Cellulitis

“ Cellulitis is excited by their presence, and the lymphatic glands become inflamed and enlarged. In pernicious forms they produce a sero-purulent oedema, which spreads rapidly with a wave-like progress after the manner of erysipelas; or in milder cases the progress of the disease-germs is arrested by the lymphatic glands or the resistance offered by the tissues themselves, and the ordinary circumscribed phlegmon is produced. ”

“ The uterus, if freely movable, is liable to be thrown out of its accustomed position by the heavier, unyielding sound. The sound also causes much more pain and exposes the patient to great danger of cellulitis. The frequent lighting and relighting of pelvic inflammation by injudicious slight manipulations of the uterus doubtless led Emmet to the utterance of a prophecy which ought to become classical: "A great advance in the treatment of the diseases of women will be made whenever practitioners become so impressed with the significance of cellulitis as to apprehend its existence in every case. ”

“ TREATMENT.—If complicating cellulitis or peritonitis exist, in the relation of either cause or effect to the flexure, its removal becomes the prime indication, because unless removed it is a positive contraindication to the more direct treatment of the malposition itself. Chronic metritis, hyperplasia, hypertrophy, and irremovable tumors sometimes render cure impossible. Improvement of the general health, treatment of complications, and palliation then become the only resources. ”

“ The cellulitis, which resembles that occurring in other conditions, is attended by distension of the capillaries, the abundant formation of young round cells, and transudation of serum (Billroth) . A moderate amount of tumefaction may disappear by resolution, but if it be considerable it seldom abates in this way, but by the tedious and exhausting process of suppuration or gangrene. If the swelling at its most prominent point present a reddish hue, all hope of producing resolution must be abandoned; it cannot be effected by any medicine or appliance within the resources of our art. ”

“ Perinephritis and perinephritic cellulitis, i.e., inflammation with or without abscess formation in the connective tissue and adipose layer surrounding the kidney, always occur in cases of suppurative nephritis or pyelo-nephritis. Such inflammations may also, in exceptional cases, follow direct mechanical injury, but they almost invariably represent complications, the organisms infecting the kidney passing through the tissues and the layer of fibrous tissue, or extending by the lymphatic paths, finally attaining the fatty tissue surrounding the kidney and there undergoing multiplication. ”

“ When the inflammation of the connective tissue of the neck is extensive, involving both the lateral and anterior regions of the neck, the patient is in a perilous state. The cellulitis, when extensive and accompanied by much swelling, may produce oedema of the glottis, may obstruct respiration by compressing the air-passages or the laryngeal nerves, may cause compression of the jugular veins, and thus give rise to dangerous cerebral symptoms, or may lay bare and injure important muscles and nerves, as we have seen. ”

“ In the human subject, multiplication in the blood-stream does not occur to any great extent. In some general acute pyogenic infections, such as osteomyelitis, cellulitis, etc., pure cultures of staphylococci or of streptococci may be obtained from the blood. In pneumococcal and typhoid infections, also, the organisms may be found in the blood.
It is by the vital changes they bring about in the parts where they settle that micro-organisms disturb the health of the patient. ”

“ In such cases it pursues its course between the walls of the bladder and the uterus, and along the round ligament to the inguinal canal. In a few cases the cellulitis mounts above Poupart's ligament, between the peritoneum and the abdominal wall.
The course of the inflammation is not simply fortuitous, but follows prearranged pathways in the connective tissue. König7 and Schlesinger8 have shown that when air, water, or liquefied glue is forced into the cellular tissue between the broad ligaments the injected mass has a tendency to invade the iliac fossæ. ”

“ The idiopathic form of this disease is almost 212always rheumatic or gouty in origin, furnishing still another indication for the remedy. In orbital cellulitis we have swelling of the lids, chemosis, protrusion of the eyeball, almost complete abolition of motion with pain on the attempt and also on pressure, aching in and around the eye, with the probable formation of pus in the deeper structures, all conditions curable by rhus tox., which is one of the best remedies for this disease whatever may be its origin, traumatic or otherwise, and has cured many of the most desperate cases. ”

“ Cellulitis may occur in any of the cellular planes in the neck, the most important form being that which occurs under the cervical fascia, for example in the course of acute infective diseases, such as scarlet fever, measles, or pyæmia. ”

“ According to the mode of action of the associated organisms and the combined effects of their toxins on the tissues, the gangrenous process presents different pathological and clinical features. Some combinations, for example, result in a rapidly spreading cellulitis with early necrosis of connective tissue accompanied by thrombosis throughout the capillary and venous circulation of the parts implicated; other combinations cause great oedema of the part, and others again lead to the formation of gases in the tissues, particularly in the muscles. ”

“ Cellulitis of scalp Excludes2: cellulitis of face (L03.211) L03.818 Cellulitis of other sites L03.89 Acute lymphangitis of other sites L03.891 Acute lymphangitis of head [any part, except face] L03.898 Acute lymphangitis of other sites L03.9 Cellulitis and acute lymphangitis, unspecified L03. ”

“ Perhaps the most striking example of the protective influence of hyperleucocytosis is afforded by the experimental infection described under the name of cholera peritonitis of the guinea-pig. If a fatal quantity of cholera germs be injected into the peritoneal cavity of a guinea-pig, symptoms of poisoning quickly set in and death results in a few hours. A study of the conditions present in the peritoneal cavity shows that the bacteria have developed freely, that some have been broken up and disintegrated, and that very few preserved phagocytes can be found. ”

“ It is the gathering of soldiers to destroy an invader. This is accomplished partly by means of phagocytosis—actual ingestion of the enemy—and partly by means of chemic substances which the leukocytes produce.
In those diseases in which leukocytosis is the rule the degree of leukocytosis depends upon two factors: the severity of the infection and the resistance of the individual. A well-marked leukocytosis usually indicates good resistance. A mild degree means that the body is not reacting well, or else that the infection is too slight to call forth much resistance. ”

“ It is ordinarily provoked by some foreign body, a pathogenic microbe, for instance, which has introduced itself into the place and spread its irritating secretion or cause of infection there. The phagocytes, attracted from the interior of the vessel, come up and devour the invader. But if they are incapable of dissolving it they bear it away to work their own ruin; they degenerate in their turn, become transformed into globules of pus, and the inflammation results in purulence. The study of the mechanism by means of which the leucocytes traverse the tissues is very interesting. ”

“ Then a little distance away from the toxin and toxin-forming organisms, the leucocytes are coming up in large numbers, forming a sort of protecting army, as it were. This is known as leucocytosis. In the small patent vessels around this commencing abscess numerous leucocytes, far in excess of the usual proportion, may be seen—the nearer the abscess, the more numerous they become. Thus the leucocytes make their way to what is to become the wall of the abscess, and form a layer around a mass of micro-organisms, localizing, or attempting to localize, such mass. ”

“ The local phenomena of inflammation usually follow the introduction of living bacteria into the tissues, and general symptoms of poisoning follow later, when the bacteria, toxins, or ptomains, have entered the circulation. Some bacteria, however, excite no local reaction, but enter the circulation at once. The pyogenic variety, it should be noted, cause the production of pus.
Elimination. Bacteria can be eliminated from the blood in several ways; the kidneys, however, are the organs which carry the burden of most frequently relieving the body of them. ”

“ In the streptococcal inflammations spreading by the lymph channels appears to be specially prevalent. In the blood the organisms, if in small numbers, are usually destroyed by the plasma, which has a powerful bactericidal action; should they escape, however, they are carried without multiplication into the capillaries of the general circulation, of the lung, or of the liver, where, being stopped, they may give rise to a second focus of infection, especially if at the point of impaction the vitality of the tissues is in any way lowered. ”

“ The value of hyperleucocytosis as a defensive measure against infection must, probably, always remain greater than its value as a cure for established infection. There are several reasons that make this conclusion probable: the capacity of the blood is increased in the direction of destroying bacteria without being augmented at the same time in the direction of neutralizing bacterial poisons; the organism that is already severely poisoned by infection reacts less certainly to the chemical agents that provoke hyperleucocytosis than the uninfected organism. ”

“ The process consists in the proliferation of epithelial cells from the mucous layer. The cell-growth takes place downward in the form of finger-like prolongations or columns, or it may spread out laterally, so as to form rounded masses, the centres of which usually undergo horny transformation, resulting in onion-like bodies, the so-called cell-nests or globes. The rapid cell-growth requires increased nutriment, and hence the blood-vessels become enlarged; moreover, the pressure of the cell-masses gives rise to irritation and inflammation, with corresponding serous and round-cell infiltration. ”

“ It is an important property—without it life such as we know it would be impossible. These tubes, which perhaps you have thought were made of glass, are really made of a porous substance known as celloidin.”
“Then you mean to say that the poison in her blood,” I exclaimed, “is passing slowly through those celloidin walls into that salt solution which surrounds the tubes?”
“Precisely,” he returned. “Any substance, any poison that is dialyzable is diffused into the surrounding salt solution and the blood is passed back into the body, with no air in it, no infection, no further alteration. ”

“ In that article he expounded the phagocyte theory of immunity. [209] Among concrete examples of its application, he quoted the indications concerning the evolution of an infectious disease provided by the quantity of leucocytes in the blood, and the process employed by certain surgeons to diminish the danger of infection during an operation: just as, in case of an enemy menace, the Government mobilise an army, certain surgeons employ divers means to attract an army of phagocytes and to stimulate their activity in case any microbes should penetrate into the wound. ”

“ The infection begins with elementary bodies or elementary corpuscles which live at first extracellularly. An elementary body is a minute speck of chromatin, apparently devoid of cytoplasm, which can pass through a bacterial filter. It can enter a host cell, but the entry is not a process of phagocytosis.
2. Inside the host cell the elementary body grows in size, and becomes an initial body (fig. 119, a) .
3. A reaction on the part of the host cell results, for nucleolar, plastin substance is extruded from the cell-nucleus and surrounds the parasitic initial body. ”

“ Results of Bacterial Growth.—Some organisms, such as those of tetanus and erysipelas, and certain of the pyogenic bacteria, show little tendency to pass far beyond the point at which they gain an entrance to the body. Others, on the contrary—for example, the tubercle bacillus and the organism of acute osteomyelitis—although frequently remaining localised at the seat of inoculation, tend to pass to distant parts, lodging in the capillaries of joints, bones, kidney, or lungs, and there producing their deleterious effects. ”

“ The disease may be localized in certain organs because only in these do the bacteria find favorable conditions for growth. In spite of a high general resistance to infection the lesions in chronic glanders are most marked in the muscles, those of poliomyelitis in the spinal cord. There are few bacterial diseases which are localized in the blood, but many of the diseases caused by protozoa have this localization. In every infection some organisms enter the blood, which acts as a carrier and deposits them in the organs. ”

“ 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. ”