Pain is a symptom seldom absent in inflammation. Tenderness—that is, pain elicited on pressure—is one of the most valuable diagnostic signs we possess, and is often present before pain is experienced by the patient. That the area of tenderness corresponds to the area of inflammation is almost an axiom of surgery. Pain and tenderness are due to the irritation of nerve filaments of the part, rendered all the more sensitive by the abnormal conditions of their blood supply. In inflammatory conditions of internal organs, for example the abdominal viscera, the pain is frequently referred to other parts, usually to an area supplied by branches from the same segment of the cord as that supplying the inflamed part.

For purposes of diagnosis, attention should be paid to the terms in which the patient describes his pain. For example, the pain caused by an inflammation of the skin is usually described as of a burning or itching character; that of inflammation in dense tissues like periosteum or bone, or in encapsuled organs, as dull, boring, or aching. When inflammation is passing on to suppuration the pain assumes a throbbing character, and as the pus reaches the surface, or "points," as it is called, sharp, darting, or lancinating pains are experienced. Inflammation involving a nerve-trunk may cause a boring or a tingling pain; while the implication of a serous membrane such as the pleura or peritoneum gives rise to a pain of a sharp, stabbing character.

Interference with the function of the inflamed part is always present to a greater or less extent.

Constitutional Disturbances.—Under the term constitutional disturbances are included the presence of fever or elevation of temperature; certain changes in the pulse rate and the respiration; gastro-intestinal and urinary disturbances; and derangements of the central nervous system. These are all due to the absorption of toxins into the general circulation.

Temperature.—A marked rise of temperature is one of the most constant and important concomitants of acute inflammatory conditions, and the temperature chart forms a fairly reliable index of the state of the patient. The toxins interfere with the nerve-centres in the medulla that regulate the balance between the production and the loss of body heat.

Clinically the temperature is estimated by means of a self-registering thermometer placed, for from one to five minutes, in close contact with the skin in the axilla, or in the mouth. Sometimes the thermometer is inserted into the rectum, where, however, the temperature is normally 3/4 F. higher than in the axilla.

In health the temperature of the body is maintained at a mean of about 98.4 F. (37 C.) by the heat-regulating mechanism. It varies from hour to hour even in health, reaching its maximum between four and eight in the evening, when it may rise to 99 F., and is at its lowest between four and six in the morning, when it may be about 97 F.

The temperature is more easily disturbed in children than in adults, and may become markedly elevated (104 or 105 F.) from comparatively slight causes; in the aged it is less liable to change, so that a rise to 103 or 104 F. is to be looked upon as indicating a high state of fever.

A sudden rise of temperature is usually associated with a feeling of chilliness down the back and in the limbs, which may be so marked that the patient shivers violently, while the skin becomes cold, pale, and shrivelled—cutis anserina. This is a nervous reaction due to a want of correspondence between the internal and the surface temperature of the body, and is known clinically as a rigor. When the temperature rises gradually the chill is usually slight and may be unobserved. Even during the cold stage, however, the internal temperature is already raised, and by the time the chill has passed off its maximum has been reached.

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

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

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

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

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

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



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

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

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



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



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There are other groups of chronic inflammation, the origin of which continues to be the subject of controversy. Reference is here made to the chronic inflammations of the synovial membrane of joints, of tendon sheaths and of bursae—chronic synovitis, teno-synovitis and bursitis; of the fibrous tissues of joints—chronic forms of arthritis; of the blood vessels—chronic forms of endarteritis and of phlebitis and of the peripheral nerves—neuritis. Also in the breast and in the prostate, with the waning of sexual life there may occur a formation of fibrous tissue—chronic interstitial mastitis, chronic prostatitis, having analogies with the chronic interstitial inflammations of internal organs like the kidney—chronic interstitial nephritis; and in the breast and prostate, as in the kidney, the formation of fibrous tissue leads to changes in the secreting epithelium resulting in the formation of cysts.

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

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

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



CHAPTER IV

SUPPURATION

Definition—Pus—Varieties—Acute circumscribed abscess—Acute suppuration in a wound—Acute Suppuration in a mucous membrane—Diffuse cellulitis and diffuse suppuration— Whitlow—Suppurative cellulitis in different situations—Chronic suppuration—Sinus, Fistula—Constitutional manifestations of pyogenic infection—Sapraemia—Septicaemia—Pyaemia.

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

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

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

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

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

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

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

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

The pus may form and collect within a circumscribed area, constituting a localised abscess; or it may infiltrate the tissues over a wide area—diffuse suppuration.

ACUTE CIRCUMSCRIBED ABSCESS

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

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

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

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

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

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

An abscess forming in the deeper planes is prevented from pointing directly to the surface by the firm fasciae and other fibrous structures. The pus therefore tends to burrow along the line of the blood vessels and in the connective-tissue septa, till it either finds a weak spot or causes a portion of fascia to undergo necrosis and so reaches the surface. Accordingly, many abscess cavities resulting from deep-seated suppuration are of irregular shape, with pouches and loculi in various directions—an arrangement which interferes with their successful treatment by incision and drainage.

The relief of tension which follows the bursting of an abscess, the removal of irritation by the escape of pus, and the casting off of bacteria and toxins, allow the tissues once more to assert themselves, and a process of repair sets in. The walls of the abscess fall in; granulation tissue grows into the space and gradually fills it; and later this is replaced by cicatricial tissue. As a result of the subsequent contraction of the cicatricial tissue, the scar is usually depressed below the level of the surrounding skin surface.

If an abscess is prevented from healing—for example, by the presence of a foreign body or a piece of necrosed bone—a sinus results, and from it pus escapes until the foreign body is removed.

Clinical Features of an Acute Circumscribed Abscess.—In the initial stages the usual symptoms of inflammation are present. Increased elevation of temperature, with or without a rigor, progressive leucocytosis, and sweating, mark the transition between inflammation and suppuration. An increasing leucocytosis is evidence that a suppurative process is spreading.

The local symptoms vary with the seat of the abscess. When it is situated superficially—for example, in the breast tissue—the affected area is hot, the redness of inflammation gives place to a dusky purple colour, with a pale, sometimes yellow, spot where the pus is near the surface. The swelling increases in size, the firm brawny centre becomes soft, projects as a cone beyond the level of the rest of the swollen area, and is usually surrounded by a zone of induration.

By gently palpating with the finger-tips over the softened area, a fluid wave may be detected—fluctuation—and when present this is a certain indication of the existence of fluid in the swelling. Its recognition, however, is by no means easy, and various fallacies are to be guarded against in applying this test clinically. When, for example, the walls of the abscess are thick and rigid, or when its contents are under excessive tension, the fluid wave cannot be elicited. On the other hand, a sensation closely resembling fluctuation may often be recognised in oedematous tissues, in certain soft, solid tumours such as fatty tumours or vascular sarcomata, in aneurysm, and in a muscle when it is palpated in its transverse axis.

When pus has formed in deeper parts, and before it has reached the surface, oedema of the overlying skin is frequently present, and the skin pits on pressure.

With the formation of pus the continuous burning or boring pain of inflammation assumes a throbbing character, with occasional sharp, lancinating twinges. Should doubt remain as to the presence of pus, recourse may be had to the use of an exploring needle.

Differential Diagnosis of Acute Abscess.—A practical difficulty which frequently arises is to decide whether or not pus has actually formed. It may be accepted as a working rule in practice that when an acute inflammation has lasted for four or five days without showing signs of abatement, suppuration has almost certainly occurred. In deep-seated suppuration, marked oedema of the skin and the occurrence of rigors and sweating may be taken to indicate the formation of pus.

There are cases on record where rapidly growing sarcomatous and angiomatous tumours, aneurysms, and the bruises that occur in haemophylics, have been mistaken for acute abscesses and incised, with disastrous results.

Treatment of Acute Abscesses.—The dictum of John Bell, "Where there is pus, let it out," summarises the treatment of abscess. The extent and situation of the incision and the means taken to drain the cavity, however, vary with the nature, site, and relations of the abscess. In a superficial abscess, for example a bubo, or an abscess in the breast or face where a disfiguring scar is undesirable, a small puncture should be made where the pus threatens to point, and a Klapp's suction bell be applied as already described (p. 39). A drain is not necessary, and in the intervals between the applications of the bell the part is covered with a moist antiseptic dressing.

In abscesses deeply placed, as for example under the gluteal or pectoral muscles, one or more incisions should be made, and the cavity drained by glass or rubber tubes or by strips of rubber tissue.

The wound should be dressed the next day, and the tube shortened, in the case of a rubber tube, by cutting off a portion of its outer end. On the second day or later, according to circumstances, the tube is removed, and after this the dressing need not be repeated oftener than every second or third day.

Where pus has formed in relation to important structures—as, for example, in the deeper planes of the neck—Hilton's method of opening the abscess may be employed. An incision is made through the skin and fascia, a grooved director is gently pushed through the deeper tissues till pus escapes along its groove, and then the track is widened by passing in a pair of dressing forceps and expanding the blades. A tube, or strip of rubber tissue, is introduced, and the subsequent treatment carried out as in other abscesses. When the drain lies in proximity to a large blood vessel, care must be taken not to leave it in position long enough to cause ulceration of the vessel wall by pressure.

In some abscesses, such as those in the vicinity of the anus, the cavity should be laid freely open in its whole extent, stuffed with iodoform or bismuth gauze, and treated by the open method.

It is seldom advisable to wash out an abscess cavity, and squeezing out the pus is also to be avoided, lest the protective zone be broken down and the infection be diffused into the surrounding tissues.

The importance of taking precautions against further infection in opening an abscess can scarcely be exaggerated, and the rapidity with which healing occurs when the access of fresh bacteria is prevented is in marked contrast to what occurs when such precautions are neglected and further infection is allowed to take place.

Acute Suppuration in a Wound.—If in the course of an operation infection of the wound has occurred, a marked inflammatory reaction soon manifests itself, and the same changes as occur in the formation of an acute abscess take place, modified, however, by the fact that the pus can more readily reach the surface. In from twenty-four to forty-eight hours the patient is conscious of a sensation of chilliness, or may even have a rigor. At the same time he feels generally out of sorts, with impaired appetite, headache, and it may be looseness of the bowels. His temperature rises to 100 or 101 F., and the pulse quickens to 100 or 110.

On exposing the wound it is found that the parts for some distance around are red, glazed, and oedematous. The discoloration and swelling are most intense in the immediate vicinity of the wound, the edges of which are everted and moist. Any stitches that may have been introduced are tight, and the deep ones may be cutting into the tissues. There is heat, and a constant burning or throbbing pain, which is increased by pressure. If the stitches be cut, pus escapes, the wound gapes, and its surfaces are found to be inflamed and covered with pus.

The open method is the only safe means of treating such wounds. The infected surface may be sponged over with pure carbolic acid, the excess of which is washed off with absolute alcohol, and the wound either drained by tubes or packed with iodoform gauze. The practice of scraping such surfaces with the sharp spoon, squeezing or even of washing them out with antiseptic lotions, is attended with the risk of further diffusing the organisms in the tissue, and is only to be employed under exceptional circumstances. Continuous irrigation of infected wounds or their immersion in antiseptic baths is sometimes useful. The free opening up of the wound is almost immediately followed by a fall in the temperature. The surrounding inflammation subsides, the discharge of pus lessens, and healing takes place by the formation of granulation tissue—the so-called "healing by second intention."

Wound infection may take place from catgut which has not been efficiently prepared. The local and general reactions may be slight, and, as a rule, do not appear for seven or eight days after the operation, and, it may be, not till after the skin edges have united. The suppuration is strictly localised to the part of the wound where catgut was employed for stitches or ligatures, and shows little tendency to spread. The infected part, however, is often long of healing. The irritation in these cases is probably due to toxins in the catgut and not to bacteria.

When suppuration occurs in connection with buried sutures of unabsorbable materials, such as silk, silkworm gut, or silver wire, it is apt to persist till the foreign material is cast off or removed.

Suppuration may occur in the track of a skin stitch, producing a stitch abscess. The infection may arise from the material used, especially catgut or silk, or, more frequently perhaps, from the growth of staphylococcus albus from the skin of the patient when this has been imperfectly disinfected. The formation of pus under these conditions may not be attended with any of the usual signs of suppuration, and beyond some induration around the wound and a slight tenderness on pressure there may be nothing to suggest the presence of an abscess.

Acute Suppuration of a Mucous Membrane.—When pyogenic organisms gain access to a mucous membrane, such as that of the bladder, urethra, or middle ear, the usual phenomena of acute inflammation and suppuration ensue, followed by the discharge of pus on the free surface. It would appear that the most marked changes take place in the submucous tissue, causing the covering epithelium in places to die and leave small superficial ulcers, for example in gonorrhoeal urethritis, the cicatricial contraction of the scar subsequently leading to the formation of stricture. When mucous glands are present in the membrane, the pus is mixed with mucus—muco-pus.

DIFFUSE CELLULITIS AND DIFFUSE SUPPURATION

Cellulitis is an acute affection resulting from the introduction of some organism—commonly the streptococcus pyogenes—into the cellular connective tissue of the integument, intermuscular septa, tendon sheaths, or other structures. Infection always takes place through a breach of the surface, although this may be superficial and insignificant, such as a pin-prick, a scratch, or a crack under a nail, and the wound may have been healed for some time before the inflammation becomes manifest. The cellulitis, also, may develop at some distance from the seat of inoculation, the organisms having travelled by the lymphatics.

The virulence of the organisms, the loose, open nature of the tissues in which they develop, and the free lymphatic circulation by means of which they are spread, account for the diffuse nature of the process. Sometimes numbers of cocci are carried for a considerable distance from the primary area before they are arrested in the lymphatics, and thus several patches of inflammation may appear with healthy areas between.

The pus infiltrates the meshes of the cellular tissue, there is sloughing of considerable portions of tissue of low vitality, such as fat, fascia, or tendon, and if the process continues for some time several collections of pus may form.

Clinical Features.—The reaction in cases of diffuse cellulitis is severe, and is usually ushered in by a distinct chill or even a rigor, while the temperature rises to 103, 104, or 105 F. The pulse is proportionately increased in frequency, and is small, feeble, and often irregular. The face is flushed, the tongue dry and brown, and the patient may become delirious, especially during the night. Leucocytosis is present in cases of moderate severity; but in severe cases the virulence of the toxins prevents reaction taking place, and leucocytosis is absent.

The local manifestations vary with the relation of the seat of the inflammation to the surface. When the superficial cellular tissue is involved, the skin assumes a dark bluish-red colour, is swollen, oedematous, and the seat of burning pain. To the touch it is firm, hot, and tender. When the primary focus is in the deeper tissues, the constitutional disturbance is aggravated, while the local signs are delayed, and only become prominent when pus forms and approaches the surface. It is not uncommon for blebs containing dark serous fluid to form on the skin. The infection frequently spreads along the line of the main lymph vessels of the part (septic lymphangitis) and may reach the lymph glands (septic lymphadenitis).

With the formation of pus the skin becomes soft and boggy at several points, and eventually breaks, giving exit to a quantity of thick grumous discharge. Sometimes several small collections under the skin fuse, and an abscess is formed in which fluctuation can be detected. Occasionally gases are evolved in the tissues, giving rise to emphysema. It is common for portions of fascia, ligaments, or tendons to slough, and this may often be recognised clinically by a peculiar crunching or grating sensation transmitted to the fingers on making firm pressure on the part.

If it is not let out by incision, the pus, travelling along the lines of least resistance, tends to point at several places on the surface, or to open into joints or other cavities.

Prognosis.—The occurrence of septicaemia is the most serious risk, and it is in cases of diffuse suppurative cellulitis that this form of blood-poisoning assumes its most aggravated forms. The toxins of the streptococci are exceedingly virulent, and induce local death of tissue so rapidly that the protective emigration of leucocytes fails to take place. In some cases the passage of masses of free cocci in the lymphatics, or of infective emboli in the blood vessels, leads to the formation of pyogenic abscesses in vital organs, such as the brain, lungs, liver, kidneys, or other viscera. Haemorrhage from erosion of arterial or venous trunks may take place and endanger life.

Treatment.—The treatment of diffuse cellulitis depends to a large extent on the situation and extent of the affected area, and on the stage of the process.

In the limbs, for example, where the application of a constricting band is practicable, Bier's method of inducing passive hyperaemia yields excellent results. If pus is formed, one or more small incisions are made and a light moist dressing placed over the wounds to absorb the discharge, but no drain is inserted. The whole of the inflamed area should be covered with gauze wrung out of a 1 in 10 solution of ichthyol in glycerine. The dressing is changed as often as necessary, and in the intervals when the band is off, gentle active and passive movements should be carried out to prevent the formation of adhesions. After incisions have been made, we have found the immersion of the limb, for a few hours at a time, in a water-bath containing warm boracic lotion or eusol a useful adjuvant to the passive hyperaemia.

Continuous irrigation of the part by a slow, steady stream of lotion, at the body temperature, such as eusol, or Dakin's solution, or boracic acid, or frequent washing with peroxide of hydrogen, has been found of value.

A suitably arranged splint adds to the comfort of the patient; and the limb should be placed in the attitude which, in the event of stiffness resulting, will least interfere with its usefulness. The elbow, for example, should be flexed to a little less than a right angle; at the wrist, the hand should be dorsiflexed and the fingers flexed slightly towards the palm.

Massage, passive movement, hot and cold douching, and other measures, may be necessary to get rid of the chronic oedema, adhesions of tendons, and stiffness of joints which sometimes remain.

In situations where a constricting band cannot be applied, for example, on the trunk or the neck, Klapp's suction bells may be used, small incisions being made to admit of the escape of pus.

If these measures fail or are impracticable, it may be necessary to make one or more free incisions, and to insert drainage-tubes, portions of rubber dam, or iodoform worsted.

The general treatment of toxaemia must be carried out, and in cases due to infection by streptococci, anti-streptococcic serum may be used.

In a few cases, amputation well above the seat of disease, by removing the source of toxin production, offers the only means of saving the patient.

WHITLOW

The clinical term whitlow is applied to an acute infection, usually followed by suppuration, commonly met with in the fingers, less frequently in the toes. The point of infection is often trivial—a pin-prick, a puncture caused by a splinter of wood, a scratch, or even an imperceptible lesion of the skin.

Several varieties of whitlow are recognised, but while it is convenient to describe them separately, it is to be clearly understood that clinically they merge one into another, and it is not always possible to determine in which connective-tissue plane a given infection has originated.

Initial Stage.—Attention is usually first attracted to the condition by a sensation of tightness in the finger and tenderness when the part is squeezed or knocked against anything. In the course of a few hours the part becomes red and swollen; there is continuous pain, which soon assumes a throbbing character, particularly when the hand is dependent, and may be so severe as to prevent sleep, and the patient may feel generally out of sorts.

If a constricting band is applied at this stage, the infection can usually be checked and the occurrence of suppuration prevented. If this fails, or if the condition is allowed to go untreated, the inflammatory reaction increases and terminates in suppuration, giving rise to one or other of the forms of whitlow to be described.

The Purulent Blister.—In the most superficial variety, pus forms between the rete Malpighii and the stratum corneum of the skin, the latter being raised as a blister in which fluctuation can be detected (Fig. 9, a). This is commonly met with in the palm of the hand of labouring men who have recently resumed work after a spell of idleness. When the blister forms near the tip of the finger, the pus burrows under the nail—which corresponds to the stratum corneum—raising it from its bed.

There is some local heat and discoloration, and considerable pain and tenderness, but little or no constitutional disturbance. Superficial lymphangitis may extend a short distance up the forearm. By clipping away the raised epidermis, and if necessary the nail, the pus is allowed to escape, and healing speedily takes place.

Whitlow at the Nail Fold.—This variety, which is met with among those who handle septic material, occurs in the sulcus between the nail and the skin, and is due to the introduction of infective matter at the root of the nail (Fig. 9, b). A small focus of suppuration forms under the nail, with swelling and redness of the nail fold, causing intense pain and discomfort, interfering with sleep, and producing a constitutional reaction out of all proportion to the local lesion.

To allow the pus to escape, it is necessary, under local anaesthesia, to cut away the nail fold as well as the portion of nail in the infected area, or, it may be, to remove the nail entirely. If only a small opening is made in the nail it is apt to be blocked by granulations.



Subcutaneous Whitlow.—In this variety the infection manifests itself as a cellulitis of the pulp of the finger (Fig. 9, c), which sometimes spreads towards the palm of the hand. The finger becomes red, swollen, and tense; there is severe throbbing pain, which is usually worst at night and prevents sleep, and the part is extremely tender on pressure. When the palm is invaded there may be marked oedema of the back of the hand, the dense integument of the palm preventing the swelling from appearing on the front. The pus may be under such tension that fluctuation cannot be detected. The patient is usually able to flex the finger to a certain extent without increasing the pain—a point which indicates that the tendon sheaths have not been invaded. The suppurative process may, however, spread to the tendon sheaths, or even to the bone. Sometimes the excessive tension and virulent toxins induce actual gangrene of the distal part, or even of the whole finger. There is considerable constitutional disturbance, the temperature often reaching 101 or 102 F.

The treatment consists in applying a constriction band and making an incision over the centre of the most tender area, care being taken to avoid opening the tendon sheath lest the infection be conveyed to it. Moist dressings should be employed while the suppuration lasts. Carbolic fomentations, however, are to be avoided on account of the risk of inducing gangrene.

Whitlow of the Tendon Sheaths.—In this form the main incidence of the infection is on the sheaths of the flexor tendons, but it is not always possible to determine whether it started there or spread thither from the subcutaneous cellular tissue (Fig. 9, d). In some cases both connective tissue planes are involved. The affected finger becomes red, painful, and swollen, the swelling spreading to the dorsum. The involvement of the tendon sheath is usually indicated by the patient being unable to flex the finger, and by the pain being increased when he attempts to do so. On account of the anatomical arrangement of the tendon sheaths, the process may spread into the forearm—directly in the case of the thumb and little finger, and after invading the palm in the case of the other fingers—and there give rise to a diffuse cellulitis which may result in sloughing of fasciae and tendons. When the infection spreads into the common flexor sheath under the transverse carpal (anterior annular) ligament, it is not uncommon for the intercarpal and wrist joints to become implicated. Impaired movement of tendons and joints is, therefore, a common sequel to this variety of whitlow.

The treatment consists in inducing passive hyperaemia by Bier's method, and, if this is done early, suppuration may be avoided. If pus forms, small incisions are made, under local anaesthesia, to relieve the tension in the sheath and to diminish the risk of the tendons sloughing. No form of drain should be inserted. In the fingers the incisions should be made in the middle line, and in the palm they should be made over the metacarpal bones to avoid the digital vessels and nerves. If pus has spread under the transverse carpal ligament, the incision must be made above the wrist. Passive movements and massage must be commenced as early as possible and be perseveringly employed to diminish the formation of adhesions and resulting stiffness.

Subperiosteal Whitlow.—This form is usually an extension of the subcutaneous or of the thecal variety, but in some cases the inflammation begins in the periosteum—usually of the terminal phalanx. It may lead to necrosis of a portion or even of the entire phalanx. This is usually recognised by the persistence of suppuration long after the acute symptoms have passed off, and by feeling bare bone with the probe. In such cases one or more of the joints are usually implicated also, and lateral mobility and grating may be elicited. Recovery does not take place until the dead bone is removed, and the usefulness of the finger is often seriously impaired by fibrous or bony ankylosis of the interphalangeal joints. This may render amputation advisable when a stiff finger is likely to interfere with the patient's occupation.

SUPPURATIVE CELLULITIS IN DIFFERENT SITUATIONS

Cellulitis of the forearm is usually a sequel to one of the deeper varieties of whitlow.

In the region of the elbow-joint, cellulitis is common around the olecranon. It may originate as an inflammation of the olecranon bursa, or may invade the bursa secondarily. In exceptional cases the elbow-joint is also involved.

Cellulitis of the axilla may originate in suppuration in the lymph glands, following an infected wound of the hand, or it may spread from a septic wound on the chest wall or in the neck. In some cases it is impossible to discover the primary seat of infection. A firm, brawny swelling forms in the armpit and extends on to the chest wall. It is attended with great pain, which is increased on moving the arm, and there is marked constitutional disturbance. When suppuration occurs, its spread is limited by the attachments of the axillary fascia, and the pus tends to burrow on to the chest wall beneath the pectoral muscles, and upwards towards the shoulder-joint, which may become infected. When the pus forms in the axillary space, the treatment consists in making free incisions, which should be placed on the thoracic side of the axilla to avoid the axillary vessels and nerves. If the pus spreads on to the chest wall, the abscess should be opened below the clavicle by Hilton's method, and a counter opening may be made in the axilla.

Cellulitis of the sole of the foot may follow whitlow of the toes.

In the region of the ankle cellulitis is not common; but around the knee it frequently occurs in relation to the prepatellar bursa and to the popliteal lymph glands, and may endanger the knee-joint. It is also met with in the groin following on inflammation and suppuration of the inguinal glands, and cases are recorded in which the sloughing process has implicated the femoral vessels and led to secondary haemorrhage.

Cellulitis of the scalp, orbit, neck, pelvis, and perineum will be considered with the diseases of these regions.

CHRONIC SUPPURATION

While it is true that a chronic pyogenic abscess is sometimes met with—for example, in the breast and in the marrow of long bones—in the great majority of instances the formation of a chronic or cold abscess is the result of the action of the tubercle bacillus. It is therefore more convenient to study this form of suppuration with tuberculosis (p. 139).

SINUS AND FISTULA

Sinus.—A sinus is a track leading from a focus of suppuration to a cutaneous or mucous surface. It usually represents the path by which the discharge escapes from an abscess cavity that has been prevented from closing completely, either from mechanical causes or from the persistent formation of discharge which must find an exit. A sinus is lined by granulation tissue, and when it is of long standing the opening may be dragged below the level of the surrounding skin by contraction of the scar tissue around it. As a sinus will persist until the obstacle to closure of the original abscess is removed, it is necessary that this should be sought for. It may be a foreign body, such as a piece of dead bone, an infected ligature, or a bullet, acting mechanically or by keeping up discharge, and if the body is removed the sinus usually heals. The presence of a foreign body is often suggested by a mass of redundant granulations at the mouth of the sinus. If a sinus passes through a muscle, the repeated contractions tend to prevent healing until the muscle is kept at rest by a splint, or put out of action by division of its fibres. The sinuses associated with empyema are prevented from healing by the rigidity of the chest wall, and will only close after an operation which admits of the cavity being obliterated. In any case it is necessary to disinfect the track, and, it may be, to remove the unhealthy granulations lining it, by means of the sharp spoon, or to excise it bodily. To encourage healing from the bottom the cavity should be packed with bismuth or iodoform gauze. The healing of long and tortuous sinuses is often hastened by the injection of Beck's bismuth paste (p. 145). If disfigurement is likely to follow from cicatricial contraction—for example, in a sinus over the lower jaw associated with a carious tooth—the sinus should be excised and the raw surfaces approximated with stitches.

The tuberculous sinus is described under Tuberculosis.

A fistula is an abnormal canal passing from a mucous surface to the skin or to another mucous surface. Fistulae resulting from suppuration usually occur near the natural openings of mucous canals—for example, on the cheek, as a salivary fistula; beside the inner angle of the eye, as a lacrymal fistula; near the ear, as a mastoid fistula; or close to the anus, as a fistula-in-ano. Intestinal fistulae are sometimes met with in the abdominal wall after strangulated hernia, operations for appendicitis, tuberculous peritonitis, and other conditions. In the perineum, fistulae frequently complicate stricture of the urethra.

Fistulae also occur between the bladder and vagina (vesico-vaginal fistula), or between the bladder and the rectum (recto-vesical fistula).

The treatment of these various forms of fistula will be described in the sections dealing with the regions in which they occur.

Congenital fistulae, such as occur in the neck from imperfect closure of branchial clefts, or in the abdomen from unobliterated foetal ducts such as the urachus or Meckel's diverticulum, will be described in their proper places.

CONSTITUTIONAL MANIFESTATIONS OF PYOGENIC INFECTION

We have here to consider under the terms Sapraemia, Septicaemia, and Pyaemia certain general effects of pyogenic infection, which, although their clinical manifestations may vary, are all associated with the action of the same forms of bacteria. They may occur separately or in combination, or one may follow on and merge into another.

Sapraemia, or septic intoxication, is the name applied to a form of poisoning resulting from the absorption into the blood of the toxic products of pyogenic bacteria. These products, which are of the nature of alkaloids, act immediately on their entrance into the circulation, and produce effects in direct proportion to the amount absorbed. As the toxins are gradually eliminated from the body the symptoms abate, and if no more are introduced they disappear. Sapraemia in these respects, therefore, is comparable to poisoning by any other form of alkaloid, such as strychnin or morphin.

Clinical Features.—The symptoms of sapraemia seldom manifest themselves within twenty-four hours of an operation or injury, because it takes some time for the bacteria to produce a sufficient dose of their poisons. The onset of the condition is marked by a feeling of chilliness, sometimes amounting to a rigor, and a rise of temperature to 102, 103, or 104 F., with morning remissions (Fig. 10). The heart's action is markedly depressed, and the pulse is soft and compressible. The appetite is lost, the tongue dry and covered with a thin brownish-red fur, so that it has the appearance of "dried beef." The urine is scanty and loaded with urates. In severe cases diarrhoea and vomiting of dark coffee-ground material are often prominent features. Death is usually impending when the skin becomes cold and clammy, the mucous membranes livid, the pulse feeble and fluttering, the discharges involuntary, and when a low form of muttering delirium is present.



A local form of septic infection is always present—it may be an abscess, an infected compound fracture, or an infection of the cavity of the uterus, for example, from a retained portion of placenta.

Treatment.—The first indication is the immediate and complete removal of the infected material. The wound must be freely opened, all blood-clot, discharge, or necrosed tissue removed, and the area disinfected by washing with sterilised salt solution, peroxide of hydrogen, or eusol. Stronger lotions are to be avoided as being likely to depress the tissues, and so interfere with protective phagocytosis. On account of its power of neutralising toxins, iodoform is useful in these cases, and is best employed by packing the wound with iodoform gauze, and treating it by the open method, if this is possible.

The general treatment is carried out on the same lines as for other infective conditions.

Chronic sapraemia or Hectic Fever.—Hectic fever differs from acute sapraemia merely in degree. It usually occurs in connection with tuberculous conditions, such as bone or joint disease, psoas abscess, or empyema, which have opened externally, and have thereby become infected with pyogenic organisms. It is gradual in its development, and is of a mild type throughout.



The pulse is small, feeble, and compressible, and the temperature rises in the afternoon or evening to 102 or 103 F. (Fig. 11), the cheeks becoming characteristically flushed. In the early morning the temperature falls to normal or below it, and the patient breaks into a profuse perspiration, which leaves him pale, weak, and exhausted. He becomes rapidly and markedly emaciated, even although in some cases the appetite remains good and is even voracious.

The poisons circulating in the blood produce waxy degeneration in certain viscera, notably the liver, spleen, kidneys, and intestines. The process begins in the arterial walls, and spreads thence to the connective-tissue structures, causing marked enlargement of the affected organs. Albuminuria, ascites, oedema of the lower limbs, clubbing of the fingers, and diarrhoea are among the most prominent symptoms of this condition.

The prognosis in hectic fever depends on the completeness with which the further absorption of toxins can be prevented. In many cases this can only be effected by an operation which provides for free drainage, and, if possible, the removal of infected tissues. The resulting wound is best treated by the open method. Even advanced waxy degeneration does not contra-indicate this line of treatment, as the diseased organs usually recover if the focus from which absorption of toxic material is taking place is completely eradicated.



Septicaemia.—This form of blood-poisoning is the result of the action of pyogenic bacteria, which not only produce their toxins at the primary seat of infection, but themselves enter the blood-stream and are carried to other parts, where they settle and produce further effects.

Clinical Features.—There may be an incubation period of some hours between the infection and the first manifestation of acute septicaemia. In such conditions as acute osteomyelitis or acute peritonitis, we see the most typical clinical pictures of this condition. The onset is marked by a chill, or a rigor, which may be repeated, while the temperature rises to 103 or 104 F., although in very severe cases the temperature may remain subnormal throughout, the virulence of the toxins preventing reaction. It is in the general appearance of the patient and in the condition of the pulse that we have our best guides as to the severity of the condition. If the pulse remains firm, full, and regular, and does not exceed 110 or even 120, while the temperature is moderately raised, the outlook is hopeful; but when the pulse becomes small and compressible, and reaches 130 or more, especially if at the same time the temperature is low, a grave prognosis is indicated. The tongue is often dry and coated with a black crust down the centre, while the sides are red. It is a good omen when the tongue becomes moist again. Thirst is most distressing, especially in septicaemia of intestinal origin. Persistent vomiting of dark-brown material is often present, and diarrhoea with blood-stained stools is not uncommon. The urine is small in amount, and contains a large proportion of urates. As the poisons accumulate, the respiration becomes shallow and laboured, the face of a dull ashy grey, the nose pinched, and the skin cold and clammy. Capillary haemorrhages sometimes take place in the skin or mucous membranes; and in a certain proportion of cases cutaneous eruptions simulating those of scarlet fever or measles appear, and are apt to lead to errors in diagnosis. In other cases there is slight jaundice. The mental state is often one of complete apathy, the patient failing to realise the gravity of his condition; sometimes there is delirium.

The prognosis is always grave, and depends on the possibility of completely eradicating the focus of infection, and on the reserve force the patient has to carry him over the period during which he is eliminating the poison already circulating in his blood.

The treatment is carried out on the same lines as in sapraemia, but it is less likely to be successful owing to the organisms having entered the circulation. When possible, the primary focus of infection should be dealt with.

Pyaemia is a form of blood-poisoning characterised by the development of secondary foci of suppuration in different parts of the body. Toxins are thus introduced into the blood, not only at the primary seat of infection, but also from each of these metastatic collections. Like septicaemia, this condition is due to pyogenic bacteria, the streptococcus pyogenes being the commonest organism found. The primary infection is usually in a wound—for example, a compound fracture—but cases occur in which the point of entrance of the bacteria is not discoverable. The dissemination of the organisms takes place through the medium of infected emboli which form in a thrombosed vein in the vicinity of the original lesion, and, breaking loose, are carried thence in the blood-stream. These emboli lodge in the minute vessels of the lungs, spleen, liver, kidneys, pleura, brain, synovial membranes, or cellular tissue, and the bacteria they contain give rise to secondary foci of suppuration. Secondary abscesses are thus formed in those parts, and these in turn may be the starting-point of new emboli which give rise to fresh areas of pus formation. The organs above named are the commonest situations of pyaemic abscesses, but these may also occur in the bone marrow, the substance of muscles, the heart and pericardium, lymph glands, subcutaneous tissue, or, in fact, in any tissue of the body. Organisms circulating in the blood are prone to lodge on the valves of the heart and give rise to endocarditis.



Clinical Features.—Before antiseptic surgery was practised, pyaemia was a common complication of wounds. In the present day it is not only infinitely less common, but appears also to be of a less severe type. Its rarity and its mildness may be related as cause and effect, because it was formerly found that pyaemia contracted from a pyaemic patient was more virulent than that from other sources.

In contrast with sapraemia and septicaemia, pyaemia is late of developing, and it seldom begins within a week of the primary infection. The first sign is a feeling of chilliness, or a violent rigor lasting for perhaps half an hour, during which time the temperature rises to 103, 104, or 105 F. In the course of an hour it begins to fall again, and the patient breaks into a profuse sweat. The temperature may fall several degrees, but seldom reaches the normal. In a few days there is a second rigor with rise of temperature, and another remission, and such attacks may be repeated at diminishing intervals during the course of the illness (Figs. 12 and 13). The pulse is soft, and tends to remain abnormally rapid even when the temperature falls nearly to normal.

The face is flushed, and wears a drawn, anxious expression, and the eyes are bright. A characteristic sweetish odour, which has been compared to that of new-mown hay, can be detected in the breath and may pervade the patient. The appetite is lost; there may be sickness and vomiting and profuse diarrhoea; and the patient emaciates rapidly. The skin is continuously hot, and has often a peculiar pungent feel. Patches of erythema sometimes appear scattered over the body. The skin may assume a dull sallow or earthy hue, or a bright yellow icteric tint may appear. The conjunctivae also may be yellow. In the latter stages of the disease the pulse becomes small and fluttering; the tongue becomes dry and brown; sordes collect on the teeth; and a low muttering form of delirium supervenes.

Secondary infection of the parotid gland frequently occurs, and gives rise to a suppurative parotitis. This condition is associated with severe pain, gradually extending from behind the angle of the jaw on to the face. There is also swelling over the gland, and eventually suppuration and sloughing of the gland tissue and overlying skin.

Secondary abscesses in the lymph glands, subcutaneous tissue, or joints are often so insidious and painless in their development that they are only discovered accidentally. When the abscess is evacuated, healing often takes place with remarkable rapidity, and with little impairment of function.

The general symptoms may be simulated by an attack of malaria.

Prognosis.—The prognosis in acute pyaemia is much less hopeless than it once was, a considerable proportion of the patients recovering. In acute cases the disease proves fatal in ten days or a fortnight, death being due to toxaemia. Chronic cases often run a long course, lasting for weeks or even months, and prove fatal from exhaustion and waxy disease following on prolonged suppuration.

Treatment.—In such conditions as compound fractures and severe lacerated wounds, much can be done to avert the conditions which lead to pyaemia, by applying a Bier's constricting bandage as soon as there is evidence of infection having taken place, or even if there is reason to suspect that the wound is not aseptic.

If sepsis is already established, and evidence of general infection is present, the wound should be opened up sufficiently to admit of thorough disinfection and drainage, and the constricting bandage applied to aid the defensive processes going on in the tissues. If these measures fail, amputation of the limb may be the only means of preventing further dissemination of infective material from the primary source of infection.

Attempts have been made to interrupt the channel along which the infective emboli spread, by ligating or resecting the main vein of the affected part, but this is seldom feasible except in the case of the internal jugular vein for infection of the transverse sinus.

Secondary abscesses must be aspirated or opened and drained whenever possible.

The general treatment is conducted on the same lines as on other forms of pyogenic infection.



CHAPTER V

ULCERATION AND ULCERS

Definitions—Clinical examination of an ulcer—The healing sore.—Classification of ulcers—A. According to cause: Traumatism, Imperfect circulation, Imperfect nerve-supply, Constitutional causes—B. According to condition: Healing, Stationary, Spreading.—Treatment.

The process of ulceration may be defined as the molecular or cellular death of tissue taking place on a free surface. It is essentially of the same nature as the process of suppuration, only that the purulent discharge, instead of collecting in a closed cavity and forming an abscess, at once escapes on the surface.

An ulcer is an open wound or sore in which there are present certain conditions tending to prevent it undergoing the natural process of repair. Of these, one of the most important is the presence of pathogenic bacteria, which by their action not only prevent healing, but so irritate and destroy the tissues as to lead to an actual increase in the size of the sore. Interference with the nutrition of a part by oedema or chronic venous congestion may impede healing; as may also induration of the surrounding area, by preventing the contraction which is such an important factor in repair. Defective innervation, such as occurs in injuries and diseases of the spinal cord, also plays an important part in delaying repair. In certain constitutional conditions, too—for example, Bright's disease, diabetes, or syphilis—the vitiated state of the tissues is an impediment to repair. Mechanical causes, such as unsuitable dressings or ill-fitting appliances, may also act in the same direction.

Clinical Examination of an Ulcer.—In examining any ulcer, we observe—(1) Its base or floor, noting the presence or absence of granulations, their disposition, size, colour, vascularity, and whether they are depressed or elevated in relation to the surrounding parts. (2) The discharge as to quantity, consistence, colour, composition, and odour. (3) The edges, noting particularly whether or not the marginal epithelium is attempting to grow over the surface; also their shape, regularity, thickness, and whether undermined or overlapping, everted or depressed. (4) The surrounding tissues, as to whether they are congested, oedematous, inflamed, indurated, or otherwise. (5) Whether or not there is pain or tenderness in the raw surface or its surroundings. (6) The part of the body on which it occurs, because certain ulcers have special seats of election—for example, the varicose ulcer in the lower third of the leg, the perforating ulcer on the sole of the foot, and so on.

The Healing Sore.—If a portion of skin be excised aseptically, and no attempt made to close the wound, the raw surface left is soon covered over with a layer of coagulated blood and lymph. In the course of a few days this is replaced by the growth of granulations, which are of uniform size, of a pinkish-red colour, and moist with a slight serous exudate containing a few dead leucocytes. They grow until they reach the level of the surrounding skin, and so fill the gap with a fine velvety mass of granulation tissue. At the edges, the young epithelium may be seen spreading in over the granulations as a fine bluish-white pellicle, which gradually covers the sore, becoming paler in colour as it thickens, and eventually forming the smooth, non-vascular covering of the cicatrix. There is no pain, and the surrounding parts are healthy.

This may be used as a type with which to compare the ulcers seen at the bedside, so that we may determine how far, and in what particulars, these differ from the type; and that we may in addition recognise the conditions that have to be counteracted before the characters of the typical healing sore are assumed.

For purposes of contrast we may indicate the characters of an open sore in which bacterial infection with pathogenic bacteria has taken place. The layer of coagulated blood and lymph becomes liquefied and is thrown off, and instead of granulations being formed, the tissues exposed on the floor of the ulcer are destroyed by the bacterial toxins, with the formation of minute sloughs and a quantity of pus.

The discharge is profuse, thin, acrid, and offensive, and consists of pus, broken-down blood-clot, and sloughs. The edges are inflamed, irregular, and ragged, showing no sign of growing epithelium—on the contrary, the sore may be actually increasing in area by the breaking-down of the tissues at its margins. The surrounding parts are hot, red, swollen, and oedematous; and there is pain and tenderness both in the sore itself and in the parts around.

Classification of Ulcers.—The nomenclature of ulcers is much involved and gives rise to great confusion, chiefly for the reason that no one basis of classification has been adopted. Thus some ulcers are named according to the causes at work in producing or maintaining them—for example, the traumatic, the septic, and the varicose ulcer; some from the constitutional element present, as the gouty and the diabetic ulcer; and others according to the condition in which they happen to be when seen by the surgeon, such as the weak, the inflamed, and the callous ulcer.

So long as we retain these names it will be impossible to find a single basis for classification; and yet many of the terms are so descriptive and so generally understood that it is undesirable to abolish them. We must therefore remain content with a clinical arrangement of ulcers,—it cannot be called a classification,—considering any given ulcer from two points of view: first its cause, and second its present condition. This method of studying ulcers has the practical advantage that it furnishes us with the main indications for treatment as well as for diagnosis: the cause must be removed, and the condition so modified as to convert the ulcer into an aseptic healing sore.

A. Arrangement of Ulcers according to their Cause.—Although any given ulcer may be due to a combination of causes, it is convenient to describe the following groups:

Ulcers due to Traumatism.—Traumatism in the form of a crush or bruise is a frequent cause of ulcer formation, acting either by directly destroying the skin, or by so diminishing its vitality that it is rendered a suitable soil for bacteria. If these gain access, in the course of a few days the damaged area of skin becomes of a greyish colour, blebs form on it, and it undergoes necrosis, leaving an unhealthy raw surface when the slough separates.

Heat and prolonged exposure to the Rontgen rays or to radium emanations act in a similar way.

The pressure of improperly padded splints or other appliances may so far interfere with the circulation of the part pressed upon, that the skin sloughs, leaving an open sore. This is most liable to occur in patients who suffer from some nerve lesion—such as anterior poliomyelitis, or injury of the spinal cord or nerve-trunks. Splint-pressure sores are usually situated over bony prominences, such as the malleoli, the condyles of the femur or humerus, the head of the fibula, the dorsum of the foot, or the base of the fifth metatarsal bone. On removing the splint, the skin of the part pressed upon is found to be of a red or pink colour, with a pale grey patch in the centre, which eventually sloughs and leaves an ulcer. Certain forms of bed-sore are also due to prolonged pressure.

Pressure sores are also known to have been produced artificially by malingerers and hysterical subjects.



Ulcers due to Imperfect Circulation.—Imperfect circulation is an important causative factor in ulceration, especially when it is the venous return that is defective. This is best illustrated in the so-called leg ulcer, which occurs most frequently on the front and medial aspect of the lower third of the leg. At this point the anastomosis between the superficial and deep veins of the leg is less free than elsewhere, so that the extra stress thrown upon the surface veins interferes with the nutrition of the skin (Hilton). The importance of imperfect venous return in the causation of such ulcers is evidenced by the fact that as soon as the condition of the circulation is improved by confining the patient to bed and elevating the limb, the ulcer begins to heal, even although all methods of local treatment have hitherto proved ineffectual. In a considerable number of cases, but by no means in all, this form of ulcer is associated with the presence of varicose veins, and in such cases it is spoken of as the varicose ulcer (Fig. 14). The presence of varicose veins is frequently associated with a diffuse brownish or bluish pigmentation of the skin of the lower third of the leg, or with an obstinate form of dermatitis (varicose eczema), and the scratching or rubbing of the part is liable to cause a breach of the surface and permit of infection which leads to ulceration. Varicose ulcers may also originate from the bursting of a small peri-phlebitic abscess.

Varicose veins in immediate relation to the base of a large chronic ulcer usually become thrombosed, and in time are reduced to fibrous cords, and therefore in such cases haemorrhage is not a common complication. In smaller and more superficial ulcers, however, the destructive process is liable to implicate the wall of the vessel before the occurrence of thrombosis, and to lead to profuse and it may be dangerous bleeding.

These ulcers are at first small and superficial, but from want of care, from continued standing or walking, or from injudicious treatment, they gradually become larger and deeper. They are not infrequently multiple, and this, together with their depth, may lead to their being mistaken for ulcers due to syphilis. The base of the ulcer is covered with imperfectly formed, soft, oedematous granulations, which give off a thin sero-purulent discharge. The edges are slightly inflamed, and show no evidence of healing. The parts around are usually pigmented and slightly oedematous, and as a rule there is little pain. This variety of ulcer is particularly prone to pass into the condition known as callous.

In anaemic patients, especially young girls, ulcers are occasionally met with which have many of the clinical characters of those associated with imperfect venous return. They are slow to heal, and tend to pass into the condition known as weak.

Ulcers due to Interference with Nerve-Supply.—Any interference with the nerve-supply of the superficial tissues predisposes to ulceration. For example, trophic ulcers are liable to occur in injuries or diseases of the spinal cord, in cerebral paralysis, in limbs weakened by poliomyelitis, in ascending or peripheral neuritis, or after injuries of nerve-trunks.

The acute bed-sore is a rapidly progressing form of ulceration, often amounting to gangrene, of portions of skin exposed to pressure when their trophic nerve-supply has been interfered with.



The perforating ulcer of the foot is a peculiar type of sore which occurs in association with the different forms of peripheral neuritis, and with various lesions of the brain and spinal cord, such as general paralysis, locomotor ataxia, or syringo-myelia (Fig. 15). It also occurs in patients suffering from glycosuria, and is usually associated with arterio-sclerosis—local or general. Perforating ulcer is met with most frequently under the head of the metatarsal bone of the great toe. A callosity forms and suppuration occurs under it, the pus escaping through a small hole in the centre. The process slowly and gradually spreads deeper and deeper, till eventually the bone or joint is reached, and becomes implicated in the destructive process—hence the term "perforating ulcer." The flexor tendons are sometimes destroyed, the toe being dorsiflexed by the unopposed extensors. The depth of the track being so disproportionate to its superficial area, the condition closely simulates a tuberculous sinus, for which it is liable to be mistaken. The raw surface is absolutely insensitive, so that the probe can be freely employed without the patient even being aware of it or suffering the least discomfort—a significant fact in diagnosis. The cavity is filled with effete and decomposing epidermis, which has a most offensive odour. The chronic and intractable character of the ulcer is due to interference with the trophic nerve-supply of the parts, and to the fact that the epithelium of the skin grows in and lines the track leading down to the deepest part of the ulcer and so prevents closure. While they are commonest on the sole of the foot and other parts subjected to pressure, perforating ulcers are met with on the sides and dorsum of the foot and toes, on the hands, and on other parts where no pressure has been exerted.

The tuberculous ulcer, so often seen in the neck, in the vicinity of joints, or over the ribs and sternum, usually results from the bursting through the skin of a tuberculous abscess. The base is soft, pale, and covered with feeble granulations and grey shreddy sloughs. The edges are of a dull blue or purple colour, and gradually thin out towards their free margins, and in addition are characteristically undermined, so that a probe can be passed for some distance between the floor of the ulcer and the thinned-out edges. Thin, devitalised tags of skin often stretch from side to side of the ulcer. The outline is irregular; small perforations often occur through the skin, and a thin, watery discharge, containing grey shreds of tuberculous debris, escapes.

Bazin's Disease.—This term is applied to an affection of the skin and subcutaneous tissue which bears certain resemblances to tuberculosis. It is met with almost exclusively between the knee and the ankle, and it usually affects both legs. It is commonest in girls of delicate constitution, in whose family history there is evidence of a tuberculous taint. The patient often presents other lesions of a tuberculous character, notably enlarged cervical glands, and phlyctenular ophthalmia. The tubercle bacillus has rarely been found, but we have always observed characteristic epithelioid cells and giant cells in sections made from the edge or floor of the ulcer.



The condition begins by the formation in the skin and subcutaneous tissue of dusky or livid nodules of induration, which soften and ulcerate, forming small open sores with ragged and undermined edges, not unlike those resulting from the breaking down of superficial syphilitic gummata (Fig. 16). Fresh crops of nodules appear in the neighbourhood of the ulcers, and in turn break down. While in the nodular stage the affection is sometimes painful, but with the formation of the ulcer the pain subsides.

The disease runs a chronic course, and may slowly extend over a wide area in spite of the usual methods of treatment. After lasting for some months, or even years, however, it may eventually undergo spontaneous cure. The most satisfactory treatment is to excise the affected tissues and fill the gap with skin-grafts.



The syphilitic ulcer is usually formed by the breaking down of a cutaneous or subcutaneous gumma in the tertiary stage of syphilis. When the gummatous tissue is first exposed by the destruction of the skin or mucous membrane covering it, it appears as a tough greyish slough, compared to "wash leather," which slowly separates and leaves a more or less circular, deep, punched-out gap which shows a few feeble unhealthy granulations and small sloughs on its floor. The edges are raised and indurated; and the discharge is thick, glairy, and peculiarly offensive. The parts around the ulcer are congested and of a dark brown colour. There are usually several such ulcers together, and as they tend to heal at one part while they spread at another, the affected area assumes a sinuous or serpiginous outline. Syphilitic ulcers may be met with in any part of the body, but are most frequent in the upper part of the leg (Fig. 17), especially around the knee-joint in women, and over the ribs and sternum. On healing, they usually leave a depressed and adherent cicatrix.

The scorbutic ulcer occurs in patients suffering from scurvy, and is characterised by its prominent granulations, which show a marked tendency to bleed, with the formation of clots, which dry and form a spongy crust on the surface.

In gouty patients small ulcers which are exceedingly irritable and painful are liable to occur.

Ulcers associated with Malignant Disease.—Cancer and sarcoma when situated in the subcutaneous tissue may destroy the overlying skin so that the substance of the tumour is exposed. The fungating masses thus produced are sometimes spoken of as malignant ulcers, but as they are essentially different in their nature from all other forms of ulcers, and call for totally different treatment, it is best to consider them along with the tumours with which they are associated. Rodent ulcer, which is one form of cancer of the skin, will be discussed with new growths of the skin.

B. Arrangement of Ulcers according to their Condition.—Having arrived at an opinion as to the cause of a given ulcer, and placed it in one or other of the preceding groups, the next question to ask is, In what condition do I find this ulcer at the present moment?

Any ulcer is in one of three states—healing, stationary, or spreading; although it is not uncommon to find healing going on at one part while the destructive process is extending at another.

The Healing Condition.—The process of healing in an ulcer has already been studied, and we have learned that it takes place by the formation of granulation tissue, which becomes converted into connective tissue, and is covered over by epithelium growing in from the edges.

Those ulcers which are stationary—that is, neither healing nor spreading—may be in one of several conditions.

The Weak Condition.—Any ulcer may get into a weak state from receiving a blood supply which is defective either in quantity or in quality. The granulations are small and smooth, and of a pale yellow or grey colour, the discharge is small in amount, and consists of thin serum and a few pus cells, and as this dries on the edges it forms scabs which interfere with the growth of epithelium.

Should the part become oedematous, either from general causes, such as heart or kidney disease, or from local causes, such as varicose veins, the granulations share in the oedema, and there is an abundant serous discharge.

The excessive use of moist dressings leads to a third variety of weak ulcer—namely, one in which the granulations become large, soft, pale, and flabby, projecting beyond the level of the skin and overlapping the edges, which become pale and sodden. The term "proud flesh" is popularly applied to such redundant granulations.



The Callous Condition.—This condition is usually met with in ulcers on the lower third of the leg, and is often associated with the presence of varicose veins. It is chiefly met with in hospital practice. The want of healing is mainly due to impeded venous return and to oedema and induration of the surrounding skin and cellular tissues (Fig. 18). The induration results from coagulation and partial organisation of the inflammatory effusion, and prevents the necessary contraction of the sore. The base of a callous ulcer lies at some distance below the level of the swollen, thickened, and white edges, and presents a glazed appearance, such granulations as are present being unhealthy and irregular. The discharge is usually watery, and cakes in the dressing. When from neglect and want of cleanliness the ulcer becomes inflamed, there is considerable pain, and the discharge is purulent and often offensive.

The prolonged hyperaemia of the tissues in relation to a callous ulcer of the leg often leads to changes in the underlying bones. The periosteum is abnormally thick and vascular, the superficial layers of the bone become injected and porous, and the bones, as a whole, are thickened. In the macerated bone "the surface is covered with irregular, stalactite-like processes or foliaceous masses, which, to a certain extent, follow the line of attachment of the interosseous membrane and of the intermuscular septa" (Cathcart) (Fig. 19). When the whole thickness of the soft tissues is destroyed by the ulcerative process, the area of bone that comes to form the base of the ulcer projects as a flat, porous node, which in its turn may be eroded. These changes as seen in the macerated specimen are often mistaken for disease originating in the bone.



The irritable condition is met with in ulcers which occur, as a rule, just above the external malleolus in women of neurotic temperament. They are small in size and have prominent granulations, and by the aid of a probe points of excessive tenderness may be discovered. These, Hilton believed, correspond to exposed nerve filaments.

Ulcers which are spreading may be met with in one of several conditions.

The Inflamed Condition.—Any ulcer may become acutely inflamed from the access of fresh organisms, aided by mechanical irritation from trauma, ill-fitting splints or bandages, or want of rest, or from chemical irritants, such as strong antiseptics. The best clinical example of an inflamed ulcer is the venereal soft sore. The base of the ulcer becomes red and angry-looking, the granulations disappear, and a copious discharge of thin yellow pus, mixed with blood, escapes. Sloughs of granulation tissue or of connective tissue may form. The edges become red, ragged, and everted, and the ulcer increases in size by spreading into the inflamed and oedematous surrounding tissues. Such ulcers are frequently multiple. Pain is a constant symptom, and is often severe, and there is usually some constitutional disturbance.

The phagedaenic condition is the result of an ulcer being infected with specially virulent bacteria. It occurs in syphilitic ulcers, and rapidly leads to a widespread destruction of tissue. It is also met with in the throat in some cases of scarlet fever, and may give rise to fatal haemorrhage by ulcerating into large blood vessels. All the local and constitutional signs of a severe septic infection are present.

Treatment of Ulcers.—An ulcer is not only an immediate cause of suffering to the patient, crippling and incapacitating him for his work, but is a distinct and constant menace to his health: the prolonged discharge reduces his strength; the open sore is a possible source of infection by the organisms of suppuration, erysipelas, or other specific diseases; phlebitis, with formation of septic emboli, leading to pyaemia, is liable to occur; and in old persons it is not uncommon for ulcers of long standing to become the seat of cancer. In addition, the offensive odour of many ulcers renders the patient a source of annoyance and discomfort to others. The primary object of treatment in any ulcer is to bring it into the condition of a healing sore. When this has been effected, nature will do the rest, provided extraneous sources of irritation are excluded.

Steps must be taken to facilitate the venous return from the ulcerated part, and to ensure that a sufficient supply of fresh, healthy blood reaches it. The septic element must be eliminated by disinfecting the ulcer and its surroundings, and any other sources of irritation must be removed.

If the patient's health is below par, good nourishing food, tonics, and general hygienic treatment are indicated.

Management of a Healing Sore.—Perhaps the best dressing for a healing sore is a layer of Lister's perforated oiled-silk protective, which is made to cover the raw surface and the skin for about a quarter of an inch beyond the margins of the sore. Over this three or four thicknesses of sterilised gauze, wrung out of eusol, creolin, or sterilised water, are applied, and covered by a pad of absorbent wool. As far as possible the part should be kept at rest, and the position should be adjusted so as to favour the circulation in the affected area.

The dressing may be renewed at intervals, and care must be taken to avoid any rough handling of the sore. Any discharge that lies on the surface should be removed by a gentle stream of lotion rather than by wiping. The area round the sore should be cleansed before the fresh dressing is applied.

In some cases, healing goes on more rapidly under a dressing of weak boracic ointment (one-quarter the strength of the pharmacopoeial preparation). The growth of epithelium may be stimulated by a 6 to 8 per cent. ointment of scarlet-red.