excoriated ; and it is preceded by phlegmonous inflamma- tion only when the poisonous matter has been introduced into the subcutaneous areolar tissue, or has found its way into the lymphatic vessels. X. There is no period of ' incubation,' in the sense in which this word is generally understood. There is for the suppura- ting sore but one process of development, from the contact of the contagious pus to the formation of an ulceration. XI. The chancre is in its origin a local disease. XII. The origin of the affection must date from the period of contact, and not from the time that the patient perceived the disease. Such are the results of M. Ricord's investigations published in 1838, and they furnish a very faithful abstract of the evidence which he had obtained by his experimental mode of investiga- tion. Every conclusion is based upon direct observation ; and if there had been one form of syphilitic disease, and one only, M. Ricord's conclusions must have stood the test of subsequent experience. But it has now been proved by numberless obser- vations, and by more direct experiments than may, perhaps, be justified, that the syphilitic action which arises after contagion is not always the same. The specific pustule, it is true, when inoculated, will as a rule produce the specific pustule ; but there 400 SYPHILIS. is another form of disease, of far more importance to the patient, ■which does not begin with a pustule at all ; which cannot be re-inoculated upon the patient who has it ; ♦which often has a prolonged period of incubation ; which cannot be destroyed by- caustic, and which is followed very certainly by secondary symptoms. The two actions now mentioned have unfortunately, up to a recent' period, been confounded together. It will now be my endeavour to distinguish accurately the symptoms which belong to these two essentially different morbid processes, and to de- scribe each as a separate affection. M. Ricord's description, then, applies in general very accu- rately to the suppurating form of the disease ; but it does not apply to that which, in its origin, does not begin with a pustule, but which begins with some adhesive form of inflammation — such as a papule, a tubercle, or an abrasion with a thickened base. In the next chapter we shall consider the suppurating syphilitic sore, and in the chapters following the disease which gives rise to the hard chancre, and its consequent constitutional or secondary symptoms. The results of twofold inoculation as they present themselves in nature, mider different forms, will subsequently be described, together with the various complica- tions which may thence arise. CHAPTER II. SUPPUEATING SYPHILITIC SOEE. The primary suppurathuj syphilitic sore is a local disease, and is not liable, so far as I am aware from personal observation, to infect a patient's constitution so as to produce secondary symptoms. It commences as a pustule, and runs a definite course. When artificially inoculated, the inoculated point becomes red within the first twenty-four hours. From the second to the third day it becomes slightly raised, and is sur- rounded by a red areola. Between the third and the fourth day it contains a fluid more or less turbid. From the fourth to the fifth day the pustule becomes fully formed, and from this time to the termination of the disease the secretion consists of weU-formed pus. Sooner or later, the cuticle covering the pustule is detached, and in some instances it may be removed i" ^ ■ J '■^nm, a, ~jcpp\irwtxnif sort US ^ley o^ecored- en rM J-i '"^ dcv,' fihie^fmcncnd '■'■'0 dmnus M 4Ti H.-JIK-a:-. . io a- L : r. p^it .i as t C SUPPUEATING SORE. 401 at the time of the inoculation, whether artificial or natural. This alters the appearance of the affection, but in nowise interferes with its essential characters. As soon as suppuration commences, there is a loss of substance in the part, and an ulcer forms, which has peculiar characters. When not inter- fered with by any accidental causes, it increases equally in every direction, so as to form a more or less perfect circle. The edges of the ulcer are cleanly cut, and present a sharj) out- line. (See Plate 2, fig. 1.) The appearance presented is often that of a piece of skin having been removed by a punch. The edges of the ulcer are frequently slightly undermined and everted. The surface of the ulcer is irregular, sometimes presenting granulations, at other times the appearance of having been worm-eaten. Often the bottom of the ulcer is covered by an adherent, grayish, tough matter, which probably is a part of the natural texture which has undergone a kind of molecular necrosis, and is in process of being separated from the subjacent living parts. Suppuration in itself does not necessarily involve a loss of substance, but these suppurating sores nevertheless generally leave permanent and depressed scars. This evidence of loss of substance is probably in exact proportion to the degree in which the form of molecular necrosis above alluded to has been present in any individual case. The suppurating syphilitic sore gradually increases during a certain period, then remains stationary, and finally heals. The latter process is indicated by the base of the sore becoming clean and covered by red granulations, by the red areola which surrounded it becoming fainter, and by the edges of the wound gradually losing their prominence. Such is a description of the tj^ical form of a suppurating chancre ; but this may be modified by various accidental causes, of which the following are some of the most important : 1. If the specific pustule be destroyed by the application of caustic within the first five days of its existence, a simple ulcer alone will remain. This will then have none of the characters of the specific disease. 2. When a chancre during its progress meets with tissues of different natures, or when folds of the same texture are involved, its shape and appearance may be thereby modified. 3. Should the specific inflammation extend to the areolar tissue, a certain amount of inflammatory^ exudation will there VOL. I. D D 402 SYPHILIS. take place. This will produce an induration at the base of the chancre, and will sometimes very much resemble the indura- tion which oixlinarily accompanies the infecting chancre. The latter will be particularly described in the next chapter. The induration that surrounds the suppurating form of the disease gradually fades towards the circumference to the consistency of the surrounding parts. When this inflanimatoiy exudation, however, in its progress meets with a different kind of tissue, it may terminate quite abruptly, and then it may be impossible to distinguish, by the touch alone, this kind of induration from that of a chancre which infects a patient's constitution. The cha- racter of the secretion of the sore, or its inoculability on the same patient, or the history of the ca&e, must then be relied upon to distinguish the disease. Case. — A patient, who considered himself well informed upon the subject of the characters of an infecting sore, presented himself in March 1859. He had a sore on the right side of the iraenum, which spread ultimately for about three- quarters of an inch along the urethra. As the sore extended, it became sur- rounded by considerable induration, and this, as it approached the urethra, terminated quite abruptly. It was then impossible to distinguish this indura- tion from that which accompanies an indurated infecting sore, and the patient believed that his affection presented all the characters of a true Ilunterian cliancre. The history of the case and the character of the secretion furnished, however, different testimony ; and the patient was prevailed upon, not without very considerable difficulty, to be treated for a local disease. I ventured to assure him that his constitution would not be affected ; and I had the satisfac- tion of seeing him on November 5, 18G0, and again on February 21, 1802, without his having been subjected to any constitutional treatment, and without his having had any constitutional symptoms. 4. The most remarkable accidental circumstance which modi- fies the course of a suppui-ating chancre is the absorption by the lymphatic vessels of a portion of the affected tissues, or of the secretion which they have produced. Lymphatic absorption of the j)roduct of a suppurating syphilitic sore affords the same evidence of the nature of that sore as does artificial inoculation. The secretion transferred to another part is followed by the same effect, whether artificially conveyed by the point of a lancet, or by the natural process of lymphatic absorption. In either case, where the seed takes root, there will it germinate and produce its natural consequence. The morbid process which ensues terminates surely, and without any period of incubation (in the ordinary acceptation of the term), in the formation of a small quantity of matter which always has peculiar properties. This matter is pus, and pus which has the SUPPURATING SOEE. 403 property of always reproducing its specific action when again applied to another part of the same body, or when inoculated upon another person. This pus is therefore called sjpecific. To the naked eye and to the microscope it presents all the charac- ters of ordinary pus ; but it has, in addition, its specific qualities, which are known only by their effects. It presents, as seen by the microscope and even by the naked eye, characters which distinguish it from the secretion of the indurated sore, or of the infecting form of syphilis. It consists of well formed pus ; and each globule is of nearly the same size, and distinct from the rest. If, in any doubtful case, some of the secretion from a sore be mixed with a little dilute acetic acid and placed under the microscope, the distinctive characters of the pus-nuclei will be seen, as represented in Plate 2, fig. 2. The aj)pearances pro- duced are quite distinct from those which are afforded by the secretion from an infecting sore treated in the same manner, as will be more fully shown in the next chapter. When this specific pus has produced its natural effect either in a lymphatic vessel or in a lymphatic gland, the fresh por- tion of pus thus generated produces a fresh specific irritation, and this irritation produces an abscess which, breaking exter- nall}', discharges its contents. In such a case the matter in the interior of the gland, or lymphatic vessel, constantly retains its specific characters ; but that which during the process of sup- puration is formed outside the vessel or gland is ordinary non- specific pus. As the disease advances, these two secretions may be mixed together, and then the whole acquires the characters of the specific fluid, and the surface of the whole sore will become inoculated. Lymphatic absorption from a suppurating syphilitic sore then necessarily produces a sujjpurating bubo. Any attempt to prevent such an affection from suppurating is entirely futile. The disease within the lymphatic system is the same, and runs a similar course as that upon the surface of the body. The disease now described is not beneficially influenced by mercurial treatment ; and inasmuch as it has no tendency when left to itself to infect a patient's constitution, any mercurial treatment in order to j)revent such an infection is entirely superfluous. The suppurating syphilitic sore will sometimes be tedious in healing, and a variety of applications may be tried sometimes without producing any apparent effect upon the course of the disease. In a case lately under my own care at D D 2 404 SYPHILIS. St. George's Hospital, a sore of this nature lasted four months, apparently little influenced by treatment ; but the patient at the end of that time made a very good recovery, and now remains -well without having taken any mercury. The suppm-ating syphilitic sore has been often repeatedly inoculated for the supposed purpose of producing what has been termed syphilization. But inasmuch as the disease, however often repeated, remains a local one still, no constitutional or permanent effect can be produced in this way ; still less can any condition of the system be produced which would render it insusceptible to the infecting form of the disease. It must, however, be admitted that when a patient has already constitu- tional syphilis, the symptoms which have developed themselves will often disappear nnder this so-called syphilization. It is principally efi&cacious in diseases of the skin, and these are probably removed, under the circumstances, in consequence of a kind of counter-irritation produced by the repeated inocu- lation of the syphilitic matter, and suppuration of the inoculated points. One very important and interesting fact will require especial notice with regard to the so-called syphilization — viz., that after repeated inoculations have been made on a part, that i^art becomes less and less susceptible to the influence of the poison, and a time arrives at which the inoculations will cease to secrete pus, and then they will no longer be inoculable. If fresh matter, however, be used, the inoculations will again succeed ; but these will gradually lose their effect, as at first. This process may be repeated until a part is no longer susceptible to any inoculation from the secretion of a suppurating syphilitic sore. But then a fresh part may be inoculated, and the same process repeated. Under this mode of treatment it is said that a time ultimately arrives at which no further inoculation can be effected from a suppurating sore upon any part of the body. Even then, however, after the lapse of a certain interval, the suppurating syphilitic sore may again be communicated, but always without imparting any constitutional or syphilitic taint to the patient. This subject will be considered more at length in a future chapter. "N*r ^ I'UJ c hioUiraJxd' siP't. not surean^ pus rwt uwrulaiU m the- same' poutwiM After GuJAjtrvtr Sec/'Uwrv Trom vrdurated sore eouimvved' m the same way ds F^: v/i'VJ v(r<'^r" SYPHILITIC INFECTION. 405 CHAPTER III. SYPHILITIC INFECTION. Syphilitic infection of a patient's system, as far as it can be traced by local symptoms, commences as a crack, an abrasion, or a pimple. These affections, in the origin, are often ex- tremely difficult to recognise. They frequently do not present any characters by which they can be distinguished from similar results arising from a variety of accidental causes, and they may be masked by the coexistence of other local venereal com- plaints. Syphilitic infection at its first appearance generally attracts but little attention. It is attended with no inconvenience, and the patient is willing to believe that it is 'nothing' — an opinion which has been but too often endorsed by the surgeon. As the disease declares itself, it assumes one of three forms, which are all modifications of the adhesive kind of action : I. The cuticle may appear as if peeled off from the upper part of the glans penis, or a circumscribed patch may remain for days together, presenting a livid or purple colour. (See Plate 3, fig. 3.) The structures below are not infiltrated, and there- fore there is no specific induration. The secretion, consisting of epithelial scales and lymph-globules of various sizes, and more or less perfectly formed, is thrown off from the surface. In women there is probably a corresponding affection of some parts of the mucous membrane, not accompanied by induration ; but on account of the difficulties attending the investigation of these complaints in their origin in females, such a condition has not hitherto been described. II. An indurated tubercle, without ulceration, may form in the skin or under the mucous membrane, and will then present all the characters of the specific induration without any loss of substance. (See Plate 3, fig. 3.) III. The most ordinary form of syphilitic infection is that which has been called the indurated or Hunterian chancre. In this a deposit of lymph occurs in the areolar texture of the skin or of the mucous membrane, and is succeeded by a process of molecular necrosis, by means of which the newly deposited matter is in part thrown off*, and an ulcer is formed ; but, in- asmuch as it is the newly-deposited material which alone perishes, 406 SYPHILIS. no depressed scar or permanent loss of the natural tissue occurs. The secretion from an infecting chancre, when the disease is not accompanied with irritation from any accidental cause, is not pus ; it consists of epithelial debris, of globules of lymph more or less perfectly formed, or of these same products undergoing disintegration, and of serum more or less turbid. These diiferent products may often be found matted together, mixed occasionally with a few pus cells. During the time that the adhesive matter is being thrown off from the surface, or whenever a part has been irritated by an adherent scab, or by the application of lotions, some suj)puration may take place ; but as soon as the accidental cause of irritation has been removed, the natural non-puriform secretion alone remains. If the secretion from an uncomplicated infecting sore be placed upon a piece of glass, and a drop of dilute acetic acid be added, the microscopic appearances will be found to be very different from those which were described in the last chapter as charac- teristic of the secretion from a naturally suppurating sore. The accompanying drawing (Plate 3, fig. 4) represents the aj)pear- ances of some of the secretion from an ordinary infecting sore, examined in the manner above described. In this case the sore, which was in a state of progress, had been dressed with water dressing, in order to prevent any accidental cause of irritation, for two or three days previous to the examination. In debilitated and unhealthy constitutions infecting sores will suppurate as any non-specific lesion would do, and in such cases it is sometimes very difficult to distinguish the secretion produced by the local disease from that which depends upon constitutional peculiarity. The three forms of infection now described are all modifica- tions of the adhesive form of inflammation ; and there is much reason to believe that the first two have not been recognised by a large majority of the writers on syphilis, and that hence a number of cases have been eiToneously recorded, in Avhich con- stitutional syphilis was supposed to have been acquired, without any primary affection. The induration which accompanies the second and third form of the specific adhesive inflammation is peculiar, and, when well marked, it furnishes a diagnostic test of the nature of the complaint. It surrounds the edges and base of the chancre in every direction to nearly an equal extent. It terminates quite abruptly in the surrounding tissue ; so that it not unfre- SYPHILITIC INFECTION. 407 quently affords the sensation as if a foreign substance, such as a piece of cartilage or half of a pea, had been introduced into the substance of the skin. (See Plate 3, fig. 5.) This induration depends upon the effusion of lymph into the areolar texture of the skin, or into the cellular tissue below the mucous mem- brane ; and when it is considerable, the part is raised above the surrounding surface, and then gives rise to the variety of ulcer which has been called the ulcus elevatum. This induration has no doubt often been confounded with the infiltration which surrounds the phlegmonoid variety of the suppurating sore, and with that produced by accidental irrita- tion ; but in the great majority of cases it may be distinguished by its abrupt termination, and by its equal consistency through- out. Another form of disease, from which it is not so easily distinguished, is the secondary induration, which may form part of the constitutional symptoms of syphilis. This secondary in- duration may show itself in the same parts as primary infecting sores, and may, like them, be accompanied by induration. In both cases the induration depends upon plastic effusion from a specific cause ;. in both this has a tendency to assume, more or less, the tubercular form ; and in both the induration may ter- minate abruptly. In general, however, this defined outline is more marked in the primary than in the secondary form of the disease. It will sometimes happen when there is great induration that the circulation through the part does not readily take place. The surface of the sore may then slough to a certain extent (Plate 4, fig. 6), but this will not prevent the appearance of secondary symptoms. Syphilitic infection does not manifest itself immediately upon the application of the poison ; a period of incubation follows the inoculation, during which nothing is perceived, and the patient thinks himself well. Prom ten days to seven weeks after the application of the cause the primary disease will manliest itself. In the interval there may possibly be some other vene- real affections, such as arise from the contact of impure secre- tions, but the characteristic symptoms of the syphilitic infection Avill not appear until after the period of incubation above named. There is, however, one remarkable exception to this rule, and that is with regard to the re -inoculation of the secretion of an infecting sore soon after its first appearance. At that time the inoculation will succeed much more quickly, and the induration 408 SYPHILIS. which follows will be sooner developed. It has been said that if a person be inoculated with the vaccine matter on several successive days, the vesicles will all ari'ive at maturity about the same time. Now, something like this obtains with regard to syphilitic infection. If a person becomes infected, and a sore appears some three or four weeks afterwards, and some of the secretion from that sore be immediately re-inoculated, the inocu- lation will probably succeed, and the induration of the two sores will then appear about the same time. After the charac- teristic induration has been established, the infecting chancre is no longer capable of being re-inoculated ; but for a considerable time, if fresh action be excited in the part, as, for instance, by the application of a blister, a secretion may be obtained which is re-inoculable upon the patient himself. The inoculations thus produced do not resemble in their course the results of inocula- tions on a patient who has not j)reviously been infected. They have no period of incubation. They are not accompanied by induration. They rarely ulcerate ; and if a sore forms, it soon heals. The stains, however, of these inoculations from an irritated infecting sore may last for weeks or for months. Some very remarkable statistics have been produced on the subject of the re-inoculation of the secretion from in- fecting sores. In 1855, M. Clerc announced the doctrine, that tliis secretion could not be inoculated — a theory which cor- responded with, and might have been deduced from, Ricord's dogma, that a person can have syphilis once only. As the in- durated sore was said to be the necessary precui'sor of con- stitutional syphilis, and as syphilis was supposed always to follow an indurated sore, it followed that, when once the con- stitutional affection was established, the patient's system in which it was so established would no longer be capable of being re-inoculated so as to produce again the same disease. In 1856, this point was experimentally tested in the Lock Hospital, and the results are recorded in the British and Foreign Medico- Chirurgical Review for the same year. It was then found that the indurated chancre was not capable of being inoculated upon a patient whose system was already syphilized in the proper acceptation of the term. In 1856, M. Fournier also inoculated a hundred patients from their own infecting sores, and succeeded in his experiments once or twice only. His results were not published until 1858. M. Rollet, in his recent work, mentions having inoculated SYPHILITIC INFECTION. 409 two hundred patients who had mfecting sores with the secre- tion of their own chancres. He found that those in whom the inoculation succeeded were six per cent. These sores were said to be auto-inoculahle. In the remainder the inoculation failed. Now, Fournier's experiments and Rollet's experiments coin- cide in a wonderful manner with practical statistical details as carefully observed. During- the years 1855-56, I kej)t an accurate register* of such cases, and out of one hundred that had been diagnosed as suppurating non-infecting sores, secondary symptoms followed, as far as I was able to ascertain, in two instances only. Out of so large a number, the proportion is curiously in accordance with the exceptions in Fournier's and in Rollet's experiments. The exceptions in all three series of observations may be attributed to the same cause — a twofold inoculation may in all the instances have taken place, and pro- duced the suppurating local syphilitic affection as well as the infecting chancre. (See Plate 4, fig. 7.) The former had pro- bably in Fournier's and in Rollet's exceptional cases furnished the inoculable pus, and had, in my own observations, masked the characters of the affection that I was attempting to dia- gnose. This conclusion is confirmed by the results of the inoculations as far as the experiments were concerned. The affection produced by the inoculation fi-om the supposed indu- rated sores was, not an indurated sore of the same nature, but a ijustule, the characteristic origin of the local suppurating disease. Practically, then, we conclude that if a syphilitic sore yields a secretion, capable of being inoculated so as to produce the specific pustule, the evidence, so far as it goes, is in favour of its being a local disease, and not requiring constitutional treatment. If, on the contrary, a disease which we believe to be primary syphilis yields a secretion which is not auto-inocu- lable, then the evidence is against the local character of the affection, and indicates a constitutional mode of treatment in order to prevent or to mitigate the secondary symptoms. A few years only have elapsed since the test of a really syphilitic sore, and the propriety of giving mercury for its cure, was supposed to be its auto-inoculability. This doctrine was upheld even in some of our most widely-circulated works on the subject of syphilis. But, as now shown, the idea was not only an unsafe guide scientifically, but it was practically the very re- verse of the truth. The confusion which thus arose was one of * Cases regarded as doubtful or mixed were not included in this table. 410 SYPHILIS. the many natural results of some of our leading authorities, both here and on the continent, having confounded together, and mixed up in their descriptions, the two varieties of syphilitic disease. These are now, it is hoped, sufficiently clearly dis- tinguished, never again to be confounded.* In a weU-marked infecting sore, the edges are firmly adherent to the subjacent and surrounding tissues. (See Plate 3, fig. 5.) They are smoothly bevelled ofi", or rounded so that the well- defined sharp edge noticed in the description of the primary suppurating sore is here wanting. The surface of the infecting sore varies in colour. It sometimes presents a fawn colour ; at other times it is uniformly red ; at others, again, portions of adhesive matter of a grayish colour will be seen on its surface. These different appearances depend uj^on the accidental cir- cumstance of the separation, or otherwise, of a portion of the plastic exudation which forms the thickened base of the sore. Besides the nature of the secretion, and the auto-inoculability of that secretion, there is another diagnostic test of very great value in distinguishing primary syphilitic infection, and that is the condition of the corresponding inguinal glands. In the previous chapter we saw that some of the material involved in the local suppurating form of the disease might be conveyed through the lymphatic vessels, and again reproduce its particular morbid action either in the lymphatic vessels them- selves, or in the inguinal glands, and we regarded this as a kind of re-inoculation, or as a translation of the disease by a natural process from one locality to another; and it has been shown in the present chapter that during the early stage of a syphilitic infection the part first contaminated produces a secretion which is auto-inoculable. These two circumstances will prepare us for understanding the pathology of the chronic indolent enlarge- ment of the glands which constantly attends a syphilitic infec- tion. The part first inoculated, as we have seen, takes on the ad- * The distinction between the two kinds of disease in their mode of orirjin was first recognised in 1854. In my Pathological and Surgical Observations, published in that year, the local disease, which commences with a suppurative form of infianimation, is described as a morbid process, distinct and separate from the specific adhesive action which is followed by constitutional symptoms. That the auto-inoculability of a chancre was evidence of its non-infecting cha- racter, was first pointed out by me in the British and Foreign Medico- Chirur- gical Hevieio for 1856. SYPHILITIC INFECTION. 411 hesive form of inflammation. If some of the secretion from this infected spot be inoculated with the point of the lancet before the specific adhesive action developes itself, both inoculated points will become similarly affected ; and if by a natural process the same thing be effected — if a portion of the contaminated matter be conveyed along the lymphatic vessels — then at the point where such matter is arrested the specific adhesive action will take place. Thus both forms of the syphilitic disease are auto-inoculable : the su]3f)urative form during its whole continuance ; the adhesive form during its early stage only, before the specific hardness has appeared. Each form of syphilis is capable, by natural auto- inoculation (or by lymphatic absorption), of being conveyed to the inguinal glands, and of there reproducing its specific and peculiar action. It would appear, however, that in the suppu- rative form of the disease, in which the discharge is soon thrown off" from the surface, lymphatic absorption does not so generally take place as in the specific adhesive action, where the infected tissue remains often for months as a portion of the living structure of the part. In the suppurating form of the disease lymphatic absorption by no means always occurs. It is the exception, and not the rule ; and when it does occvir, one gland only is generally afl'ected ; whereas in the adhesive form of the disease, the inguinal glands are almost always involved, and in general there are several affected at the same time. This has caused the name of muUiijle indolent huho to be given to this si^ecific affection of the inguinal glands : a condition very surely indicating that the patient's system will shortly be, if it is not already, infected. The characters of the inguinal glands attacked with specific adhesive inflammation are peculiar. The affection appears at, or about, the same time as the specific induration. This peculiar form of auto-inoculation occurs, therefore, at the same period at which the chancre might be inoculated by the lancet upon another part of the same patient's skin. After an indurated chancre has ceased to be auto-inoculable upon the skin, it probably ceases to furnish any matter to the absorbents which can cause their specific induration. The sup- purating syphilitic sore, on the contrary, which furnishes a secretion which is auto-inoculable during its whole existence, may also at any period of that existence give rise to a suppu- rating bubo. 412 SYPHILIS. Sometimes one gland only is involved in a case of syphilitic infection ; but generally there are several. Each gland becomes enlarged without causing any pain or inconvenience to the patient, and without his being aware that anything unusual is taking place in the part. The enlargement is confined to the gland structure itself, and does not involve the surrounding cel- lular tissue. Each tumour may become the size and shape of the dried shell of an almond ; and I have been in the habit of describing this peculiar affection as the amygdaloid condition of the inguinal glands. Each separate gland may be felt rolling in its bed of loose cellular tissue, and the unaffected skin will move freely over it. These glands are very hard, and give very much the same sensation to the touch as the induration of a primary chancre. The peculiar hardness depends upon the fact that this newly effused plastic material is confined to the gland, and acciu'ately circumscribed by its capsule. Lymphatic glands affected with specific induration do not sup- purate. When the disease is uncomplicated this may be received as a universal rule. Yet in practice we every now and then hear of buboes suppurating in connection with infecting sores. Some of these are scrofulous buboes ; some are buboes arising from some accidental cause of irritation ; and some are buboes which occur upon the accession of secondary symptoms, and in consequence of some eruption on those parts of the skin, whence the lymphatics which empty themselves into the glands arise. When all these sources of error in diagnosis have been guarded against, there will still remain a few cases in which an infecting chancre has apparently given rise to a suppurating bubo. The number of such cases has not been ascertained statistically, but they are very few indeed, and probably not even so great in pro- portion as the cases in which an infecting sore retains its auto- inoculability after the development of its specific induration. The exception in both classes of cases depends, in all probability, upon the same cause — namely, a twofold inoculation upon the same part. A very remarkable circumstance remains to be noticed with regard to lymphatic absorption, both from the suppurating sore and from the primary infection. The glands into which the ab- sorbent vessels directly enter are those only which are affected. These are called the glands first in order. The glands second in order — that is, those glands which receive their lymphatic vessels SYPHILITIC INFECTION. 413 only from other glands, are never affected with the specific action peculiar to any form of primary syphilitic disease. It is evident, therefore, that no form of syphilitic action can find access to a patient's system through the lymphatics. The specific action ceases with the first system of glands with which the affected matter is brought in contact, and therefore the affection of the lymphatic glands may be looked upon as a part of the primary symptoms. An inguinal gland affected with specific induration would, no doubt, if no other cause of infection existed, produce constitutional disease ; but it would be by means of the blood that circulates through its diseased structure, and not by the passage of the poison into the circulation through the thoracic duct. In the same way a chancre infects a patient's constitution by the morbid action communicated to the blood circulating through its texture, and not by lymphatic absorption. Wlien once the general system of a patient is affected with syphilis, the same disposition to the effusion of plastic matter may occur in any situation as was manifested at the original seat of the disease. This disposition to plastic effusion may be traced in every stage of the disease. We have considered it in the primary infection, and as giving rise to the peculiar charac- teristic induration of the lymphatic glands. In the secondary forms of the disease the same action may also be traced in effusion of lymph upon the iris ; in the deposit of tubercles in the cellular tissue and in various internal organs ; in nodes upon the bones ; and in various kinds of papular and tubercular erup- tions upon the skin. All these different forms of secondary disease may be referred to the same tendency to plastic effusion ; the effused material, if allowed to remain, being influenced by, and becoming part of, the structure in which it occurs. In the treatment of syphilitic infection, after the disease has manifested itself, cauterization is of no avail, as far as the pre- vention of constitutional symptoms is concerned. The period of incubation which has already elapsed forbids the idea that the poison can then be destroyed by the application of caustic to any particular part. Practically the same truth is found unfortunately to be but too evident. Infecting sores, that have been destroyed on the very day of their appearance, have subsequently continued to spread, and have prodrced their natural consequence. Even if an infecting sore be cut out, the infection of the patient's system will not thereby be prevented. The diseased action has already spread to other parts, and has already perhaps com- 414 SYPHILIS. raenced in the lymphatic glands before any visible indication of its existence presents itself. A sustained, judicious and consti- tutional mode of treatment is the only one that can be relied upon in the treatment of this disease. CHAPTER lY. LYMPHATIC ABSOEPTION. Physiologists have usually recognized three modes by which absorption may take place : I. That by which foreign substances find their way directly into the blood through the coats of the bloodvessels. II. The absorption of the chyle from the mucous surface of the intestines by the lacteals. III. Absoi-ption by the lymphatics. To these three modes of absorption, by all of which extraneous substances have been supposed to enter the circulation, we may add a fourth means by which the system may be influenced by the action of some kinds of poisons ; namely, that in which a direct local effect is produced upon the nerves of a part, and through them upon the brain (and consequently upon other organs), without the poisonous material being taken into the blood. Examples of this mode of the action of poisons are afforded by the effects of the juice of the leaves of the aconite, and of the infusion of tobacco, as illustrated in some of Sir B. Brodie's physiological experiments. In most instances the action of a poison commences immedi- ately upon its application. But in the case of morbid poisons, a certain interval must elapse, and a certain morbid jarocess must be gone through, before these can produce their specific actions upon the general system. The deleterious materials of which these poisons essentially consist, or the secretions in which they are contained, may be applied to the living body in any quantity, and for any length of time ; and unless the j)rocess, which is jjeculiar to each of them respectively, be gone through, its characteristic effects will not as a rule be j)roduced upon the constitution. f LYMPHATIC ABSORPTION. 415 If the particular action by wliicli these poisons individnallj enter the system be disturbed or interfered with — so as not to be carried out — other results may follow, but their full general and specific influence will not be experienced. If the first step in the process be defective, so will be its natural consequences. The knowledge which we thus obtain furnishes us with a most important power ; for, by modifying or altering the morbid process by which a poison enters the system, as, for instance, by the early application of caustic to the infected part, we may, under certain circumstances, modify or control its effects. I purpose now to consider how far the action of the syphilitic poison upon the constitution may be thus modified or controlled, by the kind of action which is produced when it is first applied to the living tissues of the body. For this purpose it is requi- site to consider what the morbid actions really are by which the syphilitic poison gains an entrance ; and what the natural processes are by which it joins itself to, and becomes as it were incorporated with, the living being. The opinions of Hunter on the absorption of the syphilitic poison have given a bias to all subsequent reasonings upon the subject ; and the theories based upon his experiments are very generally received even up to the present time. He demon- strated, as he believed, that the lymphatic vessels were the true absorbents ; and he concluded from his discovery that they were the only absorbents in the system. The experiments upon which his idea was founded deserve attention. Assisted by his brother and several other eminent medical men, he confined some warm milk in a portion of small intestine ; and having tied the artery and vein which supplied the intestine, he saw, as he believed, the lacteals of the part presently become filled with the white milk. Upon puncturing the vein upon the distal side of the ligature, it was soon (by pressure of the finger) emptied of its blood. No white fluid could, during the continuance of the operation, be found in tlie vein. Upon a, repetition of the experiment, in which the circulation through the mesenteric vessels was left free, the blood in the vein was carefully examined and compared with that in the neighbouring veins, but it was found not to he light-coloured, nor milky, nor could any difference whatever be detected in it. It was found that even by firm pressure, which was continued until the intestine burst, the milky fluid could not be made to pass into the veins. 416 SYPHILIS. In another animal, some thin starch, coloured with indigo, was introduced into the small intestine, and the lacteals were soon afterwards seen of a fine blue colour. A vein in this part of the mesentery was opened, and the blood which flowed was allowed to separate into coagulum and serum. The next day the serum had not the least bluish cast. An injecting pipe was then fixed in an artery of the me- sentery, where the intestine was filled with blue starch ; and all communications both in the mesentery and intestine were closed, with the excejDtion of the vein corresponding with the artery. Warm milk was now injected until it returned by the vein. This was continued until all the blood was washed away, and the vein returned a bright white milk. The milk thus circulating through the intestine containing the blue starch was not in any degree changed in colour. In a third animal, some musk in warm water was confined in a portion of the intestine ; after waiting a little time, some of the lacteals of the part were opened with a lancet, and some of the watery fluid which they contained was received into a small spoon. This was thought to smell strongly of musk. Some blood received into a clean spoon from one of the veins of the same part had not the least smell of musk. From these and similar experiments. Hunter arrived at the inference, which must have appeared one of the greatest dis- coveries of his age, that the veins do not absorb in the hiiman body. It necessarily followed from this that the lymphatics were to be considered as the only absorbents ; and this is stated by Hunter to be the fact, in his work on the venereal disease. If the lymphatics were the only absorbents, they must of necessity have been looked upon as the only channels through which poisons could, under ordinary circumstances, enter the system ; and accordingly we find Hunter asserting that the venereal matter is taken up by the absorbents of the part in which it is placed, and carried along the absorbent vessels to the common cii'culation. This view, deriving as it does such an apparent confirmation from the frequent occurrence of inflammation of the lymphatic glands in venereal diseases, was adopted with more or less modification by almost all the writers on syphilis who followed Hunter. The accuracy of the experiments upon which Hunter based his theory has, however, justly been doubted by other physiolo- LYMPHATIC ABSOEPTION. 417 gists ; but tlie theory itself, as regards the syphilitic poison, was up to a recent date, strange to say, scarcely questioned. MM. Tiedemann and Gmelin, after mixing various substances, which might easily be detected, with the food of animals, not unfrequently found unequivocal traces of these substances in the venous blood and urine, whilst it was only in a very few instances that traces of them could be discovered in the chyle. In repeating Hunter's experiments, Mayo found that half an hour after a solution of starch and indigo had been placed in the cavity of the intestine, the lacteals appeared of a clear blue colour; and those present were for a time satisfied that the indigo had been absorbed. But upon placing a sheet of white paper behind the mesentery, it was found that the blue tinge had disappeared. On removing the white paj)er, the vessels re-assumed their blue colour. It became, therefore, evident that the blue tinge was the natural colour of the empty lacteals ; that while they continued to absorb the chyle they were white, but that as soon as they were simply empty they appeared blue. Thus a repetition of the Hunterian experiments rather tends to prove that the function of the lacteals is limited in the absorption of chyle : and that the lymphatics are not the only absorbents, appears most conclusively demonstrated by the experiments of MM. Magendie and Segalas. M. Segalas varied Hunter's experiment in the following manner : A fold of small intestine was drawn out of a wound in the belly of a dog ; all the bloodvessels passing to and from it were tied, with the exception of one artery ; a vein punctured upon the mesentery allowed the blood to escape, which would otherwise have stag- nated in the part. The lacteal vessels and nerves were left entire. The fold of intestine was then tied at both extremities, and an aqueous solution of the alcoholic extract of nux vomica was poured into it. During the hour which followed, the poison produced no symptoms. The ligatures being then removed from one of the veins, the blood was allowed to return in the natural course of its circulation. In six minutes from this time the poison took effect. The experiments of M. Magendie illustrating the same point are well known. The thigh of a dog was separated by M. Magendie from the body, by a division of every part, with the exception of the artery and vein ; into each of these vessels a quill was introduced VOL. I. E E 418 SYPHILIS. and tied by two ligatures ; between tbese ligatures the vessels were divided, and thus all communication was cut off between the body and the limb, except that which was maintained by the circulation of the blood. Two grains of the upas tieute were then inserted into a wound in the foot of the separated limb. In about four minutes the poison manifested its effects upon the system. From these and other facts, it appears certain that Hunter's idea of the lymphatics being the only absorbents is incorrect ; and we are thence naturally led to the consideration of the value of the theory of the mode of absorption of the syphilitic poison, which was based upon that notion. When lymphatic absorption takes place in connection with a suppurating syphilitic sore, the action of the poison may be traced in the clearest way along the absorbent vessels. In any part of its course, the poison may inoculate the vessel in which it is contained, and may produce a fresh syphilitic sore, the secretion of which may again be inoculated. It usually happens, however, that the inguinal gland in which the absorbent vessels terminate is the part affected. Here alone, in the great majority of cases, does the poison exercise its influence uj)on the absor- bent system ; but that the poison actually passes, as such, through the absorbent vessels, we have abundant proof in the specific effects of the poison in the course of those vessels. Between the lymphatic gland and the primaiy disease, a small abscess will occasionally form. This will present tumid and iiritable edges, wiU afford all the characteristics of a suppurating syphilitic sore, and will furnish an inoculable secretion. "We can then distinctly trace the entrance of the syphilitic poison into the lymphatic vessels, and from them into the absorbent glands in which these vessels terminate. The actual existence of the virus in any part of this course may be demonstrated by experiments, which have been far too often repeated to requii'e any additional confirmation. Arrived at this point of its course, on its way apparently towards the thoracic duct, and from thence to the general circulation, what becomes of it ? A very wonder- ful change is here brought about. The specific virulent poison, which before was liable to contaminate every living part that it came in contact with, cannot be traced beyond this point. The absorbent vessels between the inflamed gland and the thoracic duct do not ulcerate or suppurate; the glands into which they empty themselves do not become enlarged or in- LYMPHATIC ABSOEPTION. 419 flamed. The influence of the poison is here then gone. Beyond the glands first in order, the fluids which the absorbent vessels contain are bland and harmless, incapable of being inoculated, or of infecting any part with which they come in contact. What then has become of the poison ? We find it in the vessels going into the inflamed absorbent glands, but we do not find it in the vessels which proceed from those glands. In a certain number of cases, no doubt, the poison is in great measure discharged in the suppuration to which its presence gives rise. But, when we consider the exceedingly minute quantity of an animal poison that is capable of producing its specific action on a part, this explanation is not sufiicient. Some of the fiuid or particles which enter the gland must, in some form or other, we should think, pass through it, whether it suppurate or not. Even although we should suppose that the inflammation pro- duced in the gland entirely obstructed its channels, still, before such obstruction could take place, some fluid would surely have time to pass ; and this, if its quality remained unchanged, would be sufiicient to inoculate any part with which it came in con- tact, or to infect the general system. A similar series of phenomena may be observed in the afiec- tions of the lymphatic vessels which accompany an indurated primary syphilitic sore, with the exception that the action in the glands is of the same nature as that which constitutes the primary disease. The poison taken up by the lymphatics may dm'ing the earliest stage of the disease inoculate a lymphatic vessel ; and it almost always inoculates one or more of the lymphatic glands, so as to produce in them exactly the same kind of disease as existed in the part from whence the morbid material was derived. But beyond the lymphatic glands first in order, no farther effect is produced upon the lymphatic vessels. The fiuids which they contain are bland and harmless, and afford no indication of containing any poisonous or irritating ingredients. Up to this point, then, we have unequivocal evidence of the presence of the syphilitic poison, and of its power of contamin- ating fresh parts. Beyond this, the poison can no longer be traced. The fluids in which it was before contained now neither possess the power of irritating the vessels through which they pass, nor, when extravasated from these vessels, of infecting other structures. Here, then, some wonderful change is pro- duced. The specific characters of the poison can no longer be E E 2 420 . SYPHILIS. detected either by its morbid effects, or by inoculation. Even Hunter noticed this circumstance. He says, ' we never find the lymphatic vessels or glands that are second in order, affected.' And he remarks that, when the disease has been contracted from a cut upon the finger, he has seen the bubo come on a little above the bend of the arm, upon the inside of the biceps muscle. In such instances no bubo has formed in the arm-pit, the most common place for glands to be affected by absorption. Yirchow has noticed the same point. In speaking of the occasional introduction — or intravasation, as he terms it — of pus and other diseased products into venous and lymphatic vessels opened by abscesses and ulcers, he remarks that the transit of pus by lymphatic vessels is not at all uncommon, but he contends strongly against the production of general pytemic infection by this means. ' All the lymphatic vessels,' he says, * which are in a condition to take up pus in this way are peri- pheral ones, whether they arise from external or internal parts, and only after a somewhat lengthened course do they gradually reach the bloodvessels. In all, interruptions are formed by the lymphatic glands ; and since we know that the lymphatic vessels do not pass through the glands as wide, tortuous, and inter- lacing canals, but that, after they have broken up into fine branches, they enter into spaces which are filled with cellular elements, it is manifest that no pus-corpuscles can pass a gland.' This very important point of view, although it meets with the best possible confirmation in the daily experience of the practical physician, is generally overlooked, as Vu'chow conceives. He instances the process of tattooing. However minute the sub- division may be of the substances introduced, we never find these conveyed beyond the nearest lymphatic gland. In proof of this statement, Virchow adduced an example in which sub- stances, introduced for this purpose by a soldier fifty years before, had not penetrated farther than the nearest lymphatic gland, as proved by microscopical examination of the parts. Although, as he remarks, these glands act as a filter, in mechanically retaining the coarser particles, contained in the current of fluid passing through the glands, that is not by any means their whole office. ' They have manifestly another part to play, inasmuch as the substance of the glands indubitably takes up into itself certain ingredients from the fluid mass of the lymph, retains them, and thereby also alters the chemical LYMPHATIC ABSOEPTION. 421 constitution of the fluid, so that it quits the gland all the more altered, because it must at the same time be assumed that the glands yield up certain constituents to the Ijmph, which did not previously exist in it.' Virchow illustrates these statements by an appeal to ordinary phenomena observed in cases of malig- nant tumour and syphilis. ' When an axillary gland becomes cancerous, after previous cancerous disease of the mamma, and when, during a long period, only the axillary gland remains diseased, without the group of glands next in succession or any other organs becoming affected with cancer, we can account for this upon no other supposition than that the gland collects the hurtful materials absorbed from the breast, and thereby for a time affords protection to the body ; but at length this protec- tion proves insufficient ; and perhaps at a later period the gland itself becomes a new source of independent infection to the body, and a further propagation of the poisonous matter may take place from its diseased parts.' Neither observation nor experiment, then, afford any proof that the syphilitic virus is conveyed, as such, through the absorbent glands ; all the direct evidence which we have points to an opposite conclusion. The particles in which the poison resides here undergo some change, become perhaps disinte- grated, and after that process the eifects of the poison in the lymphatic vessels appear to cease. The evidence upon which it has been assumed that the syphilitic poison enters the system through the absorbent vessels must, therefore, be regarded as most inconclusive. Arrived at the first lymphatic gland which it meets, and there undergoing some change, it becomes incapable any longer of producing its specific effects ; and we cannot therefore admit that this is the way in which ihe system becomes infected after the specific primary adhesive action. If we reflect upon the different ways in which foreign sub- stances can be taken into the living body, we shall find that every such way is furnished with certain sentinels or guards, which oppose the entrance of materials which, if admitted, would prove injurious. Whenever any irritating matters are applied to the skin, which might, by being absorbed, become injurious to the system, the delicate sense of touch informs us of what is going on, and urges us to get rid of the offending material. This is a sense common to the whole body. But the parts through which foreign matters are usually taken 422 SYPHILIS. into the system are guarded in an especial manner. Thus, in addition to the sense of touch, we see the mouth guarded by the sense of smeU and that of taste : three out of five senses concentrated around the opening by which the food enters into the system ; and one at least of the other two always ready to assist in affording information of its nature. If we trace the food onward, we find that it has to pass the double row of teeth, which are acutely sensible to the presence of any hard particles that may have become accidentally mixed with it. Should any fresh flavour be produced in the process of mastication, there are the means provided for appreciating it as the food passes through the posterior fauces. The stomach we find ready, in its turn, to reject that which is injurious ; and throughout the alimentary canal there is an apparatus composed of a multitude of different parts, all combining to huriy on and eliminate from the system any materials which, if left, would be detrimental to it. Finally we have a wonderful system of minute capillary tubes (endowed with the faculty of distinguishing, so to speak, the chyle from other matters), taking up, and pouring freely into the blood, that which is requhed for the nourishment of the system, but refusing to admit anything else. These lacteals are very similar indeed in structure, in disposition, and in function, to the absorbent vessels elsewhere. It is true that we cannot trace equally well the processes involved in the assimi- lation and absorj)tion of the different individual organs of the body, as in the analogous actions which convert the food origi- nally into part of the living being ; but, from what we do know, we have abundant evidence that the same care is taken with regard to each part as with respect to the whole ; and we have reason to believe that other channels, through which foreign matters may enter the system, are guarded Avith the same care as that by which the common food is received. Such facts would lead us to the a priori conclusion that some means must exist to prevent the indiscriminate introduction into the circulation of any materials which might find then* way into the absorbents dm-ing the active ulceration of a pai-t ; and observation demonstrates to us that such a provision really exists. The particles taken up by absorption ultimately again form part of the general circulating fluid from which they were at first derived. They have as much to be assimilated as animal matter taken fresh into the stomach. The bone, the tendon, I LYMPHATIC ABSOEPTION. 423 the muscle, the nerve, which are thus removed, can no longer be recognised as such after they have been acted upon by the absorbents. All the different tissues that undergo this process form a single fluid, v^hich ultimately becomes a part of the general circulating mass, and can then in no way be distin- guished from similar products derived from the process of ordinary digestion. The action which converts foreign animal matter into blood, and that which converts parts of the living- body into blood by the agency of the absorbents, are then ana- logous ; and they agree in having the very remarkable property of converting some substances, which when introduced in any other way act as poisons upon the system, into harmless agents. It has been shown by the Abbe Fontana, that the poison of the viper, when introduced into the stomach, undergoes some change which prevents its poisonous effects upon the system. It has also been shown by two French physiologists, that the same thing happens with regard to the woorara poison, and we have it upon no less authority than that of Sir B. Brodie, that opium may be digested in the stomachs of some ani- mals, and that in that process its poisonous qualities are destroyed. ' I have injected,' says Sir B. Brodie, ' a strong watery solution of opium into the stomach of a rabbit, but no poisonous effect was produced, although a similar solution, injected into the cellular membrane, occasions stupefaction and death.' In like manner, we find that cancerous matter cannot be propagated from a part to the general system through the lymphatic glands ; but we have evidence to prove that it may, under certain circumstances, be so propagated through the bloodvessels. It is true that the veins in the immediate neigh- bourhood of a cancer are very frequently blocked up with coagula, affording another instance of the preservative power above mentioned; but when this is not the case, the cancer cells may apparently be conveyed in the course of the circulation and infect distant parts. We have an experiment on the authority of Langenbeck, related in the Encyclopedie anatomique, in which some fresh cancerous matter was injected into the veins of a dog, and cancerous tubercles were consequently developed in the animal's lungs. In like manner, I suppose, it might be possible under certain peculiar circumstances to infect the general system with cancer through the absorbent vessels ; but the fact that the glands first in order only are affected in consequence of local cancerous 424 SYPHILIS. || diseases, forbids the idea that this is the way in which the disease is usually conveyed to other parts. These observations will enable us to consider on sound physiological j)rinciples the change that is produced in the syphilitic jjoison during the passage of the matters in which it is contained through the lymphatic glands. These materials are themselves undergoing a change which will fit them for becoming part of the circulating fluid, and it would seem that the poison also undergoes a change similar to that produced in the poison of the viper, or in the woorara poison, by the stomach. The difference in the nature of the fluid in the lymphatic vessels, before and after it has passed the inguinal glands, is then analogous to the difference in the qualities of the woorara poison before and after it has undergone digestion in the stomach and the lacteals. In both cases do the fluid contents of the lymphatic vessels undergo a change fitting them to become a part of the circulating fluid ; in both cases are poison- ous matters sometimes converted or assimilated, and sometimes rejected ; by vomiting in the case of the stomach, by suppura- tion in the case of the lymphatics. In looking over my notes of cases which presented them- selves at the Lock Hospital during the year 1854, I collected together and arranged in a tabular form forty-nine consecutive cases of suppurating bubo. Of these, five only are recorded as having been accompanied, or followed, by any secondary affec- tion during the period that they remained under observation. In one of these five there was a distinct history of previous disease, both primary and secondary. In another, the cervical glands were enlarged, and the suppuration in the groin may therefore probably have been of a strumous character. In two cases, the secondary eruption was tubercular — an affection most obstinate in its nature, very liable to recur after having once disappeared, and comparatively seldom occurring as the first symptom of cutaneous disease. These, then, I regard in all probability like the first of the five cases, as the result of some previous syphilitic infection. This analysis would thus leave only one case out of forty-nine in which a disease which produced a suppurating bubo also produced secondary syphilis. On the other hand, I collected and tabulated in the same way thuiiy-one consecutive cases of secondary sj^^hilitic eimption. DESTRUCTIVE SYPHILITIC INFLAMMATION. 425 In one only of these cases does the history afford any mention of a suppurating bubo, and in that one case the history is not satisfactory upon the point. Such facts aj)pear to establish indisputably the proposition that the chances of the infection of the system in cases of syphilis are inversely in proportion to the degree of irritation and inflammation of the absorbent vessels leading from the primary seat of disease. biological absorption. — Hunter believed that the syphilitic poison might be simply absorbed by the vessels of a part, with- out giving rise to any local affection ; and ever since his time there have been original observers who have held the same doc- trine. Thus Mr. Lane, one of the present consulting surgeons of the Lock Hospital, has shown, by inoculation, that a bubo was of a specific character, when no primary lesion could be found upon the most minute examination ; Dr. Marston, of the Royal Artillery, has lately recorded cases in the Transactions of the Royal Medical and Ghirurgical Society, in which constitutional syphilis occurred without any previous primary symptom. And cases have occurred in my own practice in which every effort has been made to discover a primary lesion in cases of constitu- tional syphilis without any such being detected. CHAPTER V. destructive syphilitic inflammation: phagedena: serpigi- nous sores. Destructive Syphilitic Inflammation. It is a very remarkable fact that some of the most vascular parts of the body, and those the best supplied with nerves, are, under certain circumstances, the most prone to mortification. The parts of generation, amply supplied with nerves and bloodves- sels, will, under the influence of the syphilitic poison, occa- sionally become intensely inflamed, and that inflammation will speedily terminate in gangrene. If the gangrene so produced occurs within a short time after the application of the syphilitic poison, the death of the part involves the destruction of the poison. They together cease to exist ; and, when the slough separates, an ordinary sore alone remains, requiring no specific treatment. 426 SYPHILIS. Mortification of some part of the organs of generation some- times appears to depend upon a diseased state of the blood, in- dependent of any local cause. The blood will stagnate in the capillaries of the skin here as elsewhere ; and the tendency to mortification will first show itself in the most vascular parts. The skin will be affected before the areolar tissue, and the areo- lar tissue before the fibrous and membranous parts. I. The mortification, which involves the whole of the infected tissues, will sometimes be of the dry kind, but generally it will be of the moist variety. In the first there will be little pain or swelling, but in the second there will be much effusion, with great pain and a considerable amount of constitutional disturb- ance. Both these varieties of mortification may occiu' where there is no evidence of the disease having arisen from the appli- cation of any poison ; and, on the other hand, they will occa- sionally as evidently appear to depend upon direct contagion. Patients in apparent health will sometimes, within three or four days after exposure, find some part of the organs red, swollen, and extremely painful. In the centre of the inflamed part a dusky spot will indicate that the blood has already begun to stagnate in the vessels. The nutrition of the parts is no longer maintained ; irregular excavations are made by small portions of the tissues being thi'own off in the sanious discharge. The whole part affected becomes of a darker hue, and ultimately presents the ordinary appearance of gangrene. After a time a line of demarcation is established, the slough is thrown off, and the wound generally cicatrizes without difficulty. This process, effected by nature, is very similar to that which is artificially produced by the application of caustic to a syphilitic sore. In both cases, if the mortification has reached all the parts which have imbibed the poison, the destruction of the poison wiU take place in that of the tissues which contained it. In this first practical division of mortification, viz. : that in which the whole of the infected tissues perishes, as it occurs naturally, there is very seldom indeed any subsequent affection of the patient's system, even supposing he has been in a position to contract an infecting sore ; and the reason of this doubtless is, that the action w^hich terminates in mortification commences at the same time as, or very soon after, the application of the poison. In cases where the mortification has been artificially produced, on the contrary, a period of incubation may have existed, of some days or weeks, before the disease has shown PHAGEDENIC SORES. 427 itself, and consequently before the caustic is applied ; and during this time the tissues will have imbibed the poison, to a greater extent than the caustic can reach. The morbid action, which we are now considj' Bring, appears to be communicable by contact, although this c^^not be so closely traced as in the other forms of syphilitic inoculation. In patients, for instance, in whom the general health has not been impaired, parts which have no direct connection, either by blood- vessels or nerves, will appear to infect each other. Thus the glans and the prepuce, the opposed surfaces of the labia or of the nates, will sometimes become affected in a similar manner and exactly to the same extent ; and when lymphatic absorp- tion accompanies the gangrenous inflammation, the destructive action is tolerably sure to be communicated from the primary sore to the corresponding inguinal gland, and from it to the surrounding areolar tissue and skin. II. The second form of destructive inflammation is by far more common, and ordinarily of much longer duration. In it the infected tissue dies slowly, bit by bit, by a kind of mole- cular necrosis ; and, in consequence of this tardy action, the whole of the infecting portions never perish at the same time. A part is always left as a focus of contagion, and this involves fresh portions, which, in their turn, are thrown off, but not before they have communicated the disease to parts beyond. This action constitutes the phagedcenic syphilitic sore. It may appear as an original disease, or it may supervene upon any of the forms already described. It is inoculable, and generally arises from the direct result of the application of the syphilitic poison ; but secondary forms of syphilitic disease may assume precisely the same characters. These, however, cannot readily be inoculated upon the patient, whereas the primary phage- dajnic ulcer can.^ (See Plate 5, fig. 8.) The phagedsenic ulcer spreads irregularly in different direc- tions, is accompanied often by much pain, and yields a profuse discharge. This consists of an ill-formed sanious pus, mixed up with the debris of organic tissues. It does not affect the inguinal glands, provided these have not become implicated before the * The experiment of inoculating this form of disease slioiild be carefully avoided ; for a surgeon can never tell when the artificial inoculation which he produces will heal, and he will have the credit of having prolonged the disease if the orijnnal sore should heal before the inoculation. 428 SYPHILIS. pliagedajnic action has fairly set in ; if they have, the bubo will probably open and present the same phagedsenic appearance as the original sore. There is one form of the destructive syphilitic inflammation which presents very peculiar characters. Instead of spreading from one point in a more or less circular form, the disease may slowly extend in the form of portions of circles, from several points at once ; or, while the central portion first attacked heals, the affection will spread in a circular form, continually attacking fresh parts. The skin which is healed will then present a shining glazed appearance, surrounded by a dark- coloured circle of irregular so-called ulceration. This affection has been named the serpiginous chancre. (See Plate 5, fig. 8.) Like every other form of chancre, it may be accurately simu- lated by a form of secondary disease, the capability of ready inoculation upon the patient who has it alone excepted. This affection spreads by a true necrosis ; as one part heals, another becomes in succession red, livid, and disintegrated, the particles being thrown off in a thin sanious discharge. The loss of sub- stance is occasioned entirely in this way, and not at all by the action of the absorbents. This form of destructive inflammation will sometimes continue for months, or even years ; occasionally nearly healing, and then again, without any apparent cause, spreading in the same peculiar manner. It affects the folds of the groin, and the inside of the thighs and nates, perhaps more frequently than any other jjarts. The destructive inflammation that occurs on the surface of an indurated chancre will sometimes present the same appearance for a short time as a soft phagedtfinic sore. This must be re- garded as an accidental complication only, and not as a variety of the true phageda^nic ulceration. (Plate 4, fig. 6.) A patient had a most obstinate serpiginous sore which defied all treatment. lie was inoculated with different kinds of syphilitic matter. Nothing remark- able occurred from these inoculations : he was then inoculated with the secre- tions from his own sei"piginous sores. The results of these inoculations were the production of sores exactly similar in character to those from whence the secretion was taken. Upon each inoculated point a very well-developed and fully formed pustule appeared within the first few days. These pustules were depressed in their centres, and when they broke left exceedingly irritable ulcers. These ulcers were extremely painful, and surrounded by a deep red margin. A series of three sets of inoculations were performed, and the poison appeared quite as active and virulent at last as at first. Plate 5, fig. 9, represents the first inoculation I S'yre Jker CuUnnf iS:\ m.. '[3'.tA 90 TwoFoldL mccidcUion; iuppijjnjjjjn/j ■isre rex^i'j-viaJbU on t^te paMjent- i r ,:\:.;i ' .1 'ar ■■rt r/.// i' ' vmri'ii/ri.'; ■W SAO.J LITE ^CligXauS f^. U SrV HAMTiART JIL- Plaie. Alter CuZiernr hiocidatum/ from serpupnous sore \l & hioculatunu seamd ui order -fimri surpiqinoiis sore BA&a ir.ia. London, LorifeTTAUs a. Or IC earance of a vesicle, from wliich a serous fluid exuded. This fluid was again inoculated upon the patient's thigh. The original sore, which had been dressed with water, now again yielded no pus. 17th. The inoculation from the inoculation had succeeded. It presented the appearance of a red circular patch, with slight thickening of the skin, from which the cuticle was abraded. It had not in the least assumed the appearance of a pustule, nor was anything like pus secreted from its surface. A single pus- 438 SYPHILIS. tule, surrounded by very little inflammation, had, however, formed in one of the points first inoculated. 19th. The inoculations appeared as separate red patches on the skin, which in these situations was slightly raised and thickened, but no induration extended into its substance. The solitary pustule which appeared had dried up. 24th. One of the inoculations first made had a slight tendency to ulcerate ; the others were desquamating and losing their colour. Case 3. Bridget C, aged seventeen, was admitted into the Lock Hospital on August 26, 1858. She had suffered from a thick yellow discharge between two and three months. This was followed, in the course of as many weeks, by the appearance of two small places on the upper part of the left thigh. These, upon her admission, presented all the characters of well-marked primary in- durated chancres in a state of progress. The surfaces of these sores were covered by a scanty tenacious secretion, in small quantity, which, upon micro- scopic examination, yielded no pus. This secretion was carefully inoculated upon the patient's thigh. Aug. 28th. The inoculation was repeated. There was at this time no indica- tion of the sores having any tendency to heal. 31st. No result from the inoculations. The two sores had now been dressed for two days with the savine ointment, and yielded an abundant secretion, dis- tinctly purulent. The secretion from each sore was inoculated in several points close together in two separate places in the thigh. Sept. 2nd. The inoculations last made have produced the appearance of small incipient pustules in both situations. The secretion from one of these was ino- culated in two or three points on the thigh lower down. 4th. The inoculations from the inoculations had apparently succeeded. One of the inoculations of August 31 had produced a small pustule. The others had produced only vesicles. The skin over one of these was broken. 9th. The inoculations from the inoculations, performed on September 2, have dried up. The inoculations fii-st in order of August 31 had entirelj- lost their puriform character. They now appeared as cu-cular patches, and yielded a serous secretion, mixed with epithelial scales. The original chancres ■were now in process of healing. 11th. The inoculations first in order were desquamating, and of a light-red coloiir. The inoculations from the inoculations appeared as small red pimples, which were gi'adually losing their colour. 17th. The original chancres were cicatiized. The inoculations were fading and desquamating. 23rd. The inoculations from the inoculations were stiU visible, and appeared as shining scales of discoloured epithelium. 25th. A few faint secondary spots appeared on the body. The original sores were quite healed, leaving slight induration. The coi-responding glands in the groin were stiU enlarged and hard. Oct. 4th. This patient now left the hospital, but again presented herself on the 8th. The inoculations appeared as brown spots, the colour of which gradu- ally faded into that of the surrounding skin. It is quite possible that tlie persistence of the inoculations, and their peculiar colour in the two last-recited cases, may have depended upon the syphilitic diathesis of the patients. But INOCULATION MODIFIED BY PEEVIOUS DISEASE. 439 this in no way militates against the fact that inoculations suc- ceeded at one time, while they failed at another, under precisely the same conditions of the general system. In Case 1 the inoculations succeeded so long only as the sores furnishing the secretion maintained their irritable cha- racter, and failed as soon as this irritability subsided. In Cases 2 and 3, the sore, the natural secretion of which could not be inoculated with the lancet upon the patient, fur- nished an inoculable secretion when artificially irritated. In all the inoculations above recorded, the effects appear to have been in direct relation to the amount of irritation present, and generally in proportion to the puriform condition of the secretion inoculated. It might be supposed that in the first case the sores ceased to be inoculable because they were in a healing condition, but this would not account for the fact that the inoculations produced from them, ceased to afford an inoculable secretion within four or five days of their first appear- ance. The inoculation, then, of the secretion of a sore affected with specific adhesive inflammation may take place ; but is not easily performed, when once the patient's system has been affected with syphilis. When successful, the results are very different from those which follow the inoculation of the secr^ tion upon patients not previously syphilitic, or the inoculation of the secretion from naturally suppurating sores. In the latter case each puncture produces a pustule, which by repeated inoculation will produce its like a great number of times. The inoculation of the secretion from infecting sores upon patients previously syphilitic, as a rule fails, or succeeds only under circumstances of accidental irritation. It then can be repeated a very limited number of times ; and the results ob- tained, even by a number of punctures in one situation, are com- paratively of a trifling description. There is one circumstance which requires to be noted in connection with this modified form of inoculation, and which, unless duly understood, might sometimes lead to an erroneous diagnosis. It will occasionally happen that a patient, pre- viously syphilitic, will become inocuLited again in a modified form, and upon the point thus inoculated a secondary effusion of plastic material, dependent upon the first infection, may occur. The irritation produced by the modified inoculation will then become surrounded by a certain amount of induration, and this affection may then easily be mistaken for a primary 440 SYPHILIS. infecting ulcer. Again, it will sometimes liappen that a se- condary induration upon the prepuce (the consequence of a previous infection) will become abraded, or will ulcerate spon- taneously. The appearances then produced are very similar to those which accompany the primary infection, and they are here particularly noted in order that these different diseases may not be mistaken for each other."' Case. — M. IT., aged eighteen, had previously suffered from syphilis. She •was inoculated -with the secretion of an infecting sore which had previously been irritated by the application of the savine ointment, and in another place she was inoculated with the secretion from a syphilitic ecthymatous pustule in its natural condition. On the third day the lirst inocidation appeared to have taken ; but on the eighth the appearances had faded. At the expiration of five weeks there was a slight accurately defined induration around the second inocu- lation. Case. — A woman, who, from her previous mode of life had everj' chance of becoming syphilitic, was inoculated with the secretion from an infecting sore. A pimple followed the inoculation. At the expiration of a month the pinipL.' was still there, and was surrounded by a faint-brown, copper-coloured eruption. These spots occupied a diameter of about six inches, and faded ultimately of their own accord. No other local or constitutional aftectiou appeared as the result of the inoculation. A modified syphilitic eruption, confined to the neighbourhood of a second inoculation on a patient previously s}^hilitic, is not uncommon. It is not unfrequently observed in women of the lower class. A sj-philitic affection, presenting the distinc- tive characters of the primary' infecting sore, more or less modi- fied, will appear perhaps on some portion of the skin, and after a comparatively short interval an eruption will follow, confined to within a few inches of the modified inoculation. Any general mercurial influence is scarcely required for such affections. Plate 6, fig. 11, represents an indurated sore which was made to suppurate artificially. Fig. 12 represents the inoculation from that sore, and fig. 12a the inoculation second in order. The drawings were made on the eighth and ninth days respec- tively, and show the inoculations already fading awaj'. Some- times, however, especially after the lapse of time, inoculations on a patient previously syphilitic may run much the same course, and be followed by the same symptoms as if the -patient had not previously had syphilis. A gentleman had a sj^hilitic sore, which was followed by a general eruption on the skin. He then passed two years in the "West Indies. xVfter this he * The inoculation of ordinary pus will, in certain states of a patient's consti- tution, bo followed by a well-developed pustule. Plalje . 6 rrritatal -aijSxoateA sere i: cidcUwri. /r-0"h uif ohmt on, die th^h if''' day 'roadatwn second/ xn ar^- ■w3A0a JJtH Jf » N HABHAR r HCP INOCULATION MODIFIED BY PREVIOUS DISEASE. 441 returned liome, \ritli the faint brown stains of the eruption still visible. lu London he contracted fresh disease. Two well-formed indurated and circular chancres presented themselves on the glans penis. In a few weeks these were followed by a well-marked crop of syphilitic lepra, of a bright copper colour, and quite distinct in appearance from the brown stains of the first eruption. When a second infection occurs in this way after the lapse of some years, it is not in general attended with the same amount of enlargement of the inguinal glands, but something- like the usual period of incubation exists between the appli- cation of the poison and the appearance of the symptoms. There can now be no doubt that a patient's constitution may so far become free from the consequences of a syphihtic infection that, in exceptional cases, he may become infected a second time, and that the fresh infection may then run its natural course much in the same way as if no previous disease had existed ; such cases, however, are very rare. In general, if a second infection occurs, it is in a modified form ; and if it should be followed by any constitutional symj)toms, these present themselves also in a very mild manner. In patients whose constitutions are under the influence of syphilis the period of incubation of a second infection is as a rule comparatively short. Case. — A medical student became diseased for the first time in the year 1856. As soon as the sore appeared, and before it had become indurated, he inoculated some of the secretion on his own thigh. I saw him three or four days afterwards. There were then signs of irritation on the inoculated spot. This spot soon became converted into a small, hard, button-shaped sore, and then accurately resembled that from which the inoculated secretion had been taken. A small quantity of white lymph was at first visible in the inoculation, but both sores subsequently remained as small, hard, circular indurations, and fui'nished scarcely any secretion from tlieir surfaces. It would therefore appear — 1. That after a first infection, and before the induration has appeared, a patient is susceptible of being inoculated again with the same disease, from the same or from another source. 2. That after the induration has appeared he is no longer capa- ble of being inoculated with the infecting variety of the disease, except in cases where the inoculated matter is derived from a part which has been subject to considerable irritation, and that even then the inoculations produce comparatively little effect, and are not followed by any additional constitutional symptoms. 3. That after a certain time the effects of the first infection may, in a great measure, subside, ai;d that then a modified 442 SYPHILIS. form, of inoculation may take place, wliicli may be followed by fresb constitutional disease ; but that tliis also, when it does occur, apj)ears usually in a very modified form. 4. That this second infection is not likely to be accompanied by enlargement of the inguinal glands, 5. That the period of incubation of the second infection varies in inverse proportion to the degree in which the constitution is at the time influenced by previous disease. The various forms which have now been described in which syphilitic inoculation may be modified, often render the dia- gnosis of a case in its earl}'- stages very difficult. If a case be seen once only, some accidental complication is particularly liable to lead to an erroneous opinion ; but if the case be watched for a short time, there will seldom be any doubt as to its real natui'e. Nature is, as I believe, always true to herself, and if inter- rogated fairly, she will famish a faithful answer. But this answer is given at her own time and in her own way. If the surgeon demands an immediate response the first time he sees a syphilitic sore, he may be disappointed ; but if he will care- fully watch the course of the disease, he may with confidence rely upon the information he receives. If a persistent form of suppuration be established after inoculation, natural or arti- ficial, that disease is of the non-infecting kind, as far as the patient's constitution is concerned. If the adhesive form of inflammation be established, although after the lapse of some weeks, secondary symptoms will follow. If both kinds of in- flammation be present, then the patient has received a twofold inoculation, and each disease will run its course, modified, perhaps, by, but in spite of, the other. (Plate 4, fig. 7.) Twofold inoculation may occur either in the same or in different parts, at the same or at different times. When it occurs in the same part and at the same time, the results of the inoculation of the secretion from the suppurating sore will first develope themselves, and, subsequently, the results of the inoculation of the secretion from the infecting sore. This de- pends upon the different period of mcubation which naturally belongs respectively to each kind of disease. The cases which have led to the greatest confusion in prac- tice are those in which the inoculation of the secretion from a suppurating sore has followed, after the lapse of three or four weeks on the same spot, the inoculation from an infecting sore. TEANSMISSION OF SECOND AEY SYPliii.io. ^.o We have, then, the results of two kinds of action, and their respective products in close proximity. The suppurative in- flammation does not, then, jyr event the infection of the patient's constitution ; the adhesive inflammation does not prevent the appearance of the 'specific pustule.' The means of diagnosis, which would refer these mixed sores either to the infecting or to the suppurating class exclusively, are therefore absent. Although, in such cases, it may be very difiicult to form a correct diagnosis at once, yet by watching the course of the symptoms this may be done with much accuracy. CHAPTER yni. TRANSMISSION OF SECONDARY SYPHILIS. The contagious character of secondary syphilitic affections was generally admitted before the time of Hunter, In the experi- ments which he made he was led to the conclusion that the products of constitutional syphilis were ' not capable of acting in some respects on the same body or same state of constitu- tion as that matter does which is produced from a (primary) chancre.' He says that the secretion from a chancre generally when absorbed produces a bubo, but that we never find a bubo arising from a secondary syphilitic sore. When there is a venereal ulcer in the throat, no buboes appear in the glands of the neck. Venereal sores on the arms, or even suppurating nodes on the ulna, do not as a rule produce swelling of the axillary glands, although these will very certainly be affected if syphilitic matter from a primary chancre be inoculated on the skin of the arm. Again, when syphilitic blotches or nodes form on the legs and thighs, the specific affection of the glands in the groin, which accompanies primary infection, does not occur. These considerations so far biassed Hunter's mind, that he came to the conclusion that the secretions from the secondary syphilitic affections were not inoculable. He mentions, how- ever, that it was asserted in his day that ulcers in the mouths of children derived from constitutional and hereditary disease, produced the same disease upon the nipples of women who suckled them. That is, the children were contaminated either by their mothers or fathers ; the child received the disease by SYPHILIS. hereditary descent ; and the nurse was infected by the child. ' If,' Hunter observes, ' it were possible to contaminate once in this way, it would be possible to contaminate for ever. How far the observations upon which the before-mentioned opinion is founded have been made with sufficient accuracy I know not.' As has been aheady pointed out, Hunter committed the grave error, in which he was eagerly followed by a host of subse- quent writers, of supposing, because the syphilitic poison was not inoculable as a rule upon the person who produced it, that, therefore, it was not inoculable upon a person who had not previously had the disease. Experiments and observations have now been made with sufficient accuracy, and repeated a sufficient number of times, to show that the circumstances contemplated by Hunter actu- ally do exist, and that syphilis may be communicated in this way, and that it may be so communicated from one patient to another an unlimited number of times, so long as the poison is brought in contact with a person not previously infected. With the increased light which modern investigations have shed upon this subject, it is not uninteresting to contemplate some of Hunter's o-wn cases. A child was supposed to liave infected its nurse -witli sypUlis. The parents had been mai-ried about twelve years. The mother fell into a weakly state of health, and miscarried of hor third child at the end of five months. The fourth child came at seven months, but was puny, wealc, and had hardly any cuticle when born. It was immediately after birth attacked with a violent disorder of the bowels, so as to purge blood. It died in a few days and was opened by Hunter. The whole skin was almost one excoriated surface. The intestines were much inflamed and thickened. With her fifth child, from great care, this patient went eight months, and it was hoped she might go her full time, and also that this child might be more healthy than the former. "When she was delivered the child was very thin, but free from any visible complaint. Some days after birth, it became blistered in a vast number of places on its body. These blisters were filled with a kind of matter which broke and dis- charged a thinnish pus. The inside of the mouth was in the same condition. About three weeks after its birth it died. Some weeks after the death of the child, the nurse's nipple, and the ring round the nipple, inflamed, and sores or ulcers were formed with a circumscribed base. They were poulticed, but without benefit. She also complained of a sore throat, but the sensation she complained of was so low in the throat that nothing diseased could be seen. A swelling took place in the glands of the arm-pit, but they did not suppurate. She applied to a physician, and from the account she gave he pronounced her disease to be venereal, and that she had ftiven suck to a fuiil child : and ordered ten boxes of mercurial ointment to be TEANSPLANTATION OF TEETH. 445 rubbed in on ber legs and thigbs, eight of -wbich bad been used when Iluntor saw ber, and tben ber mouth was become extremely sore. These circumstances came to the ears of the family, and an alarm took place. The husband went from surgeon to surgeon, and from physician to physician, to Icnow if it was possible for him to have the disease for fourteen years, and never to have perceived a single symptom of it in all that time : or if it was possible be could get children with the disease now, when the two first were healthy. He also wanted to Icnow if it was possible for his wife to have caught the disease from him under such circumstances ; and also, if she could breed children with this disease, although she herself never had a single symptom of it. Hunter ordered hemlock, but that appeared to have no effect. While this was going on, eruptions broke out on the skin. The skin of the bands and lingers peeled off, the nails of both fingers and toes separated, and sores formed about their roots, which were all supposed to be venereal. She looked dejected and sallow. She was desired to go into an hospital, which she did. As soon as she got into a warm bed, and had good wholesome food, she began to mend, and in about five or six weeks she had got fat and almost well, the sore only about the root of the nail of the great toe had not healed ; but that appeared now to be owing to the root of the nail being detached, therefore acting as an extraneous body. She came out of the hospital before this toe had got well, and by returning to her old poor mode of living the soreness in the mouth returned ; however, she mended in the end without the use of more mercury. Had not Hunter been deceived by bis own experiments and come to the conclusion that constitutional disease could not be communicated by contact, sucb instances as he has himself related must have led him to a different conclusion. The following cases are among those which he has recorded, in which the disease was supposed to have been produced by the transplantation of teeth : A young lady had a tooth transplanted, and the tooth fastened extremely well. It continued firm for about a month, when the gum began to ulcerate, leaving the tooth and socket bare. The ulcer continued, and blotches appeared upon the skin, and ulcers also in the throat. The disease was treated as venereal, and the symptoms disappeared, but they recurred several times after very severe courses of mercury. She at last got well. A gentleman had a tooth transplanted, and the tooth remained without giving the least disturbance for about a month. The edge of the gum then began to ulcerate, and the ulceration went ou until the tooth dropped out. Some time afterwards, spots appeared almost everywhere on the skin. lie was put under a course of mercury, and all disease disappeared. Some time after, the same appearances returned, with the addition of swelling in the bones of the meta- carpus. He was now put under another course of mercury more severe than the former, and in the usual time all the symptoms again disappeared. Several months after, the same eruptions came out again, but not in so great a degree as before, and without any otlier attendant symptoms. He a third time took mercury, but it was only ten grains of corrosive sublimate in the whole, and he got quite well. The time between his first taking mercury and his being cured was a space of three years. 446 SYPHILIS. In the Medical Traixsactions of the College of Phi/sicians of Lonchn, published in the year 178o, Dr. "William Watson, at that time the vice-president of the Eoyal Societ}-, gives an account of the case of a young immanied lady, about twenty-one years of age, who had a tooth transplanted into the socket of one of the incisors of the upper jaw. The new tooth fastened exceedingly well. It remained firm for a month, when her mouth became veiy painful. The gimi became ulcerated, and part of the alveolar process was left bare. Before another month, the ulceration occupied the whole space under the upper lip, between the teeth and nose. It extended likewise to the cheeks and throat. Blotches then appeared on her face, neck, and various parts of the body ; several of these became ulcerated painful sores. After trying a variety of tonic medicines without benefit, two grains of calomel were ordered once or twice a day. She took about fourteen pills when she was obliged to discontinue the use of the calomel, on account of the griping and purging. During the time that she was taking the pills the ulcerations of her mouth and cheeks did not spread, but were less painful, and of a milder appeai-ance. The blotches on her face and body grew paler, and such of them as had ulcerated healed apace, and no new ones appeared. The mercurial inunction was now tried, but in ten or twelve days the griping and purging returned, and the ointment was discontinued. The good eflects of the mercury were, however, Dr. Watson observes, very apparent. The blotches all disappeared ; the ulcerations in her face and body completely healed, and those of the mouth nearly so. A portion of the alveolar process subsequently exfoliated, and ultimately the patient died. Dr. Watson remarks, tliat the progress of this disease not being impeded by the most powerful antiseptics, and its giving way to mercurials, even in small doses, cannot but suggest that the disease was truly venereal. At the time that such cases as the above were recorded, had not the idea taken possession of some men's minds that absorp- tion of syphilitic poison under the circumstances was impossible, the diseases described would doubtless have been assigned to their right cause. In some of the cases care was taken to wipe the surface of the tooth before it was transplanted, and it was thought that by so doing, every chance of inoculation would be prevented, but a brief reflection on some of Hunter's own experiments is sufficient to show how futile such a notion is. In the experiments which Hunter performed of transplanting teeth and other parts from one animal to another, in was clearl}^ proved that each pai-t of a living being has its independent vitality, which it can maintain for a certain time independent of the rest. In the Museum of the College of Surgeons there is now a tooth which Hunter trans- planted into the comb of a cock. The tooth grew in its new situation, and when the cock died. Hunter injected the tooth through the bloodvessels of the cock. During the time that TEANSMISSION OF SECONDAEY SYPHILIS. 447 the tooth was withdrawn from its natural socket, and before it had acquired any fresh connection in its new bed, it main- tained its own vitality". Subsequently its bloodvessels com- municated freely with those of the cock, and their contents passed into each other. Now it has clearly been shoAvn that the blood of an infected person may, when inoculated, communicate syphilis. If, then, the tooth of an infected person be transplanted into the mouth of a person who never before has had the disease, the minute quantity of blood which it contains may be sufficient to infect the healthy person ; and it is quite clear that simply wiping the outside of the tooth would not j)revent such an occurrence. It is not, however, only the blood of an infected person, or the secretion of what are usually called secondary symptoms, which may become the means of communicating sjqphilis from a person constitutionally affected to one who has not previously had the disease. There is reason to believe that the secretion of any of the mucous membranes of a syphilitic patient when in a state of increased activity or of inflammation may produce the same effect. Dr. Marston, who has lately contributed a very valuable paper to the Medico-Chirunjical Transactions, has, by quite an original and independent series of observations, arrived at very much the same conclusions as myself upon this subject ; and his cases are the more valuable, since his opportunities as an army surgeon of ascertaining the exact condition of his patients dur- ing their illness and of observing them afterwards, are much greater than can ordinarily occur in private practice. The following are among Dr. Marston's cases : Two men were admitted into hospital with gonorrhoea, Br. A. and Gr. S. The men came to hospital within forty-eight hours of each other, and were placed in contiguous beds. Gr. S. went with the police, and pointed out the source of his contagion. Br. A. went upon the same en-and to the same house, and foimd the woman already removed. Gr. S. told me that, to their mutual surprise, they discovered that it was the same woman in each case. Both suf- fered from all the symptoms of gonorrhoea, and there was no suspicion to the contrary. Br. A. had suffered from syphilis before, Gr. S. never. After remaining in hospital a long time, Br. A. was discharged cured, and no further symptoms, so far as I could trace, appeared in his case, Gr. S.'s recovery was delayed from gleet and irritable bladder, for which instruments (No. 10 and 12) were used. They passed without difficulty, local tenderness, or haemorrhage. After appearing anaemic and in ill-health, Gr. S. had sore throat (ulcerated tonsils) and a guttural voice ; subsequently papules appeared on the inside of the lips and the buccal membrane, coincidently with psoriasis palmaris and 448 SYPHILIS. • nocturnal rheumatism.' The inguinal glands -were slightly enlarged symme- trically. For these symptoms he took iodides of mercury and potassium, with mercurial vapour batli, by Avhich means, after manj' relapses, he was cured. The case was shown to some surgeons, who, of coui'se, suggested a concealed chancre ('chancre larvi? ' of Ricord). I passed sounds, and tried to discover a localised induration, without avail. If anything, perhaps the canal was firmer and more swollen to the touch than usual. Some urethral discharge was ino- culated in the skin of thigh (at the time it was gleety and apparently prostatic secretion), without any effect. The woman in this case, I learnt from the civil surgeon, had a vaginal dis- charge, but no primary ulcer that he could find. She was, however, suffering from acne of the face and a cutaneous syphilide. Gr. C. five or six days after connexion, had urethral discharge, and was admitted as suffering under ' gonorrhoja ' by another medical officer. After the use of nitrate of silver injections and salines, as abortive treatment, he rapidly improved, but a slight gleet remained, for which the penis was blistered. This urethral discharge afterwards augmented in amount, and became most copious and purulent, and symptoms of cystitis set in. After having been in hospital eight weeks, he caine under my care. Upon the dorsum of the penis were two large, oval, indolent, indurated, raised lumps. To me they appeared chancres. The glands of both inguinal regions were passively enlarged. In answer to my questions, and without any suggestion whatever on my part as to their nature, he said, ' One has existed about forty-five, and the other about forty-six days, as near as I can tell. They gradually became and remained as you now see them, and they came, I think, from the discharge getting in contact with two sore places from which the skin had been removed after blistering.' In seventeen days both healed under the influence of mercury. I learn that a papular syphilide has since appeared upon the trunk. By a later report it appears that this man has again passed under treatment for marked anaemia, and ecthj-matous sores upon the extremities. Numerous cases similar to those of Dr. Marston liave occurred under my own observation. A surgeon in much practice in Tyburnia brought a young gentleman, who was supposed to have gonon-hoea only, for my opinion. There was a discharge from the urethra, but in addition there was a small circumscribed induration on one side at the junction of the glans with the prepuce. This was not accom- panied by any ulceration and might easily have escaped detection. There was in my mind no doubt as to the nature of the case, and I at once told the surgeon and the patient that secondary symptoms would follow. My prediction was but too surely verified. It is by no means always easy to say whence the secretion is derived which contains the infecting matter. I have lately had under my care three medical men, each of whom had become infected in their hands during their attendance upon midwifery cases. In one of these instances craniotomy liad been per- formed, and in attempting to extract the child the surgeon had his finger between the bones of the foetal head. A pain then occun-ed, and pressed the bones violently against the surgeon's finger ; an abrasion was the consequence. At the expiration of four weeks, a phagedasnic-looking sore, surrounded by induration, appeared on the finger at the part corresponding to tliat which had been injured by the foetal bones. This was followed by secondary symptoms, TRANSMISSION OF SECONDARY SYPHILIS. 449 with extreme depression. For several years, this gentleman was unable to attend to his business ; but ultimately his health was entirely restored by a course of calomel baths. In a second instance an indurated sore formed on the finger of a medical man, and his health was entirely broken down by the symptoms which followed. This case was complicated by the occurrence of secondary abscesses. In the third case, the surgeon would scarcely believe that the small irritable indurated spot which had formed on the side of his forefinger could have been, the original cause of his faihng health. The subsequent history of the case, however, fully revealed the real nature of the disease. The drawing (Plate 0, fig. 13) represents an indurated primary tubercle on the hand of another medical man, which was but too surely followed by secondary symptoms. Susan B., set 66, presented herself at Iving's College Hospital on October 24, 1853, with a seal}'', copper-coloured eruption raised above the surface of the skin, and having in some parts a tubercular appearance. She had also a well- defined and extensive indurated sore on the lip. She stated that she never had any venereal affection, and had given birth to twelve healthy children. Eighteen months before applpng to the hospital she had noticed a pimple on the inside of the upper lip, which contained a little clear fluid. This broke, and a small sore formed, which, however, again healed in about a month, leaving a circumscribed induration. Three weeks ago the sore again broke out, and gradually extended until the date of her application at the hospital. An eruption made its appearance between three and four months from the first com- mencement of the pimple on the lip, and this had continued to recur at intervals ever since. This old lady had taken her gi-anddaughter to nurse, and having become exceedingly fond of it, was in the habit of constantly kissing it. Her son, she knew, had suffered from some venereal disease five months previous to the birth of the child; her daughter-in-law had died a few days after her confine- ment, and had not suckled her infant, which was consequently brought up by hand. When the child was ten weeks old, some sores appeared on its tongue and lips. These were followed, a week afterwards, by an eruption on the nates, which was still visible when the grandmother applied at the hospital, and was clearly of a syphilitic nature. This woman might have, and probably often did, kiss her son with perfect impunity, but the sj'philitic poison appears to have acquired increased activity with the new life of the child, and with that increased activity to have become more readily communicable by contact. The wife of a missionary applied to me vdth her husband, on January 1, 1861. She was the mother of a healthy family, and until recently had enjoyed good health. She had kept a kind of home for destitute girls, and to one of these girls, who was subsequently known to have been a patient of the Lock Hospital, was entrusted the care of this person's baby. After the lapse of a certain time the baby had a well-marked syphilitic eruption on the body and nates, the mother remaining in the meantime quite healthy. Four months after the affection showed itself on the baby the mother had charac- teristic symptoms of secondary disease. I had an opportunity of tracing the course of the disease both in the child and in the mother ; but, although every effort was made, I could never discover how it was that the child first received the disease, or by what means it was communicated to the mother. But the whole of the circumstances left no doubt whatever on the minds of any who witnessed the case that the disease had been given, by the girl who was taken VOL. I. G G 450 SYPHILIS. into the missionary's family, to the baby, and that it was commimicated by the child to its mother — an interval of four months having occurred between the first appearance of the symptoms in the child and in the mother. One of the most interesting cases proving the inoculiibility of the secretion from a syphilitic patient, is one that occurred to Hunter himself, and which from being misinterpreted led many subsequent waiters to doubt its accuracy. It, however, shows clearly enough that the initated and inflamed mucous membrane of the urethra may furnish at the same time a secretion resembling that of a simple gonorrhoea, and also the poison which will give rise to an infecting chancre. Hunter inoculated himself on a Friday with matter from a patient supposed to be suiFering from gonorrhoea. On the Sunday following there was a sense of itching which continued imtil the Tuesday. The inoculated part now appeared as a speck, was red and thickened. By the Tuesday following the speck had increased and discharged some matter. Caustic was applied and the sore healed, but four months afterwards it broke out again. It healed and opened again several times. A swelling took place in the right groin. This was followed by an ulcer on the tonsil and copper-coloured blotches on the skin. The disease recurred more than once on the tonsil and on the skin, and was ultimately cured by mercury at the expiration of three years. The same disease which Hunter conveyed to himself in the secretion from the inflamed mucous membrane of the urethra, may readily be communicated by the secretion from the diseased mucous membrane of the mouth in syphilitic patients. The commimication of the infection from one adult to another by the same means is not very uncommon. A yoimg woman had an eruption which was supposed to be syphilitic. Upon being questioned upon the subject she indignantly denied the possibility of such being the case. When I saw the eruption, and the accompanying sore throat, I had no doubt whatever as to its specific nature. I found on the tongue a raised, circular, hard lump, and the submaxillary lymphatic glands were in a state of chronic indui'ation. This patient submitted to an examination. There was no enlargement of the glands in the groin, and the hymen was perfect. Upon enquiry it was ascertained that this patient was in the habit of using the same spoons as another servant who was known to have a syphilitic afi'ection of the mouth. The mode of entrance of the syphilitic poison in this case was indicated by the persistent induration on the tongue, and by' the corresponding chronic multiple enlargement of the submaxillary lymphatic glands. A yoimg gentleman about to be married had a well-marked circular in- duration, superficially excoriated, on his tongue. The submaxillary lymphatic glands were in a state of chronic indolent enlargement. The patient maintained that his symptoms could not be syphilitic, but admitted, upon being closely questioned, that he might have caught the disease on his tongue from the lips of an infected person. The nature of the disease was fully proved by the appearance, in a short time, of a very well-marked general syphilitic eruption. M. Eollet has recorded a very striking case in which the disease was trans- mitted by the mouth from one individual to another, and from him to a third. A. S. had primary syphilis in 1858, followed by a papular syphilitic eruption, and excoriations on the lips. This patient was a glass blower, and in his occu- pation passed the tube through which he blew to another workman who carried on the process. TRANSMISSION OF SECONDARY SYPHILIS. 451 This second worknaan had in October a hard lump the size of a cherry stoae on the anterior surface of the right side of the lower lip. The corresponding lymphatic glands became specifically affected, and on December 10 he had ulceration of the throat. This patient passed the tube in his tm-n, after he had done his part, to another workman (F. G.) who completed the process. This third workman in December had several ulcerations on his lips, and a mucous tubercle at the back of the throat with pain in swallowing. The following case was communicated to me by Dr. Marstoii, to wliom I am mucli indebted for many valuable suggestions in reference to the present subject. ' A gentleman was suffering from symptoms of constitutional syphilis. Besides other symptoms, he had some fissures and epithelial ulcers upon the inside and angles of the lips. These were certainly not primary, but a part of the secondary symptoms under which he was suffering. He stated that he feared he might have infected a female, by labial contact. From the nature of her symptoms I inferred that his fears were well grounded. In due course of time, this female suffered from constitutional syphilis, and was treated for such by some eminent professional men. ' The first symptom in her was an irritable-looking and indolent fissure upon the mucous membrane of the lower lip.' M. RoUet is of opinion that a gonorrhoea in a syphilitic pa- tient will not communicate syphilis. In this opinion he is probably correct, inasmuch as we know that the products of other morbid poisons, when inoculated from a syphilitic patient,. wiU produce only the specific disease in which they originated. But the case is very different when a purulent discharge originates or is continued in a syphilitic patient, independent of any adventitious cause. This secretion may then, without any distinctly recognised form of secondary syphilis, communicate the specific morbid action in which it had its origin. The viscid muco- purulent discharge which flows from the neck of the uterus in a state of chronic inflammation, m a syphilitic patient, may, doubtless, communicate a discharge (not necessarily gonor- rhoeal) to a man, and that discharge may be the means of convey- ing syphilitic infection. In the cases of this nature which have fallen under my own observation I have thought the discharge more viscid and tenacious than that of ordinary gonorrhoea, not accompanied by the same amount of ardor urina3, and of shorter duration. But it is evident that a twofold disease, each of a specific nature, viz. a real gonoiThcea and a genuine syphilitic infec- tion, may in this way be conveyed. This point is well illus- trated by the following case. On May, 6, 1861, I received the O G 2 452 • SYPHILIS. following in a letter from a weU-informed surgeon in large practice : ' Mr. came to me in the middle of February, with acute gonorrhoea, which -R'as relieved by ordinary treatment in about five weeks. ' Early in Api-il, nearly six weeks after I had seen him, a sore appeared on the prepuce, which I thought was an excoriation produced by the gonorrhoeal discharge. After a few local applications this healed, but after healing it became surrounded with an indurated circumference, which makes me suspect venereal mischief.' In due course this induration was followed by well-marked secondary symp- toms. The natural secretions of tlie body, when the structures pro- ducing them are in a healthy state, cannot, in my opinion, be the means of communicating s}^hilis to another person, although the patient from whom these secretions are derived be constitutionally syphilitic. The following case may illus- trate this subject: A married woman was admitted into St. George's Hospital, on October 5, 1864. After her last confinement (having been previously quite healthy), she took a child to nui'se in addition to her own. The strange child proved syphi- litic. The woman had an ulcer on the breast, represented in the accompany- ing di'awing. This was followed by a well-marked syphilitic eruption. (See Plate 7, fig. 14.) This woman had taken the precaution to keep each child to one breast ; and, although her own cliild was allowed to suck for six weeks after the eruption had appeared, yet it remained imafiected. We have here the natural secretion going on in a syphilitic mother ; the organ itself, which produced it, not being specifi- cally affected. We have the constant contact of a diseased and healthy person, and the transmission of the secretion from one to the other, and yet no disease is imparted. Few of the natural secretions of the human body have been •accused of being the means of communicating sj^ihilis. The saliva and the semen are perhaps, besides the milk, the only two which are supposed to be capable of transmitting the disease. There is no reason why these secretions in themselves should be more susceptible of the syphilitic poison than any of the other natural secretions of the body. If the organs which secrete them are not specifically affected, we cannot see why they should be more likely to contain the syphilitic poison than the urine or the bile. Now, all these secretions, before they pass out of the body, liave to pass over tracts of mucous membrane. These j^ortions of mucous membrane are peculiarly liable to secondary syphilitic affections ; and, if the secretions in question become mixed in their passage with the products of specific inflammation, we may Fwl4 Plate.?. >'• 1^.15. nosyphdis ''■) HAGS :.ITS -,oadon LonSmann & C° U & B BAUBJilLI iKP. HEEEDITARY SYPHILIS. 453 readily understand how they may be the means of carrying the disease, although, by themselves, they may have no power of communicating it. The fitful and uncertain way in which syphilis is imparted by hereditary transmission from the father, and the very small number of cases in which it has been sup- posed to be transmitted by the saliva, seem to point rather to some accidental causes of contamination than to any inherent disease in the semen or in the saliva in syphilitic subjects. Such accidental causes at once present themselves to our minds when we contemplate the admixture of the diseased secretions of the mucous membranes with the proper secretions of the glands. The conclusions to which I have arrived myself, and which I would submit for the consideration of others, are : 1. That the infectious form of syphilis is communicated by the secretions from both primary and secondary syphilitic affec- tions. 2. That the secretion of other specific diseases existing in syphilitic subjects (including the specific syphilitic pustule, and the sores which result from it) have no power of imparting constitutional syphilis. 3. That the natural secretions of glands in syphilitic subjects, when those glands are not themselves specifically diseased, have no power of imparting constitutional syphilis. CHAPTER IX. HEREDITART TRANSMISSION OF DISEASE : VACCINO-STPHILITIC INOCULATION. If it be true that a patient is generally liable to syphilitic in- fection once only in his lifetime, the question presents itself with much point, how far a person who has had sj^hilis by hereditary transmission is protected from any fresh attack of the same nature. Several cases have lately come under my notice in which the effects of hereditary syphilis have manifested themselves as the patients were approaching puberty ; and it is more than probable that if the visible effects of the disease can remain so long in a patient's constitution, its more subtle and secret in- fluences may continue to a much later period. It is a point of very grave moment to determine how far such an influence derived by hereditary descent may have the same effect in pre- 454 SYPHILIS. venting tlie re-inoculation of sjpliilitic matter, as it is weU known that acquired syphilis has. Whatever may have been the cause of the failure of the in- oculation, where the products of secondary syphilitic affections have been artificially introduced into the system of those, who were said not previously to have had the disease, it is obvious that one link in the chain of evidence has hitherto been wanting in those cases. In order to be of any real value in demonstrating the non- inoculability of secondary syphilis, it would be necessar}- to show that the patients upon whom the experiments were made were susceptible oi 'primary syphilitic inoculation. If in any case it were found that a patient showed no syphilitic symptoms after being repeatedly inoculated with the secretions from secondary sj'philitic affections, and if afterwards the inoculation of the secretion from a primary infecting sore gave rise in him to an infecting chancre, then we might say that such an experiment was of some value in proving the non-inoculability of secondary disease. But until the susceptibility of a j^atient's constitution to syphilitic infection from any source is thus demonstrated, the negative evidence derived from his not being susceptible to in- fection from any particular form of disease is of little moment. Among those who habitually expose themselves to syphilitic infection, it occurs every now and then that an individual is found who never has had the infecting form of the disease ; and the question naturally arises — Why has he not suffered in the same way as others who have been similarly exposed? The answer which would generally be given to such a question would probably be, that it depended upon some peculiarity in the per- son's constitution. But we are bound, if possible, to ascertain and determine, as far as may be, what that peculiarity of consti- tution is. If we say that a patient can have sj^hilis once only during his lifetime as a rule, and if we find that a certain number of children have hereditary sy|)hilis, does it not appear probable that these childi'eu, when they grow up, would have some kind of immunity from further infection ; or that, if the disease did appear again in them, it would be in a greatly modified form? Modern researches in this branch of science bring us back to that which shrewd observers, without the advantages which we at present possess, had long ago noted. In 1812, Dr. Fergu- son came to the conclusion that syphilis had become so much mitigated in Portugal, by reason of general diffusion or other HEREDITAEY SYPHILIS. 455 causes, that after running a mild course it exhausted itself, and ceased spontaneously. Dr. Ferguson further mentioned that he had reason to believe that at that time, in other countries, the disease had become modified in a similar way. He mentions that in certain German regiments, and in some districts of the Russian empire, the medical attendants had found that mercury was not necessary for the treatment of syphilis, and that in the patients to whom he referred, the disease from being allowed to run its course probably for ages, had become as weak as it was found to be in the Portuguese. All adventitious diseases, says Dr. Ferguson, that are not connate, endemic, nor sporadic, appear more or less to run this course of exhausting themselves while retained upon the same ground to which they have been trans- planted; but let the field be changed, and fresh sources of development be presented, and they will instantly resume their primary powers, and, taking a fresh departure of violence, repeat the almost forgotten inflictions of their original visitation. The powers which they thus acquire bear some resemblance to a phenomenon which is everywhere observable in the vegetable kingdom. The same species of seed may be sown upon the same ground until it shall so degenerate in point of vigour, as to become almost incapable of reproducing itself; but let it be changed to any other kind of soil, though even of far inferior quality, and it will immediately display new powers of life, and fructify and vegetate with its native strength. Corresponding with this description appears to have been the effect of inoculation of the exhausted syphilitic virus of Portugal into the constitution of the British or other strangers. It was in some measiu'e new, therefore unfriendly, and seems to have had the power of exciting new actions of more than ordinary violence. The Portuguese, through apathy, and at a dreadful price levied on the generations that are passed, and never in all probability to be redeemed by their descendants, appear to have gained a great exemption from both syphilis and variola ; but the price is too high for us ever to offer up our bodies to be the unresisting subjects of disease, the fatal consequences of which, though they might go far to extinguish one or two ills, would be felt in the deterioration of our race to the most distant ages. The same facts, with regard to the modified form in which syphihs appears in some of the lower classes of the community, have been observed in our own country. Mr. Rose, formerly surgeon to St. George's Hospital, found 456 SYPHILIS. from experiments conducted at one time on a large scale in one of the regiments of tlie Guards, that he could treat syphilis "when it appeared amongst the common soldiers by topical applications alone. It is true, that at the time Mr. Eose conducted his experiments, no clear distinction was drawn between those syphilitic affections which, if left to themselves, would infect the constitutions of the patients, and those which would not ; and, therefore, a great many sores were, no doubt, said to be cured without mercury which, under no circum- stances, would have been followed by secondary symptoms. It is exceedingly probable, however, that a certain proportion of the cases treated by Mr. Eose really depended upon the infect- ing variety of the disease ; and as Mr. Eose found that he could deal with these cases without administering mercm-y, we can only conclude that the disease he was treating had appeared in some modified form, such as Dr. Ferguson had noticed in Portugal, and such as he states to have existed also in Germany and in Eussia. As soon as Mr. Eose tried his plan of treating syphilis without mercury amongst the officers of the regiment in which his experiments had been made, the plan was found to be unsuccessful ; and we have the authority of Sir Benjamin Brodie, who witnessed these experiments, for stating that, in private, Mr. Eose treated syphilis with mercury like other medical practitioners ; and that in cases where he did not administer it, he was continually becoming involved in diffi- culties. To what, then, is to be attributed this comparative immunity to the severer forms of acquired syphilis, and the modified form in which it has been occasionally noticed, not only in Portugal, in Germany, in Eussia, but also in our own country? The answer to this important question arises out of the observations already made. That which Dr. Ferguson observed in his day may be seen at present. A person who has had hereditary syphilis in his youth wiU either not contract the infecting form of syphilis in after life, or will have it in a modified form. An extensive observation of cases as they occur in public hospitals will at once show that syphilis as it presents itself among those classes who are likely to have inherited the disease, is a different affection from that which is observed under other cir- cumstances. The same law may be traced in the history of individual cases. Instances have come before me where HEEEDITAEY SYPHILIS. 467 patients, the offspring of parents supposed to have been syphilitic, have shown some modified syphilitic symptoms for many years after they have grown up ; and these patients have appeared insusceptible to any further infection. But it may be said that certain individuals, who have never shown any symptoms of either hereditary or acquired disease, are also apparently not capable of receiving the infecting form of syphilis, or, if infected, that they have the disease in so mild a form as not to reqiiire mercurial treatment. The explanation of the occurrence of even these cases is not difficult. An instance lately came under my notice, where a woman with the remains of what I believed to be a syphilitic eruption, had been impregnated ten times. Seven of the children had died, either from the premature confinement of the mother, or within a year or two after their birth ; of the remaining children, two had eruptions which were treated with mercury, and one only never had had any symptom of hereditary disease. Shall we say, in this exceptional case, that because the visible symptoms of any hereditary affection were wanting, therefore something like the same diathesis was not communicated to her, as to the other children ? Or are we quite sure that hereditary syphilis, like gout and certain other diseases, may not pass over some individuals, or even a generation (as far as its sensible effects are concerned), again to appear in some modified form in their descendants ? It would obviously be wrong, in the case of any hereditary disease, to say, because the symptoms were absent in an individual, or in one generation, that therefore the dia- thesis had ceased ; and we know not yet through how many generations the latent effects of hereditary syphilis may not produce some influence. A man advanced in years, whom I knew from seeing him in a London hospital, and who had formerly had a variety of venereal affections, had a grown-up family. One of his daughters had an eruption on the skin at about seventeen or eighteen years of age, which eruption was treated with sarsaparilla. One of the sons, although he had frequently exposed himself to contagion, never contracted the infecting form of syphilis. This son married, and had a family.. After a time his wife had an eruption on the body which was supposed to be syphilitic, and yielded readily to antisyphilitic remedies. Last of all, the son himself had an eruption exactly resembling that of his wife. This I had an opportunity of 458 SYPHILIS. seeing, and believe it to have been a mild and modified form of hereditary S}q)liilis, -wliicli bad tben developed itself in a visible form fur tlie first time. Had this son been one of Mr. Rose's patients, he no doubt would have been successfully treated with- out mercuiy ; but it would be a grave mistake to suppose that sjrphilis in what has been called a virgin constitution can be treated in the same way. Case. A yoimg •woman had an eruption for tlie first tinie after tlie age of puberty. This I considered to be sy]Ailitic. The origin of the syphiUs could, however, in no way be traced, until one day I accidentally saw the mother ; the eruption on the mother's arm and on the daughter's chest are represented in Plate 8, figs. 16 and 17. Several cases have come before me during the last few years in which symptoms to all appearance syphilitic could only be explained by hereditary transmission. In some of these there was a distinct history of syphilis on the father's side. Dr. Viennois, in his thesis presented to the Faculty of Med- icine in Paris in the year 1860, and also in the Archives of Medicine for the same year, has collected together and given a detailed account of some cases in which an infecting syphilitic sore, or, more proj)erly speaking, the specific adhesive inflamma- tion, followed vaccination. Dr. Viennois has carefully excluded those cases in which a fresh set of symptoms followed vaccina- tion in patients who had previously had hereditary or acquired syphilis, and has confined himself to cases in which the primary affections could be clearly verified, and their effects upon the constitutions of the patients satisfactorily traced. Dr. Viennois' investigations led him to the belief that, if the lymph from a vaccine vesicle be alone inoculated, the cow-pox alone will be produced ; but that if, in addition to this, the blood of a person affected with constitutional syphilis be inoculated at the same time, then syphilis may also be communicated. The cow-pox would then appear first, as havmg a shorter period of incubation ; and after a time the syphilitic tubercle (or primary specific inflammation) would make its appearance upon the inoculated jDart, and would in due course be followed by second- ary symptoms. The cases which Dr. Viennois has collected are related with so many circumstantial details, that, if con-ectly reported, they cannot fail of themselves to establish the fact that the poison of syphilis, and that of the cow-pox, may be communicated, and sometimes have been communicated, at the same time. : en itau/fMAT w •f-^'^'v \ SASS V.TE YACCmO-SYPHILITIC INOCULATION. 459 During tlie period of doubt and suspense wliich followed Dr. Viennois' publi- cations, two most remarkable circumstances took place. One of these was an artificial inoculation performed at the Hotel Dieu ; and the other the transmis- sion of a disease, both by artificial inoculation and by natural means, to a large number of children, and to several adults at Ivivalta in Piedmont. These cir- cumstances have occurred at the exact time in the history of syphilitic inocula- tion best calculated to dissipate the doubts which still hung over so many minds, and the S3'mptoms which they present will, I believe, if faii-ly inter- preted, satisfy every unprejudiced enquirer. The first of these remarkable facts occurred in a woman eighteen years of age, who was admitted into the Hotel Dieu, imder M, Trousseau. This woman was vaccinated while in the hospital, in the beginning of October. The day after the vaccination the punctures were prominent, and surrounded by a slight inflammatory areola, with intense itching. Four or five days afterwards there were no longer any traces of the inoculation. This excited no surprise at the time, as the patient had previously been properly vaccinated. The patient left the hospital on November 9. In the beginning of December, two ulcers, covered with thick scabs, were seen on the inoculated spots. These ulcerations were at first con- sidered to be vaccine vesicles abnormally developed, with an unusually pro- longed period of incubation. On January 11, 18(32, upwai'ds of three months from the date of the vaccination, this patient was re-admitted into the Hotel Dieu. At this period the ulcerations on the arm were still unhealed ; the corresponding arm-pit was the seat of multiple indolent bubo ; and on the body, the arms, and the chin, was a syphilitic roseola, concerning the nature of which no one has hitherto expressed any doubt. The patient reported that this eruption had existed from the middle of December. It was followed by pains in the head, and indolent enlargement of the post-cervical glands. M. Ricord now examines the patient at M. Trousseau's invitation, and reports that she is the subject of two indurated chancres on the left arm ; that she has multiple enlargement of the glands in the axilla ; and that she has specific roseola, typical of constitutional syphilis. This constitutional aflectiou he moreover declares to have had its origin, its entrance into the patient's system, through the ulcerations on the left arm. A much more startling series of facts have comparatively recently been brought to light by a sad tragedy enacted at Rivalta. Here a child, named Chiabrera, was vaccinated ; from him another child, name Mazone, was vacci- nated ; with forty-five other children. Chiabrera we shall call the first vac- cinifer, and Mazone the second vaccinifer. A disease was conveyed from the first vaccinifer to thirty-nine children; from the second vaccinifer to seven children. Both vaccinifers were very ill, and one died three months after vaccination. The first vaccinifer communicated the disease to his mother ; the second to his wet-nurse. Twenty nm-ses or mothers were known to have been similarly aftected. In three cases the same disease was again communicated from the mothers to their husbands ; and in three other cases the disease was commimicated to other, previously healthy, children. The annexed diagram furnishes a view of the progress of this terrible malady, previously (as would appear) unknown at Rivalta, a village containing not more than two thousand inhabitants : 460 SYPHILIS. 1 First vaccinifer. I Communicated the disease to 2nd vaccinifer. His mother. . I . Communicated the disease to His wet-nurse. To 7 other children. Thii-ty-nine other children. Communicated the disease to Eighteen other mothers or Three other children, not nurses. vaccinated. From the care and attention that have been given in England to the subject of vaccination, vaccino-sjphilitic inoculation is extremely rare. I have never witnessed an example of the kind, but am able with Dr. Druitt's permission to reproduce the drawing of a case which he saw in Paris. It is represented in Plate 7, fig. 15, and shows the results of the inoculations and the secondary eruption as thev existed at the same time. A second series of cases of a like hon-ible nature to those which occurred at Eivalta, is related by Dr. Marone to have happened at Lupara. Dr. Marone ascribes the cause of the in- oculation to the admixture of some blood Avith the vaccine lymph, and this is the explanation which is now generally received. It has been demonstrated by direct experiment that the blood of a syphilitic patient (in certain states of the constitution) may be directly inoculated so as to produce a primary syphilitic sore. On February 6, 18G2, Professor Pelizzari inoculated Dr. Bargioni with the blood of a sj'philitic patient, who had not been subject to any specific treat- ment. On the morning of March .^, Dr. Bargioni announced to Professor Pelizzari that in the centre of the inoculated surface he had noticed a trifling elevation which produced a little itching. Professor Pelizzari examined the arm, and found, at the point indicated, a small papule, of a roundish form, and of a dull- red colour. There was then no induration at the base of the papule, nor any enlargement of the coiTesponding axillary glands. To prevent its being rubbed, it was covered with some dry charpie and diachylon. Professor Pelizzari exa- mined it daily. On the eighth day the papule had augmented to the size of a twenty-centime piece. On the eleventh day it was covered with a very thin adherent scale, resembling silver paper, which, upon the two succeeding days, became denser and less adherent, and in its central part commenced to crack. \ CONSTITUTIONAL SYPHILIS. 461 On the fourteentli d, 1856, this man had con- nection. Upon May 18 following he was admitted into hospital with a glan- dular swelling in each groin, lie discovered afterwards tliat two soldiers had caught a venereal aflection from the same woman. There were many glands affected in both groins, and one upon the left side inflamed and threatened suppuration, and was opened by caustic potash. Subsequently, an abscess appeared in the right groin, and was similarly treated. No sore of any kind existed on the penis, nor was there any urethral discharge, or cicatrix, or mark on the penis. Six weeks aftex-wards he suliered from a red rash over the whole VOL. I. II 482 SYPHILIS. body, and the skin came off in scales. This exanthem was followed by the appearance of numerous pustules, and iritis of the right eye. For these symptoms he was treated by mercurials for a fortnight, but his mouth was not affected. He subsequently took large quantities of iodides in the decoct, sarsfe. comp. At the end of two months he was discharged cured (?). About seven or ten days afterwards he was re-admitted with ' rheumatism in all his bones,' particularly the legs. The rheumatism prevented him sleeping at night. After about four months' further treatment he was discharged cured, but he has never enjoyed the health he had before these attacks. In the beginning of 1858 his teeth began to decay in the most curious manner. A dark spot would first appear upon the front aspect of the enamel, close to the gum. The lateral incisors of the upper jaw were first affected, and disease of the remaining front teeth speedily followed. This discoloured spot became the seat of caries, and a minute circular hole resulted, situated in the middle line of the tooth, bordering upon the gum. The disease in each tooth gradually advanced from before backwards, extending laterally at the same time, and making its way in a very definite manner, until the line of caries passed through the tooth, and severed it at its jimction with the fang. He has lost the upper teeth in this way. The two central incisors, however, are not quite destroyed ; the disease in these has nearly severed the crown from the fang. The lower teeth have commenced to be affected in a similar manner. A line of caries has appeared upon the incisor and canine teeth, exactly at the jimction of the crown and fang, and threatens their destruction. Dr. Marston informs me tliat lie has seen this very peculiar disease of the teeth follow the same course in tw^o other cases. He directs attention to an interesting paper, read June 25, 1862, by Dr. Roberts of Manchester, upon two cases of double facial paralysis, apparently due to syphilitic disease, wherein there was a curious destruction of the teeth ; and he refers to a similar case by the late Dr. Todd, in his volume of Clinical Lectures uioon Nervous Diseases. Diseases of periosteum, hones, and joints. — Perhaps the most important of all these tertiary affections are those which attack the bones and their coverings. They may be included under the heads of periostitis, acute and chronic ; nodes and exostoses ; inflammation of bone ; caries and necrosis. Acute periostitis is a rather rare result of syphilis ; but when it occurs, it is apt to be extensive and destructive. Chro- nic periostitis is very common. It is attended with great pain at nig-ht, and aching at every change of temperature or weather. The interior as well as the surface of bones may be affected. The cancellous structure becomes thickened, condensed, and often much harder than natural. Fixed and long-continued pain in the bone, without much tenderness of its surface, may TEETIARY SYPHILIS. 483 characterise this condition. The pain appears to arise from the pressure produced by the increased formation of bone, and is relieved, often permanently, by making an opening through the crust of the bone with a trephine. No fluid is found in the interior of the bone on these occasions. Caries and necrosis of bone occur as tertiary forms of syphilis in the same parts as from other causes; the former in the can- cellous structure, and the latter in the shafts of long bones or the dense parts of others. Necrosis is generallj the result of acute periostitis. Caries is almost always produced by an extension of ulcerative action from soft parts to the bones. Thus, the bones of the ear are often affected by ulceration of the cartilage or lining membrane of the meatus ; the bones of the palate, from ulceration of the mucous membrane lining it ; the bones of joints, from ulceration of the surrounding soft struc- tures. It is very rare for caries, to begin as a primary disease, at least in tertiary syphilis. During this ulceration of bone, serious destruction may take place. Joints may be disintegrated, the organs of hearing lost, and the bones of the nose or palate de- stroyed. The bones of the skull are usually affected in their outer and middle tables only. The diploe becomes filled with bony matter, and then ulcerates or dies. Sometimes, although rarely, the inner table is affected to a greater extent than the outer or middle. Effusion may then take place between the bone and dura mater, and the disease may extend by continuity of action to the brain. The brain may then become affected with red softening, and a part of it be ultimately softened down to the consistence of cream. In these cases it is the surface of the brain which is primarily affected ; but in those cases where the brain has been supposed to be affected independently of the bones, some of the central portions, such as the corpora striata, are the parts that have been found softened. Syphilitic orchitis will be more fully described under the head of diseases of the testicles. The course of the disease is remark- ably slow and indolent, lasting for years, unless remedies have been applied ; sometimes, as Dr. Wilks has well pointed out, the- testicle may atrophy, from absorption of the effused material, and come to resemble a form of cirrhosis — as a firm alveolated- looking fibroid tissue, from the shrinking of the organ, thicken- ing of the tunica albuginea, and the disposition of the atrophied remains of the spermatic ducts, and the fibrous processes from the fibrous investment. The sexual desires are not changed, I I 2 484 SYPHILIS. unless in very clironic cases, or wlien the state last described has affected both organs. The dej^osit usually occurs in the body of the testicle. Circular nodules of a yellowish-white material may be found dispersed through the substance of the organ or collected in one mass. At other times, according to Lancereaux, radiating bands of a tendmous appearance, starting from the thickened tunica albuginea, traverse a part or the whole of the thickness of the organ, insinuate themselves between the seminiferous canaliculi, and compress and separate them one from the other. The organ may then undergo a true fibro-fatty change. Dr. Lancereaux has, under the head of gummy deposits, given a description of syphilitic affections of a great variety of internal organs. The deposits which he describes are sometimes ex- tensive and comparable to the chronic phlegmasise ; sometimes limited and circumscribed. These deposits appear in the form of nodules or tubercles, and it is to this condition that the term * gummy tumour ' is particularly applied. Dr. Wilks has also given an admirable description of them as they occur in muscles, in the lungs, liver and spleen, in different parts of the nervous system, and in other internal organs. The limits of this essay preclude the possibility of tracing here the peculiar- ities which syphilitic disease presents in these different parts. The ahsorhent glands are very frequently enlarged in tertiary syphilis. The condition of those situated in the upper and back part of the neck has, by many eminent writers, been re- garded as diagnostic of a patient's system being affected with syj)hilis, or otherwise. But the absorbent glands are generally only affected in secondary and tertiary syphilis, in consequence of disease in the parts from whence they have their origin. It very frequently indeed happens, both in primary and secondarj^ syphilis, that there is a sore upon some part of the head, and then the posterior cervical glands will be enlarged ; but if the sore be confined to one side only (as, for instance, a chronic ulceration on one cheek), then the cervical glands will be enlarged only on that side. Treatment of Tertiary Syphilis. The same general remedies are used for this so-called tertiary, as for the secondary forms of syphilis. Patients labouring under tertiary syphilis have, however, often undergone more than one course of mercury, im^Derfectly administered perhaps, TEEATMENT OF TEETIAEY SYPHILIS. 485 or tlae effects of which may have been ill-regulated. In the great majority of cases, any further prolonged exhibition of mercury internally is out of the question. Iodide of potassium, sarsaparilla, bark, the mineral acids, and opium, are therefore the remedies most generally used. The iodide of potassium is an excellent remedy in many forms of tertiary syphilitic ulceration, in cases of enlarged glands, and in syphilitic affections of the bones. From, three to five grains of this medicine three times a day v^^ill seldom fail to relieve the pain of a syphilitic node within a few days. The benefits of sarsaparilla are most marked in those cases in which the patient's constitution has been debilitated by the abase of mercury, or where the bones have become affected with caries. In order, however, to obtain the remedial effects of this medicine, it should be given in sufficient quantity ; a pint of the decoction should be given daily, or half an ounce of the fluid extract three times a day, and continued for some weeks. The iodide of potassium may very conveniently be combined with any of the preparations of sarsaparilla. Bark, iron, and the mineral acids are all of use in restoring the strength of the patient, impaired either by the disease, or by the injudicious use of remedies ; and opium, by relieving pain and giving rest, will often prove most useful. But none of the medicines now mentioned will cure syphilis. Every form of this disease may ultimately be cured by the unassisted powers of nature, and the remedies above mentioned may render much assistance ; and some of them, especially the iodide of potassium, have great influence in removing particular symptoms, but they do not cure the disease. The only medicine which can be considered as doing this is mercury ; but in the tertiary forms of disease this medicine can scarcely be administered internally, and in- unction is apt to be followed by troublesome pustules and ulcera- tions. Where other means fail, the slow imbibition of calomel through the skin affords an excellent means of introducing the medicine into a patient's constitution. If this remedy is really indicated, there is scarcely any condition in which it may not be used. In consequence of not interfering with the internal organs, it does not in any way increase the weakness under which the patient may be suffering, and may be given as a patient lies in bed. A large class of cases, in which a few years ago mercury was thought altogether inadmissible, are now habitually and effectually treated in this way. In the treat- 486 SYPHILIS. ment of tertiary sj'pliilis, the action required is less than in the secondary forms of the disease, but it should be maintained for an equal length of time. Ten grains of calomel, used with the fumigating-lamp, as described in the next chapter, are often sufficient ; and if there are any open sores, still less may some- times be used. Any of the usual tonics may of course be ad- ministered internally, at the same time that the patient is using mercurial fumigation. If the patient suffers much from per- spiration, the calomel may be volatilised with a slight flame without any Avater. In this way any increase of debility in consequence of the sweating will be avoided. In cases where a patient's constitution has not been impaired, other forms of mercury may occasionally be used. Some of these have been thought to be peculiarly adapted to one kind of affection, and some to another. Thus, for iritis calomel has generally been given internally, combined with opium. For the deep ulcer of the tonsils the bichloride of mercury has very often been prescribed ; and for eruptions on the sldn the proto-iodide of mercury has been most extensively employed. But, generally speaking, whatever may be done with these remedies, may also be effected by the imbibition of mercury through the skin ; and the adoption of this mode of treatment, when properly carried out. is attended with a great saving of the powers of the patient's constitution. CHAPTEE XII. ADMINISTRATION OP MEECUET. Three different ways of giving mercury have been recommended. 1. The administration of the medicine internally. 2. Its intro- duction into the patient's system through the skin, by means of mercurial frictions. 3. The use of mercurial vapour baths. 1. The blue pill is one of the most ordinary forms in which mercury is given. From three to five grains, combined with half a grain or a grain of opium, may be ordered two or three times a day. The hydrargyrum cum creta may be given in doses of from three to five grains, either alone or with an equal quantity of Dover's powder. Calomel, either alone or mixed with opium, or in the form of the red pill, may also be given in doses of from one to three ADMINISTRATION OF MEECURY. 487 grains two or three times a day. All these preparations of mercury, as well as those which have been previously mentioned, are very valuable remedies under certain circumstances. But where a sustained and continued action is required they are very apt to produce irritation of the digestive organs. Even when combined with opium, the internal use of mercury can seldom be continued as long as is desirable. It will be found in some way or other to affect the patients' constitutions inju- riously, and to make it extremely distasteful for them to con- tinue the course for a proper and necessary time. Mercury introduced into the stomach and intestines produces, as is well known, a powerful effect upon the liver. This doubt- less depends upon the blood from these parts being directly conveyed through the vena portse to that organ. Sir Ranald Martin, in his admirable work on the influence of tropical climates, observes, that mercury enters into intimate union with the elements of the blood, and that it must therefore modify its plasticity, and influence all the organic functions to which it is subservient. The parts upon which this influence expends itself, when mercury is given internally, are the liver ^ and intestines. Even robust and healthy persons can seldom bear any prolonged irritation of these organs with impunity ; and in patients of relaxed enfeebled habits, any sustained mercurial action which produces its priuiary and direct influence upon those parts is quite out of the question as a remedial measure. 2. Mercurial inunction is a very efiicient way of using mer- cury ; but is dirty, laborious, and often little suited to the taste of those who require its use. On this account, patients very frequently apply the remedy with great irregularity or even omit it altogether. It is, however, much less liable to produce griping and purging than when the drug is given internally, and the effect upon the constitution is not nearly so debilitating. When mercurial ointment is used, half a drachm or a drachm is rubbed into the inside of the thighs by the patient every night. This in winter is conveniently done before a fire. The ointment should be rubbed in until it disappears. The process will oc- cupy about half an hour, and the patient should wear some flannel drawers, and not wash the remains of the ointment off. • A case Las recently fallen under my observation in which a young gentle- man, after the prolonged use of mercury interually, died of jaundice, to the surprise of all hia fiiends. 488 SYPHILIS. The application of the ointment must be repeated every night until the gums become soft and slightly spongy; this is the best indication of the proper action of mercury upon the pa- tient's system, and the action should be maintained by regu- lating the quantity of ointment used, for six, seven, or eight weeks, according to circumstances. Many surgeons are in the habit of leaving off the mercury soon after the patient's gums are affected. According to the author's experience, this practice not only fails to cure the disease but actually does harm. The patient's constitution is weakened to a certain extent, and the disease is not cured ; but what is of more importance still is, that the secondary symptoms, when they do appear, are often of a worse and more intractable character than if no mercury had been given. There are two principal objects in view in treating a case of syphilis ; the first is to remove the symptoms, and the second to cure the disease. Now a short course of mercury will often effect the former of these two objects, as will also, in almost all secondary cases, the iodide of potassium ; but neither the short course of mercury, nor the iodide of potassium, will in general cure syphilis. The symptoms will, it is true, be removed, but they will return ; and practically it is found extremely difficult to induce patients, particularly in the upper classes of society, to continue a course of mercurial inunction sufficiently long to prevent the occurrence or the return of secondary syphilis. By introducing mercury into a patient's constitution by in- unction, its deleterious action upon internal organs is avoided. The amount absorbed into the blood produces its influence equally throughout the system, and is not conveyed direct to the liver, as when the medicine is administered internally. But great as the advantages of the inunction of mercury are as compared with its internal administration, it nevertheless is attended with certain inconveniences which prevent its very general use. The inunction of mercurial ointment, so as to insure the proper effect of the remedy, requires considerable labour and perseverance on the part of the patients, and it is with difficulty that they can be induced to continue its use for any length of time ; and sometimes it produces a troublesome pustular eruption on the skin. 3. Fumigation of the surface of the body by means of certain mercurial preparations possesses the advantages of inunction, without some of the objections to which this is liable. But, like MERCUEIAL FUMIGATION. 489 other modes of using mercur j, it was tried in a variety of ways before a safe and efficient mode of administration was adopted. In the years 1786-7, Mr. Pearson had a fumigating machine constructed according to the directions given by M. Lalonette. This apparatus, although it was thought to be new at the time, diiFered in no material respect from that described by Nicholas de Blegnyin the year 1683. Mr. Pearson made a considerable number of experiments with this fumigating machine, and found that the gums became turgid and tender very quickly, and that the local appearances were sooner removed than by the other modes of introducing mer- cury into the system. But, to counterbalance these advantages, it was found that the mode of treatment adopted induced de- bility, and that ptyalism was often excited rapidly, and at an early period. Mr. Pearson found that he was consequently obliged often to discontinue his course of treatment. Sir Benjamin Brodie's experience coincided with that of Mr. Pearson. He found that it was difficult to regulate the mercu- rial action ; and he observes that by using mercurial fumigation ' you may affect the system too much or too little ; and you may be taken unawares by the patient's gums becoming all at once excessively sore.' "^ From observations and comparative experiments which I made during the years 1855-6, 1 feel satisfied that the irregular results noticed by Mr. Pearson and Sir Benjamin Brodie, de- pended upon the difference in the chemical composition of the powder used for the purposes of fumigation, both before and after it was raised into a state of vapour. The gray oxide of mercury (the preparation generally used) varies much in colour as obtained at different shops. Some specimens will not vola- tilise at the temperature produced by an ordinary spirit-lamp under a metallic plate. Other specimens of a lighter colour volatilise quickly enough. When the darker specimens are sublimed, they are decomposed in a greater or less degree. A deutoxide of mercury is formed by the addition of an equiva- lent of oxygen from the air ; and if the temperature be much increased, then the oxygen is driven off altogether, and metallic mercury is sublimed. Under these circumstances, with a mer- curial preparation of uncertain composition, and undergoing different changes according to the degree of heat apj^lied, there is no wonder that very different effects should have been pro- * Lectures on Pathology and Surgei'y, p. 246. 490 SYPHILIS. duced in different eases. With some samples of the gray oxide it is necessary to use a considerable quantity of the powder in order to ensure any effect ; with other samples, a similar quan- tity produces much more action than is desirable. The gray colour of the powder depends upon the admixture of a certain proportion of calomel with the protoxide, and the temperature at which any particular specimen will volatilise will depend upon the relative proportions of the two. The bisulphuret of mercury, again, which has been extensively used for the purposes of fumigation, gives off, when exposed to heat, a vapour, pro- bably the sulphurous acid gas, which has sometimes caused very considerable irritation of the lungs ; and all forms of mercurial fumigation have, in consequence, by some, been con- demned. Now, all the inconveniences above-mentioned maybe avoided with certainty, by using a mercurial preparation which is always of the same chemical composition, which does not irritate the lungs, and which is not liable to be altered by an increase of temperature. Such a preparation is calomel. We have here a definite chemical compound. It is altered in composition neither by heat nor by moisture, and when used for the pur- poses of general fumigation may be relied upon to produce its action as certainly as any medicine administered internally. A very small quantity (as compared with the other mercui'ial preparations) will ensure the required effect, and this may be regulated and controlled with great precision. General calomel fumigation may be used in cases where the administration of mercury by other methods is inadmissible. On account of the small amount of calomel required, it may be used, sometimes with the greatest benefit, even where other modes of fumigation, requiring larger quantities of mercury, cannot be borne. Calomel appears to have been formerly used for the purposes of general fumigation, as well as other preparations of mercury. But it was used in the same quantities as those other prepara- tions, and was, therefore, open to some of the same objections as they are. M. Eapou published in Paris, in 1824, two volumes on Fumi- gations as employed in various diseases. The mercurial pre- parations which he recommended were cinnabar, Lalonette's mercurial powder (which consisted of a mixture of mercury and clay), calomel, and corrosive sublimate. 1 CALOMEL FUMIGATION. 491 The quantity used for the first three, he recommended to be from ' a quarter to half an ounce each time.' The amount of the corrosive sublimate, he says, should not exceed five or six grains. Even with these very large quantities, M. Eapou had only seen salivation produced in three instances, and these were of a very short continuance, and yielded to the use of ordinary baths. M. Rapou recommended the mercurial fumigations to be used with steam, which, he said, calmed the system, softened the skin, and did not prevent the absorption of the mercury. Mr. Langston Parker recommends an apparatus, for the use of which the patient is placed on a chair, and covered with an oil-cloth lined with flannel, which is supported by a proper framework. Under the chair are placed a copper bath containing from half a pint to a pint of water, and a tinned iron plate, on which is put from one to three drachms of the bisulphuret of mercury, or the same quantity of the gray oxide, or the bin- oxide, or other mercurial preparation ; under each of these is a spirit lamp. Now, all the methods of applying mercurial fumigation above mentioned required the use of a complicated apparatus, which private individuals cannot command. In order to adapt this method to general use, it was necessary so to modify the appa- ratus that anyone could use it in his own room ; and this has now been most effectually accomplished. The most convenient calomel vapour -bath, and that which is now generally used, is one which was made at my request by Mr. Blaise, In this apparatus the lamp which sublimes the calomel boils the water at the same time. In the centre of the top, im- mediately over the wick of the lamp, is a small, separate, circular tin plate, upon which the calo- mel is placed. Around this is a circular depres- sion, which may be one-third filled with boiling water. The apparatus is then placed on the ground, and the lamp is lighted. The patient sits over it, with an American cloth cloak, or a Mackintosh, or a moleskin cloak fastened round his neck. He thus becomes surrounded by calomel vapour, which he is generally directed to inhale for two or three separate minutes during each bath. In doing this the patient should not put his head under the cloak, but simply allow some of the vapour to escape from its upper part, and breathe it mixed with a large proportion of 492 SYPHILIS. common air. At the expiration of a quarter of an hour or twenty minutes the calomel is volatilised and the water has boiled away. A portion of the calomel is deposited, together with the condensed vapour of the steam, on the patient's body, and is there to be left. The quantity of spirits of wine used upon each occasion is so regulated that the lamp goes out of its own accord about the same time as the calomel disappears. The patient then gradually unfastens the cloak, and in about a minute he is sufficiently cool to put his night-dress on without much interfering with the very fine layer of calomel which covers his body. He must be particularly told not to wipe his skin, as by so doing he would necessarily interfere with the action of the medicine. Should there be no objection on the part of the patient, he may go to bed in the cloak and sleep in it either for a part or the whole of the night. Of all the modes of administering mercury, fumigation is that which is attended with the least demand upon the patient's con- stitution. The amount administered in this way can be regulated with the greatest facility ; and the action may be maintained without inconvenience for almost any length of time. On this account, as well as for other reasons, fumigation is, in my opinion, less liable to be followed by the recurrence of secondary symptoms than any other mode of treatment whatever ; and of all the kinds of mercurial fumigation, that by calomel is the safest and the most convenient, if not the most efficacious. The imbibition of the medicine through the skin prevents its injuri- ous action upon internal parts ; while the comparatively small quantity used, although quite sufficient to produce any amount of action that may be required, insures the patient against any sudden or violent effects. In this mode of using mercury, the whole of the skin may act as an absorbing surface ; and, when requisite, the effect may be still further increased by absorption from the mucous membrane of the nose, mouth, and bronchial tubes. In secondary sj^philitic disease, the surface of the body and the mucous membranes are peculiarly liable to be affected ; and the process of fumigation has here this great advantage, that the remedy is applied du-ectly to the diseased parts, and acts imme- diately upon them. When administered internally, it has, on the contrary, first to be absorbed into the blood, and carried the round of the circulation, perhaps more than once, before it comes into contact with the affected structures. Many old and intract- CALOMEL FUMIGATION. 493 able syphilitic ulcerations yield witli surprising rapidity to local calomel fumigation ; and there is no reason why the same prin- ciple should not be taken advantage of in treating the more general forms of the disease. Calomel alone, without the vapour of water, may be used, especially where the local action of the medicine alone is re- quired. But, from a series of comparative trials which were made in the early part of the year 1856, it became evident that, for the purposes of fumigation, it was advisable that a small amount of the vapour of water should be present. In the process of sublimation some free hydrochloric acid is given off, and the vapour of water so far dilutes this as to prevent its irritating the lungs. The syphilitic poison, in a very great majority of cases, pro- duces its principal effect upon the skin. Through this organ, nature attempts its elimination ; and a free secretion from the skin assists the action which nature has already commenced. It appears, from an extensive trial, that not only is the poison eliminated from the system more effectually where there is a free cutaneous action, but that under this condition the internal organs of the body are much less likely to be affected by the disease than under other circumstances. The calomel vapour-bath combines the various advantages now alluded to, and its great practical advantage is attributable : 1. To the small quantity of mercury which is required, when used in this way, in order to produce the requisite effect. 2. To the fact that the imbibition of the medicine through the skin leaves the digestive organs unirritated and the digestion unimj)aired. 3. To the cir- cumstance that there is something in the free secretion from the skin, which the combination of steam and calomel produces, that moderates and controls the mercurial action, and at the same time determines the secondary syphilitic actions to the surface of the body rather than to internal organs. The action of the calomel bath should generally be continued until all syphilitic symptoms have disappeared, and for a week or two afterwards. During the first few weeks the patient should not be subject to the influence of much fresh air, or to cold water, and when practicable should remain in the house. The bath should be given every night, and its effects may be regulated either by the quantity of calomel used upon each occasion, or by the amount of vapour which is inhaled. Within the first few days a slight tenderness, redness, and swelling of the gums will 494 SYPHILIS. indicate the mercurial action. This condition should, if possible, be sustained during the whole of the course; but it is not neces- sary to produce at any time a greater effect. The length of time during which this action is to be main- tained must vary considerably with individual cases ; a first course should seldom be less than from two to three months. The calomel vapour bath in its present form, introduced by the author in 1857, may now be said to have come into general use. One instrument maker, Mr. Blaise, has sold upwards of 2,700 lamps for the purpose. Local calomel fumigation. — But whilst the use of calomel fumi- gation over the whole body and with a view of producing a constitutional effect is so beneficial, its local employment is not less advantageous. Scarcely any case of local syphilitic disease occurs which cannot be benefited in a marked degree by it. And whatever objections there are to its becoming of extensive application, they do not arise from any want of success in the treatment, but from a difficulty in obtaining proper apparatus. Different kinds of apparatus have been used for local fu- migation. The calomel-fumigating lamp previously described answers the purpose extremely well. The vapour of calomel, being of very light specific gravity, ascends, and any part placed over it becomes coated with a very fine layer of calomel. This forms an excellent dressing for intractable ulcers, whether of a primary or secondary natiu'e. Tubes of various shapes have also been employed so as to direct the vapour of the calomel to particular parts. Thus, a long tube has been adapted to the calomel -lamp with a mouthpiece, for the purpose of inhalation in affections of the throat. A roll of paper has been often used with the same object. But it is evident that, as the calomel mixes with the air, the simple act of resj)iration does all that is required ; and as far as the throat is concerned, any tube is much more likely to detain the calomel, than to direct its course. It is often, however, convenient to direct the vapour of calomel to parts which cannot well be brought over an ordinary lamp, and then an additional apparatiis is necessary. A reference has already been made to the inhalation of the mercurial vapour for the purpose of accelerating its constitutional effect, but in all cases of secondary sore throat, particularly those in which iodide of potassium fails to effect a cure, the inhala- tion by its local influence is exceedingly beneficial. The inhala- tion may be effected in the manner already described, or if for CALOMEL FUMIGATION. 495 other reasons it is unnecessary or inconvenient to use the general bath, an apparatus similar to a steam inhaler, but provided with a lamp and basin for the calomel and water, may be employed. Such inhalation should not be continued for any length of time unless a constitutional result be desired. Four grains of calomel once or twice a day will generally be found sufficient to remove the disease. In cases of primary sores on the penis, an apparatus pro- vided with a tube caj)able of containing the whole organ is convenient. The use of the instrument may in these instances be continued sometimes for twenty minutes or more, and may be repeated daily or even more frequently till the sore is healed or at least furnishes a healthy innocuous secretion. In cases of suppurating bubo another form of apparatus must be employed. The instrument must be furnished with a tube expanded into a funnel-shaped termination, and when in use a piece of Macintosh should be wrapped round the instrument enclosing a space large enough to contain the whole of the dis- eased surfaces. The Macintosh, by its flexibility and facility for adaptation to irregular surfaces, eifectually retains the vapour in contact with the skin as long as may be necessary. In some instances it is desirable to use local calomel fumiga- tion to the arms and legs, and as the extremities are more easily isolated from the rest of the body, the employment of apparatus is attended with less inconvenience. A simple modification of an arm or hip bath is alone sufficient. There is little danger of pushing the remedy in this kind of exhibition far enough to produce a direct constitutional effect. Generally improvement is so rapid that as the course of fumiga- tion continues, its employment becomes less frequent until it is omitted altogether, HENRY LEE. TUMOURS AND CANCER. THE natural history of new growths in the human body has of late years been the subject of much research. Virchow, especially, and many contributors in this country to the Transac- tions of the Pathological and other Societies have extended our knowledge of it. But a complete description of these diseases is not even yet possible. However desirable for its scientific interest or for the improvement of treatment, material is still wanting for so full an account of them as would include their varieties, construction, and chemical composition, their intrinsic changes of increase, propagation and decay, their influence on surrounding parts and on the system at large, and their many causes. On some points, as on the etiology, there is almost everything to learn ; the classification and nomencla- ture of the several growths are at the moment uncertain and transitional ; and, with a consideration rather for convenience than for science, certain over-growths, which are allied to tu- mours but do not adopt their form, are arbitrarily excluded from that great surgical group of diseases. Accordingly the scope of the present essay is limited as well by the positive knowledge of the times as by the particular object of Surgery. To the many diseases comprised under the title. Tumours and Cancer, both sexes, all ages, and almost every region of the body are liable. While possessing many characters in common, these growths have yet most important practical distinctions amongst themselves. They are all additions to the substance of the organ from which they arise, and they con- sequently present themselves to first view as distorting its pro- portions. In most various degrees they also deviate from the construction of their parent texture, but with the uuvarjdng efi'ect of contributing nothing to the performance of its function. When once begun, they pursue a mode of life peculiar to themselves ; they grow or cease to grow independently of the regulating forces in the part from which they deviate, as well INTRODUCTION. 497 as of the increase, the wasting, or the ordinary maintenance of the rest of the body, and they pass through changes of their own which are unknown in healthy structures. Some of them are isolated by investing layers of tissue, which strictly divide between the perfect actions of the normal organ and the morbid processes within the tumour ; whilst others, not so limited, induce continuously their own disease in the surrounding natural parts. Most of them occur singly in the body, but sometimes they are multiple, in which case they may be either alike or of different kinds. When unlike, they are independent of one another, whether occurring in separate parts or even in the same organ ; but if there be more than one of the same nature, they arise with so much connection as to be restricted to a common region, or to similar though separate tissues, or there is an order in their successive development which shows the later to be dependent on the first. Surgical operations bring out marked differences in tumours, of which some show no tendency to return, whilst others, though operated on in the same manner, recur again and again. With this tendency to local recurrence there may also, or may not, be combined an original capacity of the growth to propagate itself in other dis- tant and dissimilar parts of the body. The distinction thus broadly indicated was of old expressed in the words tumour and cancer. In the theories of former times, interpreting such different clinical issues, it was assumed that the growths were of wholly different nature and origin, and the same difference was implied in the division of them into the innocent and the malignant. The one term expressed harmless- ness if the tumour were left, and curability if it were excised ; the other the converse of these propositions. Moreover, from the frequent return of the latter tumours after operation, and from their eventually implicating the system at large, a reflec- tion upon their original nature came to be included in the epithet malignant, to indicate that they distinctively had a constitutional source. Modern opinion tends far away from assigning such malignant characters exclusively to the cancers. A great distinction must still be maintained between the various tumours, but with their substantial unity they cannot be wholly studied apart. The classification of new growths by their anatomical cha- racters would certainly be the most satisfactory, both in ex- planation of the source, and as presaging the result of any VOL. I. K K 498 TUMOURS AND CANCER. tumour, if only its clinical progress were deducible from its texture. But, in fact, there is mucli overlapping of the quali- ties of different new growths, and between tumours and cancer especially, previously recognised distinctions become more and more obliterated by the extension of clinical and microscoi^ic study. Indeed scarcely any, if any, single ground exists on which they could be decisively distinguished from one another. On the one hand, tumours (as the cutaneous) maybe hereditary, may persistently increase (as do some of the fibro-cellular) without any apparent limit of growth, may recur (as the fatty) after threefold or fourfold excision, may be repeated (as the cartilaginous and cysto-cartilaginous) in organs apart from that in which the primary tumour arose, may (as the fibroid and cysto-sarcomatous) degenerate in texture while augment- ing in rate of growth in the course of rej^eated local repro- ductions, or may prove fatal. Cancer, on the other hand, may be true cancer, and yet devoid of any of these characters. Some instances may illustrate the qualities possessed in com- mon by innocent tumours and malignant cancers. Most of the former are single ; the latter, though single originally, are usually numerous at the time of death, and scattered in dif- ferent parts of the body. But there are cancers, as in the rectum and mamma, which remain single to the end of life ; and there are tumours of the innocent kind which mul- tiply. For instance, it is usual to regard a cartilaginous tumour as innocent; yet Paget and Otto von Weber have recorded examples in which a tumour strictly cartilaginous underwent dispersion in the body, and multiple secondary carti- laginous tumours formed in internal organs, which naturally contain no cartilage. By Mr. Paget the source of the pul- monary tumours was demonstrated ; the primary disease in the testicle having, in the manner of cancer, first infected the glands, from which a protruding enchondroma opened within the inferior vena cava, and doubtless shed fragments into the blood ascending to the lungs. In the same way I have found uterine veins filled with soft epithelial growths which were identical in external and in microscopic aj)pearance with multi- tudes of tumours scattered through the liver and the lungs. As the veins of the uterus pass into both the portal and the cava, whilst those of the testicle belong to the cava only, a mechanical conveyance of the respective new growths to the corresponding organs is manifest, and no difi'erence in the natures of enchondroma and cancer can be drawn from their INTEODUCTION. 499 dissemination. Even the most virulent of the cancers spreads in the same way. A man, having lost his eyeball, came into the Middlesex Hospital with a vast bleeding mass of soft cancer protruding from the orbit. On inspecting the globe of the eye with the tumour which had previously been removed, the recurrence was explained by the discovery of cancerous elements in the optic nerve up to the very point at which it had been divided in the operation. By a combined use of the knife, cautery, and caustic, Mr. De Morgan extirpated the whole contents of the orbit; the wound cicatrised, and the man was healthy for more than a year, but in the second year he died with palsy of the lower extremities. It was then found that a third medullary tumour had formed on the stump of the same optic nerve, within the base of the skull, and that far oif from it, within the spinal arachnoid, there were similar tumours of much smaller size adhering upon the point of the spinal cord and the roots of the lumbar and sacral nerves. Recurrence by continuity, as distinguished from constitutional reproduction, was clear in the three optic tumours ; and the peculiar position of the spinal tumours, together with the date and progress of the symptoms, showed those tumours to be but detached fragments of that within the skull, which had sunk in the fluid of the arachnoid, and had adhered and grown at its lower part. A few glands were found cancerous behind the arch of the aorta, but there was no disease in any internal organ from whicli a general tendency to cancer could be inferred. Such recurrence after operation, which is characteristic in cancer, may be paralleled in growths so simple that no one ascribes to them any malignity. Not to mention the import- ance of wholly extirpating cysts, I may refer to Mr. Curling's specimen of fatty tumour four times recurrent, in which Mr. De Morgan and Mr, Hulke ascertained that a fragment, com- posed of young and growing fibrous tissue, had been left in the wound. Thus in recurrence and in mechanical dispersion dif- ferent tumours are alike. The source of new growths is the natural textures. Some tumours obviously are extravagant and disorderly overgrowths of normal parts, as when the fang of a tooth exceeds by four or five times the size of the tooth itself. Whether deviating little or much, therefore, from the parent texture, tumours bear traces of that element of an organ in which they originated. Each texture would thus appear to have its own tumour, and cell, fibre, and nucleus respectively be capable, like an ovum, of overgrowth. Hence, on the one hand, wholly dif- ferent new growths, both innocent and malignant, may coexist in separate tissues or organs of the same person ; and, on the other hand, there occur no inconsequent developments, as of brain into bone, or of skin from an exostosis. The tumours arising in similar organs are alike. This rule a])- KK 2 500 TUMOURS AND CANCEE. plies not only to parallel organs, as a right mamma and a left, but to those also of separate persons, when one is but rudimental. Thus scirrhous, or cystic, or fibroplastic disease presents the same character, whether it occur in the female mamma or the male mammilla ; the prostate has its fibro- muscular tumour equally with its homologue, the uterus ; and there is correspondence in the tumours of the testicle and the ovary. There are, however, tumours which do not resemble any part of the organ in which they lie. Of such it may be said, that a tumour unlike its seat comes from elsewhere. And this in one of two ways. Either it originates in a structure proper to one region, but dislocated into another during growth, of which there is an instance in the cartilage capping an exostosis of the shaft of the femur or tibia near the knee ; or it has escaped from a kindred morbid growth, and has travelled and rooted itself in a different soil. Cystic tumours growing in the lungs after castration of a cystic testicle, melanotic masses staining halves of organs by pigment derived from a black tumour of the skin, or scirrhus from a cancerous mamma appearing in the compact part of a femur, are some of many examples of foreign and transplanted tumours. It should be added that changes within a tumour in the course of grovrth or degeneration may obliterate almost every trace of its first textural character, and that in some rare instances the same effect may be more completely produced by the supervention of cancer in a tumour originally of a different nature. Of all questions relating to tumours, the causes are perhaps the least known. They are numerous, and more so perhaps than even the growths themselves. Either they operate primarily in the texture which is the source of the tumour, or they are such as can act upon it. Tumours thus severally caused might therefore be named spontaneous or induced. A cyst, for instance, would arise from one or the other of such causes, according as it depended on altered osmosis through its walls, or on obstruc- tion of an excretory duct. But in the production of tumours a more important distinction must be recognised according as they result from an external cause, or from one within the body, which internal one may be either distal or intrinsic. Tumours are traceable to an external cause, when it directly produces overgrowth of one or more of the suffering textures. In this manner pressure leads to the formation of a bursa, that is, of a hypertrophied and condensed state of all the parts pressed on, and the permanent maintenance of fluid within them, INTRODUCTION. 501 with possibly a fibrous tumour. And in this manner also may a growth of the natural connective tissue of the cerebral substance into a ' gliomatous ' tumour be accounted for, a rough bony projection into the substance of the brain beneath an old frac- ture of the skull inducing overgrowth by the ceaseless move- ments of the hemisphere against it at every pulse and respiration. The production of tumours by a cause which influences the misgrowing texture from within is less easy to approach. Much must here be assigned to the original power of each part of the body to outgrow its proportion to the adjacent parts, and to mul- tiply indefinitely, as do bosses of wood on the trunks of trees, when once it has escaped from the usual neighbourly restraints. Considering, however, the great activity put forth by some of the natural organs in the fulfilment of their functions, and still more the energy of the ovum, it is not difiicult to understand the power residing in textures, when misdirected, to form textural tumours. Spontaneous overgrowth sometimes presents itself in a rapid develoj)ment of epithelioma, when local efforts toward the healing of an open wound have continued for a long time, and have been unsuccessful ; or when in a mole, or near a scar, or at any region where dissimilar tissues in close contact act and react upon one another, cancer at length springs up. Such causes may be called local internal, or intrinsic, causes. There appear to be others also which are internal, but which depend on a more profound relationship of organs and textures to one another, and even act from a distance on the part in which the tumour grows. This last provocation of one organ to morbid growing by another organ remote from it, is conceivable only as reflected through nerves, and is deducible only from clinical evidence. The influence of nerves upon textures is illustrated in many ways ; sometimes in the nutritive decay of an organ ill supported by nervous force, and oftener perhaps, as in the stringed pustules of Herpes Zoster, by inflammatory changes. The neuromas which cluster along a nerve, or the fatty tumours forming in a single limb, might well be traced to such a cause, and indeed Van der Kolk once concluded respecting a cancerous tumour that it was due to nervous influence. That which is true of direct nervous excitement of a texture is likely to be equally true of an incitement reflected on it. Nerves resjjond to distant irritation with remarkable precision, and as by their intervention organs remote from one another do mutu- ally control and adapt their normal functions, so are the nerves capable of propagating a morbid influence. The well-known 502 TTJMOUES AND CANCER. effect, for instance, of gastric disturbance upon the moutli sug- gests tlie order of causation of such of the ej)ithelial cancers of the tongue, fauces, and lips as have not a local origin ; but the influence of the uterus over the breast is the most prominent instance, both of the normal control of one organ over another, and of the source of some mammary tumours, including cancers, in i^rolonged uterine ailment. Nerves indeed furnish the only means by which moral feelings and emotions can exercise their acknowledged influence over the tissues, whether to suppress or excite a secretion, or to call up, as in the instance of grief, a morbid growth. Of other once_ rej^uted causes, for instance, of a constitiitional origin particularly of cancer, none now command the general opinion, which is rather led in the estima- tion of them by more and more extensive physical research. The liability to new growths is partly determined by age. Some arise during the development of organs, but many more in the period of their involution. The tumours then usually differ in nature with the state of the organ at the time of their forma- tion. Those are the most active which begin during growth ; in completed organs they are, as anile, slower but still innocent; wdiile the malignant belong to parts of which the functions are waning. There are occasional exceptions to these usual rules. Thus Mr. Nunn recently had in his practice a case of ordinary but rather rapid epithelioma of the lip and cervical glands at so early an age as twenty-five ; and, on the contrary, I removed a very large cystosarcoma of five years' growth with the breast of a woman aged seventy-five. The rule of sex appears to be more decisive than that of age. With greater functional capacity the female generative organs are more exposed to tumours than those of the male sex, and indeed so excessive is this liability that women present many more tumours of both kinds than men, although particular growths and especially cutaneous cancers are more numerous in the male sex. In the composition of a grown tumour there are parts which are accidental, as well as those which are essential. Blood and various pigments and liquids are sometimes superadded to the original tumour, and assume by their colour and other effects an undue importance. The essential parts of the tumoiu* are the living and active. The decaying part or the dead may accumulate in it, or be harmlessly eliminated, but by the living part increase of the tumour takes place, sometimes interstitially, as in the soft cancers, sometimes on the exterior only, as in INTEODUCTION. 503 the rodent, and sometimes by a wavelike advance and return of growth, as in scirrlius. This part alone maintains the original character of the tumour, both while remaining in its primary seat, and when disseminated. The difference here indicated is shown in some innocent tumours, as well as in the cancers. Either may shed mere used-up surplusage or their own living elements. From the skin of a toothed mole within an ovarian cyst there were shed in ten rears into the cavity of the cyst seven pounds in weight of epithelium and hair. Probably no change took place in this stuff after it had been cast ; it lay harmless in the cyst, and only accumula- ting. But besides this refuse matter Avithin the cyst, there were other living cysts, some still in the thickened wall of the parent cyst, and others wholly apart from it in the peritoneum. So from some tumours dead changeless matters may be shed, and even from some cancers nothing else ; but from cancers generally, and from some tumours having other names, there pass off ele- ments which are equivalent to the cystic progeny of that ovarian cyst itself, not to its cast debris. Such elements, shed while alive, grow independently of that which produced them, and equally after its death or removal, and whether also they remain in their original place or be carried elsewhere with the movable fluids. The tissues composing innocent tiimours approach so nearly a perfection of growth as enables them, like the part they occupy, to endure, and some tumours having reached a certain size cease thenceforth to grow any more. But there is no such vital stability or such term of growth in the malignant tumours. Some indeed of their component substance, as the bony and fibrous case of medullary cancers, might live on, for their texture is true fibre and true bone. But the older elements of most cancers ulcerate, or wither, or die, and thus either remain unchanged among the more active parts, or slougL out and leave cavities where once was a healthy organ. The cancer, living still, survives only in its youngest part. The chief points of difference between tumours are set forth in the special descriptions which follow, but the diagnosis is facilitated by a methodical enquiry into the various particulars., Some of these can be noted at the first glance, and the eye often guides an experienced practitioner to facts which spare the patient a prolonged manual examination. Age and sex suggest many probabilities as to the nature of a tumour. Observance 504 TUMOUES AND CANCEE. of region narrows the investigation to such tumours as can occur in structures known to exist therein. Study of form, magnitude, absolute or varying size, pulsation and bruit, vas- cular aspect, colour, and relation to indigenous parts, now indicates and now excludes a tumour of a particular nature. Eegard to the number of growths and the relation of those which are multiple to one another, further reduces the possible kinds of tumour which may be under examination. The history, both as to duration and as to foregone changes, some- times clears up a difficulty, as when too brief existence distin- guishes from cancer the pitted skin over a dense n^ass of suppu- ration. But the most trustworthy evidence is that obtained by the sense of touch, to educate and to rely on which is most im- portant. Too often the statements of a patient are inconsistent with other apparent facts of his case, when the discrepancy may be decisivel}^ settled by an exact touch. By it an appearance of connection between tumours may be dissipated, as of chronic mammary with axillar}" hydatid. By it the broad distinction between solid and fluid tumours is usually easily made, the density of the one contrasting with the imjsressible or fluctuating character of the other. The wave of fluid in a tumour struck on one side and felt on the other loses distinctness as the tumour lessens in size, increases in tenseness, is divided by par- titions, is deejDly seated, or is closely bound with soft surround- ing tissues. Thus hydatids and chronic abscesses become difiicult to distinguish, or varicocele within an unusually dense fascia, uterine and ovarian tumours, or a deeply seated and tense mammary cyst, Avhich acquires a deceptive granular exterior from the adhesion of the lobules around it. On the other hand, a tumour which is not a cyst may fluctuate from having a loose central texture infiltrated with liquid or with oil. Soft cancers may thus be almost more than elastic, and they are sometimes opened as abscesses ; and large fatty tumours within the abdomen have proved indistinguishable from fluctuating cysts. But, with all care in estimating the various indications of the nature of a tumour, it is sometimes impossible to ascer- tain those which would be decisive ; and it may be advisable to puncture with a fine trocar a tumour suspected to contain fluid, or even to take a small portion from one that is solid for exami- nation with the microscope. In most cases of doubt, however, the practical conclusion is often obvious enough without such preliminary investigation, that, whichever it be of alternative tumours, the growth may with equal propriety be removed. CYSTIC TUMOUES. 505 Compound or proliferous. Complex cystic. With intra-cystic growths. Cutaneous. Dentigerous. TUMOURS. The subjoined classification of the non-malignant tumours will be here followed : I. Cystic tumours ; cysts. A. Simple or barren. B. Serous ; hygromata. Synovial. Mucous. Sanguineous. Oily. Colloid. Seminal. II. Solid tumours and outgrowths. Fatty; adipose. Neuralgic. Fibro- cellular; connec- Pulsating, tive - tissue ; glioma ; Floating, myxoma. Phantom. Fibrous ; fibro-muscular ; fibro-nucleated ; fibro- plastic. Cartilaginous ; fibro-carti- laginous ; mixed. Myeloid. Osseous. Glandular. Vascular. Recurrent; Sarcoma. Cystic tumours consist essentially of abnormal cysts, sacs, or bags, filled with fluid or other substance produced by secretion or growth from their walls. Some appear to be formed by the increase and coalition of spaces in the connective or other tissues, in which spaces fluid accumulates, and becomes gra- dually encysted by the definition and more distinct organisation of its boundaries. Such is, (1) probably, the origin of many synovial or bursal cysts, and of some cysts in tumours. But (2) many more cystic tumours are formed by the morbid growth of natui-al ducts, or sacculi. Such are many mucous, sebaceous, and other cysts, 3. Some are protruded portions of a serous 506 TUMOUES. membrane, which. sej)arate from that membrane by closure of their canal of communication, in the way which is natural in the case of the tunica vaginalis testis. Thus, closed cysts, sjnnmeti'ically placed outside the femoral rings, appear to be detached portions of peritoneum. Others, which once commu- nicated with the sub-arachnoid cavity through a bifid spine, are severed from it in later life by the union of the arches of the yertebrse. And (4) many are due to the enormous growth of ele- mentary structures which increase from the form of cells or nu- clei, and become sacculi with organised walls capable of secre- ting or producing other growths. After this brief indication of the general modes of origin, by one or other of which it is probable that all abnormal cysts are derived, the pathology and surgery of each kind may be more fully considered. Serous cysts, simple and barren, are probably the most numer- ous of the whole class. The name may include such as have been named hygroma, meliceris, and many forms of hydrocele ; and, generally, all the cystic tumours which have thinly liquid or honeylike contents of yellow, brownish, or other tint, not \ ery different in consistence from serum of blood. They may occur in almost any part of the body. By far their most frequent seats are in or near glands or gland-like structures, as the kidneys, the thyroid, the mammary gland,* the labial, and others ; but they are not rare in the subcutaneous tissue, especially of the neck and trunk ; they may be found too in nerves, in bone, in muscle, &c. In the neck they have been often described as ' hydroceles of the neck.' The most frequent serous cysts have their membranous walls white and moderately vascular, formed of connective tissue, usually too firmly connected with the surrounding parts to be easily detached during life, and generally lined with a tesselated epithelium, or a nucleated membrane. Such serous cysts may be single, or multiple and clustered ; hundreds, even, may be col- lected in one part or place, and may either communicate freely, or be merely collected in one mass of tissue. Their contents may be, and most of them are, like ordinary serum ; but they may be thick and honey-like; or may have various tints of green, olive, brown, ruddy, or red ; or they may glisten with * The special characters of the cysts in each organ will be described in the parts devoted to the surgery of the thyroid, mammaiy, and other glands, &c. SEROUS CYSTS. 507 crystals of cliolestearine ; or may have fibrine, and coagulate on removal: and as yet no relation or correspondence can be traced between the cyst-walls and their contents ; there is no such variety in the former as in the latter. No general rule can be stated concerning the origin, manner, or rate of development and growth of serous cysts. Of those that are of chief importance in surgical practice, some seem to originate in transformations of the structures of nsevi, and are traced to the time of birth or earliest childhood ; some, as the ovarian, beginning in enlargement of Graafian vesicles, are diseases of puberty or later life ; some, again, as the mammary, are most apt to originate during or after the time of natural degeneracy of the milk-glands. To many others no date at all can be assigned. With the exception of the ovarian, those grow largest which begin in youth, and sjoread in loose tissues, as in the axilla. The increase of most others is moderate, and they may long remain stationary. For the diagnosis of serous cysts seated in external parts these are the chief facts to be remembered. They are usually regular, well-defined swellings ; smooth, round, oval, or, more rarely, lobed ; movable with, not in, the surrounding and ge- nerally healthy or only wasted parts ; painless ; covered with healthy integument. In some situations they are translucent. Where they are large and not very tensely filled, they may give the sensation of perfect to-and-fro fluctuation; but in many instances, especially in the mammary gland and by the gums, they are so tensely filled, that the detection of fluid must rather be by their admitting of deep central pressure, and instantly recoiling as the pressure is withdrawn. By one or other test of fluid, its presence can be generally ascertained. The diagnosis is made more probable if the tumour that has these characters be in the neck, the mammary gland, or the gums ; if, in the first situation, it had its origin in some congenital error ; or if, in the second, it was first noticed during or near middle age, or can be partially emptied through the nipple. The diseases most likely to be confounded with serous cysts are the softer kinds of solid tumours, as the glandular, fibro- cellular, soft cartilaginous, &c. ; abscesses, especially the chronic; and cystic tumours of other kinds. For lielj) in the diagnosis from solid tumours, the characters related above may be com- pared with those that will be assigned jjresently to each kind of tumour ; but chiefly the detection of fluctuation, or of the 508 TUMOUES. ^ yielding and immediate recoil of fluid, must be relied on. Serous cysts assume tlie characters of a solid tumour, when deeply seated and tensely filled and rendered uneven by the close adhesion of rough surrounding textures. From acute abscess, the diagnosis is usually made clear by the pain, and other signs of active inflammation ; from chronic, Avith more difficulty, by the walls of the abscess being usually thicker, harder, and less pliant, so that the borders feel much denser than the central part. From other barren cysts, the diagnosis may depend wholly on the localities in which they are severally found ; but this will be generally sufficient. The treatment of serous cysts must greatly vary in dififerent cases. Referring here to none but those in external parts, some are too large and involve too many and important parts for curative treatment, but any m ay be punctured, Avhether for help to diagnosis or for beginning treatment ; puncture alone, how- ever, is very rarely curative, though it may be successful when followed by a chilling lotion or by pressure. Some may be cured by external irritation ; those in the mammary gland are com- monly thus curable, either before or after tapping ; with others the same remedy more often fails. Iodine injections are often successful, especially for serous cysts in or near the thyroid gland. Setons may succeed where these have failed, but they are apt to inflame the cyst too much, and with very large cysts may be dangerous. The cysts by the gums are best treated by being widely laid open, and either cauterised within or filled with lint, so that they may freely suppurate. Those in bones may be treated in the same way ; and similar means may be used, if milder measures fail, for any that are not too perilous by size or depth. Complete excision is rarely necessary for simple serous cysts, for such portions as may be left wiU granulate and scar. But if the cysts be multiple and clus- tered, it is not sufficient to remove some of them : those which are left entire will continue to increase. Hence the occasional necessity of removing a whole mammary gland con- taining many cysts. The not rare connection of clustered serous cysts with venous nsevi explains the serious bleeding which some- times occurs during their excision, and which had better be anti- cipated in operations on those in the neck or near any large veins. The prognosis of serous cysts is generally favourable. Once closed or cut away, no further mischief is likely to ensue. Yet MUCOUS CYSTS. SANGUINEOUS CYSTS. 509 in some cases great caution is neeessarj : for, in the breast, a coincidence, apparently accidental, of cystic disease with cancer is not very rare ; in the neighbourhood of a large cyst, a small one may be overlooked, and may increase after a seeming cure ; and it has happened that a serous cyst, after being obliterated by treatment, has been found to be part of a medullary cancer which its size had concealed. Synovial cysts. (Diseases of Burs^.) Mucous cysts, including all that contain a fluid like mucus, are commonly derived either from cystic disease of so-called mucous glands, or from dilatation of obstructed ducts or reser- voirs. The chief of them are the Nabothian and Cowperian cysts, ranula, and cysts of the antrum, and of these it may suflice to say that their distinctive characters are like those of serous cysts, from which they differ only in the localities in which they are found. Where the one kind are rare, the other are common. As a rule, the sufficient treatment of mucous cysts is to lay them wide open, and then keep them open, or make them granulate : smaller measures are very rarely useful ; but particular methods must be adapted to each form or locality. The prognosis is very favourable, for mucous cysts do not appear in the complications with which the serous are sometimes found. They are, however, more difficult to obliterate, and even long after apparent cure may fill again. Sangxdneous cysts (hsematoceles of the neck, and of any parts other than the tunica vaginalis) are very nearly related to the serous ; differing only in their contents, in their occasional origin from violence, and in that they are usually single, never very numerous in a cluster. They are most frequent in the subcutaneous tissue in or near the neck or trunk, but not rarely they rise from the deeper part of a limb, and reach a large size. In such a position they are likely, even more than serous cysts, to be or to become the seat of medullary cancer, although, even when of large size, they may present on being opened and explored no trace of a solid growth. Their walls may be merely membranous, like those of the most frequent serous cysts ; but sometimes they are remarkably fasciculate within, not very unlike the interior of an auricle ; and sometimes they have minute cysts in their own substance. Those which are fascicu- 510 TUMOUES. late appear to be formed by unequal distension of the natural tissues. The distending force may be a rapidly secreted fluid, but it is sometimes due to the rupture of a blood-vessel. In this way a cyst was formed in the popliteal nerve which filled the ham, although it originated in a ruj)ture of the small artery and vein within the nerve.^ The blood in some sanguineous cysts is clotted and partially decolorised, or mixed liquid and clot ; in others it is liquid like ordinary venous blood, but coagulates when withdrawn. In the former case, it is probable that the blood is derived from an accidental haemorrhage into a serous cyst (as a hydrocele may be changed into a heematocele of the tunica vaginalis) ; in the latter case it is probable that the cyst has always contained blood, and has OAved its origin to some trans- formation of the structures of a nsevus, such as an enlargement and coalition of its venous canals or spaces. And this view is confirmed by the occasional existence of growths in which blood-cysts and nsevus are combined ; and of others in which veins are found opening into the cysts. The diagnosis of sanguineous cysts from solid tumours, and all diseases other than cysts, must rest on evidences similar to those already stated for distinguishing the serous cysts. From these a diagnosis without exploration may be impossible. Both alike may be congenital, or may first appear at any later period ; both may be connected with nsevi ; neither observes any definite rule of increase ; neither belongs especially to any one period or condition of life, though both alike commonly come under treatment before middle age. A sanguineous cyst communi- cating with a blood-vessel may in some positions be made to vary in size. The treatment of sanguineous cysts may resemble that of serous. Emptying by tapping is rarely successful, but may always be allowed the chance. Iodine or other stimulant injections may be tried ; and, these failing, the cysts must be laid open or removed, with due care for the free bleeding that may ensue in those that are connected with neevi. The growth of cancer does not appear to be accelerated by opening and obliterating the foregoing cyst. Oily and colloid cysts have too little practical importance to need more of statement than that the former may be found in the place either of cutaneous cysts or of dilated milk-tubes, and * Mcd.-Chir. Transactions, vol. xlix. p. 29. PEOLIFEEOUS CYSTS. 611 the latter in any place where a serous cyst may occur, but chiefly in the thyroid gland and kidney. These may, therefore, be passed by ; and seminal cysts will be described among dis- eases of the testicle and spermatic cord. Compound or proliferous cysts. — Under either of these names (but the second is the better) may be included all the cysts on whose walls vascular or other fully organised structures are formed. The boundary line between the barren and the proliferous is not well marked, yet the distinction has some practical utility. When many simple cysts are clustered together, they may appear like a proliferous cyst : but in general the distinction can be ascertained that, in the one case, the numerous cysts are only contiguous, and in mutual contact at their adjacent walls ; in the other case, some are enclosed within others, or are out- growths from others' walls. Among the varieties of proliferous cysts, distinguished, as they may best be, by their growths or other products, the chief are enumerated at p. 505. The complex cystic, or cystigerous, growths are best typified by examples of the complex ovarian cysts, and by the cystic disease of the chorion, the so-called hydatid mole. The importance of the former in practice is almost entirely confined to those that occur in the ovaries. In other parts they are extremely rare ; there are no sufficient signs by which to distinguish them from the multiple or clustered simple cysts, and their treatment must be the same. Cysts proliferous with vascular growths, including most of the ' sero-cystic sarcomata,' are most frequently found in or near glands, especially the mammary, labial, thyroid, and prostate glands ; but they may be found also in the subcutaneous tissue, and in deep intermuscular spaces. The walls of these cysts, which may be either single or multiple, are usually formed of thin connective tissue, smoothly lined within, and externally combined closely with the sur- rounding structures, so that they are not easily dissected out entire. Their cavities, till they are filled with the vascular growths, may contain either serum or any of the fluids that occur in the simple cysts of the same parts. The intracystic growths, according to their duration, or the proportion between the rate of their increase and that of the cyst, fill more or less of the cavity. They apj)ear to spring from single points or 512 TUMOUES. spaces on the inner wall of the cyst ; thence enlarging and ex- tending, they may gradually fill it, excluding the fluid which at first surrounded them, and then, it may be, uniting with those parts of the inner surface of the cyst from which they did not spring, and coalescing with them so as to form a solid tumour, around which the former cyst-walls appear as a capsule. By still further increase the intracystic growths may protrude through the cyst- walls and their superjacent tissues, and thence may project as * fungous growths,' looking like cancerous excrescences. The form of the intracystic growths is, in different instances, extremely various. Some are low, broad-based, like heaps of granulations ; some are very lobed and ' cauliflower- like ;' some are variously branched with narrow leaf-like processes, clustered and arborescent. Their structures are not less various. Some are soft, yellowish, like laminated fibrine-clot; some spongy and succulent ; some are like soft gelatine ; some firm, like mammary gland. Again, they are all variable in vascularity, and therefore in their tints of coloui* ; cysts may form in them ; they may be diseased or degenerate. The minute structure of the intracystic growths connected with glands is generally glandular, imitating the structures of the corresponding glandular tumours, but more often than in them very rudimental, or imperfect, or altered by degeneracy or disease. (Plate 10, fig. 9.) In other parts they appear, generally, like the sti-uctures of granulations, and other examples of developing connective tissue. In the diagnosis of this form of proliferous cysts (sero-cystic sarcoma, cysto-sarcoma), one looks first to their seat. They are not rare in or near glands, or structures beset with glands ; they are very rare in any other situations. Their shape is generally roundish or oval, sometimes lowly lobed or tuberous ; they are well-defined and movable. If they still contain much fluid, this may be detected by the tension and elasticity of the cysts or by fluctuation. Before the skin gives way, and the fluid escapes, a characteristic bluish or black hue may come over the prominent soft lobes. Sometimes the combination of solid and fluid may be detected, as when one feels a hydrocele with the testicle behind the fluid. If there be little or no fluid, the tumour may not be distinguishable from a soft glandular or fibro-cellular growth. There may, indeed, be no distinction possible, seeing that many of the solid tumours thus named PROLIFEEOUS CYSTS. 513 very probably originate in such intracystic growths as are here described. The size of the growths will rarely help a diagnosis ; they may be of any size, from one just discoverable to a foot in diameter. The structures adjacent to them are always healthy, unless when they have protruded ; and then the integuments or other structures, through ulcerations of which they have passed, are thinned out to the apertures of ulceration, but are otherwise not diseased. The surface of the protrusion is usually like that of ordinary granulations : jflorid, soft, elastic, pliant ; bleeding easily on contact, yet not profusely. Sometimes the foliated arrangement of the growth is distinguishable as it lies in or projects through the circular aperture of healthy skin. The protrusion of the growth may cause general disturbance or some cachexia : but, except in this case, these tumours are not attended with ill health; and their ordinar}'" history before they come under treatment is, that they have been long observed increasing slowly and without pain, though it may be with occasional more rapid enlargements. The age at which they appear is not distinctive, for, while they are most common in the breast between thirty and forty years of age, they are met with up to seventy-five. By all these characters the most important diagnosis of the proliferous cysts — that, namely, from cancer— may usually be made. It may be nearly impossible to distinguish them, on the one hand, from simple or clustered cysts ; and, on the other, from glandular or fibro-cellular solid tumours: but this dia- gnosis is of comparatively little imf>ortance. From cancers, especially the medullary, which they most resemble, they must be distinguished by the signs just enumerated ; to which may be added the absence of corresponding disease in the lymph-glands and other distant parts. Excision appears to be the best remedy for all these prolifer- ous cysts. In the breast, the close adhesion of the cyst to the adjacent structures may require that they should be removed with it : in other parts, the cyst may usually be removed alone. The prognosis, after removal, is favourable. But by no means rarely cases occur of repeated recurrence of proliferous cysts in the breast ; and this event may be feared when care is not taken to remove the whole, and when the intracystic growth, and in a less degree the cyst-walls, are particularly soft, succu- lent, and of gelatinous appearance. The account of cases of such recurrence will be given in the section on recurrent tumours. VOL. I. L L 514 TIBIOURS. Cutaneous cysts. — Under this name may be included all those whose walls have the structure, or form any of the usual pro- ducts, of skin. Some of them, especially those which are con- genital and those which grow in the ovaries, have evident cutaneous structures lining them ; cutis, epidermis, hair-follicles, &c. : in others, including most of those that have been called sebaceous, epidermal, and atheromatous cysts, there are only such materials as the skin, or some of its included organs, produces. The cutaneous cysts in ovaries need be mentioned here only as being types of the whole group in respect of the completeness of the cutaneous structure, and the abundance of perfect hair, epidermis, and other structures that they produce. And those that occur in other parts than the subcutaneous tissue have their sole or chief interest in their singularity and rarity. They have been found in the testicle, lung, kidney, bladder, sublingual tissue, and within the skull ; in the last situation being probably such as were formed in foetal life, and shut in by the gradual closure of the ossifying skull. But of all these, no diagnosis or general rules of treatment can be given. Of those that are found in the subcutaneous, or just deeper, structures, it is useful to distinguish the congenital from those that form first in later life. The congenital cutaneous cysts ai'e by far most frequent iinder the eyebrow or in some other position in or near the orbit. They may occur in any other part, but no general account could be given of any but those in or near the orbit. Here they are usually round or oval ; often flattened ; deep-seated, resting on or embedded in the frontal bone ; and in some cases even prolonged through apertures in the inner wall of the orbit into the ethmoidal cells or the cranial cavity. Their walls are very thin, membranous, white, formed of perfect connective tissue, very closely connected with the textures around them, lined within with perfect epidermis, and often showing hairs like fine eye-lashes, growing from perfect follicles. Usually they are filled, but not tensely, with turbid or oily liquid ; or with sebaceous or spermaceti-like substance, including cast-off hairs. Cysts of this kind are usually of slow growth. They increase in the first years of life at a scarcely greater rate than the rest of the body does, and they rarely attain a greater diameter than about two-thirds of an inch ; they are usually less. They may, CUTANEOUS CYSTS. 515 Jiowever, enlarge b}^ unusual increase of their contents, and in- flaming at last may ulcerate. By the characters just described, the diagnosis of these con- genital cysts is not difficult. The existence of one may be believed in any case of a small growth having the geneiul characters of a cyst, seated near or just within the upper or the inner boundary of the orbit, observed at birth or in early child- hood. A nsevus may present some of these characters, so may a fatty tumour or a serous cyst : but the diagnosis of the latter is not very important ; and that of the former may rest on its greater softness, compressibility, and pliancy ; the bluish tmt, or visible bloodvessels, over or near it ; its soft puiiy feel, its pulsation, or its variable size. The only appropriate treatment of these cysts is excision. The depth of the cyst and its close adhesion to all the parts around it, and especially to the periosteum and bone, make the opera- tion and the subsequent healing almost always very tedious. Care should be taken to dissect away the cyst entire : for if its contents escape during the operation, the remainder of the dis- section is made much more difficult ; and if a portion of it be left, it may continue to produce cuticle and sebaceous matter, and prevent the healing of the wound. Generally, the immedi- ate union of the wound should not be attempted, lest pus form and burrow under the orbicularis muscle. If the removal of the cyst be complete, no return of the disease is to be feared. The Tnore connmon cM.taneous cystsy which are not congenital or formed in earliest life, have rarely so complete and perfect structures as those just described ; only their contents are always like the epidermal or other products of skin, more or less perfect or degenerate. In different specimens the walls of these cysts are widely various. In a great majority they are thin, pliant, formed of healthy-looking connective tissue, loosely connected with the surrounding textures, and lined with smooi h shining cuticle. In some they are thick, hard, laminated ; iii some, toughly fibrous ; in some, calcified ; but all these condi- tions are probably due to morbid changes in cyst-walls thnt were originally thin. In some rare instances the cyst-walls appear complicated by the growth of other cysts in or from their walls. Their contents are yet more various, and the varieties have suggested the several synonyms of cuticular, sebaceous, atheromatous, &c. Most commonly they consist of layers of white soft epidermis, easily scaling asunder, disorderly. 516 TUMOUES. and mixed with softer or liquid matter at the centre. In some instances, abundant crystals of cholestearine, mingled with the epidermal scales, give a peculiar glistening mother-of-pearl character to the laminae of the cyst-contents ; and many of these have been named cholesteatoma. And in many cases, probably through disease, or through degeneracy of the cyst- walls, the contents consist of turbid brownish, yellowish, or other coloured fluids, in which clusters of epidermal cells, with o-ranular, earthy, and fatty matter and crystals, are floating. But however strange the contents may seem, the microscope will always disclose in them true epidermal structures ; nucleated scales, filmy and folded, lying in clusters, or free, or collected in the form of laminated capsules (like those which some have thought characteristic of epithelial cancer) . Often, too, the smell of cutaneous secretion is as evident as the sight. The cutaneous cysts may be found under the skin of any part ; but they are probably a hundred times more common in the scalp than in any other situation. Some of them have, in the skin over their chief prominence, a small dark point, through which a fine probe may be passed into their cavity ; over others no such mark can be seen. And this diff'erence indicates a difference in their modes of origin ; namely, that the former are due to distension and overgrowth of hair- follicles, whose orifices remain obstructed by the material of the dark point ; and the latter are complete cysts, formed, it may be, after the fashion of hair-follicles, but having never contained hairs or possessed external openings. In either method the cysts are usually first formed in youth or early adult age, though they rarely come under treatment till many years later. They are very rarely referred to any local cause, but are commonly hereditary, thouo-h not connected with any constitutional peculiarity. Their rate of growth is uncertain. Many, after attaining a diameter of about half an inch, remain long or always stationary ; others, even in the same person (for these cysts are often very numerous in the scalp), maintain a regular rate of increase, and thus some have reached a diameter of six inches. But when they grow very ra.pidly, or when they are actively inflamed, as after injury, it is common to find cutaneous cysts very thinly covered with ruddy or dry skin ; and this, ulcerating, may permit them or their contents to protrude. Hence are derived most of the so- called ' horns ' of the scalp and face, and more rarely of other parts. Sometimes, too, it has hajypened that the protruded CUTANEOUS CYSTS. 517 contents of an inflamed and ulcerated cyst have become vascular, grown rapidly, and formed a granulated bleeding mass, very like an exuberant epitbelial cancer. The sebaceous cysts which grow in the tympanum and external auditory meatus claim particular notice, as they sometimes prove fatal. They increase toward the bone rather than to- ward the cavity of the meatus, and having perforated by gradu- ally producing absorption of the bone, they set up inflammation of the cerebral membranes and abscess of the brain itself. The importance of early treatment of these apparently trifling tumours is obvious. See Diseases of the Ear. In the scalp the diagnosis of cutaneous cysts is rarely difficult. The most important resemblance which they may bear is that to medullary cancers perforating the skull ; and the distinction may be the more difficult as the skull is sometimes defective beneath a congenital cyst of the scalp. In other parts it may be difficult to distinguish them from chronic abscess, fatty or fibro-cellular tumour, acephalocyst, or any sottish tumour. The chief points to be looked to, in addition to those that are common to all cysts, are their immediately subcutaneous situation ; their regular, smooth, round or oval form, which may in some instances be made to change by pressure, when the contents are a soft substance that may be moulded into various shapes ; the easy mobility ; the dark central point ; the hereditary origin ; the slow growth ; the healthiness of the im- mediately surromiding parts ; the absence of change in them from the pulse or respiration, and of head-symptoms when they are pressed. The cutaneous cysts admit of several modes of treatment. Those that have the minute openings may be gradually emptied by dilating their openings and pressing out their contents ; and being thus treated, they may be kept from being unsightly or otherwise troublesome, or may shrivel up and disappear. But if this treatment fail, or if there be no opening, and if either the size or any of the inconveniences of the cyst make their removal desirable, they may be extirpated with caustic or the knife. The latter alone might be advised, if it were not for the peril of erysipelas and other mischiefs that attend even minor cutting operations in some persons. Few surgeons of large experience have failed to see one or more deaths after the excision of cutaneous cysts, especially of those in the scalp. The treatment of wounds after operations by the sulphurous or 518 TUMOURS. carbolic acids, or by the chloride of ziuc, is likely to reduce this mortality; but whenever there appears more than average risk of such a calamity, the caustic treatment should be em- ployed. A space of half an inch or less in diameter over the most prominent part of the cyst being thoroughly cauterised Avith nitric acid or potash, the separation of the slough will lay open the C3'st, which may then be left to empty itself and wither ; or may be drawn out through the opening ; or may be eini^tied by pressure and cauterised within. Or, in another method, the cj-st being first puuctui-ed, its interior may be cauterised, and it will slough out. When excision is to be practised, it is not necessary or usually advisable to dissect round the cysts. Their connections with the tissues next to them are generally so loose that, if they be freely cut into, they may be seized at their cut edges and pulled out. If the cyst have been inflamed, or become adherent by the changes induced by friction — changes which are chiefly frequent with those on the trunk and limbs — it may be necessary to dissect out the whole cyst, and perhaps to remove a portion of skin with it. In such dissections the possible connection of the cyst with the dura mater must in doubtful cases be remembered. Cysts containing teeth are of two kinds. Some, found in the ovaries, or, much more rarely, as congenital growths, in other parts, contain, with one or more teeth, the products of skin, as hair, epidermis, &c. Others, occurring in the jaws, appear to be enlarged tooth-capsules, in which the teeth, through defec- tive or erroneous development, have not been extruded. The former will be best considered among the diseases of the ovaries ; the latter among the Diseases connected with the Teeth. Fatty or adipose tumours and outgrowths (Plate 9, fig. 6) are the most frequent of all innocent tumours. They are commonly described under the nam<^s lipoma and steatoma, and afford good examples of the two modes of growth of tumours, the contin- uous, and the encapsuled or discontinuous. The continuous or fatty outgrowths commonly appear as lumps of fat in the subcutaneous tissue, ill- defined, as if the ordinary fat of some one part had increased beyond all natural proportion to that of the parts around. The excessive double chin that some persons have is a growth of this kind ; and others, more evidently morbid, and more rare, occur especially at the nape, ov behind the ears, or over the lowest cervical vertebrae. They I FATTY. 519 do not diflfer in structure from the ordinary fat of the adja- cent parts, unless in being rather firmer ; they are generally troublesome only by their ugliness 5 yet some patients complain of pain in and about them. No good cause can be assigned for these hump-like outgrowths of fat. A child presented one in the lower part of the back of the neck, whose father had one in the corresponding place; and a woman, having seventeen of them, was aware of the existence of many similar fatty tumours in her father and grandfather. Generally they begin their growth in persons about forty years old, and slowly increase, till, attaining some uncertain size, they stay thereat. They appear not more liable to degeneration or disease than is the natural fat adjacent to them. There is very rarely any difficulty in the diagnosis of these fatty outgrowths. They are evidently only too much sub- cutaneous fat in a certain place. And generally they are hardly amenable to treatment. Sometimes they may be cured by the long-continued taking of liquor potasste ; but if this fail, excision would remove them ; and this is rarely advisable, for the scar of the operation would be as ill-looking as the growth. Fatty tumours, properly so called, are far more common than these outgrowths. Their most frequent seats are the trunk, especially about its upper half, and the parts of the limbs nearest to it. The further from the trunk, the more rarely they appear ; they are exceedingly rare in parts that do not naturally contain any adipose tissue ; but, with the rarity of curiosities, they may be met with beneath the tongue, or m the peritoneum, or perhaps anywhere. They usually lie in the subcutaneous fat, upraising the skin, and connected rather more closely with it than with any other of the tissues next to them. Among fatty tumours, some are much firmer than others, and than the normal adipose tissue ; and the firmer are usually smooth, round, or oval, or very largely lobed. These have generally tough investing capsules, from which partitions, extending inwards, intersect them, and make a kind of close brawny mesh-work filled with fat-cells. The firmer fatty tumours are, probably, more often deep-seated than subcu- taneous ; especially they are apt to grow near joints ; but they are altogether much more rare than those of the softer kind. These, which are the common fatty tumours, resemble in their minute structure, with scarcely a difference, the natural adipose tissue. They are generally of a somewhat round or oval shape, 520 TUMOUES. flattened if they lie with little prominence between the skin and fascia ; pyriform if they are pendulous. Commonly they are deeply lobed, and larg-e outlying lobes sometimes extend from them, and dip far into the adjacent fat, or, rarely, through the fascia into intermuscular spaces. They are always invested with a thin, dry, fibro-cellular capsule, isolating, and yet con- necting them with the surrounding parts, especially the skin ; and partitions extending from the capsule separate their lobes. Their jjrincipal bloodvessels ramify in the capsule before pas- sing to the lobes; and are most frequently derived from one or two trunks rising from vessels beneath the tumour. The laxity of the capsule often permits a fatty tumour to shift or slide from the place of its first growth to one lower down. Thus, one beginning in the groin may shift down the thigh ; or from the perineum one may pass into the scrotum : facts of great use in diagnosis, since such changes very rarely happen with other tumours. Fatty tumours come under treatment in young persons, and adults of all ages. They are very rare in children, but not rarely begin to grow in youth, though, growing slowly, they may be overlooked for many years ; they may begin to grow at any later age, but very seldom appear first in old age. They are sometimes assignable to local causes, as a blow, or, more com- monly, frequent friction, as by a strap or band over the skin. Sometimes, too, they have so appeared after fever or some gene- ral illness, as to seem due to a constitutional cause. But, in a majority of cases, no good cause can be assigned for them. From the first they present a perfect adij^ose structure ; no changes of development are known in them. Then* growth is commonly very slow, sometimes fitful, very rarely rapid ; but, though slow in growth, they may grow long enough to attain an enormous bulk ; some have weighed fifty pounds. They are dsually insensible, yet are sometimes referred to as the centres or causes of vague radiating aches and pains. After injury, or sometimes spontaneously, they may inflame or degenerate. Of this, the most frequent consequences, and the most impoi-tant to be remembered in diagnosis, are, central collections of serum or pus, or some glutinous fluid in a cyst ; central nodular in- duration or calcification ; sloughing or ulceration of the super- jacent skin, and exposure of the tumour, a result which is especially likely to happen with such as are pendulous. In a great majority of cases fatty tumours occur singly ; yet FATTY. 521 instances are not rare in wliicli large numbers of them appear in rapid sequence in the subcutaneous tissue of the limbs (espe- ciall}^ the arms) and trunk, all slowly increasing-, till, after attaining about an inch, or rarely more, in diameter, they usually cease to grow. Their multiplicity and general limita- tion as to size are the only characters distinguishing the tumours in this singular form of disease. In the times and conditions of life in which they may first appear ; in the absence of all evident constitutional disease ; in their varieties as to degree of firmness and amount of intersecting connective tissue ; and in every other respect, they are exactly like the more common single fatty tumours. Little need be added to the foregoing description to indicate the diagnosis of a fatty tumour. A firm deep-seated one may be not distinguishable from a fibro-cellular or fibrous tumour ; but this is of little importance : it is enough to make out, by the uniform firmness, elasticity sometimes hardly distinguish- able from fluctuation, mobility, smooth, regular, or largely- lobed shape, by the slow growth, and freedom from pain, that the tumour is not a chronic abscess, cyst, bursa, or firm me- dullary cancer, but an innocent tumour, proper, if required, to be removed. The diagnosis of the common subcutaneous fatty tumour is much more easy, and will seldom be missed if it be observed that, with most of the characters indicated above, a tumour feels soft, pliant, ' pillowy,' easily movable, and that, by com- pressing its base and borders, so as to make the skin tense over it, the skin presents dimples corresponding with the spaces between its lobes. Pendulous fatty tumours can be confounded with none but pendulous cutaneous growths ; and the diagnosis is difficult but unimportant. The consequences of inflammatory and other changes will not make the diagnosis harder than usual, if the probability of their occurrence be kept in mind. Multiple fatty tumours have nothing like them, except the neuromata or fibrous tumours that sometimes occur in great numbers in subcutaneous nerves ; but these are generally much firmer, more variable in size, often painful, and are associated with other and deep-seated tumours. Only one method of treatment, excision, is applicable to fatty tumours. It is to be recommended for any that are unsightly, or inconvenient by their bulk or hindrance of movements, or in- creasing so quickly that delay of the operation will materially 522 TUMOURS. angment its extent. In the excision it is usually sufficient, and advisable, to cut fairly, with, a single median incision, into the tumour, and draw or scoop it out by splitting- the capsule that loosely invests it. In the case of the multiple fatty tumours, removal is very seldom to be advised, unless for any one that may grow very far in advance of the rest. With those that are pendulous, all the covering skin should be cut away, except so much as may be necessary for flaps to close the subcutaneous part of the wound. The prognosis of fatty tumours is most favourable. They may be removed with as little danger as attends any cutting operation whatever ; they almost never return after removal ; and small portions left in operations commonly fail to grow. In one case, however, after several removals of a fatty tumour, there was again a recurrence; and it was found that, with the fat, there was a large quantity of young and growing fibrous tissue in a stalk of the tumour which lay beneath the pectineus muscle, and which had in each operation been cut through.* Fihro-cellidar tumours and outgrowths are such as consist entirely, or chiefly, of tissue resembling the ordinary cellular, areolar, or connective tissue of the natural structures. In difler- ent specimens the tissue may be more or less embryonic or per- fect, more or less delicate, or firm and tough, succulent or dry ; or other tissues, as the fatty, elastic, or even glandular, may be mixed with it ; but, in all these respects, the tumours scarcely exceed the differences which exist among different examples of the natural structures referred to the cellular or connective tissue in its various conditions of development or disease. The most frequent of the outgrowths are found in the softer kinds of polypi, and in the pendulous growths of skin. These will be described in other appropriate places (Nose, Ear, Skin, &c.) ; but it may be observed of nearly all the so-called mucous or gelatinous polypi, that a very large part of their substance is comj)Osed of gland-structures ; and of the cutaneous outgrowths, that not the fibro-cellular tissue alone, but aU the component structures of the skin, are usually together, though not equally, increased. Fibro-cellular tumours are among the rarer forms. Their most frequent, but not exclusive, seats are the deep intermuscu- • ^lessrs. De Morgan and Ilulke's Keport on Mr. Curling's case, Pathological ■ Transactions, vol. xviii. p. lt<6. riBEO-CELLULAR. 523 lar spaces of the limbs, the scrotum, labium, or by the wall of the vagina, and (in the form which most closely connects them with the fibrous tumours) in the subcutaneous tissue. Their typical characters are best marked in those removed from the limbs, scrotum, or labium. They are usually oval or round, more or less deeply and largely lobed, invested with thin caj)sules of con- nective tissue, by the sj)litting of which they may be each sepa- rated or enucleated from the adjacent parts (a character by which those of the genital organs are at once distinguished from the cutaneous outgrowths and hypertrophies of the same parts) . To the touch they are firm, tense, and elastic, very like tough- walled cysts tightly filled with fluid. On section they usually present a shining, pale-yellowish, or serous-coloured basis, in- tersected by opaque white bands, moderately firm, succulent, and very elastic. The intersecting bands or marks are curved, but with no regular plan, and give no distinct fibrous appearance to the section. At first sight many of these tumours, soaked as they are, or, as it were, oedematous, with yellow serous fluid, look like fat ; but when left at rest, or suspended, the fluid oozes from them, and their tissue contracting becomes firmer, whitish, and opaque. In microscopic examination the fibro-cellular tumours present the same elements as the similarly named natural tissue, but, usually, with a larger proportion of them in a rudimental form. Generally there are, or appear, abundant fine colourless filaments in undulating bundles, variously interlaced or matted ; and with these, are various proportions of nuclei, and of fusiform or cau- date, or stellate nucleated cells, such as may be found more abundantly in granulations, or in the softer kinds of connective tissue, in which the connective-tissue-corpuscles are most abund- ant. (Plate 10, figs. 9, 11, 12.) Occasionally, very soft exam- ples of the tumours are met with, in which these corpuscles predominate over the filamentous tissue. In most instances, the elements of connective tissue are alone found in these tumours ; and their varieties depend on the degrees in which these elements are developed, or variously compact, or in- filtrated with fluid. Elastic yellow tissue is very rarely seen ; a singular fact, if the almost constant presence of that struc- ture in the natural connective tissue be considered. But, oc- casionally, nodules or thin layers of cartilage or bone are found, either embedded in, or encasing the mass of the tumour, adding not a little to the difficulty of the diagnosis. 524 TUMOUES. The origin of a fibro- cellular tumour is very rarely to be traced. They are so seldom referred to violence, inheritance, or any general disease, that when they do seem to have such an origin, it is, probably, only by a chance-coincidence. Thej'^ may begin to grow at any period of life, but they do so most rarely before adult age, and most frequently at middle or older age. Their rate of gi'owth is variable, but sometimes very rapid, as much as three or four pounds in the year; or even, as Mr. Paget saw in one case (which, however, was an instance of re- current tumour), at the rate of a pound per month."^ Thus, or more slowly increasing, they may attain a weight of forty or more pounds, especially in the scrotum, whose texture offers them the least resistance, and, by its extensibility and quick growth, the best protection. The extreme distension, however, which such tumours cause, often leads at last to sloughing or ulceration of the integuments over them, especially at their lowest or most dependent part. The ulcer, in these cases, presents no specific characters ; and the tumour usually only lies exposed at its base, without protrusion ; but the purulent discharge and increased irritation to which the chang-e gives rise, being added to the burden of a huge tumour, may prove fatal. The tumour may partake of the changes of the parts over it, becoming inflamed, soft, or sloughing ; but in these changes resembling only the ordinary connective tissue, when similarly diseased. Except in these morbid states, the ordinary fibro-cellular tumours are very rarely painful. The statements just made respecting rapid growth, sloughing, and ulceration, apply to the fibro-cellular tumours of the exter- nal genital organs, much more than to those of any other parts. And corresponding differences must be had in view in making a diagnosis, during life, of any example of this form. In the scrotum, it may be difiicult to diagnosticate a fibro-cellular tumour from some disease or growth in the testicle ; and here the chief point to be looked to (in addition to those already mentioned in the description of the tumour), is the separateness of the testicle from the new-formed mass. If the testicle be free, the nearest likenesses are in large omental hernire ; in fatty tumours in the scrotum ; in hydroceles ; in elephantiasis * It Bhould T)e mentioned, however, that in these, as, in a less degree, in other tumours, there may be much incre