Alexis Thomson

“ Many bacteria have only the power of living upon dead matter, and are known as _saphrophytes_. Such as do nourish in living tissue are, by distinction, known as _parasites_. The power a given parasitic micro-organism has of multiplying in the body and giving rise to disease is spoken of as its _virulence_, and this varies not only with different species, but in the same species at different times and under varying circumstances. ”

“ The _soft cellular tumours_ are composed mainly of spindle or round cells; they grow from the marrow of the spongy ends or from the periosteum of the long bones, the diploe of the skull, the pelvis, vertebrae, and jaws. As they grow they may cause little alteration in the contour of the bone, but they eat away its framework and replace it, so that the continuity of the bone is maintained only by tumour tissue, and pathological fracture is a frequent result. ”

“ On account of the smaller amount of elastic and muscular tissue in the wall of a vein, the contraction and retraction of its walls are less than in an artery, and so bleeding may continue for a longer period. On the other hand, owing to the lower blood-pressure the outflow goes on more slowly, and the gradually increasing pressure produced by the extravasated blood is usually sufficient to arrest the haemorrhage before it becomes serious. As an aid in diagnosing the source of the bleeding, it should be remembered that the rupture of a vein does not affect the pulsation in the limb beyond. ”

“ The two great branches of the healing art--Medicine and Surgery--are so intimately related that it is impossible to draw a hard-and-fast line between them, but for convenience Surgery may be defined as "the art of treating lesions and malformations of the human body by manual operations, mediate and immediate." ”

“ If the cells undergo degeneration and absorption and the stroma contracts, the tumour becomes still harder, and tends to shrink and to draw in the surrounding parts, leading, in the breast, to retraction of the nipple and overlying skin, and in the stomach and colon to narrowing of the lumen. When the cells of the tumour undergo colloid degeneration, a _colloid cancer_ results; if the degeneration is complete, as may occur in the breast, the malignancy is thereby greatly diminished; if only partial, as is more common in rectal cancer, the malignancy is not appreciably affected. ”

“ In severe contusions associated with great tension of the skin--for example, over the front of the tibia or around the ankle--blisters often form on the surface and constitute a possible avenue of infection. When deeply situated, the blood tends to spread along the lines of least resistance, partly under the influence of gravity, passing under fasciae, between muscles, along the sheaths of vessels, or in connective-tissue spaces, so that it may only reach the surface after some time, and at a considerable distance from the seat of injury. ”

“ Clinical Aspects of Inflammation.#--It must clearly be understood that inflammation is not to be looked upon as a disease in itself, but rather as an evidence of some infective process going on in the tissues in which it occurs, and of an effort on the part of these tissues to overcome the invading organisms and their products. The chief danger to the patient lies, not in the reactive changes that constitute the inflammatory process, but in the fact that he is liable to be poisoned by the toxins of the bacteria at work in the inflamed area. ”

“ Bacterial Diseases.#--In most bacterial diseases the organisms are carried to the joint in the blood-stream, and they lodge either in the synovial membrane or in one of the bones, whence the disease subsequently spreads to the other structures of the joint. Organisms may also be introduced through accidental wounds. It has been shown experimentally that joints are among the most susceptible parts of the body to infection, and this would appear to be due to the viscid character of the synovial fluid, which protects organisms from bactericidal agents in the tissues and fluids. ”

“ Physiological secretions, such as saliva, milk, or tears, are not capable of communicating the disease unless contaminated by discharge from a syphilitic sore. While the saliva itself is innocuous, it can be, and often is, contaminated by the discharge from mucous patches or other syphilitic lesions in the mouth and throat, and is then a dangerous medium of infection. Unless these extra-genital sources of infection are borne in mind, there is a danger of failing to recognise the primary lesion of syphilis in unusual positions, such as the lip, finger, or nipple. ”

“ The gap in the muscle becomes filled with blood, and this in time is replaced by connective tissue, which forms a bond of union between the ends. When the space is considerable the connecting medium consists of fibrous tissue, but when the ends are in contact it contains a number of newly formed muscle fibres. In the process of repair, one or both ends of the muscle or tendon may become fixed by adhesions to adjacent structures, and if the distal portion of a muscle is deprived of its nerve supply it may undergo degeneration and so have its function impaired. ”

“ 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. ”

“ The glands act as filters, arresting not only inert substances, such as blood pigment circulating in the lymph, but also living elements, such as cancer cells or bacteria. As it passes through a gland the lymph is brought into intimate contact with the leucocytes, and in bacterial infections there is always a struggle between the organisms and the leucocytes, so that the glands may be looked upon as an important line of defence, retarding or preventing the passage of bacteria and their products into the general circulation. ”

“ When the nose is attacked, both the skin and mucous surfaces are usually involved, and the nasal orifices may be narrowed or even obliterated; sometimes the soft parts, including the cartilages, are destroyed, leaving only the bones covered by tightly stretched scar tissue.
The disease progresses slowly, healing in some places and spreading at others. The patient complains of a burning sensation, but little of pain, and is chiefly concerned about the disfigurement. Nothing is more characteristic of lupus than the appearance of fresh nodules in parts which have already healed. ”

“ Injuries which act abruptly or instantaneously are illustrated in the crushing of a nerve by the sudden displacement of a sharp-edged fragment of bone, as may occur in comminuted fractures of the humerus. The symptoms include perversion or loss of sensation, motor paralysis, and atrophy of muscles, which show the reaction of degeneration from the eighth day onwards. The presence of the reaction of degeneration influences both the prognosis and the treatment, for it implies a lesion which is probably incapable of spontaneous recovery, and which can only be remedied by operation. ”

“ Bed-sores are most frequently met with in old and debilitated patients, or in those whose tissues are devitalised by acute or chronic diseases associated with stagnation of blood in the peripheral veins. Any interference with the nerve-supply of the skin, whether from injury or disease of the central nervous system or of the peripheral nerves, strongly predisposes to the formation of bed-sores. Prolonged and excessive pressure over a bony prominence, especially if the parts be moist with skin secretions, urine, or wound discharges, determines the formation of a sore. ”

“ The organism does not readily establish itself in the human body, and seems to flourish best when it finds a nidus in necrotic tissue and is accompanied by aerobic organisms, which, by using up the oxygen in the tissues, provide for it a suitable environment. The presence of a foreign body in the wound seems to favour its action. The infection is for all practical purposes a local one, the symptoms of the disease being due to the toxins produced in the wound of infection acting upon the central nervous system. ”

“ So long as a person is in good health, the tissues are able to resist the attacks of moderate numbers of most bacteria. Any lowering of the vitality of the individual, however, either locally or generally, at once renders him more susceptible to infection. Thus bruised or torn tissue is much more liable to infection with pus-producing organisms than tissues clean-cut with a knife; also, after certain diseases, the liability to infection by the organisms of diphtheria, pneumonia, or erysipelas is much increased. ”

“ Regeneration of Bone.#--When bone has been lost or destroyed as a result of injury or disease, it is capable of being reproduced, the extent to which regeneration takes place varying under different conditions. The chief part in the regeneration of bone is played by the osteoblasts in the adjacent marrow and in the deeper layer of the periosteum. The shaft of a long bone may be reproduced after having been destroyed by disease or removed by operation. The flat bones of the skull and the bones of the face, which are primarily developed in membrane, have little capacity of regeneration ”

“ The patient complains of increasing disability of the limb, movements of the joint becoming more and more restricted and painful. There is swelling corresponding to the distended capsule of the joint, and on palpation the bodies moving under the fingers yield a sensation as of grains of rice shifting in a bag. If the bodies are so numerous as to be tightly packed together, the impression is that of a plastic mass having the shape of the synovial sac. The stiffness and the cracking on movement may suggest arthritis deformans, but the X-ray appearances make the diagnosis an easy one. ”

“ The dressing and the after-treatment are the same as in epidermis grafting.
There is a degree of uncertainty about the graft retaining its vitality long enough to permit of its deriving the necessary nourishment from its new surroundings; in a certain number of cases the flap dies and is thrown off as a slough--moist or dry according to the presence or absence of septic infection.
The technique for cutis-grafting must be without a flaw, and the asepsis absolute; there must not only be a complete absence of movement, but there must be no traction on the flap that will endanger its blood supply. ”

“ In attempting to arrive at a conclusion as to the innocence or malignancy of any tumour, too much reliance must not be placed on its histological features; its situation, rate of growth, and other clinical features must also be taken into consideration. It cannot be too emphatically stated that there is no hard-and-fast line between innocent and malignant growths; there is an indefinite transition from one to the other. The possibility of the transformation of a benign into a malignant tumour must be admitted. ”

“ A contusion or bruise is a laceration of the subcutaneous soft tissues, without solution of continuity of the skin. When the integument gives way at the same time, a _contused-wound_ results. Bruising occurs when force is applied to a part by means of a blunt object, whether as a direct blow, a crush, or a grazing form of violence. If the force acts at right angles to the part, it tends to produce localised lesions which extend deeply; while, if it acts obliquely, it gives rise to lesions which are more diffuse, but comparatively superficial. ”

“ The most common exciting cause is increased pressure within the veins, and this may be produced in a variety of ways. In certain diseases of the heart, lungs, and liver, for example, the venous pressure may be so raised as to cause a localised dilatation of such veins as are congenitally weak. The direct pressure of a tumour, or of the gravid uterus on the large venous trunks in the pelvis, may so obstruct the flow as to distend the veins of the lower extremity. It is a common experience in women that the signs of varix date from an antecedent pregnancy. ”

“ Malignant tumours may be primary in the muscle, or may result from extension from adjacent growths--for example, implication of the pectoral muscle in cancer of the breast--or they may be derived from tumours situated elsewhere. The diagnosis of an intra-muscular tumour is made by observing that the swelling is situated beneath the deep fascia, that it becomes firm and fixed when the muscle contracts, and that, when the muscle is relaxed, it becomes softer, and can be moved in the transverse axis of the muscle, but not in its long axis. ”

“ If the natural protective effort is successful, the resulting tissue changes subserve the process of repair, but if the bacteria gain the upper hand in the struggle, the inflammatory reaction becomes more intense, certain of the tissue elements succumb, and the process for the time being is a destructive one. During the stage of bacterial inflammation, reparative processes are in abeyance, and it is only after the inflammation has been allayed, either by natural means or by the aid of the surgeon, that repair takes place. ”

“ If a series of children, one after the other, suffer from inherited syphilis, it is almost invariably the case that the mother has been infected.
In contrast to the acquired form, inherited syphilis is remarkable for the absence of any primary stage, the infection being a general one from the outset. The spirochaete is demonstrated in incredible numbers in the liver, spleen, lung, and other organs, and in the nasal secretion, and, from any of these, successful inoculations in monkeys can readily be made. The manifestations differ in degree rather than in kind from those of the acquired disease ”

“ Infection by bacteria must be assumed to have taken place in all wounds made in any other way than by the knife of the surgeon operating through unbroken skin. On this assumption the modern system of wound treatment is based. Pathogenic bacteria are so widely distributed, that in the ordinary circumstances of everyday life, no matter how trivial a wound may be, or how short a time it may remain exposed, the access of organisms to it is almost certain unless preventive measures are employed. ”

“ The transference of cancer from one human being to another, whether by accident, as in the case of a surgeon wounding his finger while operating for cancer, or by the deliberate introduction of a portion of cancerous tumour into the tissues, has never been known to occur. It is by no means infrequent, however, that when recurrence takes place after an operation for the removal of cancer, the recurrent nodules make their appearance in the main scar or in the scars of stitches in its neighbourhood. In the lower animals the grafting of cancer only succeeds in animals of the same species ”

“ The extent of the wound influences the rate of healing; it is only natural that a long and deep wound should take longer to heal than a short and superficial one, because there is so much more work to be done in the conversion of blood-clot into granulation tissue, and this again into scar tissue that will be strong enough to stand the strain on the edges of the wound. ”

“ There is evidence that the most important factors in the causation of rickets are ill-health of the mother during pregnancy, and the administration to the child after its birth of food which is defective in animal fat, proteids, and salts of lime, or which contains these in such a form that they are not readily assimilated. The occurrence of the disease is favoured, and its features are aggravated, by imperfect oxygenation of the blood as the result of a deficiency of fresh air and sunlight, want of exercise, and by other conditions which prevail in the slums of large towns. ”

“ The aneurysm is usually of the sacculated variety, and may spring from the front or from the back of the vessel. It may exert pressure on the bones and ligaments of the joint, and it has been known to rupture into the articulation. The pain, stiffness, and effusion into the joint which accompany these changes often lead to an erroneous diagnosis of joint disease. The sac may press upon the popliteal artery or vein and their branches, causing congestion and oedema of the leg, and lead to gangrene. ”

“ Tissues appear to be most liable to cancer when, having attained maturity, they enter upon the phase of decadence or involution, and this phase is reached by different tissues at different periods. It is not so much, therefore, the age of the person in whom it occurs, as the age of the tissue in which it arises, that determines the maximum incidence of cancer. Cancer of the stomach appears and attains a maximum frequency earlier than cancer of the skin; cancer of the uterus and mamma is more frequent towards the decline of reproductive activity than in the later years of life ”

“ The laminated clot not only strengthens the sac, enabling it to resist the blood-pressure and so prevent rupture, but, if it increases sufficiently to fill the cavity, may bring about cure. The principle upon which all methods of treatment are based is to imitate nature in producing such a clot.
Sacculated aneurysm, as compared with the fusiform variety, tends to rupture and also to cure by the formation of laminated clot; natural cure is sometimes all but complete when extension and rupture occur and cause death. ”

“ When a bone, such as the scapula or mandible, is involved, it is better to excise the bone, or at least the part of it which bears the tumour. In the case of central tumours the shell of bone is removed over an area sufficient to allow of the enucleation of the tumour, or the affected portion of bone is resected. Should there be evidence of malignancy, such as increased rate of growth, a tube of radium should be inserted, and in advanced cases with destruction of tissue, amputation may be called for. ”

“ Simple structures, such as skin, cartilage, bone, periosteum, and tendon, for example, have a high power of regeneration, and in them the reparative process may result in almost perfect restitution to the normal. More complex structures, on the other hand, such as secreting glands, muscle, and the tissues of the central nervous system, are but imperfectly restored, simple cicatricial connective tissue taking the place of what has been lost or destroyed. ”

“ In _arterial_ haemorrhage the blood is bright red in colour, and escapes from the cardiac end of the divided vessel in pulsating jets synchronously with the systole of the heart. In vascular parts--for example the face--both ends of a divided artery bleed freely. The blood flowing from an artery may be dark in colour if the respiration is impeded. When the heart's action is weak and the blood tension low the flow may appear to be continuous and not in jets. The blood from a divided artery at the bottom of a deep wound, escapes on the surface in a steady flow. ”