CHAPTER XV

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SURGICAL ASPECTS AND SEQUELS OF OTHER INFECTIONS AND DISEASES.

As a result of the conditions which two centuries ago and more so distinctly separated the barber surgeon from the practitioner of medicine, there has been evolved an artificial separation of surgery from so-called internal medicine. The consequence has been a more or less deep-rooted feeling that medical cases were to be treated exclusively by non-operative measures, and that surgical cases could scarcely be expected to present any perplexities that were not to be solved by an operating surgeon. It has been no small part of the benefit resulting from modern teachings that these imaginary boundaries and limitations have been swept away; and one of the lessons which this text-book is intended to inculcate is that broad principles underlie disease conditions, and that their bearings must be appreciated thoroughly in order to practise either medicine or surgery successfully. In order better to inculcate this teaching a chapter with the above general heading has been inserted, in order to impress the statement that any of the so-called internal diseases may present at almost any time indications for distinctly surgical intervention.

Some of the surgical sequels of the exanthematous and continued fevers are well known and commonly recognized: for example, _orchitis following mumps_, _suppurative inflammation of the middle ear after scarlatina_, _and bed-sores after typhus and typhoid_. These are easily recognized. Moreover, scarlatiniform eruptions occasionally follow various operations and give rise to great perplexity.[4]

[4] Medical News, February 20, 1897, p. 234.

DYSENTERY.

Joint complications in this disease have been recognized from the earliest times. One hundred and fifty years ago Strack expressed himself thus: “If the dysenteric poison affect only the chest, it causes asthma; if the limbs, it produces arthritis; if both, abscess.”

Joint pains and swellings, with other suppurations, have been noted in several of the epidemics of this disease which have ravaged various parts of the world at different times. Postdysenteric arthritis may assume noticeable and even pyemic aspects, and is occasionally fatal. The bones and joints may become involved in painful and even suppurative swellings, not alone during the active stage of the disease, but during the period of convalescence; while mildness of the primary attack does not necessarily provide immunity from later complications. Here thrombosis of large veins or thrombophlebitis are also observed. When the joints are involved it is usually in irregular order and not simultaneously. Joint lesion does not necessarily proceed to suppuration, but perhaps only to the point of edema and fluid exudation or hydrops. In the Cuban and South African campaigns, during which dysentery prevailed, joint complications were noted.

CHOLERA.

Cholera is usually too rapid and too violent in its course to be followed by secondary infections. Nevertheless, Poulet reports from Val-de-Grace several instances of articular and osseous lesions, some of these characterized by effusion of fluid which was sometimes very thick and resembled balsam, while at other times pus was present.

PNEUMONIA.

Pneumonia having now taken its place as a distinct germ disease, and the micrococcus of Fränkel and the capsule coccus of Friedländer being well established as the active agents in the two principal forms of this disease, pus may be found in other parts of the body. The most common surgical sequels of pneumonia occur as postpneumonic pyarthrosis, which has been wrongly considered a rheumatic affection. These lesions are of embolic or of metastatic origin.

INFLUENZA, OR LA GRIPPE.

This disease has assumed prominence in medical literature, and not a few instances have been reported of surgical sequels--abscesses, purulent ear disease, pyarthrosis, bone lesions, etc. Even necrosis has been repeatedly observed.

MEASLES AND SCARLATINA.

The infectious agent in these affections is not yet recognized and their surgical sequels should be regarded as due to secondary pyogenic infections.

Surgical tuberculosis appears often as a sequel of the exanthemas. In the lymphatics, periosteum, bones, and joint cavities, and in and about the eye and ear, manifestations of suppurative disease are often found. It is believed that these sequels are likely to appear when the eruption has been incomplete. Hyperplastic thickening of periosteum and neuralgic pains of the affected parts occur without suppuration, hence the rheumatic character which Bonnet and others have wrongly ascribed to these manifestations.

While the absence of pus takes these out of the category of pyogenic infections, it nevertheless leaves them still as surgical complications which have often to be dealt with by mechanical measures, such as orthopedic apparatus, etc.; while more or less formidable operations, as for relief of ankylosis, have to be performed. Postscarlatinal arthralgia may be explained as a local ischemia; so may acute swelling or chronic thickening. But pus is an expression of infection, and cannot be otherwise regarded. Retropharyngeal abscesses and a peculiar necrosis of the alveolar process of the jaws, described by Salter, are among the various serious surgical complications of scarlatina. Epiphyseal separations and purulent destruction of ribs have also been noted.

TYPHOID FEVER.

Although in elaborate treatises, as by Liebermeister and Murchison, there is no mention of bone and joint complications as sequels of typhoid, they have, nevertheless, been recognized by surgeons. Post-typhoid hip dislocations have been reported by several German surgeons. Boyer observed spontaneous dislocation of both thighs after what he called “essential fever,” and the general topic of spontaneous luxations subsequent to typhoid has been frequently discussed.

Those affections of joints formerly considered rheumatic occur much less often after typhoid than after dysentery. Nevertheless, post-typhoidal arthralgia and myodynia have been recognized by several French writers. Some with affected joints, supposed to be rheumatic, have later been discovered to be suffering from genuine typhoid fever, and it has been afterward recognized that the joint lesion was a bizarre expression of the typhoid poisoning. The works on general practice call attention to the frequent complications of the pleural and pericardial serous membranes in this disease. They say little, however, about the implications of the articular serous membranes, though one is as easy to explain as the other. Post-typhoidal polyarticular serous arthritis has been described by more than one writer. Multiple joint abscesses have been rarely seen. Pus has been known to collect not only in the joints, but also in the tendon sheaths and bursæ. The lymph nodes are also frequently affected, and cervical, axillary, and inguinal abscesses are not rare. Post-typhoidal pyarthrosis, as leading to spontaneous luxation, has had a medicolegal interest, for luxation has been known to occur while raising or lifting a patient, the question of violence being subsequently brought into court. When the joint disease assumes the mono-articular form it is likely to terminate in suppuration; when polyarticular, pyarthrosis is less common. In the pus from many of these abscesses typhoid bacilli may be recognized, but by no means in all. The writer has found them in a case of abscess in the abdominal wall occurring during convalescence from typhoid in a young woman. A non-suppurative but painful form of periostitis is occasionally observed. I have never seen more exquisite tenderness nor expressions of suffering than I met in a case of this kind in a boy in whom the bones of both lower extremities, of the pelvis, and the lower spine were involved. The slightest jar upon the floor would make him exclaim with pain, and to minister to his ordinary wants was a distressing task. He eventually recovered without any pus formation. Deep suppuration in bones occasionally occurs, and even necrosis with separation of sequestra.

Thrombosis and thrombophlebitis are also well-known sequels of typhoid, which may lead to unpleasant complications. Typhoid fever appears to bear a peculiar relation to the growth of bones, as it has been noticed that during its course, or during convalescence, they show an extraordinarily rapid growth in length, even to the extent of 1 Mm. a day. This is probably caused by the irritation of the typhoid toxin upon the osteogenic tissue, since hyperemic areas have been found in the bone-marrow of those dying of the disease, and bone pains are a frequent accompaniment of the disease. Typhoid bacilli have the power of remaining latent in the tissues for a long time after cessation of

## active symptoms, and have been found alive and capable of active growth

seven months after cessation of the fever. Remembering the multiple ulcers of the lymphoid tissue which characterize the intestinal lesions of typhoid, it is difficult to explain pyogenic or other septic infection by absorption through these open ports of entry; and the typhoid bacilli themselves, entering the circulation through these paths, may be carried to all parts of the body, and have been found in the pia.

A large amount of interest has attached to the so-called “_surgery of typhoid fever_,” which, however, has been permitted to include only abdominal section for perforation of intestinal ulcers. The mortality due to this accident is nearly 70 per cent.--_i. e._, is formidable. It occurs generally during the third week. It is usually preceded by leukocytosis, and is followed by profound shock. Operation offers almost the only hope. It has been successful in about one out of five cases. (See Surgery of the Intestines.)

Post-typhoidal infections of the _biliary and pancreatic ducts_, with their resulting complications, play a conspicuous part in the etiology of biliary obstruction. They are regarded as among the most common causes of acute and chronic or latent disease in these passages.

DIPHTHERIA.

This also belongs to the diseases frequently complicated by lesions, aside from those of laryngeal obstruction calling for surgical relief. Abscess occurs so frequently as to scarcely call for comment. Here, as in the cases of scarlatina, the location of the throat lesions and the absorbing powers of the lymphadenoid tissue so completely involved will readily account for all septic or pyogenic manifestations at a distance. Multiple abscesses have been found in the liver, the spleen, and lungs, in and around bones, betokening thereby a pyemic manifestation. Infectious nephritis is also common.

Mann, of Denver, has communicated to me personally cases of embolus of the femoral artery with resulting gangrene as sequels of diphtheria, as well as instances of true diphtheria of the penis, established by bacteriological diagnosis.

MUMPS.

The infectious character of this disease is not questioned, although not definitely established. Orchitis, ovaritis, stomatitis, enlargement of the tonsils and spleen, and albuminuria are frequent accompaniments of the disease, while articular and peri-articular complications have been noted. Bursal abscesses and pyarthroses have also been reported. These surgical complications have been regarded as rheumatoid or rheumatic, their essential significance not being recognized until recently.

VARIOLA.

The writers of the earlier part of this century allude frequently to the rheumatoid complications of smallpox, among which pyarthrosis seemed the most common and most serious. The various arthropathies are the most interesting of the surgical complications of this disease. The joints become swollen, red, and painful, one joint after another being involved.

INFECTIOUS ENDOCARDITIS.

The individuality of this condition has been recognized only within the last thirty years. That it deserves the characterization of “malignant” often given to it is well known. It is an infectious disease with a special localization in the heart, the term _cardiac typhus_ being very expressive. Although so apparently spontaneous, it is usually a secondary lesion, sometimes a primary infection. The arthritic manifestations often assume a pyemic character, and even at the beginning of the affection, as Trousseau pointed out, there are frequently severe joint pains.

DENTAL CARIES.

Nearly one hundred species of microörganisms from the mouth have been studied and identified by W. D. Miller, who has clearly established that dental caries is due to the specific action of some of these parasites, which, gaining entrance into the dental tubules, determine fermentation and acid production, with erosion of the dental structure of the teeth and an increase in softening and destruction. In this way the teeth, as already indicated in