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OF TH. «»IOAl BOAKB OF UFMR OAITADA; M.D. OF IB. rK,V.M.IT OF K.W YORK • •..E.C.B.,E«OLAK»; FORMRLT H0U8. 8««0K0» ,0 TB. 8»A1.«-B B08PITAL, ».W TOM FOR 80IIE Tin A. A. 8URaiON TO BER BRITAKMO MAJMTT'S FOROM; lATl ' PR0FI880R OF OElflRAl PAIBOIOOT AWD THE PRI!tOIPlE8 AND PRAC Tioi OF snROERr, rwv. TIOTDRIA COLUOE, TOROWTO, O.W.I ABB FOR A 8H0BT TIME A. A. 8CR0I0II 10 TBI DNITID STATU ARNT. PHILADELPHIA: LINDSAY & BLAKI8T0N. 1 oat! VS\^'^}. . Entered, according to Act of Congress, in the year 1866, Br Lindsay A BiiAKisTON, In the Clerk's OfiBoe of the District Court of the United States for the Eastern District of Pennsylvania. SHERMAN & CO., FRIMTERB. FREF AC E. This volume was commenced while the author was engaged in lecturing upon the Principles and Practice of Surgery. Finding that a single session, although of six months, was not suflBciently long to permit him to embrace in his course both the principles and the practice of the science, he proposed to himself to prepare a handbook of the principles for his class, that he might thereby he enabled to devote more time to the practical part of the sub- ject. Circumstances having led to his withdrawal from the col- lege, he has been induced to extend the limits of the work to the present size, ia the hope that it may be found more useful. In doing so great attention has been devoted to surgical pathology, believing that it is most essential to a knowledge of all rational treatment. The groundwork is mainly derived from the lectures delivered by him opon General Pathology and Surgery. In the preparation of those lectures the following works were freely con- sulted : Rokitansky's, Jones and Sieveking's, and Gross's Patho- logical Anatomy, Simon's General Pathology, Principles and Practice of Surgery by Miller, Cooper's Surgical Dictionary, Chelius's System of Surgery, and especially Paget's Surgical Pa- thology. Other works were also often examined. And in com- pleting the work much assistance has been obtained from Virchow's Cellular Pathology and Holmes's System of Surgery. It follows that much contained in these pages may be found in those works, and it gives the author pleasure to thus make this distinct acknow- ledgment. But the author, in appropriating the labors of others, IV PREFACE. was Steadily careful to exclude what seemed irrelevant or unne- cessary for his purpose, ever endeavoring to simplify the subject under consideration by avoiding useless technicalities; while at the same time embodying such appropriate facts as had come under his personal observation, and advancing such theories as thought and study had suggested to his mind. The illustrations, as will be seen, are taken from Paget's Surgical Pathology. The arrangement and division of subjects are original, and the hope is entertained that they will be found advantageous to the student. The work has been prepared more particularly for the student, but the opinion is hazarded that it will prove useful to the practitioner. That in these pages there will be found many imperfections is very well known; but the profession is requested to remember that this is the first undertaking of the kind in our young country. The writer enjoyed not the advantages of early literary training. As his grandfathers and his father were pioneers in the wilderness of Canada, and paved the way for a more scientific agriculture, so the writer hopes this volume will be the forerunner of other and more excellent treatises, that will hereafter proceed from the pro- fession of our province. Not having personally superintended the work through the press, there may consequently be found a few blemishes which the printer and proof-reader could not feel at liberty to remove. Bellevillb, Canada West, January, 1866. CONTENTS. CHAPTER I. PASS Nutrition— Development— Growth— Assimilation— The " Formative Process"— Ordinary Decay— Repair— Pour conditions necessary for Repair, j- X)i-viszo3sr I. INFLAMMATION, AND DI8KA8B8 ARISING OUT OF INFLAMMATION. CHAPTER II. Inflammatory Process— Incubation— Congestion— Inflammation Esta- blished-Stagnation— Changes in Blood— Fibrin— Change of Func- tion, 24 CHAPTER III. More Extensive View-Number of Products, viz.. Serum, Liquor San- guinis, Fibrin, or Inflammatory Lymph, «&c.— Causes of Inflam- mation — Various Divisions, .... 84 CHAPTER IV. Symptoms of Inflammation— Causes of each— Value in Diag nosis. 38 CHAPTER V. Prognosis of Inflammation— Course and Termination, viz. : 1. Resolu- tion. 2. Delitescence. 8. Extension, first, by Continuity ; second, by Contiguity ; third, by the Circulation— Each explained-Fibrin in the System and out of' it-" Cupped and Bufi-ed ;" fourth, by ab- sorption ; fifth, by the agency of the nerves, ... 46 VI CONTENTS. CHAPTER VI. PAM The Products of Inflammation: 1. Serum; 2. Liquor Sanguinis— Fi- brin— Coagulation— Development— Hypertrophy, True and False- Atrophy — Induration, g2 CHAPTER VII. Products of Inflammation— Degeneration of Lymph— Corpuscular and Fibrinous Elements— Cause of each— 1. Pus : How formed ; Differ- ent ways found— 1. Abscess ; 2. Diffused ; 3. Upon the Surface— 2d Formof Degeneration of Pus— Fatty ; 3d. Calcareous; 4th. Pigmen- tal—Blood as a Product — Changed Mucus, 57 CHAPTER VIII. Treatment of Inflammation— In its First Steps— 1. Nature as a Guide. 2. Prevention of Further Progress. 8. Sedatives. 4. Cold. 5. Heat. 6. Stimulants. 7. Astringents, 66 CHAPTER IX. Treatment continued— Evacuants, including Derivatives, Emetics, Pur- gatives, Diuretics, Diaphoretics— General Bleeding— Direct Evacu- ation of Blood— Cupping— Leeching— Puncturing— Counter-irri- tants — Rubefacients — Pressure, . . , • . 74 CHAPTER X. Constitutional Treatment— Special Medicines— Antimony*-Mercury— Opiates— Veratrum Viride— Aconite—Nitrate of Silver— Potash, . 84 CHAPTER XI. Treatment of the Products of Inflammation— Of Serum— Liquor San- guinis— False Hypertrophy— Induration— Atrophy— Degenerated Lymph— Pus— Abscess— Pointing of Abscess— Diffused Pus— Mu- cus — Blood, 90 CONTENTS. Vii CHAPTER XII. PAM DiseaseB arising out of Inflammation— Passive : 1. Congestion ; Results —Treatment, Local and General. 2. Chronic Inflammation ; Pro- ducts — Treatment 101 CHAPTER XIII. Chronic Abscess— Results— Treatment— Sinus or Fistula— Treatment, . 107 CHAPTER XIV. Pyemia — Causes — Treatment — Softening — Ulceration— Sloughing— Gangrene — Treatment, 115 CHAPTER XV. Varieties of Inflammation— Phlegmon— Anthrax— Chilblains— Frost- bites — Burns 125 CHAPTER XVI. Scrofulous Inflammation— Causes ; Tubercle— Scrofula— Terminations — Treatment, 186 CHAPTER XVII. Gonorrhoeal Inflammation, 144 CHAPTER XVIII. Syphilitic Inflammation— Pathology— Question of Duality— Hard Chan- cre—Its Treatment— Soft Chancre— Its Treatment— Buboes— Treat- ment of Buboes — Constitutional Treatment of Syphilis, . . .149 CHAPTER XIX. Erysipelatous Inflammation— Causes. Varieties: 1. Simple; Symp- toms—Treatment: Local— Constitutional. 2. Phlegmonous; Pa- thology—Treatment 164 • •• Vlll CONTENTS. xjivisioisr II. THE HEALING PB00K88, AND DISEASES OP THE HEALIXO PROCESS. CHAPTER XX. • * • • t , CHAPTER XXI. Five Methods of Repair-Immediate Union-Primary Adhesion- , Granulation-Second Intention, or Second Adhesfon-Unr~ Scab, Cicatriaation-Requisite for Granulation. i,- ' ' • • • 177 CHAPTER XXII. ^'''"~^.ll?''t!'^ Healing Process-Division of Ulcers-Causes of Unhealthy Ulcer-ConstUutional Causes-Treatment of Zlhy vlT 7 ^°^'''"^y-^««'^-I'^dolent-Irritable- Inflamedi Phagedenic— Cancer, . . I3I"V-ISIOlsr III. EXTEBNAL INJURIES- CONTUSIONS AND WOUNDS. PAOI 172 185 CHAPTER XXIII. Contusions— Results— Treatment, . 192 11 CHAPTER XXIV. Wounds-Deflnition-dassification-The several Dangers attending Wounds -Incised Wounds -Characteristics- Gaping -Hemor- rhage— Arterial— Natural Hsemostatics, . ^ jg^ CONTENTS. IX CHAPTER XXV. PAOI Treatment-General Indications-To Arrest Hemorrhage-Cold Air- Cold Water-Pressure-Styptics-Escharotics-Nitrate of Silver- Ligature-Torsion-Acupressure-Conatitutional Means-Of Se- condary Hemorrhage— Of Venous Hemorrhage, 2OI CHAPTER XXVI. 2d General Indication: Remove Foreign Bodies. 3d: Close the Wound and Retain-Means: Plasters-Sutures-Twisted Sutures-Quilled. 4th: Prevent Inflammation, gn CHAPTER XXVII. Lacerated Wounds: Characteristics-Treatment. Contused Wounds- Treatment. Punctured Wounds : Characteristics-Treatment, . 217 CHAPTER XXVIII. Gunshot Wounds : History-Division-Missiles-Velocity-The Kind of Injury— Position of Body— Location of Ball, .... 224 CHAPTER XXIX. Symptoms of Gunshot Wounds-Treatment: Local-General-Pri- mary, or Secondary Operations 231 CHAPTER XXX. Poisoned Wounds-Three Varieties.-(l) Dissecting Wounds-Symp- toms— Treatment.— (2) Stings, &c \ 237 CHAPTER XXXI. Third Variety: Hydrophobia-Two Kinds-Dog-madness-Symptoms -Three Stages-Symptoms in Man-Coih-se-Diagnosis-Patho- logy— Period of Latency- Prognosis— Treatment, .... 242 CHAPTER XXXII. Tetanus : Symptoms-Stages-Pathology-Diagnosis-Treatment, 256 B CONTENTS. IDIVISIOIT I v. Dlf EASES OF CERTAIN TISSUES, BONES, JOINTS (INCLUDING FRACTURES AND DISLOCATIONS), ARTERIES, AND VEINS. CHAPTER XXXIII. PAGE Diseases of Bono : Hemarks— Classification— Course to be Pursued— In- flammation of Periosteum— Of Bone— Causes— Synptoms— Local- General— Prognosis— Pathology— Terminations— Duration— Treat- ment of Acute — (Jhronic — Of Products — Fibrin, .... 262 CHAPTER XXXIV. Necrosis: Kinds— Sequestration— Symptoms— Treatment. Softening of Bono : Kinds— Rickets— Diagnosis— Treatment. Hypertrophy and Induration of Bone — Atrophy — Causes of Each, .... 274 CHAPTER XXXV. Caries : Pathology— Causes— Symptoms— Diagnosis— Prognosis— Treat- ment— General— Local— Operation-Tubercle in Bone, . 284 CHAPTER XXXVI. Fractures: Definition-Causes — Bones most liable— Classification- Variety of Displacement— Causes-Symptoms of Fracture — Diag- nosis — Mode of Examining — Prognosis, 290 CHAPTER XXXVII. Healing Process of Bono: Pathology— Treatment. Three Indica- tions: 1, Restore Bono; 2. Retain; 3. Prevent Inflammation. Ap- pliances: Bandages — Compresbca — Splints, 801 CHAPTER XXXVIII. Treatment of Compound Frnoture: Irregular Callus— Causes-Treat- ment — Exuberant Callus — FiiIho .Joint — Cuuses Treutuient Dias- tasis ai2 CONTENTS. XI .CTURES AND CHAPTER XXXIX. PAOI Surgical Affections of Joints — Joints most liable — Inflammation — Causes — Synovitis — Symptoms — Prognosis — Pathology — Inflam- mation of outer Tissues — White Swelling — Morbus Coxarius— Ro- sults, 316 PAOI CHAPTER XL. Treatment: Rest — Applications — Excision, . 323 262 274 284 CHAPTER XLI. Dropsy of Joints : Causes— Treatment. Elongation of Ligaments. Car- tilt ge in Joint: Diagnosis— Prognosis — Treatment. Wounds of Joints : Diagnosis— Treatment. Deformities of the Joints : Va- rietios— Congenital— Non-congenital— Treatment, .... 330 CHAPTER XLII. Dislocations : Causes — Classification — Diagnosis — Prognosis — Patho- logy— Treatment— Indications— Reduce the Principal One— Re- move Obstacles — Complications, 340 290 CHAPTER XLIII. Surgical Afiectiono of Arteries : Inflammation— Coagulated Fibrin in Vessel— Pathf logy. Aneurism : Divisions— Varieties— Causes- Symptoms and Di \gnosi8— Prognosis— Course— Results, 348 801 CHAPTER XLIV. Treatment of Aneurisms: Three General Methods— Compression- Digital Compression— Trent by Flexion- By Manipulation— By Ligature— By Hunter's Metliod— By Brnsdor's— By Wftrdroi)'8— By Injections— By a Current of Electricity. Varieties; Vari- co80—Arterio-venou8— Treatment. Aneurism by Anastomosis, . 358 ai2 CHAPTER XLV. Huriricttl Affootions of Veins : Rumarka, Th!!>?!itia; H"rTin*ntr- Trea*- ment. Entrancoof Air into Veins: Symptoms— Treatment, . 3G8 xu CONTENTS. i^ivxsioisr V. MORBID GROWTHS. CHAPTER XLVI. PAGE Morbid Growths: Division-Analogous-Heterologous-Fibrous Di- agnoses -Treatment-Fibroid-Patty-Cartilaginous-Myeloid- —Glandular— Vascular— Sarcomatous, ... CHAPTER XLVII. Cancerous Tumors : Romarks-In two forms-Two stages-Mlcrosco- m'JJTT"- ^"'''""'^ '^'"'''''- Colloid-Encophaloid- Epithehal-Course-Symptoms-Tcrmination-Effects upon con- 8t:tution Treatment: Local and Gcneral-E^tirpation-Caustic —Congelation- Pressure, ^ ^ ERRATA. , r.»a »ne applioiUion of a cooling or sedative lotion." Pag. 192 9th line from bottom, instead of "the coats are so lacerated " r.a.l -iH vessels are so lacerated." » »™ "o lacerateU, read " the Pnge 331, 7th line from bottom, instead of « rally," read "volley." PRINCIPLES OF SURGERY. CHAPTER I. ' not going s '3 ion," read 1 r sedativo •l * read oth* i INTRODUCTION. Nutrition— Development— Growth— Assimilation— The "Formative Process" —Ordinary Decay- Repair- Four conditions necessary for Repair. In the following pages, I shall first treat of Inflammation, dis- eases arising therefrom, and its varieties ; secondly, of the Healing Process ; thirdly, of External Injuries ; fourthly, of Diseases of certain Tissues ; and fifthly, of Tumors, or morbid growths. Although the inflammatory process and the healing process are distinguished by a separate consideration, I shall endeavor to show that healthy inflammatory action is a step— a first step— in the process of healing; that, while healing more expeditiously takes place when inflammation is absent, yet, under certain circum- stances, the inflammatory process is necessary to prepare the way and supply the means for successful healing. When, however, the inflammatory action is unhealthy, when there is presented some one of the several varieties of inflammation, then there is a de facto disease. The distinction between the two will be found to be the same as that which exists between a healthy ulcer and an unhealthy one ; when, in the former, healing kindly takes place in accordance with physiological laws, and in the latter it fails to take place. In order to understand aright the phenomena of inflammation, it is necessary to bear in mind the physiology of healthy nutrition of tissues. It is essential to understand what tak«H «la«ft ia the 18 PRINCIPLES OP SURGERY. ordinary course of life ; the manner in which tissues grow, are developed, anu their natural integrity maintained, notwithstanding the constant wear and tear of their substance. This knowledge of physiology is requisite, inasmuch as there is a very close resem- blance between the process of nutrition and the commencement of inflammatory action, and also because of the striking analogy between the process of repair constantly going on in the various tissues and those steps taken by nature to heal the structure after a solution of its continuity; and, furthermore, because of the resemblance between all of the foregoing processes and those mor- bid conditions known as Hypertrophy and Atrophy. In health, we have development, growth, and assimilation. These, together, may be called the " formative process." (Paget.) While there is a difference between development and growth, yet the two go on generally together until maturity of the body : thus, in the foetus, development and growth go hand in hand; also in childhood, and up to mature age. There is, however, this manifest difference between the two, of which the student should have a distinct understanding : development is not necessarily an increase of substance, but an advancement,— an elevation to a higher state of existence ; as, for instance, in the brain, the heart, &c. These are gradually developed from the most simple con- stituents to those of the most complex. Growth, on the contrary, means merely an increase in the bulk, taking place according to certain general laws. When the body is in a state of health, the one process attends the other ; but either may proceed without the other ; as, for instance, the brain may cease to grow at any period of foetal life, while development continues ; or the reverse may occur ; that is, development may be arrested, although growth is continued. Paget, in his most useful work (" Surgical Pathology"), refers to two specimens : " Among the malformations in the mu- seum of St. Bartholomew's Hospital, arc the brains of two adult idiots. They are equally diminutive, and of nearly equal size : but in one, so far as we can see, there is a due proportion of the several parts ; it is only too small : in the other, the parts are not well proportioned ; the posterior parts of the cerebrum do not half cover the cerebellum ; indeed, no posterior cerebral lobes appear to be formed. Herein wo recognize something more than a checked growth ; for this truncation of the cerebrum indicates an arrest of INTRODUCTION. 19 its development at the lime when its hinder lobes — the parts last produced, and peculiarly characteristic of the human brain — were only just beginning to be formed. Our explanation of this most interesting specimen must be, that, when the brain had at- tained that degree of development which, according to Professor Retzius, is proper to the human foetus about the beginning of the fifth month, and corresponds with the completed development of the brain of lower mammalia, then its development ceased. But though in form it is like the foetal brain in the fifth month, yet, in all its dimensions, it is larger ; so that, although its develop- ment had ceased, its growth continued, and was not checked till the brain had attained the size of that of a mature foetus. In this brain, therefore, we find at once defective development and defective growth ; but in the other, the development proceeded, and the growth alone was checked." On the other hand, examples in which development was checked while growth continued, may be seen in malformed hearts, where only a single cavity exists, no partition having been developed ; yet where growth proceeded in regular order. At all periods of life decay in the body is going on. Every living body, everything indeed in all animated nature, has a lim- ited period of life — has a period of growth, maturity, and decay ; and so it is in the human body. Not only the body as a whole has its period of existence terminating in death, but every parti- cle of tissue, every element which enters into the formation of the whole, has its own limit of life. It is begotten, it matures, it fades, it dies. This is independent of the life-course of the whole frame. And, from the earliest period of embryonic life until the heart finally ceases to beat, this process of limited life in the tissues is constantly being enacted. Paget gives two sources of decay in the tissue, or, as it is aptly expressed, of "wear and tear," one of which is exercise, and the other natural death, in accordance with a general law. After growth and development are completed, assimilation — a process coeval with the life of the body — is the only remaining way by which the " formative process" is manifested. In passing, I may just state that these worn-out, or dead particles, are, when the body is in a state of health, duly removed from the system — excreted by some one or more of the excretory organs ; or it may .# m 20 PRINCIPLES OP SURGERY. be, acoordmg to the view, of some recent writer,, th.t eome of Iheir elements enter into new combinationa and continue to serve 1 ko^ ^ '" " "7 "T":?- '^^' °°»»'it"e"t« of some tissues of the body are endowed wth a more protracted life than those of oth rs ; .ndeed, the function of some tissues is such that removal of effete matter and repair cannot with readiness conveniently take 'r:;e:e"rve;r° "^ Tr"""'^'-"™'""''^'""'"' *»- «-' are preserved from speedily wearing ont-as the cartilages of the jom s hgamcnts, tendons of muscles, &c. It is, then, a physiolo g.cal law, hat some tissues should be more mutable than 0^. bu , more than th.s, any one tissue may be rendered sbort-1 ved by unnatural weakness, which weakness may have primarily existed or subsequently have been acquired ; that is to say, a system or an .nd,v,dual fssue, perfectly sound, will live and weir longe"'unde; the same circumstances, than one which is defective. There is a close hkeness between this life of individual tissues, and the bebg wh,ch hey together compose. As every living being beget, off epnng hke unto .tself, so the constituents in their mint life cease only to hve, when other similar ones are begotten and prepared to succeed them m the part they have played. It is this pr ee s wh,eh ,s called assimilation. This question, however interes nT canno here be further discussed ; for a com'plete consider tCff b sulyect the reader ,s referred to Pagefs " Surgical Pathology,"' and Virohow's " Cellular Pathology." ^ Bat not only does every elementiry structure in the body decay •nd d,e; „, as well, under certain morbid influences, de.erLates! or degenerates-becomes changed in its essential character in consequence of which it is incapacitated for a proper discharg^ of Its duties ; just as the whole body may, as the result of disease! be- come unfit to act its part aright. We have now learned that, when the body is in a state of health, . all periods of life there is a constant loss being sustained by th eementary structure of the body, in some of which the loss is rapid, and in others tardy ; yet invariably taking place. Now if the integrity of the body is to be maintained, repair must be mldc n tl e same proportion a, there is loss. This repair is known by show the close connection, or resemblance, perhaps I might say INTRODUCTION. 21 identity, of this process and that generally known as the Healing Process. Of this I shall more particularly speak hereafter. At present let us glance at the " conditions" which are neces- sary to the efficient repair of every part of the body, so constantly being made, and for the successful carrying out of which we find nature so fully adequate. And I cannot do better than to give Paget's own words. " Doubtless," he says, " the conditions neces- sary to the normal nutrition of parts are very many ; but the chief of them are these four : " 1. A right state and composition of the blood, or rather nutri- tive material. " 2. A regular and not far distant supply of such blood. " 3. (At least in most cases) a certain influence of the nervous system. "4. A natural state of the part to be maintained." With regard ta the first. A builder, if he wish to have a per- feet, a time-enduring edifice, will endeavor to procure good sound material for its construction ; and so it is with respect to repair of tissue. To secure a continuance of health in the physical frame there must be a healthy condition of the blood— that fluid which streams to and from every part of the body, and whose current carries thereto the elements of nutrition, and therefrom those which have ceased to be tissue. The second condition is, there must be a regular supply of such blood— not too much, not too little— at all times the same, to every tissue according to its necessities. It is the bread of life to the tissue, and the demand is imperative. If a tissue be not regu- larly supplied with blood, disease will result. On the one hand, if there be too little blood for a length of time, atrophy will follow ; or, should it be entirely cut off", mortification will ensue. On the other hand, where too much blood exists in a part, it constitutes congestion, which may lead to inflammation ; or a long-continued congestion may give rise to hypertrophy. These two diff^erent results of hyperemia may depend upon other circumstances ; but here can only bo explained that a mdden influx of blood to a part is likely to produce inflammation, while a gradual and limited increase is more likely to be followed by hypertrophy. The power of assimilation belongs to every tissue ; it is a law of life. After the body is fully grown the extent of assimilation in health will 22 PRINCIPLES OP SURGERY. depend upon the amount of decay, otherwise the natural condition will not be maintained. It would seem that a redundant supply of arterial blood, long continued, may cause the tissue thus supplied, to assimilate to a greater extent than there is wear and tear ; the result of which will be hypertrophy. The third requirement for ordinary repair of tissue is a certain nervous influence. Assimilation may possibly continue, although imperfectly for a time, notwithstanding the nervous influence is witndrawn ; but very soon after its withdrawal the tissue will ex- hibit signs of impairment. Examples of this is often seen where nerve-trunks have been injured, or are pressed upon by a morbid growth. The tissue to which this nerve is distributed seems inca- pable of propagating itself. The absence of the nervous supply may prevent the normal circulation of nutritious fluid. At all events the result is atrophy of the structure. The fourth condition necessary is a natural condition of the part to be maintained in a state of repair. Now, if a part has been originally healthy, and the three previously stated conditions be continually present, this, the fourth, will never be absent. If, however, the structure have been originally abnormal or weak, then, although the three conditions mentioned be not wanting, the fourth will not exist. Again, as has been stated, if one or more of the first three conditions be absent, it will result in a want of the fourth — that is, if the blood is not pure in composition, or if it is not regularly supplied to a part, or if there be a want of nervous influence, there will soon be an abnormal state of the tissue, so as to render it incapable of assimilating, even although the other conditions had been restored. It does not come within the scope of this work to do more than allude to the physiological necessities to secure the above-men- tioned requisites for repair of the constantly wearing-out tissues of the body. In the first place, as already intimated, a healthy constitution is a prerequisite ; then there must be a natural volume of healthy blood, which must be maintained in its purity and ful- ness of quantity. In order to this, proper food, properly taken, followed by healthy digestion, and formation of blood, are essen- tial. It is well to remember that chyle, just entered into the cir- culating blood, is not itself blood,— that changes of a vital nature have to take place before it can enter upon the high duty which it INTRODUCTION. 28 is intended to perform. This crude material has to undergo a process of development. The blood, like the solid constituents of the body, is developed and grows. Within the blood-mass there is constantly to be found development, maturity, and decay; and the worn-out portion of blood is quite as much an eflFete material as those of the tissues. Consequently, where anything interferes with any one of the natural processes of blood development, there will be an imperfectly elaborated pabulum for the wasting tissues. Again, it is necessary that eflFete matter should be eliminated from the blood, — those elements which can no longer serve any purpose in the physical economy. These products of decay are constantly forming, and an eflScient state of the excretory organs is demanded. In the venous blood are found elements which are poisonous in their effects when not duly removed, and which are separated from the blood in the lungs by the substitution of oxygen. To insure this, a sound state of the lungs and pure air are required. When effete material is not excreted, proper development of the blood cannot proceed, and assimilation in the tissues is disturbed, or perhaps impossible. Moreover, their retention may be the source of a poison more or less destructive to the system, as in the non-excretion of carbonic acid and of urea. If these functions of life referred to be quite normal, then the blood will be preserved at its natural standard, — will be duly fitted to repair wasted tissue in every part of the body. If not, then disease of some kind will surely arise. In concluding this chapter, it may be stated, in connection with the foregoing, that, in order to have the healing process, hereafter to be described, successfully carried on, the same conditions and the same prerequisites are equally necessary ; and it is because such is the case, as well as because of the close resemblance be- tween ordinary repair of tissue and that which we may call extra- ordinary repair, where there is a palpable breach of tissue, that it has been deemed desirable to take this brief survey of these few physiological truths. And although a knowledge of inflammation may be acquired without having previously studied these points, the task would be less easy, the labor greater, the result less satisfactory. r, . mPLAMMATIOX, AND DISEASES ARISINa OUT OE INFLAMMATION. CHAPTER II. Inflammatory Process-Incubation-Coneestion Tr.fl<.™ .• t, st.,n..,.n-c..„,. ■ Lupmr Extractivo do. o Sanguinis. Albumen. ^■4 Fibrin. ■1^ Red Corpuscles Crassa- ^ mentum. Colorless Corpuscles. s Granules. J p DISEASES ARISING OUT OP INFLAMMATION. 31 Now, may it not reasonably be supposed that the fibrin, thus placed without the capillaries, and unable to enter into the forma- tion of tissues, either on account of its own beginning metamor- phosis, or the inability of the tissue to appropriate it, or perhaps both, and having thus been turned aside from the high position for which it had been intended, assumes a new position in respect to its vitality, and its capability of acting any part in the opera- tions of life in the system. Although it has, on account of cir- cumstances, apart from its own developnlent, failed in fulfilling its primary destiny, it constitutes a no less useful material. Although it may not act a part in ordinary repair of tissue, it serves a pur- pose quite as important and indispensable, in effecting extraordinary repair. The elements of the blood which would, had not the natu- ral functions been disturbed, have become tissue, deviate from this natural course of development and become the agent of the healing process. The nature of this change is not uncertain ; there is not only a change, but a degeneration— a descent from one state of existence to another. It is a retrograde development. Here the question as to nature and oflSce of fibrin of the blood in healthy might with propriety be discussed ; but it will be more appropri- ately done in connection with the subject of healing. I will here simply venture the statement, that the object for which fibrin exists in the blood is to heal, or effect extraordinary repair. That it is a material limited in quantity, which is kept in store for that purpose, and which is always found to increase rapidly in quantity, and become more efficient in quality, when a demand for it is made. The varied ways in which it is employed will hereafter be duly considered, as well as the grounds upon which this belief is based. Here, then, is a substance called liquor sanguinis, transuding, in consequence of the morbid irritation, which has resulted in overdistension of the vessels' coats. The fibrin of this compound is altered in character. It differs from natural fibrin in being more higiily vitalized. It has degenerated from nutrient material ; but it constitutes a higher typo of fibrin than that which exists ordinarily in the blood. Derived from lusty elements which had been elaborated for nutrition, and suddenly exposed to conditions which caused an early degeneration, there results a higher typo of fibrin, in which is manifested that high degree of vitality wliinh, it will be seen, is so essential to a speedy restoration of the diseased :|^ i i*i I I! i 82 PRINCIPLES OP SURGERY. part. This fibrin is more plastic than the natural ; and, not un- likely, this plasticity assists in delaying the ultimate stagnation of the blood in the vessels, to which there is a tendency thereafter. The cau8e of stagnation of blood is another vexed question. While the state of paralysis was being reached, the flow of blood was becoming more and more tardy, and, finally, after oscillating in the vessel for a brief time, as if trying to force its way, it ceased to move — it was stagnant. The explanation of this has been sought by many investigators, and each of the individual elements of the blood has enjoyed the credit of being the cause, or one of the causes. Thus the white corpuscles, it is asserted by some, although strenuously denied by others, are increased in number, and in consequence of their crowding against the coats of the vessels they increasingly adhere, until the whole stream is in- terrupted. Again, the red corpuscles, it is thought, show an un- natural tendency to run together in the form of rouleaux, and in that way adhere together, as they are seen to do, in blood taken from the system even of a healthy person. A. Htcroscopleal appearance of henlthj blood, n. Illood of a patient aufferlng from acute rhenma. tiam or inflammation. (Paget.) With regard to the white corpuscles, whether they in any way take a part, it is asserted by Paget, II. Bennet, Wharton Jones, and others, that, inasmuch as the white corpuscles cannot be sepa- rated from the fibrin, no positive evidence can be advanced in sup- port of that theory. This view is opposed by Williams (" Princi- ples") and by Virchow. Moreover, it has been observed that in those cases where the white corpuscles are in excess, the individual was otherwise unhealthy. And still more, these corpuscles are DISEASES ARISING OUT OP INFLAMMATION. 33 i^m Mute rhenm»- relatively increased in pregnant women, and in those with tubercu- losis, and in ill-fed persons. That the fibrin acts a very important part in effecting the stag- nation in inflammation, there is, I believe, a general belief; but in what way is not quite so certain. Increased in plasticity, it may, by adhering to the walls externally, tend to induce paralysis of the capillary coats. Again, it may be that, at least in some cases, the fibrin coagulates around the canal, and by contracting in places arrests the onward flow of the blood. But, as will be seen hereafter, coagulation generally does not quickly take place in the tissue under these circumstances; indeed, the increased vitality already said to exist in the fibrin teaches the same thing. Probably, the principal cause, at least that which first leads to the stagnation, is the loss of tone or power to contract in the ves- sels. It has been demonstrated that even the smaller arteries and veins possess not only contractile tissue, but also muscular fibre. The capillaries, as well, have contractile tissue ; indeed, although no muscular fibre has been detected in the coats of capillary tubes, it is not going far to doubt they, being a continuation of the larger vessels, would partake, although in a limited degree, of their cha- racter. May it not be that the bloodvessels perform an action analogous to that performed by the intestinal canal. It is difficult to conceive the object for which muscles exist in the coats of vessels if it be not to assist in passing the blood along the canal. The heart has long had imposed upon it the responsibility of forcing the blood to every part of the body ; but it will not diminish the importance of that organ to admit that it may be assisted by the vessels themselves. With regard to the capillaries, there is cer- tainly reasonable doubt as to their power to assist {vide Virchow, already quoted) ; if, however, it be true that some vital action re- siding in the extra-capillary cells causes the fluid to permeate these minute tubes, then it may at once be inferred that this cellular power is disturbed or destroyed in consequence of the morbid ac- tion going on, and hence the stagnation. We have now reached a point in the "inflammatory process" at which a change of function is apparent. All the conditions neces- sary to healthy nutrition are absent, the blood is stagnant, the nervous influence is deranged, assimilation impossible, the period of incubation has passed, — the disease is established. m u PRINCIPLES OF SURGERY. t I ff! ! , CHAPTEE III. More Extensive View— Number of Products, viz., Scrum, Liquor Sanguinis, Fibrin, or Inflammatory Lymph, &c.— Causes of Inflammation— Various Divisions. Thus far, in studying the inflammatory process, our attention has been necessarily confined to a single vessel. Now, let us take a more extensive and comprehensive view of the inflamed part. Not only one but several, perhaps many, capillary vessels will be simultaneously involved ; be aff'ected in all respects the same ; and finally in all, about the same time, the blood will cease to move. Extending the view, it will be seen that in the immediate neigh- borhood of these paralyzed vessels are others, undergoing those primary changes which have been described, and which are duly affected in the same manner as were those primarily aff'ected. Con- tinuing our observation to tissue farther removed from the central point of disease, there will even yet be observed active congestion or limited excitement, and apparent efforts being made to make accommodation for the in-rushing blood. In speaking of the dilatation, over-distension, and final para- lysis, I did not state the important fact that the vessels are not alone increased in calibre, but are, as well, elongated. The small vessels, indeed, present a varicose or tortuous appearance. More- over, they are not uniformly dilated, but here and there they pre- sent a sacculated appearance, as seen in the annexed diagram. Now, must not this be considered an already anxious preparation of nature to form new bloodvessels in connection with the plastic material which has been copiously eff'used for the purpose of com- pleting repair, should the inflammatory action fortunately be ar- rested ? These points of sacculation may very easily be converted into offshoots, and, as will be seen hereafter, thus made to afford channels by which blood may be supplied to complete the healing process. There are certain products of inflammation which will have to receive attention as we continue to trace the inflammatory process. CAUSES OF INFLAMMATION. 35 At present I will only enumerate them. They are, 1st. Serum ; 2d. Liquor sanguinis ; 3d. Inflammatory lymph, or altered fibrin ; 4th. Blood; and, 5th. Altered mucus. These are immediate Small TeaieU of an inflamed pericardium. (Paget.) products of the disease, but there are others which are more re- mote, yet of no less importance. These latter products result from changes which may take place in the lymph, and from the effects of that product upon the tissue involved. Speaking generally, the lymph may become organized, as will be hereafter explained, or ifc may degenerate into pus. Before proceeding to fully consider these products of the disease, I purpose to consider the various Causes of Ivflammation. — They are numerous and varied, but may, by classification, be made easy to remember. A common and convenient division is into predisposing and ex- citing ; or, it may be, into local and general, or external and in- ternal, or specific and non-specific. The predisposing causes may be subdivided into local and general. A local predisposing cause may have been inherited, or it may have been acquired after birth. It is a fact frequently observed that a certain tissue or organ is preternaturally weak, a condition which has existed all the life- time, or since a certain period of life. A tissue thus weak is more liable to be attacked with disease than those which are in health. Individual tissues or organs, like individual persons, are, in consequence of imperfect development, more subject to the casualties of life. It requires no proof to make it plain that cer- 86 PRINCIPLES OF SURGERY. '\ !: Hi tain parts of the foetus may be imperfectly developed in conse- quence of faulty conception or faulty uterine nourishment. The vice or imperfection of either parent may be represented in the child ; or certain other influences may aflfect the integrity of the ovum or the more mature foetus, so as to mar the process of devel- opment. Mal-nutrition, either during foetal life or after birth, or an attack of some disease, may beget a condition permanently weak in a part, whereby that patt is susceptible to any exciting cause of inflammation. It has already been shown that certain conditions are necessary to secure healthy nutrition — natural repair ; and that if but one of these conditions be absent, there will follow, sooner or later, a morbid condition in the part affected ; and when the body is ex- posed to an exciting cause of inflammation that morbid tissue is likely first to feel the effects. But the whole system may be pre- disposed to inflammation. Primarily the whole structure of the body may have been defective; or, secondarily, the blood may have become vitiated. This general defect may have been induced, or it may be a heritage. When acquired there are many causes which may have been in action. The blood may be impure. It may always have been so, or it may have become so, as the result of imperfect performance of duty on the part of certain organs, or from the reception of crude or deficient aliment, derived from vicious food, or from taking too much, or perhaps too little food, or it may be from a failure in digestion. Again, the blood may not be duly developed. The conditions necessary for this may be wanting. Impurity of the blood, so injurious to health and the well-being of tissues, will ensue, if that fluid be not continually aerated, or if morbid material should enter by the lungs. If one or more of the excretory organs fail to discharge its function aright and the effete matter — those elements which have formed a part of the fabric, but which now have perished, and are floating in the fluids of the body — be not duly removed from the system by the kidneys, or the skin, or the bowels, then it may be the blood will be poisoned, and individual tissues in consequence become sufferers, and therefore predisposed to inflammatory disease. Still, again, the blood, in consequence of a certain condition in which it happens to be found, or in consequence of being possessed of certain elements, may receive from without poisonous elements, CAUSES OF INFLAMMATION. 87 specific elements, which possess the power to beget specific inflam- matory disease, such as small-pox, measles, scarlet fever, &c. Still further may be mentioned the taking of too much food, even though that food may be digested. When a state of plethora is induced by overmuch eating, the blood can scarcely be in a healthy con- dition, but rather becomes gross and ill-fitted for nutrition, and a predisposing cause of inflammation, ready to act, should any part be subjected to pathological irritation. Lastly, changes of weather, by which the body is exposed to great and sudden variations in temperature, whereby nutrition and development are impaired, will, if long continued, render the whole system liable to inflam- matory disease. Exciting or Local Causes of Inflammation. — The first are those which actually injure organized structure, as mechanical injuries and chemical agents, which tend to immediate destruction of tis- sue; also heat, extreme cold, and friction. 2dly. Those which act through the sentient extremities of the nerves, as concussion, pressure, irritating applications, as mustard, cantharides, &c. 3dly. Anything which produces a peculiar impression and gives rise to a specific action of an inflammatory nature, such as decom- posed animal matter, pus arising from specific diseases, dissecting wounds, &c. A fourth class of causes is given ; that is, such cir- cumstances as produce a sudden change in the feeling of a part as that experienced in the viscera of the abdomen after the removal of fluid in ascites. Under this class may be included any change in local nerves, whereby deviations from normal nutrition may take place. (Simon.) The terms specific and non-specific, as applied to causes of in- flammation, scarcely require to be explained. They are almost synonymous with unhealthy and healthy, a division already indi- cated, yet an inflammation maybe unhealthy without being specific. A specific cause of inflammation is one which gives rise to a defi- nite kind of inflammation, as in the poison of small-pox and of syphilis, &c. A non-specific cause is one which has a more general source. 88 riMi! PRINCIPLES OP SURGERY. CHAPTER IV. Symptoms of Inflammation— Causes of each — Value in Diagnosis. And now, bearing in mind the varied causes of inflammation, and fixing the attention upon the pathological condition of an inflamed part; not alone upon a single vessel, whose coats are paralyzed, and from which exudation of liquor sanguinis is copi- ously taking place, but upon a wider district, in which are to be found many vessels in the various stages of the inflammatory pro- cess ; some with blood stagnant, some in which it moves sluggishly, some through which it rushes with increased speed, — taking this more comprehensive view of an inflamed part, it will be a more easy task to consider the various symptoms which characterize the inflammatory process, so far as we have traced it, and to examine the symptoms which may be looked upon as diagnostic marks of the disease. The symptoms of inflammation may be divided into local and general. The local are pain, heat, redness, swelling, to which is commonly added throbbing. Pain is a very early and constant symptom as a general thing, and such would naturally be ex- pected. It is the office of the peripheral extremities of the nerves to guard the structures wherein they are distributed, and to give warning to the central system on the approach of danger. The invitation by which the inflammatory process is initiated, acting upon and through the nerves, will from the first produce uneasi- ness in the nerve-tissue itself, and prompt and constant pain is the common result of the inflammatory process. The pain of inflam- mation may be said to arise from two causes, one of which is dis- turbance of or injury to the nerve-substance ; the other is derived from indirect effects upon the nerves, due to the morbid condition of the tissue, — changes, perhaps, in the cellular elements, and the free transudation which follows the paralysis of the vessels. The in-rushing blood may be supposed to increase the pathological irri- tation which has arisen by pressing upon the irritated nerves while SYMPTOMS OF INFLAMMATION. 39 in a disturbed state ; also the several products of inflammation, the exuded serum, the liquor sanguinis, and subsequently the pus when it has formed, will, no doubt, in like manner by pressure maintain and increase the pain. But the pain of inflammation is not always alike with the same cause and amount of inflammation. The intensity of pain depends upon the nature of the tissue in- volved. If it be abundantly supplied with nerves, the pain will necessarily be greater. Again, if the tissue be dense and unyield- ing, the pain will be correspondingly great. For instance, in in- flammation of the periosteum, a dense, unyielding, fibrous mem- brane, the pain is very great ; and the same is witnessed in the bone itself when inflamed, also in the torturing toothache. In such tissues where the nerves are irritated, attended by congestion or efi"usion, the pain becomes exquisite ; for, with the pressure, there is an equal counter-pressure. On the contrary, when the so-called cellular tissue is the seat of inflammation, the pain by no means corresponds with the actual amount of inflammation. This difier- ence between certain tissues of the body with regard to suscepti- bility and inability to accommodate themselves to abnormal condi- tions, bears an analogy to that well-known diff'erence which exists between individual beings. All persons are not equally aff"ected in the same degree of inflammation, or in any other disease. Some individuals are more sensitive than others ; and some tissues are likewise more sensitive than others, although in other respects there may be equality. To what extent may pain be considered a diagnostic mark of in- flammation ? It must be mentioned that pain may be absent in consequence of paralysis ; it therefore cannot be recognized as an infallible diagnostic mark ; but when pain is absent in consequence of paralysis, the most superficial observer will be able to discern it. On the other hand, pain attends other diseases as well as in- flammation. The pain of neuralgia is very severe, but it may be distinguished from the pain of inflammation by the manner in which it commences. Unlike the pain of inflammation, it is sudden in its onset, and is quite as severe at first as at any subsequent period, while at the same time there will be an absence of the other ordinary symptoms of inflammation. Again, the pain of colic may be mistaken for that of inflammation ; indeed, it is very commonly done by the non-nrofessional -, but this, alsoj is sudden in its an- 40 PRINCIPLES OP 8DR0ERY. pearance, and .s often as great at first as at any subsequent time. Moreover, the pam of colic is relieved by pressure, while the pain of mflammafon ,s always increased thereby. And, it is important 1/n ^^''' ir^ '^' ''"''' °^ inflammation in an internal organ the pam suddenly cease and does not recur, it is always to be regarded with concern, inasmuch as it indicates that the tissue and that the relief which the patient so much enjoys is but a fore taste of that ease from bodily pain which death brings ffeat la a very constant symptom of infiammation. A difference of opinion prevails as to the cause of this symptom. Physiolo- gists do not quite agree as to the source of animal heat in the human body ; as to the nature of that process by which a certain amount of heat is constantly created in the body. All, however are agreed that in the process of nutrition there is a certain amount of heat regularly developed in every part of the body. Wherever he blood flows, there heat is evolved. It may be by waste of tissue, or It may be by some strictly chemical change in connec- tion with the transudation which takes place through the capillary coats; but it matters not for our purpose as students of the science ot surgery. It ,s sufficient to know that the process by which heat IS produced in the body in health, or some like process' i^ found be actively at work where inflammation has been kindled, and con- sequently in that part a superabundance of heat is always found Lr/K ; i'?" '' ^''^ ''"'"^■"S satisfaction, demonstrated the fac that the emperature of a part inflamed is greater than that of the arterial blood going to the part, and that the heat of the blood going from the part is less than the temperature of the blood m the part, while at the same time it is greater than the blood in a corresponding artery. Heat in most cases, is a trustworthy diagnostic s„tom of in- flammation, but It IS not altogether so. The heat may seem to be great to the patient in consequence of a morbid state of the nerves- and again, a structure inflamed, when freely supplied with nerves' may seem to have a higher temperature than it really has, as wli ol2 V/ "'"t "P"'"^"'- '' '' ^^-'^ «--«-/ to point out the difference between the heat of inflammation and fhat which characterizes the burning cheek of shame, and also that of hectic. They can always be distinguished from the absence of all the symp- SYMPTOMS OF INFLAMMATION. 41 quent time, ile the pain 3 important an internal s always to t the tissue ommenced, but a fore- . difference Physiolo- eat in the 1 a certain , however, lin amount Wherever ' waste of n connec- ! capillary he science ?hich heat J found to , and con- lys found ;rated the than that at of the the blood blood in >m of in- em to be 3 nerves ; 1 nerves, 3, as will to point at which f hectic, le symp- toms and circumstances of inflammation in the one case, and the presence of graver constitutional symptoms in the other. Redne89.—ln inflammation the flow of blood is increased to the affected part, and as the capillary coats gradually yield under the constantly increasing pressure, greater space is allowed for the presence of red corpuscles. Small vessels, through which the cor- puscles could but pass in single file, have crowding through them much larger numbers. Bloodves- sels are not suddenly formed in an inflamed part, as was at one time . supposed. The redness is due to this crowding of the distended ves- sels by red corpuscles. The liquor sanguinis exudes, leaving the cor- puscles mainly to occupy the capil- lary tube. Often the little cells will break down, or part with the coloring matter, which will tinge the transuding liquor sanguinis. Redness, although a constant symptom of acute inflammation, may not be recognized as a certain sign of the disease, for redness sometimes results from other mor- bid conditions. There are certain conditions of the blood, as in r- , K, vuvi, aa in Enlargement of vesBels, shown in Hunter'a scurvy, where the red corpuscles •?"«'"'«'> of t»>« ears of a rabbit, one of which easily part with their co\ovmgZ^T(Zt^'''"^'''^ ''"'""" '''"^'^'' matter, which, being admixed with the serum, may collect in a part, and give rise to a very high degree of redness. The intensity of the redness, whatever may be the cause, will, of course, vary much, according as the blood is arterial or venous. In the former case it will be of a brighter hue ; in the latter it will be darker, perhaps even dusky. Swelling.— When a part becomes inflamed there is a tendency therein to swell ; the relative size of that part is increased. The supposition would naturally arise that an increase of blood would increase the volume to a corresponding extent, and generally, no doubt, such is the case= Yet the vessels may be dilated so as to 1 '& i^^^H 4 1 t ''i 1 liraH mi m| ne|i¥« 99HBI '■ V I^H 1 i ^f ■ li : I 42 PRINCIPLES OP SURGERY. contain a very much larger quantity of blood than is natural, and at the same time the structure in which these vessels are located may be lessened in dimensions (perhaps by the pressure of the dilat- ing vessels), so that the natural volume of the whole is retained. In the first step of the inflammatory process such is the case, but when the coats become paralyzed, then the liquor sanguinis occu- pies the intercapillary substance. Indeed, the cells of which the tissue is composed are soon engaged in a morbid action,— unnatural development. They individually swell by imbibition of the fluid which has transuded. (Virchow.) In those tissues which are yield- ing the swelling will be greater than in those which are not. And here I wish to point out the important fact that swelling is salu- tary in its efi'ects ; it may, indeed, be looked upon as a curative effort. In a given amount of inflammation in a certain tissue, the degree of pain to some extent depends upon the amount of swell- ing which attends ; that is, whether the tissue is yielding or other- wise, for we have already learned tliat inflammation of dense tissue is more painful, because the irritated nerves are more pressed upon. Consequently, when swelling takes place, one of the most active agents in feeding the inflammation is removed or modified. Swelling then relieves the irritated nerves, and tends to arrest in- flammatory action. The degree of swelling, we have seen, will depend upon the nature of the tissue or organ involved. As a diagnostic gymptom, swelling is not very trustworthy. It has been shown that considerable inflammation may exist without a corresponding amount of swelling. Moreover, swelling often takes place independently of inflammatory action, as in passive congestion, where there is a mechanical obstruction to the return of venous blood, or when something interferes with the circulation of blood in a part. These four symptoms, pain, heat, redness, and swelling, when taken singly, cannot be said always to indicate inflammatory ac- tion,— are not diagnostic marks ; but when two are found coexist- ing, the one increases the importance of the other ; and when the whole four are seen in connection, they may be regarded as very reliable symptoms of inflammation. Another symptom, which is mostly always given with the fore- going, is throbbing. It may be said to indicate a certain stage of the disease, to which wo havn nnf ab vnf trono/1 ♦».<» 'Vfl^. .*---. I SYMPTOMS OF INFLAMMATION. 48 iiiuiaLui process, namely, commencing suppuration. This sensation of throb- bing is due to the wave of blood which, coming from the heart, endeavors to force its way into and through the inflamed part, and which, being obstructed, causes the arteries and heart to labor in their eff"orts to overcome the obstruction. Every wave of blood increases the pressure already felt by the sensitive nerves ; and the pain, constantly experienced, is at each pulsation intensified for a moment, and hence the throbbing. Other local symptoms E,re sometimes given in connection with the above, as derangement of function. It is, however, unneces- sary to say more here than that the absence of the natural condi- tions necessary for nutrition infers derangement of function. Constitutional Symptoms of Inflammation.— The system gene- rally does not remain impassive or unaffected when a part of the body is inflamed. There is a most intimate connection between one part of the body and every other part, so that one part or organ cannot long go in pain or be disturbed without the whole taking cognizance of the local distress, and to a great extent becoming aff-ected thereby. The quickness with, and extent to which this is accomplished, will depend upon the degree or inten- sity of the local afl'ection, and the susceptibility which may attach to the constitution. The general symptoms may all be included u?ider the general term " inflammatory fever." Fever is always present when inflam- mation is at all worthy the notice of the surgeon. It is generally preceded by a well-marked chill, which is of short duration and varying intensity. The fever is characterized by a dry and heated Bkin, and an arrest of all the secretions. IIow is this fever pro- duced ? In the first place, the irritation and pain which give rise to, and also result from the inflammation, and which cause irre- gular action in the vascular structure of the part, gradually pro- duce a similar eff"oct upon the whole vascular systoin, including the heart itself. The morbid action of the vessels in the aff-ected part, characterized at first by increased tone, seems to extend by continuity along the network of capillnriea and the smaller arte- ries, and then on to the heart itself. The pronipt manner in which the heart sometimes becomes aff-ected and increased in action would lead to the belief that it was through the nerves' reflex action that tne conatituiioiiui irritation was created. T^ r 'I 44 PRINCIPLES OP SURGERY. ;/ m ^.'ii i In the second place, the blood becomes gradually contaminated by the products of the local disease. In consequence of those changes which we have seen take place in an inflamed part, a poison is engendered. This poison, by collateral circulation, soon finds its way into the general circulation. In this way certain changes are effected in the whole volume of blood, which will be fully ex- plained hereafter. What is important here is the fact that the blood, thus poisoned, acting in conjunction with the nervous irri- tation already referred to, gives to the whole vascular system, including the lymphatics, an unnatural degree of tone, and this is the commencement of inflammatory fever. The explanation of this can be easily understood. The vessels contract, and thereby their calibre is diminished. The coats are brought into such a state that transudation of fluid cannot take place, at least as in health. The pores, so to speak, are closed. At the same time the heart labors, and the blood hurriedly streams along to and from every part of the body incapable of supplying nutriment to or carrying eff"ete matter from any structure. If, under such circum- stances, the skin be examined, it will be found there is an absence of the usual moisture,— there is no perspiration. The skin is dry while the blood is welling forth from the heart with determined force into the integument, in common with every other part of the body. The amount of heat generated in the body at such times is probably greater than in healthy action, while at the same time the absence of evaporation from the surface of the body tends very much to increase the temperature. Here, then, is an expla- nation, easy and simple, of two common symptoms of inflammation, namely, excessive heat and dryness of skin. This increase of tone, or closeness, I may say, in the texture of vessels, by which transudation \h arrested, is exhibited as well in the lymphatic and glandular structures, so as to affect the various sources of excretion. Secretion cannot go on as in health ; hence the fact that in inflammation the urine becomes scanty. But little fluid can transude, and that is loaded with the eff'ete matter of the body so as to make it highly colored. The bowels, also, are con- stipated, because the various glands connected therewith iiro inca- pable of action, the vessels therein being contracted, and there is but little secretion upon the mucous surface. The tongue, in com- mon with other parts of tho prisna yitn. nartici»ateH in thfl "^^neral ! PROGNOSIS OF INFLAMMATION. 45 i itarainated e of those •t, a poison soon finds in changes e fully ex- t that the rvous irri- ir system, !, and this anation of id thereby ito such a east as in e time the and from lent to or ;h circum- in absence kin is dry etermined •art of the juch times same time ody tends an expla- immation, e texture od as well lie various th ; hence But little ter of the are con- iiro inca- 1 there is e, in com- i- general disturbance, and, as it comes under convenient notice, its appear- ance is anxiously studied by the surgeon. The papillae of the tongue stand out prominently and with unusual redness, and the surface generally k covered with a whitish or brownish coat, due to the partially arrested and changed condition of the mucus, while the borders of the organ are reddened. The head is also more or less affected in inflammation, there being generally headache, with some obtuseness or disturbance of the mental faculties. This may be the effect of nervous sympathy, at least in part ; for there is at all times a close sympathy between the head and the bowels. But the cerebral disorder is also in part due to the state of the bloodvessels within the head, which will participate in the common vascular excitement. These various constitutional symptoms are not likely to be mistaken, and when preceded by and accompanied wih the local symptoms, the diag- 110818 of the disease is most certain. CHAPTER V. Prognosis of Inflammation— Course and Termination, viz. : 1. Resolution. 2 Delitoscence. 3. Extension, first, by Continuity; socond, by Contiguity- tbird, by tlie Circulation-Each cxplained-Fibrin in the System and out of it-" Cupped and Buffed;" fourth, by absorption ; «fih, by the agcnev of the nerves. The decision of the surgeon with regard to prognosis will depend upon a variety of circumstances, such as the age of the patient, the constitution, the cause of the disease, the stage, and the general surroundings of the patient,— the care and attention he will proba- bly receive, and the faithfulness with which the surgeon's instruc- tions will be carried out. As a general thing inflammation runs high in the young, and also up to middle life ; at the same time its course is sooner run to one or other termination. In the young the powers of life are active, and quick to resist anything which causes pain, and speedy in their efforts to get rid of the irritation and to effect restoration, ,. ..-^waij JwiH^,^ iii iiic juuiig uizij icad 50 senous results. i ,.;:-i 46 PRINCIPLES OF SURGERY. Hi '. ■ ,H I' i On the contrary, in the aged there is a comparative slowness to redress an evil condition, to attempt to get rid of a cause of irrita- tion, and to regain the normal state. The constitution of the patient will be fully considered. When it is quite sound we have circumstances analogous to those just mentioned as characterizing inflammation in the young ; and Avhen it is unsound they are analogous to the condition of the aged in this disease. The cause or causes of the inflammatory action must be remem- bered in order to form a correct prognosis ; the predisposing cause and the local cause, whether each can be readily removed or not and whether it is potent or otherwise. The stage of the disease also will govern the prognosis ; that is, the extent to which morbid changes have taken place in the part, and the eff'ects thereof on the constitution. And lastly, the course and termination of the disease will often and very much depend upon the position of the patient, and the fidelity with which the various directions of the surgeon are adhered to. Too often an over wise nurse, or an attendant led by inconsiderate kindness, acts contrary to essential orders in regard to remedial measures, and consequently the sur- geon's calculations are subverted. The surgeon will be expected to give his opinion, first, as to whether the life of the patient is in danger; and secondly, in re- spect to the integrity of the tissue or organ affected ; whether it is likely to be permanently or seriously impaired ; how long a time must elapse before a cure can be expected by the unaided powers of nature, or by the assistance of the surgeon ; or how long will it probably be ere the irresistible fatal termination will arrive. These are the questions which will have to be replied to in render- ing a complete prognosis. The Course and Terminations of Inflammation.— A.t any time during the inflammatory process, it may be arrested and resolution supervene. If the cause be removed before the inflammatory action has too far advanced, resolution may quickly supersede the morbid action. And here I must not omit to point out the inte- resting and important fact, that many of the phenomena of in- flammation are clearly indications of nature, intended to remove, if possible, the cause of the inflammation ; as, for instance, when a grain of sand is lodged in the oye, the immediate effect is a COURSE AND TERMINATIONS OF INFLAMMATION. 47 slowness to use of irrita- sred. When o those just 5 ; and when the aged in it be remem- posing cause oved or not, the disease 'hich morbid i thereof on ation of the !ition of the tions of the urse, or an to essential tly the sur- first, as to ndly, in re- whether it long a time ided powers )w long will will arrive. 3 in render- t any time 1 resolution flammatory persede the lit the inte- Qcna of in- to remove, ancc, when effect is a copious secretion by the gland, and thereby, in many cases, the offending object is washed away. Other instances might be ad- duced to show the same kind workings of nature; but I shall hereafter have occasion to dwell on this fact, and also point out certain morbid conditions which evidently indicate curative efforts. The terminations of inflammation may be given as follows: First, into Resolution ; secondly, by Delitescence, or by what is called metastasis ; that is, morbid action may pass away entirely (delitescence), or it may disappear from one place and appear in a second place (metastasis). The latter is often seen in connection with gonorrhoea, a specific inflammation ; the disease commences in the urethra, and after a time it suddenly ceases in that mem- brane, and simultaneously attacks the testicles. Thirdly, the inflammation may extend to other structures. This may take place, 1st, by continuity, along a membrane in the same tissue, as from the Schneiderian membrane to the mucous membrane of the larynx, and to the bronchial tubes ; or from the duodenum to the liver, along the ductus communis choledochus. 2dly, by contiguity; that is, from one tissue to another which lie in contact ; as from the mucous membrane of vhe intestine to the muscular coat, and then to the serous portion ; or from the periosteum to the bone, and vice versa. 3dly, the disease may extend through the agency of the circulating blood. The fact has been before stated, that during the progress of inflammation the blood, sooner or later, becomes seriously affected, which causes, or assists to produce inflammatory fever. The blood may be so impregnated with poison, that, as it courses from the inflamed part, it will carry disease to other and remote parts, where, perhaps, in consequence of some predisposition, inflammation is also established. It now becomes necessary to consider more particularly in what these changes of the blood consist— what is the condition of the various elements of the blood when it thus possesses the unnatural power to produce inflammatory disease in a part remotely situated from the tissues originally affected. Looking for a moment at the blood when in a state of health, as it circulates in the bo«ly, it may bo divided into the fluid and solid constituents; the latter floating in the former. The fluid, or liquor sanguinis, is composed of the eerum and the fibrin. The more solid elements are the corpuscles, red and white, and some granular matter. The serum of th* 48 PRINCIPLES OF SURGERY. ' a liquor sanguinis is composed of a large quantity of water, albu- men, salts, and fatty matter. Now, if this healthy blood be taken from the system, the following changes will be observed to take place. Under ordinary circumstances, the blood soon ceases to be altogether fluid; the fibrin, instead of remaining in a soluble condition, begins at once to solidify, coagulate, and separates itself from the serum ; while it embraces in its substance the corpuscular elements. In this way the blood is divided into a clot and the serum. The change is altogether due to the action of the fibrin. But when inflammation exists, blood taken from the body exhibits somewhat different characteristics, the first and most striking of which is, that some time will elapse before this coagulation of the fibrin commences to take place, and when, finally, it has been effected, the clot is found to be unusually firm and tough. Before attempting to account for these phenomena, it will not be out of place to allude to the important question, which has of late so much engaged the attention of physiologists and pathologists; namely, what is the office of the fibrin in the human system? Upon this subject there is even yet some difference of opinion. The statement of Carpenter, that " albumen, fibrin, and organized tissue are somewhat of the same nature as that which exists be- tween the raw cotton, the spun yarn, and the woven fabric," cannot be received at the present day ; indeed he has, in a later edition, very materially modified his teachings in this respect. He admits that fibrin does not constitute the pabulum of repair for wasting tissues in the higher structures of the body ; and such, certainly, it has been proved, is a physiological fact. Now, if such be the case, the inference is forced upon us, that it cannot be the most highly developed or vitalized element of the blood. Moreover, if some tissues of the body derive their nutriment from other elements of the blood than fibrin, it must be conceded that those elements may possibly supply reparative material to all. Fibrin, so long exalted as the highest element of the blood, and as the one which directly entered into the construction of tissues, cannot readily bo compelled to take a lower place; but the dis- coveries of recent physiologists necessitate that humiliation. But, although fibrin may no longer occupy so proud a position as that of being a reparative material for ordinary waste and decay, it does fulfil a no less important duty in the physical economy; il COURSE AND TERMINATIONS OF INFLAMMATION. 49 water, albu- ood be taken rved to take on ceases to in a soluble parates itself ! corpuscular clot and the f the fibrin. >ody exhibits t striking of lation of the it has been igh. Before lot be out of •a of late so jathologists; lan system ? ! of opinion, id organized h exists be- i^en fabric," IS, in a later •espect. He f repair for ; and such, ;t. Now, if it it cannot ' the blood, riinent from needed that mn\ to all. ) blood, and 1 of tissues, but the dis- ition. But, tion as that id decay, it I economy; namely, that of supplying material for extraordinary repair. The tissues of the body are constantly exposed to the vicissitudes of life— to dieease, and to accidents— and nature would fail to main- tain her reputation as a conservator, and as wise to provide all things necessary for life, did she not have in readiness an agent to meet the .sudden requirements of disease, and of the various disturbances to which the ^ssues are continually exposed. Here- in, I would venture to assert, consists the importance of fibrin. This is the special object for which it exists. It is by this that the " healing process" is carried on. Of this I shall have to speak hereafter; so much, however, it was necessary to say here, that we might be prepared to understand that, during the inflammatory process, this element becomes endowed to a fuller extent with those attributes by which it is capable of acting an important part : no less, indeed, than that of restoring the structure inflamed to its normal condition, when at any time the morbid action may have ceased; nay, even more, that of arresting the inflammatory pro- cess, and thereafter of healing. During the inflammatory process, the fibrin is said, at least by some, to increase in quantity; but Paget says such is not invaria- bly the case. Of this fact there is no doubt, that its plasticity becomes greater— that its vitality is increased by the inflammatory action. Coagulation is the last act of life in the fibrin; and when it refrains from this act for a time, after being separated from the circulating blood, it indicates increased vitality. Now, such is observed to occur in the fibrin of inflamed blood; but when coagulation does take place, it forms a mass in which higher efi'orts are exhibited' to form a permanent structure. However, when the clot is entirely removed from the body, it has its limited period of what might be called its rigor mortis (Simon), after which disintegration of its substance commences. The blood of inflammation, by remaining fluid for a time when drawn into a vessel, allows certain changes to take place in the individual elements which do not occur in healthy blood, when it promi)tly coagulates. In that case the blood coagulates, the several constituents retaining their relationship as when circulating in the body. But when blood stands in a vessel uncoagulated, as it does in inflammation, the more solid corpuscles gravitate toward the bottom of the vessel. This sinking of the red cornusrlos !« f..niH. ^ 1 I ' I- 50 PRINCIPLES 0:f surgery. tated by a peculiar property they possess of attracting one another and adhering together in a very regular manner in the form of rolls (see diagram). The consequence of this action is that fibrin alone occupies the surface of the mass. The natural color of fibrin is a light yellow, and the surface of the clot, instead of presenting the color which red corpuscles would have imparted .to it, has that hiff hue which is always referred to in connection with inflamma- tory blood. The superficial portion of the fibrin coagulates first, while the lower stratum is crowded with corpuscles. These corpuscles in sinking drag upon the superior solidifying coat : the clot at its cir- cumference being attracted by cohesion to the side of the vessel, and thereby counteracting the weight of the corpuscles, the cen- tral portion will be principally aff'ected by the sinking bodies. In connection with this, another property of fibrin is exhibited; that of contraction as it coagulates. It not only solidifies, but its volume is lessened at the same time. It contracts into a narrower space, squeezing out the serum. The lower stratum is the last to coagulate and contract, and the result is that the surface of the buffy coat is depressed at its centre or cupped. This is another characteristic of the clot of inflammatory blood. In the coagula- tion of inflammatory blood, according to Paget, no distinction nor separation can be detected between the fibrin and the white cor- puscles. Virchow, on the contrary, observes, that " on looking for the colorless corpuscles, we find them forming a separate layer at the lower border of the buffy coat. This peculiarity is simply ex- plained by the diS'erent specific gravity of the two kinds ol blood corpuscles. The colorless ones are always light, poor in solid matter, and very delicate in structure, whilst the red ones are as heavy as lead in comparison, owing to their richness in hsematine." Such is the state of blood in inflammation resulting from the inflammatory process. At first the blood in the diseased part is alone afl'ected : this contaminated fluid passes away by collateral capillaries into the circulation, while fresh blood takes its place in the aff'ected part. In time the whole volume of blood participates in the morbid changes. These changes, to repeat somewhat, con- sist in an increase of white corpuscles, which are perhaps altered ; also a relatively increased number of red corpuscles, which are constantly undergoing changes perhaps of degeneration, or are COURSE AND TER'lINATIONS OF INFLAMMATION. 51 actually dying ; and the fibrin possessing increased vitality is like- wise increased in quantity. The blood is, by these morbid changes, rendered irritating, and, as it passes into every part of the body, it carries the seeds of inflammatory disease to be planted in tissues preternaturally weak, or otherwise predisposed to inflammation ; and thus it is that through the agency of the blood inflammation may extend from its original seat to parts remote. Absorption is another way by which inflammation may be said to extend. Apart from the network of capillaries is a system of nutrient vessels (cells, Virchow), by which, no doubt, nutrition is immediately carried on ; and through which extensive territories, to which the capillaries approach not, are supplied with nutritive juice. Through these most likely are conveyed from the seat of disease, morbific elements, derived either from the blood or elements of the tissue. These may find entrance into the lymphatic sys- tem, and, passing along to the glands, be there arrested, to create disease ; or perhaps, passing onward, ultimately to aff'ect the mass of blood. A familiar instance of extension by absorption is afforded in the inflammation of the glans penis caused by' specific poison. In this case the poison being absorbed, it passes to the glands of the groin, which, in the discharge of their function to keep back anything which is deleterious to the system, arrest the poison ; and thereafter, in consequence, themselves become affected. In ordinary inflammation it is not so likely to extend by absorp- tion as when the system is in a vitiated condition ; because in such a case morbid elements are more likely to be formed within reach of the absorbents. Another means whereby inflammation extends is through the agency of the nerves. We have discussed the subject as to the part taken by the nerves in establishing the inflammatory process, and it will be more easily understood how a morbid action of the nerves may cause the disease to extend. There are nervous cen- tres ; and, going from these, are nerves which divide into branches to be distributed to different parts. Now, when a part of the body is inflamed, not only the nerves thereof are deranged, but as well the nervous centre from which they immediately proceed. And more than that ; other branches proceeding from this centre par- ticipate to some extent in the irritation. The action and reflex action of nerves are very well understood in lioalth • hut when the '!!i 'll - Ml 52 PRINCIPLES OF SURGERY. action is morbid, when the ultimate constituents of the nerve- trunks are disarranged, the electrical condition thereof disturbed, the action of the nerves cannot be natural, and the reflex action is likewise unnatural. Also the various nerves arising and pro- ceeding from the disturbed centre will sympathize in the general disturbance. Hence it is that a part supplied with nerves from a centre common to it and a part inflamed, is likely to become aff"ected and inflamed. Hilton, in his admirable lectures on " Rest," has fully elucidated this question, to which reference will be more fully made in connection with diseases of joints. These are the several ways by which the inflammation may ex- tend from the part in which it arises : 1st. By continuity ; 2d. By contiguity ; 3d. By the blood ; 4th. By absorption ; 5th. By the nerves. '■ :l i CHAPTER VI. The Products of Inflammation : 1. Serum ; 2. Liquor Sanguinis— Fibrin- Coagulation— Development— Hypertrophy, True and False— Atrophy- Induration. Having considered the ^Hnjlammatory process,'' the causes of inflammation, the symptoms, and, in connection therewith, the di- agnosis, the prognosis, and the course and terminations of the dis- ease into either resolution or into further morbid displays by exten- sion, and the several ways by which it may take place, we are fully prepared to investigate the several products of the disease, or the results of the inflammatory action. (Paget.) ■ It will be well to recall to mind the changes which take place in the capillary coats during the inflammatory process, a change from healthy nutrition to the existence of morbid products of diseased action. To illustrate, let us take a common cold in the head. The first indication is a watery discharge from the nose, or perhaps a dryness of the mucous membrane, causing a sensation of stuffiness. In reality, the first efi"ect of the " cold" is an exalted action of the mucus-secreting glands, by which there is a copious secretion of THE PRODUCTS OF INFLAMMATION. 53 healthy material, only that it is more watery. When the vessels contract under the irritation the secretion is arrested, and the dry stage results. Thereafter, when the coats relax secretion again takes place ; but it now is not only greater in quantity but also changed in character. ' Everybody has experienced a catarrh in the head, and can at once understand the illustration. The inflam- matory process is identical in other tissues, only that instead of the effects being exhibited upon a mucous surface in the altered secretion of mucus, they present themselves in the transudation of abnormal material into the structure immediately around the capil- laries ; or, in other words, instead of transudation of those ele- ments required for nutrition, there is, as a result of the inflamma- tion, transudation of material which cannot become in any case elements of ordinary repair. The first product to be noticed is serum. This may often be seen when there is o.ily congestion, before the vessels "have lost their tone ; but it is when they become much relaxed that it more particularly abounds. Very often in what seems to be serum only there is a quantity of fibrin, which shows a tardy disposition to coagulate even when separated from the body. As a general thing, the quantity of serum is greater when the inflammation is more chronic, and when the action is acute, fibrin will preponderate. The exudation of serum from engorged vessels is no doubt a cura- tive effort ; the turgescence is often thereby very much relieved ; and should the cause of irritation then cease to exist, the serum would very soon be reabsorbed. The second product of inflammation— liquor sanguinis. This, it will be remembered, is composed of serum and fibrin. But the fibrin now receives another name. Changed in character, and probably increased in quantity, as a result of the inflammation, it takes the name of « inflammatory lymph." After transuding, the fibrin remains soluble in the serum for some time; but sooner or later it begins to separate from it, or rather the serum flows, or is pressed away by the coagulating fibrin. The length of time which elapses before it thus separates into its component parts— serum and fibrin— varies; it may take place at once, or it may not for some length of time; or a portion of the fibrin may become soli- dified while another portion remain? in solution. In each event It is not difficult to observe an attempt to arrest disease or re- '/'if I, M.ir ; p 54 PRINCIPLES OF SURGERY. Store to health. Perhaps further observation will enable us to say that there is always an early tendency in a portion of it to stiffen around the small vessels, and thus by external support assist to prevent over-distension and paralysis ; and further, by fixing the tissue, as it were, to secure a degree of rest which will favor re- covery, Paget, as well as Virchow, has shown that a very long time may pass away while the fibrin remains in solution ; indeed it would sometimes almost seem that exposure to air alone will cause the lymph to coagulate. Coagulation, it will be remembered, is the last act of life in fibrin when separated from the body, and in the main it must be considered the same when only without the blood- vessels ; hence the unwillingness of nature, so to speak, to take a step by which the fibrin becomes in most respects a foreign body. While in solution, or only solidified in a limited quantity, it can readily be absorbed ; but after coagulation, the process of absorp- tion is necessarily slow. This property, therefore, possessed by inflammatory lymph, of remaining in solution for a longer time than natural fibrin does, is one of salutary importance, in so far as recovery is concerned. Virchow, in his cellular pathology, states his belief that there is at all times two kinds of fibrin in the system,— one the fibrin of the blood, the other that of lymph ; and that it is the latter which manifests this tardiness to coagulate. As yet we may feel some unwillingness to receive this doctrine ; but should further experi- ments attest the truthfulness thereof, the important fact would still remain, that in inflammatory conditions the fibrin which so abundantly transudes is tardy in coagulating ; and that, while the solidification of a limited quantity will prove beneficial by affording external support to distended capillaries, the fluid state of the greater quantity is one favorable to absorption, on the cessation of the inflammatory action. And still more, as we shall see when we come to describe the healing process, this fluid condition of the fibrin allows the formation of new bloodvessels to take place in its substance, whereby the coagulated fibrin is preserved from be- coming altogether a foreign body, and by which it is afterwards gradually removed, as natural tissue is substituted for it. The sacculated and tortuous state of the paralyzed vessels may be con- sidered a first step toward the formation of these new vessels. I THE PRODUCTS OF INFLAMMATION. 55 will risk being tedious, to endeavor to make this clearly under- stood. Let us suppose lymph to have been effused between two capilla- ries (see diagrams, pages 28, 35), which are dilated, elongated, and sacculated. Now, suppose further, the inflammation to have been ar- rested, and the lymph and serum about to be separated ; the latter to be absorbed, the former to attempt organization. Should the lymph coagulate all together, it will, in many respects, be a foreign body, and its removal be difficult, tedious, or impossible, unless by sup- purative degeneration. If, however, this adventitious matter be supplied with vessels, then its removal will be more easily effected. Now it seems to be by those sacculated points that the first steps are ordered to form new capillaries which shall traverse the new mate- rial. These sacculated portions continuing to dilate and extend, be- come in time an offshoot of the vessel, and eventually meet another similar offshoot from either the same or another capillary. The meeting walls break down, and thus a complete channel is made through which the nutrient fluid at once begins to flow. The part which this new vessel plays is an important one : by it no doubt the life of the coagulated lymph is prolonged ; and when it has served its purpose, as I venture to think, of fixing the tissue, and has lived its comparatively brief life, it is removed in the same manner as natural tissue after it dies or wears out. Perhaps it cannot with certainty be said that pseudo tissue, thus organized and sustained by blood, entirely fails to appropriate, like genuine tissues, from the blood, so as to perpetuate its existence. But if it possess such power it is very limited in degree, while the tissue in which it is placed will exercise a more potent influence in assimi- lating, so as eventually to substitute natural for the unnatural elements. Thus, while the temporary fabric is being pulled down, a natural structure will be erected. It is in this way that in course of time a part, in which has been, as a result of inflammation, an extensive deposit of fibrin, may be perfectly restored by a natural process of ordinary repair. There are several facts which go to support this view, to which reference will be made when speaking of the healing process. Hypertrophy, True and False.— But instead of a removal being thus gradually and fortunately effected, quite a contrary result may follow. Although inflammatory action, it may be said, has 66 PRINCIPLES OF SURGERY. Ill subsided, there sometimes remains a degree of irritation which is due to the adventitious matter before mentioned. On account either of the large amount of fibrinous deposit, or the restless nature of the tissue or organ involved, there is an absence of that condition of the part which is necessary for absorption to take place. Perhaps the coagulating fibrin within the part embarrasses its function ; perhaps the function of the part is such as almost to preclude the possibility of that repose requisite for the material to be absorbed. The consequence of either is, that pathological irritation continues, and a continued determination of blood sup- plies more than is required. The transudation of liquor sanguinis steadily in limited quantity continues, the fibrin of which con- stantly undergoes changes heretofore described ; and constant ad- dition thus is made to the previously added deposit. From time to time there will be an exacerbation of the symptoms, and inflam- matory action will take the place of the formative process ; this will subside, yet recovery cannot follow, but a renewal of the formative process. Instances of this continued irritation may often be seen after inflammation of the conjunctiva. Here the constant motion of the eyeball, and probably the exposure of the eye to light, very much interferes with the removal by absorption of the products of the inflammation. When a tissue is increased in volume in this way it is the seat of false hypertrophy, so called in contra-distinction to that hypertrophy where the volume is increased by the addition of the natural tissue. But this congestion may be followed by true hypertrophy. The irritation may constitute a "physiological stimulus," instead of a pathological one, and the result is that the part grows. Thus wo see that one immediate product of inflammation may lead to other and remote products, namely, true and false hypertrophy; the former being charjicterizcd by the addition of tissue like the ori- ginal ; the latter by the gradual addition of organizable fibrin, which becomes intimately incorporated with the tissue affected. Atrophy of Tissue. — Sometimes, however, instead of hyper- trophy, true or false, resulting, atrophy supervenes upon the coagulation of the transuded fibrin. This can bo understood when it is remembered that fibrin in process of coagulation and organi- zation always contracts. Now, under certain circumstances, this contraction of the inflnmmatory lymph affects the nutrient vessels, Sit THE PRODUCTS OF INFLAMMATION. 57 —capillaries and larger vessels. By pressing upon them, the ne- cessary supply of blood is cut off, and the nutrient fluid is pressed out ; nor can it thereafter enter as in health ; so that there results a disturbance of that condition necessary for normal ordinary repair; the effect of which is that, in the first place, the tissue is pressed together, whereby its volume may be diminished; and, secondly, in time, from want of nutrition, the part actually wastes away, and atrophy is the sequel of the primary product. Induration of Tissue. — This is not an infrequent result of in- flammation. The plastic material, which has been effused, and which has become organized and incorporated with the tissue, occupies the interstices thereof; by the presence of which the tissue is made unusually dense and hard — indurated. This con- dition may exist alone, or in connection with either /aZse hyper- trophy or, atrophy. So far, in the consideration of inflammatory lymph, I have spoken only of those changes which exhibit attempts, more or less successful, to become organized, and to cure. But it has been seen that, instead of the efforts to restore being always successful, there frequently arises therefrom other pathological conditions, namely, hypertrophy, atrophy, and induration. CHAPTER VII. Products of Inflammntion— Dogpuprntion of Lymph— Corpusculnr and Fibrin- ous Elements — Cause of eadi — 1. Pus: How formed) Different ways found— 1. Alisci'ss; 2. Diffused; 3. Upon tlio Surfiice— 2d Form of Doge- ncriition of Pus — Fatty; Jtd. Calcareous; 4th. Pigmental — Blood as a Product— Changed Mucus, Hi I. !| But inflammatory lymph does not always show this tendency to organize — to become developed.' In consequence either of the intonsity of the inflammatory action, or the state of the lymph itself, it Hometimes degenerates — descends to a lower state of exist- ence. As a result of inflauunation, the most ordinary form of dejxcneration is into pus. «) /( 58 PRINCIPLES OF SURGERY. Inflammatory lymph may be divided into two kinds, one of which is characterized by a tendency to organize, and the other to degenerate into pus. (Paget.) Or I may say that the fibrin of the liquor sanguinis is composed of two elements: one is a fibrin- ous element, the other corpuscular. These may exist in equal proportion, or one may be in excess. When the fibrinous element is in excess, there will be a tendency to organize, and a disposition to what is called the adhesive form of inflammation. When the corpuscular element abounds, the tendency to degenerate into^us tvill exist ; this constitutes suppurative inflammation. There are three conditions, to one or more of which the distinctive character of the fibrin may be due: 1st, the state of the blood; 2d, the character of the tissue involved ; 3d, the intensity of the inflam- mation, or the exciting cause. The blood of a healthy subject, in inflammation, always possesses more of the fibrinous element than that of one who is unhealthy; and especially of a scrofulous subject, or one whose system is reduced below par. And there are certain conditions of the sys- tem, or blood, in which the corpuscles are both numerous and sus- ceptible of degeneration, whenever inflammation may arise. In the second place, certain tissues, Avhen inflamed, always pro- duce fibrinous lymph; at least it is largely in excess; for instance, the fibrous tissues and serous membranes generally. It is one of the facts earliest learned by the student, that in inflammation of the serous membranes adhesions are likely to form between two surfaces which may come together. On the contrary, wlion the skin, or mucous membrane, or cellular tissue, is inflamed, the lymph resulting is composed more of the corpuscular element ; and hence the fact that pus is a probable product of the disease, as in ery- sipelas, &c. When the lung is inflamed, in the resulting lymph these two elements are about equal ; but Paget says that tlie cor- puscles show a marked tendency to degenerate. In the brain, when in flamed, there is rather a tendency to the formation of corpuscular lymph. I wish here to refer particularly to tlie interesting and important fact, one which will obtain more attention hereafter, that, in each tissue and organ of the body, such lympli is elaborated, in con- nection with the inflammation, as will best servo a curative pur- pose. ( Vide Healing Process.) THE PRODUCTS OF INFLAMMATION. 69 In the third place ; the intensity of the inflammation, to a cer- tain extent, modifies the character of the lymph. The greater the intensity, as a general thing, the larger the proportion of the fibrinous element. This is equally true in all tissues, whatever may be the controlling influence they have as such. One of the above conditions may modify another ; while, if they all act in harmony, either to favor the formation of the fibrinous element, or the corpuscular, the effect will be correspondingly great. For instance, in diphtheritic inflammation, although a mucous tissue is concerned, yet, owing to the intense nature of the disease, the fibrinous element preponderates, so that a false membrane, such as forms upon serous membranes, is produced. On the otlior hand, when inflammation arises in the serous membrane of an unhealthy person, or when the inflammation be asthenic, then, instead of adhesions taking place, pus may be expected to form, indicating a want of the fibrinous constituent of the lymph. Such, then, are the circumstances which give to the inflammatory lymph either a fibrinous or corpuscular character. And it is well to remark here, that these circumstances must be duly taken into con.sideration, when the surgeon is called upon to form a diagnosia and prognom. Pus. — As before said, the most frequent form of degeneration of lymph is into pus. This fluid presents the following character- istics. It appears to the naked eye as a creamy, thick, opaque, V and homogeneous fluid ; communicates an unctuous feeling when rubbed between the fingers; is a yellow or whity-yellow tint; sweet- ish, or insipid ; and, while warm, gives off" a peculiar, mawkish smell. Its specific gravity is 1030-1083. If allowed to stand some time in a tall, narrow glass, the fluid separates into a thickish sediment, more or less abundant, and a supernatant serum. This serum, according to Vogel, is identical with the scrum of the blood, con- taining much albumen, extractive and saline matters, and fat. The reaction is alkaline; but it readily becomes acid, from the generation of an acid, wliich is commonly supposed to bo the ! ' 'fi 60 PRINCIPLES OP SURGERY. nr lactic. In some cases, however, according to Walshe, it has an acid reaction even at the time of its formation, '< The sediment consists almost entirely of small organized corpuscles, the well- known pus-globules. These are of spherical form, have a well- defined contour, formed by a distinct homogeneous envelop, inclos- ing a soft, granulous substance, and a varying number of nuclear corpuscles. These are, in well-formed pus-globules, for the most part concealed by the surrounding substance; but, in the younger cells, even of healthy pus, and in all those of pus of an inferior kind, they are easily perceptible, even without the aid of acetic acid. Occasionally, a single nucleus exists; bnt more commonly it is made up of two, three, four, or even five large granules. The single nuclei are always the largest, and indicate, as we conceive, the most perfect kind of development." <' The nucleus is seated on the envelop, or is parietal, as it is termed. Its diameter is about gg'gg in.; that of the entire pus-globule about -^^^^ in." (Jones and Sieveking's Pathological Anatomy.) Paget calls the liquid in which the pus-cells are suspended the liquor puris ; and remarks, that "in the pus produced during healthy granulation, no other materials than these may be found." "But, often, mi- nute clear particles, not more than ^ gjgjj of an inch in diameter, are mingled with the pus-cells, to which they seem to have some relation as rudiments. And when the process deviates from health, we find not only variations in the pus-cells, but multiform mixtures of witlicred cells, molecular and fatty matter, free, or escaped and shrivelled nuclei, blood-corpuscles, fragments of granular substance like shreds of fibrin, and other materials. All these indicate de- fects or diseases of pus." "A caution is necessary against a very possible error which even practised observers have committed, viz., that of mistaking the colorless corpuscles of the blood for pus- globules. The two bodies are very much alike, but the blood-cor- puscle is somewhat smaller, generally more finely granular, and with rather less definite contour. The interior nuclei of both are identical." (Jones and Sieveking.) But Virchow says that "we can never say with certainty off-hand whether we have to deal with colorless blood- or pus-corpuscles." Such are the characteristics of pus, as observed with and without the aid of the microscope. The circumstances which attend degeneration of lymph into pus, THE PRODUCTS OP INFLAMMATION. 61 or which turn the process from organization into one of degenera- tion, may now be more fully considered. It will be remembered that it is a prerequisite for development and organization of lymph to have a cessation of the inflammatory action ; and furthermore let it be stated that the inflammation must not have been in active progress beyond a certain time, which length of time will vary ac- cording to circumstances hereafter to be fully described. But, if the exciting cause of the inflammation continue to act, then there is entered upon a new stage of the disease, another step in the inflammatory process is taken, and what has been called true in- flammation is attained. Following the stagnation of blood and the free exudation of liquor sanguinis, there is, in the part immediately concerned, in- stead of coagulation of the fibrin and a squeezing out of the serum, quite a different procedure manifested in this fluid. The corpus- cles of the fibrin undergo perhaps, I might say, a retrograde devel- opment; in reality, it is a degeneration. In this change the fibrinous element of the lymph participates. The palpable evi- dence of this change is the existence of the cream-like fluid pus, instead of the plastic buff'-colored fibrin. Before degeneration sets in, perhaps a separation more or less complete had taken place be- tween the fibrin and serum. Indeed, there is proof that a large quantity of lymph may simply coagulate, and remain so for even a few days, and then degenerate. In this latter case there is evi- dently a liquefactive, so called, degeneration. Take the surface of a wound when adhesion has failed to take place ; after a few days it will be found covered with pus. Again, take a hard swelling due to extensive eff'usion of lymph which has coagulated ; it is at first hard and unyielding, but in a limited number of hours, as every observing surgeon has seen, this hard swelling will have become soft and fluctuating. That which was solidified lymph is now a fluid pus, and that without the addition of any fluid fibrin. While this degeneration of inflammatory lymph into pus is in pro- gress, the cause of the action continuing, the inflammation is ex- tending, and where a short time before was congestion, is now stagnation ; and more remote parts not previously engaged will now be rapidly beginning to participate in the morbid action. The ayuiptoms which generally 6haracterizo the formation of pus will, 'I ?.t ^^;:flsrtf '.f 62 PRINCIPLES OP SURGERY. in another place, be considered, as well as the treatment to be pur- sued. It has been shown that in the organization of lymph there is displayed a wise and salutary effort on the part of nature to repair the injury which the part had sustained, the cause of the disease having been removed. And also, when pus is generated, although it is a degeneration, a process with a tendency directly opposite to that of organization, yet it is nevertheless a means equally wise to effect a cure. The disease having lasted for a longer time, and the effects having been correspondingly aggravated, other and more complex steps are required to restore the part, and even more than this, to prepare the way for successful restoration. It is a necessity that the cause of the disease should be removed; and when, for instance, that cause is the presence of a foreign body in the tissue, then the formation of pus and the subsequent softening of tissue has the effect of opening a channel by which the foreign body will be expelled. It is nature's method of getting rid of a foreign body, a process to which I shall have hereafter to refer. Again, when pus forms upon the surface of a wound it constitutes the most suitable covering, one, indeed, which cannot be imitated, to allow the healing, which will take place by granulation. And again, when it is seen upon a mucous surface, it will be found to protect that membrane from irritation, to some extent, at least. And lastly, although the pus may not be required for any of the above-mentioned purposes to act as a remedial measure, yet, as lymph which has been transuded, and which is incapable of removal by absorption while in that condition, it pursues the next best course to make its exit from the body, and consequently undergoes a liquefactive change. Being found in the form of pus, it may, by pressure, cause absorption of the tissue, and find its way gradually to the surface, and escape in a bulk, or it may, under favorable circumstances, be absorbed. The precise method by which the former takes place will be dwelt upon in connection with abscess. The method adopted to secure absorption of the pus-matter will now be briefly noticed. Pus as such cannot be absorbed ; the cells are bodies of too largo a size to be capable of entering the absorbent system. It is, therefore, necessary for some further change to take place be- k THE PRODUCTS OF INFLAMMATION. 63 fore this product of inflammation can be removed by the process of absorption. In the process of degeneration it has been observed that the corpuscles, which in the lymph were like the white corpuscles of the blood as well as the primordial cell, begin to increase in size. They "present a gradual increase of shining, black-edged parti- cles, like minute oil-drops, which accumulate in the cell-cavity, and increase in number, and sometimes in size, also, till they nearly fill it. The fatty nature of these particles is proved by their solu- bility in ether, and their accumulation is attended with a trradual enlargement of the cell, which also assumes a more oval form. Moreover, while the fatty matter accumulates, the rest of the con- tents of the cell become very clear, so that all the interspaces be- tween the particles are quite transparent; and, coincidently with all these, changes, the nucleus, if any had been formed, gradually fades and disappears, and the cell-wall becomes less and less dis- tinct." (Pi get.) Finally, the microscope can no longer detect the cell wall ; indeed, it is dissolved, or has undergone such changes as will permit it to be taken away by the absorbents. These mani- festations of nature arc not only interesting, but they indicate as well in many respects the course of treatment which has to be pursued by the surgeon in the different stages of the inflammatory process. Different tvai/s in ivhich pus may he found: The 1st. In the form of an abscess, in which case it is circum- scribed. The 2d. When it is diffused in the tissue, and without any defi- nite boundary. The 8d. When it is poured out upon a free surface, as the skin or mucous membrane. (Paget.) The peculiarity of each and the treatment will be taken up in duo time. While degeneration into pus is by far the most frequent in oc- 1 ■; t m 'i'- m « ^ i H ■,i i^M ;•! H :( 1 '- i '^m ' 'MM ' 9 i 1 i 9 1 1 u 1 64 PRINCIPLES OP SURGERY. currence, there are others which require our attention. Both the fibrinous and corpuscular elements may undergo several forms of degeneration. The first is where they wither, become dry, hard, horny, the cells " are collapsed, shrivelled, wrinkled, glistening,' and altogether irregular in size and form." (Paget.) The second form of degeneration is, where an essentially fatty change takes place. In the fibrinous portion will be seen gradually collecting minute drops of oil, and the corpuscles undergo a transi- tion into what is called granule-cells, or the inflammatory globules of Gluge. " This method of degeneration," says Paget, " appears peculiarly apt to occur in the inflammations of certain organs, as especially the lungs, the brain, and spinal cord ; but it may be found occasionally prevalent in the lymph of nearly all the other parts, and in the granulations forming the walls of abscesses or of fistulse." ^ The third form of degeneration is the calcareous. It is occa- sionally seen in the arteries and veins. The fourth is called pigmental degeneration ; sometimes observed in the product of peritonitis. Having considered the character of inflammatory l^mph, and the widely difi-erent changes which may mark its history until it ceases to act a part in the economy, I will proceed in the consideration of the products of inflammation. Blood as a Product of Inflammation.— TYn^ may be regarded rather as an accidental product than as a constant one, except, perhaps, in pneumonia, in which disease it is almost always pre- sent, and gives to the sputa the characteristic rust color. But at any time after the coats of the vessel have become paralyzed, they may be actually ruptured ho as to allow the blood to be extrava- sated. It must be distinctly understood that a red corpuscle can- not get without the vascular system, unless there is a distinct rup- ture of the coats. The transudation may be even highly colored, TKEATMENT OF INFLAMMATION. 65 but It IS due to the coloring matter of broken-down corpusclea which has transuded with the serum. Again, in the attempt to form new bloodvessels, the offshoot may burst and the blood escape mto the organizing fibrin. So it will be seen that in general inflammation it is but an accidental product. With regard to treatment, it requires no particular consideration. Changed Mucus as a Product of Inflammation.— Yihm inflam- mation arises in a mucous membrane, as already stated, the natu- ral secretion is at first exalted and then suppressed ; subsequently m returning, it is quite altered in character and quantity. In addition to the mucus is seen, under the microscope, epithelial par- tides, more or less degenerate, and " materials which closely resem- ble, if they are not identical, with the lymph-products of inflam- mation in other parts. I am, indeed, disposed to think that we should not draw too strong a contrast between the inflammatory products of mucous membranes and those of serous membranes and other parts, except in relation to the material with which in the several cases they are mixed." (Paget.) The foregoing are the immediate products of inflammation. Ihere are other surgical affections which are often designated pro- ducts also; these are ulceration, sloughing, and gangrene; but they, with other diseases, will be treated under the head of Dis- eases arising out of Inflammation. CHAPTER VIII. Treatment of Inflammation-In its First Steps-1. Nature as a Guide " Prevention of Further I .ress. 8. Sedatives. 4. Cold. 5. Heat. 6 Stimu- lants. 7. Astringents. There are two things which ought to be constantly borne in mind by the surgeon in the treatment of this disease; the first of which is, that in the inflammatory process itself, and at each step of the process, nature seems to be making efforts to cure, and that many of the phenomena of the disease are results of those efforts. To this subject I beg leave to direct especial attention. Writers 'Tl \ i : I !! ' J ! \ ^ M \m II 66 PRINOIPLES OP SURGERY. on surgery have been accustomed for so long time to speak of the phenomena of inflammation, and indeed of all surgical affections, as purely symptoms of disease, that it is next to impossible to dis- associate the indications therefrom, and to regard them instead as exhibitions of the admirable workings of nature to stay disease, to remove the cause thereof, and to eff"ect a cure. I have thus far, in considering the inflammatory process, taken occasion, from time to time, to point out these kind doings of nature. And unless the student starts with the perfect understanding that he can only assist nature, and that in all he does he should take counsel with her, and follow her superior guidance, he will not, I unhesitatingly aflSrm, be prepared to render that wise and judicious assistance which enlightened surgical science justly expects at his hands. The second point, and one of almost equal importance with the above, is to endeavor to have a distinct understanding as to the stage of the inflammatory process at the time he is called upon to treat the case. This is so obviously necessary that it may be deemed useless to refer to it ; yet I am sure it will be found that some writers and many practitioners treat inflammation without any reference to this consideration. Having diagnosed the disease as that of inflammation, they proceed to treat it according to pre- scribed rules, forgetting, in their routine practice, that the treat- ment suitable for one stage of the process is quite unsuitable for another ; that what may be a remedy one day may upon the next aggravate the disease. Now these two considerations, I think, stand foremost, and ought never be lost sight of. The next thing for the surgeon to consider is. How much can I do to prevent disease ? Indeed he may now and then be called in ' at a sufficiently early hour to be able to break the chain which leads from tlie exciting cause to the first stage — before physiologi- cal action has been superseded by pathological ; or, if the disease has already been established, he may yet succeed in averting the second or some succeeding step in the inflammatory process. Then he will ask himself the question, What are nature's cflTorts under the present circumstances, and how far can I assist her ? To a just appreciation of the case, and in order to arrive at cor- rect conclusions concerning the foregoing questions, a knowledge of the individual constitution will be indispensable, and should as far as possible be obtained. As well, and of equal importance it 1 I TREATMENT OP INFLAMMATION. 67 ■rive at cor- IS to ascertain what were the predisposing and determining causes of tne disease and the relative importance of each. In connection with this, the surgeon should duly weigh the circumstances of the patient and the evils connected therewith which he will have to combat and to what extent can be secured that rest of mind and of body which will so much conduce to a favorable termination. It will also be desirable to consider what are his surroundings, his posi ion will he have good nursing, comforts, necessaries, anct ;hat are his desires and his degree of contentment The primary cause of the disease will not always receive the first attention. When constitutional, it will always receive how- ever, an early attention; but when it is local, it may alreadl have parsed away. The great, the chief thing is to get at the cau^e of the cont^nuance of the inflammation, the principal acting cause of extension of the disease, and to attack it. y »« or Instead of taking one by one the various medicines which may advantageously be used in the treatment of inflammation, it will I think, be preferable to commence at the beginning of the " pro cess ; at least at that point where nature is yielding to overpower- ing influences. ^ & ^ puvyci Imagine, then an affected part, into which the Hood is rushin. w,th mcreasmg force. The small vessels are engorged to such af extent that over-distension has almost resulted. Theyhave " !t d to rece,ve the increased flow of blood, but the rush ha been o great, and a contraction has followed more or less spasmodic. Then h !o i V \ I "^ '''°"'" '™' *«'• '"•"'^ stagnation of Mood has a most resulted, and, should it ensue, inflammation wiH h really estabhshed. Now, under such circu^tances, what 1 ' Ltrat „° T "' °i ™""' '' P"'^'"^' *» -ci ing ause 1.0U d at once be removed. But the first class of remedied which IwJl no ,ee as suitable to this stage of the inflammatory prL " is SAU«> as a reneiy for inflammalion.-lS.,,, wdl fiTr hea ng proc s, is consummated. And sedatives may have the n^heCrof'm l; "'"""' -rve,, whereby an essential lL\ m the chain of morbific causes may be broken. It is by irritation V h! "Tr '"" *" ■"'""'°«'"»' ™"*«»" - initiated, ndt°" by thcr disturbance and from the pressure made upon them tliat I 'I I It m 11 i'j V, I i * 1 68 PRINCIPLES OF SURGERY. n\ ii 1 •I 1 < I t the pain is continued and the disease extended. Therefore, tu soothe them at any time is to remove the most important means of disease. By so doing we are only imitating the efforts made by nature to relieve irritation by fixing the parts involved so that they may be in a state of repose. There can, indeed, be but little doubt that the tendency to adhesion which characterizes inflamma- tion of the serous membranes is, by preventing motion of the irri- tated parts, calculated to secure rest. It is a fact most important to know that a full dose of opium will often arrest inflammatory action in the abdomen by securing rest to the viscera ; and thus will nature, when unassisted by art, attempt, by forming adhe- sions, to obtain the same thing. Anything which will alleviate irritated periphery, or pressed- upon nerves, will tend to eff"ect a cure. If the part be kept at rest much is gained. But there are agents which will, often against great obstacles, assist in securing the desired end. The first seda- tive to be mentioned is Cold. — It is generally applied to the part in the form of cold water, and it is a most valuable remedy, not alone because of its actual virtue, but, as well, because it is so easily obtained. Ex- treme cold is a powerful sedative, especially when applied with diligence. If applied to a part in health it will interfere with nutrition ; and, when applied to an inflamed region, it will lessen the morbid action therein. The object is to lower the temperature of the part not simply to that degree which is natural, but to a de- gree even below it. The coldness of the water and the evapora- tion act together in securing this reduction of temperature. To carry out this indication the water must be very cold, or there must be such an arrangement as will favor evaporation, and, if possible, both. The following method of applying cold I can, after not a little experience, strongly recommend. Take a piece of thin old cotton or muslin, folded only once, and, having dipped it in a vessel of cold water, apply it to the part. It will be neces- sary, according to my own experience, to give very explicit in- structions to the nurse about the cloth, as to thickness, &c., other- wise most likely there will be used a piece folded several times. And this, instead of being frequently dipped in the water, will be allowed to remain for a long time. The result will be a steam- ing cloth upon the inflamed part. Such an application may, it is n of cold ase of its ed. Ex- died with fere with ill lessen aperature t to a de- evapora- ure. To or there n, and, if d I can, e a piece ig dipped be neces- :plicit in- ;c., other- •al times, 'ater, will I a steam- mav, it is TREATMENT OF INFLAMMATION. 69 true, prove beneficial as a vapor bath, but not as a cold applica- tion. It is necessary to have the cloth thin to allow free evapo- ration. Just as soon as the cotton has dried or its temperature raised to that of the body, it ought at once to be reapplied. In those cases where the inflammation coexists with a wound, the dis- turbance of the cloth will irritate the wound ; consequently, in- stead of dipping the cloth in water apply the water with a sponge or another piece of cotton, allowing it to drip upon the part. In this case, however, the attention will have to be more diligent. The vessel of water must frequently be renewed, or the water have ice in it. A part may be kept wet and cold by irrigation, but this cannot be done without some diflBculty ; moreover, the continued dripping is likely to be attended with discomfort from the water running into the bed or into the clothes of the patient. Another objection to irrigation is, that unless used with constant caution, there is great danger of reducing the temperature too much, so as to de- stroy vitality of the tissue. There are other methods sometimes recommended, but as I, in the main, refer only to such as my own experience has proved worthy of recommendation, I may be par- doned for omitting them. There is, however, one other method which I wish to dwell upon for a brief time. In the winter of 1863-4 I had the opportunity, when on a visit to the United States Military Hospitals in and about Washington, of witnessing what was to me quite a new mode of applying cold, never having seen it nor heard of it before. It consisted in the application of ice to inflamed parts arising from gunshot wounds of every kind, a piece of cloth folded two or three times inter- vening. I was assured that inflammation (and these wounds are generally followed by a good deal of inflammation) was, when taken in time, to a great extent prevented, and when it had arisen was often quickly and eff"ectually subdued. Subsequently, during the following summer, when, for a time, holding an appointment in the United States Medical Service, and doing duty in the Lincoln Hospital, Washington, I availed myself of the chance of testing what I had felt sure was a most excellent practice. In the vast majority of cases which came under treatment in that Hospital, and indeed in all the hospitals of Washington, some time had elapsed from the time of receiving the wound until the entrance If «.ii r ai u :^^^ r 70 PRINCIPLES OF SURGERY. i into the hospital. Much inflammation had arisen, yet in every case, whether the wound was in a limb, or in the chest, or the abdomen, or the head, the application of ice in the manner above stated had a most decisive effect. But I had the most favorable opportunity of trying its effects upon a large number who had been recently wounded, who indeed were transported to Lincoln Hospital within twenty hours of the time of being wounaed, and who had received no previous treatment whatever. They belonged to the cavalry force, and had been wounded in the afternoon while engaged with a similar force of the enemy at Beverly Ford, and they reached the hospital about four o'clock the following morning. I happened to be the officer of the day, and many of them were placed under my own immediate care. Among a comparatively large number under my own care, and as well as of other surgeons, all of which I carefully watched, there were wounds in every part of the body. In every case where the ice treatment was pursued the result was the most happy, and, in some cases, beyond our most sanguine ex- pectations. The principles upon which this treatment is based are most reasonable. By means of the ice the temperature is constantly maintained at the same degree. It can be regulated by changing the degree of thickness of the intervening cloth, rather than by the size of the piece of ice. Another advantage is, that the patient requires a less constant attention; and if depending upon a negligent nurse he is less likely to suffer therefrom, inasmuch as a piece of ice will last a much longer time than a wetting with cold water. There is but one objection, which is, that the meltintj ice will in time make the patient uncomfortable. But this can be easily remedied by putting the ice in a bladder, or a bag made of oiled silk or gutta perclia. Heat is also a sedative, and in the form of hot fomentations is very useful. It lil'ewise acts upon the irritated nerves. The soothing effect of tl e heat is increased by the moisture. One is directly sedative, the other indirectly so. The heat immediately affects the nerves ; the moisture, by relaxing the distended tissue, lessens the pressure upon the disturbed nerves, and thus begets relief. Thus wo see that both heat and cold, used in the form of water, are useful remedies in inflammation ; and, indeed, cither might prove beneficial in the same case, poihajis almost equally 4 TREATMENT OF INFLAMMATION. 71 so. However, some tissues and organs seem to be more speedily and surely affected by the one than by the other. For instance, in surgical affections of the head, cold is by far the most service- able; while in like affections of the abdomen, hot fomentations will be found to act the most promptly ; but I must not omit to men- tion, with regard to the latter statement, that some German writers assert that, although the cold when applied to the abdomen is less • pleasant, yet its effects are all that can be desired. From obser- vation and from personal practice, I feel bold to say that hot fomentations should always be used in inflammations of the ab- domen. As a general thing, the feelings of the patient may be consulted and followed as a guide. In the eye particularly, it is found nat an inflamed conjunctiva will, in some instances, be relieved by a cold wash, while in others the irritation is thereby increased, yet it will be benefited by a warm collyrium. There are various sedative drugs which may be employed as local applications or administered internally, such as opium, — a most valuable one, — aconite, belladonna, colchicum, &c. Two or more sedatives may be used conjointly, as opium with warm fo- mentations, in the form of poppy-head fomentations. Stimulants. — Strangely enough, while sedatives are so very use- ful in breaking the chain of morbid events in inflammation, at almost every step of their progress, stimulants are also, at least in one stage of the disease, of like service. When it is remem- bered that in acute inflammation there is too much action too much irritation — it would seem that stimulants must certainly bo contra-indicated; yet experience has proved their efficiency, while theory will be found to fully support the practice. I will adduce a few common instances, in which stimulants have in practice been found decidedly beneficial. A common cold, inflammation of the Schneiderian membrane, is often relieved by the use of snuff, which stinnilatcs the tissue, although already over-congested. Again, if the "cohl" affects the mucous membrane of the bronchi, it may be, sometime promptly relieved by a hot, stimulating drink at bedtime. Con- gcstion of the liver is frequently cured by a calomel pill, which stimulates that organ. Conjunctivitis is often cured by a stimu- lating collyrium, and an inflamed throat by a capsicum irarglo. \i% ■I' i' K Hffi B HIlii 1 /ill !■' ; ■) \ 1 i ( , 0' ♦ '>( " { 72 PRINCIPLES OP SURGERY. [!1 These are instances of a similar nature. This is the successful practice. Now, how may it be explained theoretically? Fortunately, very easily. According to Paget, when a frog's foot or a bat's wing is placed under the microscope, is irritated until the pheno- mena of inflammation begin to present themselves, and paralysis of vessels is almost accomplished, a renewed effort to contract may be provoked by increasing or varying the irritant, as if de- parting life were brought back by the increased irritation. This renewed or increased contraction of the coats causes the blood, which was moving so sluggishly, to pass on with a perceptible increase of velocity, whereby the stagnation is delayed, perhaps averted. And no doubt the same events would be seen to trans- pire, could the tissue in the human body be similarly inspected under like circumstances. The stagnation of the blood marks the establishment of disease, and anything which .will delay it, cannot but be regarded as a remedial measure. Thus we find that prac- tice is supported by theory. But while stimulants do undoubtedly prove very often remedial in their effects, the use of them must be considered hazardous unless administered with great caution. Bearing in mind the pathology of inflammation, and the viodu8 operandi of stimulants, it will easily be understood that, if they fail to do good, they necessarily aggravate disease. I would not, therefore, be under- stood to recommend the indiscriminate use of stimulants as a local application in the treatment of inflammation, nor would 1 have them placed alongside 'of sedatives or astringents, which I have next to notice. Astringents. — The effects of an astringent medicine upon the mucous niombrane of the mouth, for instance, is well understood. There is a sensation of puckering— of drawing together of the tissue. Wlicn applied to the skin the effect is the same, although not so approciable. At all times, this drawing together of the tissues will necensarily tend to press out of the interstices the fluid therein contained. In inflammation, when the coats of the vessel are beginning to succumb to the pressing blood, an astringent, by virtue of external pressure which it gives to the tired-out coats, will assist to force onward the sluggish stream of blood. At tiio samo time, any fluid which may have transuded into the tissue, li TREATMENT OF INFLAMMATION. 78 will stand a chance of being pressed out of the part by being brought into contact with acting absorbents. In this way, by the calibre of the vessels being diminished, and the blood forced away from the part, the equilibrium will often be restored. No effusion had taken place which cannot be absorbed, and the disease, which may have been most threatening in its appearance, is averted, or cured, simply by the application of an agent which made gentle pressure by its physical eifects upon the tissue. Foremost among the astringents suitable for the treatment of inflammation, as well as among the sedatives, is cold water. Its virtue as a styptic will be pointed out in connection with the treat- ment of hemorrhage. Possibly the astringent action follows the sedative ; but whether this be so or not, its properties as an as- tringent are satisfactorily established. Plumbi acetas is a most valuable medicine of this kind. The powder dissolved in water, in the form of Goulard's Extract, is the way in which I generally use it, and in good strength. To it may be added some preparation of opium. Having used this almost exclusively as a local application in inflammation for many years, I feel that I may speak ex cathedra, and say, that when diligently used it will never disappoint the surgeon, and that I know of nothing that can take its place. I am aware that it is no new remedy; but in this day of change and of forsaking of old reme- dies to try new ones, there is a possibility of neglecting a useful thing for the novelty of the untried. It seems to be somewhat sedative as well as astringent. Thus far, in speaking of remedies, reference has been made to that stage of the inflammatory process where the disease is not fully established. But it must be understood that, after the dis- ease is in all respects established, the same remedial agents will continue to prove useful ; for, although the district in Aviiich the disease has arisen may have passed into a state of " true inflam- mation," there will be in the parts surrounding it the same condi- tion as had previously cxis**^'! ;« tho former part. I proceed next to speak of cvncuants. it ^1 "I >4I S m m m I \p ^ tj."!l •;".'■' ^^^^K^^ f ' Ih i;l 74 PRINCIPLES OF SURGERY. CHAPTER IX. Treatment continued — Evacuants, including Derivatives, Emetics, Purgatives, Diuretics, Diaphoretics— General Bleeding — Direct Evacuation of Blood — Cupping — Leeching — Puncturing— Counter-irritants— Kubefacients— Pres- sure. These, for consideration, will be divided into local and general, or those which draw off fluid from the part directly, and those which accomplish the same end by acting upon the general sys- tem. The latter I will speak of in the first place. Those which act through the system are emetics, pwgatwes, diuretics, diaphoretics, and bleeding. With respect to emetic i, some doubt may reasonably be enter- tained as to their being beneficial in inflammation. When food has been taken into the stomach and will not be digested, or, if so, will be very imperfectly done, and which will consequently enter the system as a crude irritant material, and not as a nutri- ment, then the administration of an emetic, to cause the stomach to eject it, will | rove highly beneficial; but when such is not the case (and it must be admitted that such instances are very rare, for the patient does not become so suddenly ill, — is not likely to have been eating in large quantities so recently), then an emetic is more likely to prove injurious than beneficial. The fruitless retching and straining is painful and exhausting, and will be fol- lowed by great reaction, which will in turn affect all parts of the body. If the depression were maintained, benefit would result ; but emosis followed by reaction is only evil, with the exception before stated. When there is nausea it may as a general thing be looked upon as intelligent information that there is in the stomach, ingesta which the system refuses, and consequently an emetic may be given. While the use of emetics may be questioned, the employment of pvrgatit'ps is always useful in the treatment of inflammation, unless the action of the bowels will, because of contiguity, increase the irritation ; the disease existing in the abdominal region. In most TREATMENT OP INFLAMMATION. 76 cases they afford the most important benefit, and cannot be over- looked. The bowels are mostly always constipated (vide, general symptoms). The dry state of the mucous membrane of the intes- tinal canal, the arrest of secretion by the liver and other glands, causes a retention of the faeces, which becoming dry and hard, prove a source of irritation to the constitution. The prompt and complete removal of this substance will prove salutary, inasmuch as the total amount of constitutional irritation will thereby be les- sened. But particularly the purgative will arouse to action the glands of the intestinal track, by which copious evacuations may be secured of watery material, in which will be found a certain quan- tity of albumen, by the means of which the richness of the blood will be lessened. The derivative effect obtained in this way is very considerable. The total surface of mucous membrane from which secretion flows is said to be about 1400 square inches (Meckel) ; and if excretion continue therefrom for any length of time the blood will be materially affected. In addition there is the counter-irritation and counter-congestion, by which nature is diverted, to a very great extent, from the seat of inflammation. Practice will show that very decided and im- portant relief can be obtained by the judicious exhibition of purga- tives in acute inflammation, with the exception above referred to, when the inflammation is located in the abdomen. Diuretics.— y^ hen inflammatory fever exists, the kidneys are unable to perform their function ; the increased tone of the vas- cular coats affects these organs in common with other parts. The urine is therefore scanty and highly colored. In the water which does transude through the tubules there is a large quantity of urea. Now, if the kidneys be not themHclvcs affected, it is at least desirable to bring about a more healthy action of these excreting organs, so that all the urea will be eliminated ; and often the sys- tem or blood may bo relieved of a certain quantity of fluid. More- over the increased action of the kidneys is a counter-irritation. As it is not my object to dwell upon individual medicines, unless such as I have fully tested, I will be pardoned if I only allude to one. All the preparations of potassa are valuable; but I have found, as is often the case, the most common to be the most use- ful ; that is, the nitrate. I do not know that my treatment in this . 1 F, ■»■ |i H 'Jii f 76 PRINCIPLES OP SURGERY. respect is very extraordinary, unless in these respects, that I trust to potash alone, and give it in large doses and every hour, as long as there is fever. The object in view is to start the kidneys ; but I think that more than this is to be accomplished. As is well known, the blood itself is beneficially affected ; of this, however, I shall speak hereafter. I have noticed, in addition, that the action of the heart is very soon diminished ; that increase of tone in the whole vascular system seems to be lessened ; in a word, there is, in a comparatively short time, a great abatement of the fever. So well has this drug answered my expectation, that I now always give it when there is heat of skin with an increased pulse. Diaphoretics are also a very important class of medicines in the treatment of inflammation. The skin is dry and hot; the pores- are closed ; excretion of effete matter, which normally takes place from the skin, has entirely cet',0'1. To relieve this unnatural con- dition, induced by the inflammatory action, and itself an additional cause of inflammatory action, diaphoresis should, as speedily as possible, be produced ; so that the material ordinarily eliminated by the skin shall no longer be retained in the system, and so that the integumentary vessels shall be relieved. Nitrate of potash, of which I have ventured to speak so highly, will serve a good pur- pose as a diaphoretic. I have, in cases of inflammation of im- portant internal organs, found the veratrum viride to act both upon the heart and skin. Regarding this medicine, I shall have something to say hereafter in connection with a case of gunshot wound. Bleeding is the next agent to which I desire to direct attention. Concerning this mode of evacuation, or depletion, a very great difference of opinion may be said to exist, and to have existed for some time past. In the blood are the elements of nutrition ; it is the tissues' food. For the welfare of the tissues it is necessary that blood should exist in a state of nature. No more normal, true blood, is produced than nature rc(i[uires. In the system is no laboratory in which a larger quantity than usual of blood can be expeditiously manufactured on demand. On the contrary, it seerae to grow, to be gradually develop«'(l. And more than thiti, con- tinued development of blood deprr 1/>, not simply upon the iu, de- duction of aliment, but especially upon the blood already in » x istence. Speaking somewhat roughly, the young blood is Hn: offspring of the old. If the old bo destroyed, removed from the Nil. TREATMENT OF INFLAMMATION. 7T body, of course it can no more beget offspring. Therefore, after abstraction of a quantity of blood, tliat which remains will be want- ing in strength and vitality, and the tissues depending upon it will become sufferers. More than this, after inflammation, repair will have to be made in the part which had been affected ; so that, in addition to ordinary repair, blood will be wanted for this extraor- dinary repair. Now, whatever may be the elements of the blood required for each of these processes, it matters not regarding this question. When blood is taken from the system, in the main all the elements of the fluid are common sufferers. Therefore I un- hesitatingly assert that, as a general rule, other modes of treat- ment ought to be sought. But many, I doubt not, are ready to say, " Granted, that abstraction of blood is followed by evils, where is your substitute ; for the testimony of hundreds speak in its favor?" Let us examine the matter. Bleeding has been practised for, or may be resorted to for one of two purposes, either to draw off blood from an inflamed region, or to cause sedation ; that is, to take blood until syncope is produced. Well, if the object be to draw off blood from an affected tissue or organ, the rational question presents itself, cannot this be done with equal efficacy without taking the precious fluid altogether from the system ? In reply to this I would say, not only that it can be accomplished as well in another way, but even better. Local abstraction of blood, while it directly relieves the part, does not to a material extent affect the whole volume of blood, — does not diminish its vitality; and therefore will not retard the curative efforts of nature, nor subsequently affect the well-being of the patient. "But bleeding," say some, "is often necessary to produce speedy sedation." At times, undoubtedly, when an important in- ternal organ is involved, the integrity of that organ, perhaps life itself, may depend upon a quick reduction of the heart's action. And when such is the case, when the surgeon or physician has been called in at the eleventh hour, and no medicine can be found to do the pressing duty, then by all means open the vein of the arm, and alloAV the blood to flow until syncope ensues. In inflam- mation of the brain, lungs, liver, &c., such urgent cases may occa- sionally be met. Hero the surgeon has to exercise a choice. Of two evils he will choose the least. Doubtful whether he can com- mand medicines to control the heart's action as speedily as is ne- I ri M 't I 'it, ti ii 1 . 1^1 ii 78 PRINCIPLES OF SURGERY. cessary, he escapes the immediate danger by incurring the risk of one that -will follow. When bleeding is practised in these urgent cases the relief experienced is generally well marked. There is not only sedation, but the organ is relieved, the quantity of blood within it is promptly lessened ; but, unfortunately, this does not continue. The depression will naturally be followed by a reaction ; the heart, momentarily reduced in action, will very soon rise to its former inordinate activity or perhaps to a greater. The volume of blood within the vascular system was for a brief time reduced ; but it was soon restored, not by true blood ; but to supply the place of the vital fluid which has been removed there will be taken up from the tissues such juices as come in contact with the absorbents. (Hence the sensation of thirst after bleeding.) And the conse- quence is that into the part inflamed again rushes the blood ; but now it is more watery ; and truly the last state of that part is worse than the first. From this consideration we may learn that, in order to maintain the reduction of the heart's action, a second bleeding may become necessary ; and such is the practice still adopted by some. For this procedure there can be no proper argument advanced and no excuse given, unless indeed it be in the backwoods, where medicines are not to be had, or when unex- pectedly the surgeon finds himself destitute of such medicines as are required. As a general thing, and I say it with due conside- ration, although a first bleeding may be imperatively demanded, a second one can never become necessary if only proper medicines are administered to produce sedation. There is one other thing to be mentioned in this connection, namely, that when the lancet is used the patient ought to be in the upright position, so that the desired eff"ect may be produced with the least possible loss of blood. Local Bleeding. — I have said that local bleeding will, in most cases, more eff'ectually draw off blood from a part than will general bleeding. The blood may be actually abstracted from the body, or it may be drawn to a neighboring part, where, being retained for a time, the affected tissue is enabled to recover its tone before stagn9,tion of blood takes place; or, if "true inflammation" exist, to take on a physiological action. The advantage of this latter is manifest. One of the objects even of general bleeding is obtained, drawing away the blood ; yet that fluid remains in the system, and TREATMENT OF INFLAMMATION. 79 although it was imprisoned for a while, it, as soon as released, starts again on its course of circulation. This treatment is often practised in the form of dry cupping. By their application a quan- tity of blood may be collected in a part for a certain length of time. We have here not simply a plausible hypothesis, but sound prin- ciples of practice. I speak from considerable experience, derived from hospital practice when house surgeon, and also from private practice ; and I must say that I have often, in treating congestion and actual inflammation of the lungs, instead of using the lancet, a la mode, covered the chest with cupping glasses, and have been surprised at the great and prompt relief that was thereby secured. Dry cupping is equally salutary oftentimes when applied to the back in spinal complaints ; and to the neck in inflammation of the brain, &c. But I have referred especially to the case of the lungs, because in this, I think, more than in any otherj general bleeding is occasionally really demanded. The practice of drawing blood to a part, and retaining it there for a time to relieve inflammation, is not new, nor is it confined to any country. Some years ago an ingenious Frenchman invented a glass vessel in which to place the leg, and then, by exhausting the air in it, caused blood to occupy ♦:he leg to an inordinate extent. This was done to evacuate blood from an engorged lung. Now I wish to repeat that ray humble opinion, based on the varied experience which I have had the opportunity to acquire in American and English, as well as in Canadian practice, is, that bleeding is rarely necessary, — that, for the purpose of evacuating an inflamed part of blood, cupping, very often dry, and if not wet, will be fully adequate to meet the requirements, — will, indeed, in that respect, accomplish as much as would general bleeding ; and that, for the object of producing sedation, we have available other means, not objectionable, yet quite as certain, and almost as speedy. ( Vide, remarks on veratrum viride, &c.) The terms wet cupping and dry cupping have been used ; these scarcely need explanation, more than has been given. In ivet cupping the scarificator is used, by which several incisions are simultaneously made through the integument ; and then the cup of glass, having been exhausted of air, is applied to the part; whereupon the blood is forced by atmospheric pressure into it, from the numerous small vessels that have been divided. Drv ■4 • tl i '1 1" 80 PRINCIPLES OF SURGERY. 'l!i m J cupping consists in using the cups alone, by which the blood is drawn to the skin and subcutaneous tissue, there to be retained for a time. Direct evacuation of blood from a part may be _ performed by three methods, — by cupping, ur by leeching, or by punctures. Cups or leeches must never be applied directly to the inflamed tissue, as it would be an additional source of irritation ; and the bite of the leech is particularly so, because of its poisonous na- ture ; the )-esult of which would be that, althouo'h the congested part might momentarily be relieved, yet the blood would thereafter be more freely drawn to the part. The blood, therefore, must be abstracted from tissue in the immediate neighborhood of that in- flamed. The current of blood pouring to the part will then be turned aside, and a diversion created which will have the effect of relieving the vessels which had wellnigh become paralyzed. The practising surgeon ought to be well acquainted with the details of practice. In cupping he should see that no unnecessary pain is inflicted, — and careless cupping may cause a good deal that ought to be avoided, — that the clothes are not soiled by blood, and at the same time that it is done in the most expeditious man- ner. In country practice it will often happen that this operation requires to be performed when the cupping glasses and scai'ificator are not at hand. But, with regard to the glasses, a ready and serviceable substitute will be found in the wineglass or tumbler ; then a few drops of alcohol dropped into it and ignited by a little slip of paper, will exhaust the air. And in the absence of the scarificator, should the patient stand in urgent need of wet cup- ping, the part, after having had the cup applied to it, may be punc- tured quickly in a few places, as a substitute for scarifying. Cur ping cannot be too highly recommended, especially m cases wh' re an internal organ is congested or inflamed. Leeches. — In cases where the surface is so uneven that a cup cannot be used, leeches will, if obtainable, take its place. Again, sometimes the part is so painful or sensitive that cupping cannot be tolerated by the patient ; in which case also leeches must be substituted. There are also many parts of the body to which cups could not be applied where leeches will be found to answer instead. The fact that the leech-bite is somewhat poisonous is to be remem- bered. Sometimes, if applied to the afi'ected part, it increases the II TREATMENT OP INFLAMMATION. 81 inflammation very much; and often, when applied to tissue that is lax, as about the eyelid, it will give rise to a good deal of serous infiltration. Puncturing.— Incisions made in the tissue inflamed will often give very great and prompt relief to the patient, prevent extension of the disease, and perhaps destruction of the tissue. These cuts should be short and quickly made. The patient will be likely to object to this practice because of the pain ; and, if the part is com- monly exposed, for fear of a scar resulting. When the incision is first made, as the tissue is more or less distended, swollen, there will be gaping, perhaps, to a considerable extent ; but generally, after the swelling subsides, in consequence of the escape of blood,' the cuts do not appear so large ; while, should no incision be made until pus form, the risk of a resulting scar will be far greater. The bleeding can be promoted by fomenting the part; at the same time the part is thereby soothed. There are other methods by which blood may be drawn from a part, or rather turned into another place, as by counter-irritants. In not a few cases of inflammation a mustard poultice will give to the patient, seriously ill, with symptoms of no little disease, the most prompt and efficient relief. This I have seen more especially follow its use when an internal organ was involved. It is not a little strange that a remedy so efficacious should, even among in- telligent practitioners, be so rarely used. I have seen it used in many hundred cases as a counter-irritant, and always with benefit, never with harmful efi*ects. The modus operandi is very simple! The mustard acts as an irritant to the skin, and engages the nerves, by which a diversion is created. I cannot find a more convenient and expressive term. The irritation is followed by a flow of blood to the part where the mustard bas been applied. Mustard and other like substances are partic arly useful in the first stage of the inflammatory process; but they are also beneficial at almost every subsequent period. The length of time necessary to produce the required irritation and congestion will depend upon the age, the sex, the sensitiveness of the part, as well as the strength of the mustard. From ten to thirty or forty minutes will, as a gene- ral thing, be sufficiently long. The directions I am in the habit of giving are to apply it immediately to the skin, and leave it there until the part is well reddened. i s I * i mi ■4 ;-iJ I- ■ 'av'.! 4 82 PRINCIPLES OF SURGERY. Mustard ia a rubefacient ; and when it cannot be had, although that is not often the case, other means may be adopted to make the skin red. Brisk rubbing will do it ; and I have seen promi- nent symptoms of congestion of the lungs dissipated by this pro- cess. Fomentations of very warm water, reaction after cold ap- plications, or a hot linseed poultice, will redden the skin, perhaps at the same time affording relief by soothing the nerves and relax- ing the tissue. Pressure made against the part, so as to force away the fluid, and prevent its entrance, and thereby to sustain the distended ves- sels, is another excellent remedial measure. The importance of such pressure has been explained in connection with astringents. Pressure is, indeed, another similar mode of using mechanical force. It is commonly effected by a bandage. But, as the pressure re- quires to be uniform, it is obvious that the bandage should be accu- rately adjusted ; otherwise it will not only fail to do good, but will be the source of very great evil. In case the bandage is not made to fit perfectly the varying form of the limb, the pressure will be greater in some places than in others, and the parts not duly pressed upon will become the seat of inflammation, at least of swell- ing. Should, for instance, a bandage be applied more tightly at the ankle than around the foot, the return of venous blood will be arrested in the superficial veins, so that it will naturally collect in the foot, and aggravate or even cause inflammatory action. As the art of bandaging can only be acquired by considerable prac- tice, I would recommend students to gain some knowledge of it by practising on one another. I will risk being thought too lengthy on this subject, that there may be no failure to bring before the reader the important bearings of this remedial measure. This is done because many instances have come under my notice where the obvious, and, one would think, simple principles of this treatment were grossly violated (and that by surgeons of experi- ence and deserved reputation), and to such an extent as to jeopar- dize a limb. I have, in not a few cases, when called upon to give advice, in consultation upon inflammatory affections of some one of the several limbs of the body, proposed the use of judicious bandaging, which proposition met with the declaration that a bandage had been tried, but could not be tolerated ; but, on making inquiries, have ascertained that the bandage had not been properly TREATMENT OF INFLAMMATION. 83 adjusted. That such had been the ease was substantiated by the fact, that subsequent bandaging was attended with the greatest benefit. Many surgeons, having seen the evils of uneven, imper- feet bandaging, cease to use it altogether. To this subject refer- ence will be made in connection with the treatment of fractures. It will suffice here to add, that the bandage should always be made a degree tighter at the extremity of the limb, where it should always be commenced ; and, as the hand carries the bandage up the limb, the roller will be less firmly applied. But pressure may be effected by other means than bandaging. Astringents are useful as such : the tincture of iron I have found particularly so in those cases where the congestion i, somewhat asthenic ; but not sufficiently so to demand the use of iodine. Now there are parts of the body to which a bandage to make pressure cannot be used ; as an inflamed breast. In such cases I can recom- mend, as an efficient agent, the collodion. By means of it uni- form and active pressure may be exertedupon as much of the part as is requisite. For a knowledge of the value of this agent in the treatment of acute inflammation of the mamma, I am indebted to Dr. Cook, of Canada West. Upon this subject Dr. Cook fur- nished an interesting and instructive paper, to be read before the Medico-Physical Society of Victoria College,-2.a society which, I would say, "in memoriam," that, although short-lived, conferred a lasting benefit upon every member who attended its meetings. In his paper were detailed several cases in which inflammation of the mammae had by him been successfully treated by collodion. Dr. Cook would not undertake to explain its modus operandi. After reading the luminous lectures of Hilton upon the subject of "rest," the necessity of such, I found no difficulty in attribu- ting the usefulness of collodion in part to the pressure which it makes upon the tissue after the ether has evaporated ; and, in part, to the rest which is thus secured to the part, the coat of col- lodion effectually preventing any motion in the inflamed structure. Thus far, in considering the treatment of inflammation, I have spoken more especially of local treatment; although much has been said relating to constitutional remedies ; particularly in speak- ing of evacuants, we have seen that purgatives, diaphoretics, and diuretics, by opening the pores of the mucous membrane of the ^: 1 it i I I ,+ ■ 84 PRINCIPLES OF SURGERY. intestinal canal, the skin, and by causing secretion in the kidneys, give relief to the inflamed part, reduce the heat of the body, and thereby obtain relief for the constitution generally. ;i * Ih i CHAPTER X. Constitutional Treatment— Special Medicines— Antimony— Mercury— Opiates — Veratrum Viride — Aconite — Nitrate of Silver — Potash. In treating the constitution specially, our attention may have to be, in the ^rst place, given to some peculiar constitutional fault, which had been a predisposing cause of the disease. It may be necessary to take steps to effect the removal of this evil at once, at least to place it in subjection, until the local disease is conquered. Subsequently, or perhaps at first, the treatment will be directed to the efi'ects of the local disease upon the constitu- tion — that is, the inflammatory fever, with all its concomitants. In many cases, however, the course pursued by the surgeon will have to be rt /ersed : the inflammatory fever will need to be sub- dued, and thereafter any previously existing evil attended to. It would be beyond the province of this work to even refer to the treatment of the various evils which constitute the predisposing causes of inflammation. Some of them, however, will be con- sidered in connection with special forms of inflammation. Of the treatment of inflammatory fever we have already learned 80 much that, in giving it a special consideration, not a great deal has to be said. I may here repeat that at first an active purgative should be administered, to start into action the sluggish or dor- mant intestinal canal ; after which, diaphoretics and diuretics, alone or combined with sedatives, will be given. And in the mean time, mental and pliysical rest should be observed. Individually Important Druys. — So far, classes of remedies have mainly been referred to ; but there are certain ih ..vidual medi- cines, in some respects specifics, which, because of their frequent use and deserved standing, demand especial notice. The ^rst of these, whicu I now proceed to notice, is CONSTITUTIONAL TREATMENT. 85 Antimony. — It is a medicine of great value, and as such has been regarded for many years. As an antiphlogistic it is adminis- tered to produce, in the first place, seciation. When given in cer- tain doses it causes nausea, the effects of which are reduction of the heart's action, and a sensible relief to the whole vascular sys- tem, the tone of which had been so much increased. Vomiting as a general thing, it will be remembered, is to be avoided ; the object is to produce that extreme nausea which precedes vomitin<». To do this, and avoid the vomiting, the drug must be given in small and frequently repeated doses. The quantity will have to be very gradually increased, as the system acquires a tolerance, else the effect will not be maintained. Antimony not only acts as a seda- tive but also as a diaphoretic, a diuretic, and, in some instances, upon the bowels, causing purgation. •Mercury is the next medicine deserving of special notice. It is a drug not so generally in use at the present time as it was formerly. It has been very extensively used, and very muc' abused. Like a great many other really useful medicines it be- came a "cure-dl," and was ruthlessly given when not required, and exhibited in larger doses than was necessary. Unfortunately it is not a harmless medicine ; and its injudicious, its empiric use, has probably done more harm than is counterbalanced by the good it has ever effected. It is, therefore, a cause of thankfulness that its popularity has so much decreased. The conviction that it led so often to evil effects, caused the Surgeon-General of the United States Army to i nsue an order, that thereafter no medical officer should employ it. There are two views now held, I believe, as to the manner in which mercury acts upon the system as a remedy for inflamma- tion, one of which is, that it stimulates the absorbents into a more healthy action. " Stimulating the absorbents" is a common and a convenient expression ; but what docs it signify ? The ab- sorbents cannot reach for material to tnke up, — cannot draw to themselves a fluid which is not in contact with them. The mate- rial must bo brought in immediate contact with the coats of the absorbent veaaela by some other process. (Williams.) Again, if fluid be in contact with them, and if the disease do not incapaci- tate them, they will readily dischnrgo their duty. But while there is inflammatory action, we have seen that tranhudation through the U'l « -,ii It M 'I 86 PRINCIPLES OF SUEGERY. '3! S 'I!' ' 15 ) uu f : ': s i 'i 11 K s' 'i coats of vessels is, to a great extent, arrested ; there is too much tone. Now, if mercury acts as a stimulant, this tone would be further increased. The inference is, that if mercury stimulates the absorbents, its use is contra-indicated, so long as there is active inflammation, at least; and it remains to be shown that the ab- sorbent vessels require any stimulation after inflammation has subsided, — that is, in acute, healthy inflammation. When the disease is more chronic, and a want of tone is manifested in the absorbents, then a stimulant is undoubtedly indicated. I would not, then, recommend mercury as a stimulant to the absorbents, because those vessels are too much irritated already. And in the treatment of eff'usion, due to a more chronic action, I think other remedies can be found to do equally well, and which are incapable of producing that mischief which mercury may lead to. But I venture to state my belief that mercury never does act as a stimulant to the absorbents. In those cases where its adminis- tration is followed by increased absorption, is it not due to the effects which the drug has had upon the fibrin of the blood, or the inflammatory lymph. And this is the second view of the two, above stated. It is conceded, by all observers, that mercury will retain the fibrin in solution — that it prevents coagulation ; and often, after coagulation has taken place, it will liquefy it again. Now, when it is remembered that such a state of fluidity is conducive to speedy recovery after the inflammation has subsided, it will be admitted that mercury, to act thus upon the fibrin, is a valuable medicine. But it must not be forgotten that it may injuriously affect the constitution, and that for life. Such being the case, it is well to inquire if some substitute cannot be provided, — a substitute which, while it will accorapliHh as much, i. c, will bave the same effect upon the fibrin, cannot, under any circumstances, lead to the aame disastrous results constitutionally. It is now well known that certain salts, as the preparations of potash, will keep the fibrin in a liquid state quite a8 well ns mercury. I will only add that I have tested the virtue of potassa, and can recommend it. Opidtca. — Opium and similar medicines are most valuable reme- dies in the treatment of inflammation. They may bo applied directly to the affected part, either alone or in conjunction with some other medicine, as an astringent; or they may bo adminis- CONSTITUTIONAL TREATMENT. 87 i tered internally. Opium is particularly useful in inflammation of the abdominal region, as before remarked. This can readily be understood. It is the function of the intestinal canal to so move, as to pass the contents along ; there is almost incessant vermicular action ; and in its various convolutions it comes in contact with every part of the abdominal parietes and the several viscera. The intestines are suspended in and confined by a membrane pecu- liarly susceptible and sympathetic. In all cases of inflammation, rest is the first and important desideratum, in order to establish a sure hope of cure. Now, opium, when given, acts directly upon the intestinal canal and the glands, and soothes the muscular fibres to rest ; it arrests those secretions which will stimulate the intes- tines to action. The use of opium is rarely contra-indicated, unless there be severe head symptoms ; and, in all forms of inflammation, it will be found to have a happy eff'ect upon the constitution gene- rally. The dose will, of course, vary according to the intensity of the pain and the age of the patient. In abdominal inflammation a full dose should be given. Where there is apprehension tliat the system will not bear it, because of some idiosyncrasy, small doses, often repeated, must be the practice. Vemtnun ViriJc is a medicine which docs not enjoy the long- established reputation which belongs to antimony, but it success- fully rivals that drug as a powerful antiphlogistic. It is a potent agent ; yet in the hands of the cautious surgeon it can»«be safely exhibited, and, according to my own experience, with the most satisfactory result. Its action upon the heart is promptly and powerfully sedative. It also acts as a diaphoretic, causing, in a very short time, the skin to become cool and moist. I have found it particularly useful in inflammation of the lungs. Two cases of such, which were also most interesting in a surgical point of view, I will particularly refer to. These were cases under my imme- diate caro in Lincoln Hospital at Washington. Both camo in at the same time direct from the battle-field. The first one which engaged my attention was unable to lie down, but had to sit leaning forward considerably. Uis efl"orts to l)reatho were most urgent, lie could barely tell me that ho was wounded in tlie che8t---thnt the ball had passed through his body. I liastily looked at the wound in front, which was the place of entrance ; it was between the fifth and si.xth ribs, on the right side of, and very near *<•> th I'l H; I k^ 88 PRINCIPLES OP SURaBRY. I ^" m sternum. I not only considered his case hopeless, but thought he could not live an hour. I ordered him a draught of compound spirits of ether, which was shortly repeated. In half an hour he went to sleep, his head resting forward on a chair, made somewhat comfortable for the head. He slept for two hours or more. During the sleep and on waking he could breathe a little more easily. I examined the wound posteriorly, and found that the ball had passed almost directly backwards and had made its escape. It was now some thirty hours since the reception of the wound. The action of the heart was labored and there was some fever ; the skin was hot and dry. I put him on veratrum viride ; to be given often, in small, drop doses. I had every reason to believe, from the symptoms, which I cannot here fully describe, that the ball had passed through the lung. It was several days before the patient could lie down. Symptoms of pneumonia presented themselves, but were kept under control, and finally the patient became con- valescent. The other patient was also wounded with a ball, which had struck the right clavicle at about its middle, and, shattering the bono, had buried itself in the part. In this case, also, there was well-marked signs of the lung being wounded. At first the dis- tress was not great, the dyspnoea but little ; in two days, however, it was very great. He was ordered the veratrum viride every three hours. I found it unnecessary to give anything else. In a few days the symptoms of inflammation subsided. Because of the important structures immediately beneath the clavicle, the ball was but slightly searched for. When the patient passed from under my care his condition was most promising. The wound remained open, from which was a little purulent dischr.v^e, which might have been due to the necrosed state of a part of the clavicle. Now, both of these men were young and full of healthy blood, but neither general nor local bleeding was deemed necessary. The inflammation was successfully treated soleli/ by the veratrum viride. Aconite is an antiphlogistic, highly recommended ; but, as I have not had occasion to use it, 1 cannot speak from personal e.xpcri- ence. Nitrate of stiver is the only other medicine to which I shall espo- oially direct attention. There are others, certainly, of no mean CONSTITUTIONAL TREATMENT. 89 value ; but many or most have been referred to in connection with the several classes of remedies, and of these I would particularly specify sugar of lead and nitrato of potash. Nitrate of silver is used as a local remedy, and as such is often valuable, especially in limited inflammation of the skin or mucous membrane. It must be used in solution, and of not too great a strength. When thus applied it seems to amalgamate with the superficial part of the skin, by which a coating is formed ; thus it seems to dry up the tissue with which it comes in contact. The covering thus formed seems to protect the irritated nerves from the air and other irritating agents. Not unlikely the periphery, which was principally engaged, is actually destroyed by the caustic effects of the silver. Even when the inflammation is sub- cutaneous, the solution, often by acting upon the nerves through reflex action, gives a degree of relief; that is to say, by soothing the cutaneous nerves, other nerves in the same district are sym- pathetically soothed. In cases where some animal poison, as that of gonorrhoea, has been deposited upon a part, and is there acting as a cause of, and is gradually begetting inflammatory action, the process of incuba- tion may be arrested by the application of the silver, which will destroy, dry up the outside tissue, and at the same time destroy the poison. To secure this happy effect the application must be made before the inflammatory action is established. Subsequently, when the active symptoms have subsided or disappeared, and there remains a chronic discharge, a gleet, the solution may again be called in requisition. Here again the beneficial effect is attribu- table to the protection given by the coating to the nerves in a morbid condition. The function of the membrane has > n changed by tiie gonorrhoea, and, although the cause of the inflammation may long since have passed away in the discharge, the membrane remains in a morbid state in consequence of the periodical dis- charge of the urine from the bladder. bM so the < •scharge con- tinues. Jut the silver, in the way dcFcni.ed, forms a covering to the surface, and the urine tlu-reaP-v r. a^es to irritate it, physio- logical rest is obtained, and recovery soon follows. I will conclude this branch jf the subject by repeating, that the treatment of the inflammatory process will always be modified by the circumstances of the case. The surgeon will not lose sight of I if,:' I i •»■ % f!P ;*f1i ri Hi! 90 PRINCIPLES OF SURGERY. the various surroundings of his patient ; the causes, local and general, which may continue to operate. He will not fail to con- sider his age, position, and particularly the nursing which he will receive ; for, the more intelligent the nurse, the less will the sur- geon have to do. He ought to forewarn the nurse of any probable or possible evil which may at any time arise to complicate the case, and render a more vigorous treatment necessary. CHAPTER XI. f' ! Ml i I I" Pi Treatment of the Products of Inflammation — Of Serum — Liquor Sangi\ini9 — False Hypertrophy — Induration — Atrophy — Degenerated Lymph — Pus — -Mucus— Blood. Abscess — Pointing of Abscess — Ditfused Pus- Thus far I have considered the treatment of the inflammatory action, have described the classes of remedies suitable to each stage of the process, and dwelt upon some of the more important medical agents with which the practising surgeon will deul. I now come to speak of such treatment as seems most suitable to each product of the disease. The products of inflammation are, it will be remembered, serum ; li(iuor sanguinis, composed of serum and of lymph; blood; altered mucus. Treatment of Serum. — As a general thing, this product of in- flammation will be easily removed by nature if the infliimmation have ceased. Familiar instances are known where it has been accomplished after plcuritis ; even large quantities have been rap- idly and completely absorbed after the disease has been arrested. So that in healthy inflammation, where serum is the only product, the surgeon need give no special attention to it. Liquor Sanguinis is also often eff'ectually removed by the un- aided powers of nature. As long as it remains fluid this may be accomplished ; and we have learned, that in inflammation, the in- creased vitality of tbe fibrin serves to retain the compound for an increased time in a state of fluidity. The separation of the serum and the lymph is followed gene- rally by the absorption of the former, and an attempt to organize on the part of the latter. TREATMENT OP THE PRODUCTS OF INFLAMMATION. 91 Speaking, generally, the lymph may coagulate or degenerate into pus. In either case removal by absorption becomes slow, or even impossible, unless art be employed to assist nature. The surgeon, then, will endeavor to promote absorption, and aim to retain the lymph in solution ; or, if it have solidified, to bring it back into the same state, so that absorption may be possible. We have seen that mercury enjoys the reputation of being a stimulant to the absorbents (this, however, is questionable), and of being competent to prevent coagulation. Further, it is able to produce liquefaction after solidification has taken place. Mercury, for these purposes, has been and continues to be frequently used. But we have also learned that the use of mercury may be attended with or followed by very great constitutional evils ; therefore, if any other medicine will accomplish as much, or nearly as much, it by all means ought to be employed instead. I repeat these state- ments here because of their great importance, as well as to bring out the importance of the fact that the lymph often remains fluid for some time, and that a medicine so heroic and dangerous as mercury ought not, as a general rule, to be administered to pre- vent coar'ulation from taking place. At least before employing it, be convinced that it, or some such agent, is demanded. Nevei- give it blindly ; never run in the grooves of routine. I am not prepared to say that, in case of pericarditis, or of pleuritis, or of peritonitis, when it is feared that adhesions will form between surfaces which come together, and by which the organ may irre- trievably suffer, perhaps by which death will be produced (for, in such cases, of two evils I would choose the least) ; but I do say that it is only in such urgent and life-important cases that mercury ought to be given to salivation. More than this, I expect to see the day when even in such cases a safer remedy will be invariably employed. And in considering this question, we must not forget that, even after coagulation has taken place, nature, in many instances, alone will do very much. The inflammation ceased, and the part at rest, even solidified fibrin is often removed. Of course when the heart and pericardium have united together, or the pleura costalis is adherent to tuo pleura pulmonalis, or one fold of the peritoneum to another, the constant motion of the parts almost precludes the possibility of that repose without which repair cannot bo effected. But even in .* '!> ff In. Il '1 ■ ! ■ r . . i . . 92 PEINCIPLES OF SURGERY. ? , I-' ,, 111 '■ ■; ! i I i F u ^^ these cases nature at least tries to ameliorate the evil ; and after a time, perhaps very lengthy, the bonds of union are very much lessened, although not removed. For instance, in granular lids of the eye, where lymph exists to a considerable extent in an or- ganized form, if the eye be kept at rest for some time — perhaps a long time may be required — nature will remove the adventitious material, while the union which had taken place between the mucous membrane of the lid and that of the eyeball will be con- siderably reduced. Under such circumstances we often speak of stimulating the abaorbents. Elsewhere it has been shown that stimulation of the absorbents, in the true sense of the term, is inappropriate, inasmuch as stimulation of the vessels would only add to the difficulty. What is necessary, and what the surgeon can only wish to secure, is the liquefaction of the material, and then the contact of it with the absorbent vessels ; and anything which may be given or applied must be in accordance with these indications. To this end mercury may be administered, and so may the iodide of potassium. Of the latter medicine I think I cannot speak too highly. For the same purpose iodine alone is sometimes given and applied to the part. However, it should not be done, so long as the part is inflamed. I have seen a large number of cases in which the tincture has been applied externally with the effect of rekindling the inflammation. It is a question whether it will, when applied to a part, have any direct effect upon the absorbents. I am disposed to believe that the iodine, when thus used on the skin, unites with the cuticle and forms a firmer covering, by which a degree of rest is secured, and at the same time a certain amount of pressure is made, whereby the material to be removed is brought in contact with the coats of the ab- sorbents. There is at the same time, undoubtedly, a degree of stimulation ; and hence the important fact that it should never be used until excitement has quite subsided ; and the other fact, that iodine is more useful when there is a tendency to, or actual state of, asthenic action. Counter-irritation is of great value, as, for instance, in granular lids and vascular cornea, a blister frequently repeated behind the ear, or in frorft of it, or perhaps a small seton. Also, where adhesions have formed between the pericardium and heart, a seton over that organ will often divert nature, and thus obtain a TREATMENT OP THE PBODUCTS OP INFLAMMATION. 93 degree of required repose. A recent and more acute irritation engages nature in one respect, while in another respect she is relieved of a degree of excitement inimical to repair. Suppuration will prove serviceable in some cases. If the lymph which has become organized, and is productive of evil, can be made to degenerate into pus, a step is thereby made toward a return to fluidity. ( Vide Treatment of Pus.) Treatment of False Hypertrophy and Induration^ and Atrophy arising from a deposit of inflammatory lymph.— V(\iQn false hy- pertrophy results from inflammation, that is, when the lymph which has been thrown out becomes incorporated with the tissue by organization, the question arises whether the surgeon can do anything to cause or hasten its removal. It will be necessary here to say a few words which will forestall remarks which I shall have to make in connection with the healing process. It is a law well recognized, that in the body, as in nature gene- rally, like begets like; that every tissue in the human fabric constantly, as parts wear out and die, beget other like structures : this we have learned. Now when inflammatory lymph w effused, and becomes organized, it possesses no such vital powers. The adventitious matter, it is true, possesses a certain degree of vital- ity, so that it lives for a time, occasionally for a long time ; but when it does die, no other like material is begotten to take its place, unless it be derived from the blood, and is a product of continued inflammation. Thus we find that fibrin, as a product of inflammation, if it coagulates and does not subsequently reli- quefy, remains in the part until it lives its period of life, when, being removed by the absorbents, in accordance with physiological laws, there gradually take its place the natural tissues of the part. In these cases, it will be seen that time is required to restore the part ; and, I will repeat, that quietude is of supreme import- ance. We understand now the doings of nature when lymph has become organized ; it matters not whether it be a case in which there is no perceptible change of form, or it be hypertrophy, or induration, or a certain form of atrophy. Bearing in mind these doings of nature, it is the surgeon's only duty tD try to assist her; and what has been -recommended heretofore, will in all cases be trusted to as the surest way in which to render service. m 94 PRINCIPLES OF SURGERY. Treatment of Degenerated Inflammatort/ X?/m;)/t.— Inflamma- tory lymph may undergo several forma of metamorphosis, com- monly called degeneration. Perhaps, with but few exceptions, all forms of metamorphosis which are not of development, are, at the same time, degenerative changes ; that is to say, when a tissue or an individual cell becomes changed, it assumes a lower place in the scale of animal life, and at the same time has taken a first step towards ultimate death. We have seen that inflammatory lymph, which is itself an ab- normal material resulting from inflammatory action, and which possesses a certain degree of vitality, may, to a limited extent, become developed, and for a time form a part of the body. On the contrary, under certain circumstances, it is found to degenerate into one of several forms. Paget speaks of the following, viz. : Into a, 1st, horny substance; 2d, fatty degeneration; 3d, calcare- ous degeneration; 4th, "pigmental degeneration of fibrinous lymph, in the various shades of gray and black, which often per- vades the lymph formed in peritonitis." Treatment of Pm8.— Degeneration of lymph into pus is by far the most frequent ; indeed, it is the only one to which we, as sur- geons, need particularly direct our attention. It is in reality a tatty degeneration. Oil globules cannot always, it is true, be seen in the pus-cells, especially when recent ; but they will soon begin to show themselves. It is difiicult to draw the line of demarcation between the cell of inflammatory lymph and the cell of pus, al- though there is no doubt that the former is gradually converted into the latter. It may with safety be said, however, that when oil globules are detected in the cell, it is no longer a lymph-cell, but a pus-cell. It is desirable to re-state here the important fact, that these degenerative changes in the lymph are seemingly so many steps taken by nature to get rid of the material which has resulted from the inflammatory action. And this brings me to the statement that pus may be absorbed. It is an old doctrine, and one which may not easily be cast aside, that pus cannot be absorbed. Cer- tainly, pus-cells are too large to be taken up by the absorbents ; but we have ascertained that pus-cells, as they grow old, gradually enlarge, while the oil globules form within. At last the wall, i' TREATMENT OP THE PRODUCTS 0.^ INFLAMMATION. 95 having become thin, breaks down ; and thus it is that pus is gra- dually prepared to be taken away by the absorbents. Pus, it has been stated, may form in three ways : 1st, in the form of an abscess, circumscribed ; 2d, diffused in the cellular tis- sue ; 3d, upon the surface of a membrane. Now we will suppose that a certain tissue has been inflamed. The disease has subsided, or, perhaps, even while it continues, there exists, as a product of the inflammation, a quantity of coagu- lated lymph. The cellular tissue has been pressed together and aside, and within the tissue is this adventitious material. Too great in quantity to be supplied with bloodvessels, it is doomed to die ; not, however, at once, but by that gradual process of degene- ration which has been described above,— a fatty degeneration, re- sulting in actual death of the component cells. In this case we have supposed that the lymph became at first a coagulated mass, and afterward degenerated into pus. Such is very likely to be the course when an abscess forms, but it is not always the case ; instead, the lymph may, after being eff"used, pass into the form of pus, not having previously coagulated. Taking the mass of solidified fibrin, it is found that, as a general thing, the degeneration commences at the centre of the mass. This is the oldest portion of the clot and the farthest removed from the sources of vitality, and may be expected to first yield to the de- generating process. The softening gradually extends from the centre towards the circumference, until the whole mass is softened. But the surrounding tissue, in which is infiltrated the lymph, and which is more or less condensed by pressure, will form a very per- fect barrier, by which the pus is completely inclosed, and by which the outside tissue is in many cases protected from the encroach- mg pus. When an abscess, then, is fully formed, there is in the centre the fluid ; around this a hardened barrier of lymph and tis- sue ; and, without the barrier, the tissue, in most cases, is very much congested. (Sec diagram, p. 96.) The Process of Pointing.— The process of degeneration, cha- racterized by increase in size of the lymph-cells, and a general mcrease of the contents, causes pressure from within. This pres- sure is equal in every direction ; consequently, upon that side where there is the least resistance, the pus will gradually make its way. Hence it is that pus. as a ereneral thinir. finrls Jt.« wq^ to ,!|t 'i'M IMAGE EVALUATBON TEST TARGET (MT-3) <. y^. :e Mo 1.0 I.I 1^ li^ 2.5 2.2 2.0 ^ • 1.25 1.4 1.6 ^ 6" - ^ ^ V] <9> el ^^^^> /j % > /^ w '/ Photographic Sciences Corpomtion 33 WEST MAIN STRUT WIBSTIR.N.Y. MSSO (7U) i/s^soa V V ^ o l\ '^■^ 4^ ;\ 96 PRINCIPLES OP SURGERY. the surface of the body. But if a resisting membrane, or a fascia intervene between the collecting pus and the surface, then it will burrow in some other direction, where there is less to obstruct its II way. Again, sometimes, when the abscess is located in an internal organ, as the liver, the matter, instead of approaching the surface of the body, takes a more easy course into the intestinal track, or perhaps a more lengthy route ; yet, nevertheless, a more easy one. While writing this, I have under u.y care a man with unmistakable symptoms of abscess of the liver, the pus of which found an outlet by way of the left lung, through the bronchial tubes. There is one general law always manifested, namely, the pus does not take the nearest way, but the easiest^ to obtain its escape. There might, seemingly, be an exception to this law, as exhibited in the fact that abscesses, although near to, rarely open into a serous sac, notwithstanding the resistance cannot be said to be very great. But in these cases a wise and preservative law of nature shows itself — one before referred to — namely, that, in connection with inflammation of serous structures, the tendency is to adhesion. Inflammatory action must precede the formation of pus. Now, if that action begets a layer of highly organizable lymph, as it will, upon a serous membrane, the part is thereby strengthened, and a barrier is formed which will generally resist any advances in that direction. There are some tisttuea which possess the ability lo resist the pressure made by pus, so that it may actually bathe them ; for instance, the coats of bloodvessels are rarely affected TREATMENT OF THE PRODUCTS OF INFLAMMATION. 97 by abscess. They are, as a general thiHg, pressed aside by the lymph ; but they have been known to traverse an abscess and yet remain unaffected. If, however, the coats be examined, they will be found thickened, as if a coating of lymph had been formed around. And so it may be, after all, that the vessel owes its pre- servation, not to the powers of resistance in the tissue, so much es Its ability to supply in this contingency lymph of high vitality. The pointing of an abscess can, from the foregoing, be readily understood. Pressure upon any tissue, if continued for a sufficient length of time, will cause its destruction. The pressure produces an early death of the ultimate particles of the tissue, which seems to be attended with a degree of softening, and the debris is carried away by the absorbents, while there is not that ordinary repair which takes place in a state of health. The result is that the tis- sue IS gradually eaten away until finally the pus breaks through and escapes-the pointing process is completed. Thereupon the pus within IS discharged until the pressure is relieved. The tis- sues which had been thrust aside will gradually resume their proper position, and, if the opening be sufficiently large, the contents of the abscess will entirely flow away. While the pus is thus escaping from the abscess, the walls, com- posed of lymph and cellular tissue, will be found to undergo cer- tain changes The lymph will, to a great extent, degenerate into pus; the cellular tissue will either die and mingle with the pus in the form of debris, or recover its vitality ; this will depend upon the degree of pressure to which it had been subjected. Around where the barrier was, physiological action will take the place of pathological. And upon the inner surface of the walls will, in due time, be found granulations and extraordinary repair taking place nrt^'^JV^' '"''^^ '''"^^'"6 ^'•^'" ^^' discharged abscess! { Vide, the Healing Process.) These, then, are the steps, either one of which maybe taken by nature to get rid of pus, when it results from inflammatory action namely, liquefaction, degeneration, until the cell-wall breaks down' thereby allowing it to be absorbed ; or, if this be impossible, from the quantity of pus, or from the continuation of the exciting cause, then steps arc promptly taken to dispose of it in a more Bummary manner by the process of pointing. Such are the workings of nature, and hereby must the surgeon 1 98 PRINCIPLES OF SURGERY. w t be guided in any step he may propose to himself to take in ren- dering assistance. In two general ways he may assist. Possibly he may remove, or limit the cause of the formation of pus — may cut off the source of supply, break a link in the chain of morbific causes, whereby the part will be placed in a condition favorable to restoration ; or, if this be impossible, if the matter will continue to collect, and will find its way by pointing to the surface to es- cape, then there is a second way in which the surgeon may assist. It is possible to abridge the process of pointing, and instead of allowing those hours and days of painful work, which attend nature's doings, to make an opening for the pus to escape, the surgeon should divide the tissues by the knife. Poulticing and hot applications may, by softening the tissue, and soothing the irritated nerves, do some good ; but, when pus is known to exist, there should be no hesitancy in promptly making an opening for the pus to escape. More than this, it is better to err on the safe side, by making too early an incision — that is, before the pus really exists — as the incision can do no harm, while it may so relieve the part of congestion that suppuration will be averted. The instrument with which the opening should be made will depend upon the position of the abscess, and its depth. If the wall be thin, the most convenient instrument is the abscess, or the ordinary lancet ; when it is deeper seated, a stout bistoury will be required to cut through the intervening tissue; and when the abscess is somewhat elevated above the surrounding surface, as in a bubo, the most convenient instrument is the curved bistoury. This must be made to transfix the elevated walls to a sufiiclent extent, and then to cut its way upwards so as to divide the inter- vening tissue. When the abscess is deep-seated, there is danger that the wound made may close again, after some of the matter has escaped ; to prevent this, a piece of lint must be introduced, and allowed to remain at least till the following day. (Hilton's Method of Opening ; Lancet, 1860, vol. xi, p. 454.) I wish here particularly to point out the evil of a practice, a long time in vogue, and yet practised by many high in authority. 1 refer to the custom of squeezing out the pus after the abscess has been opened. It is not only unnecessary, but as it is actually painful, therefore it is objectionable. Nothing can be advanced TEEATMENI OF THE PRODICIS OF INFIAMMAIION. 99 to rapport the practice, unless it be that it is gratifviog to the surgeon to see the amount of matter for which he has provided a way of escape. The surgeon', only duty is to secure a free open- .ng, and then treat w„h the view to arrest the formation of any more pus: an end which will not be reached by pressing outZ pus and pnttmg the patient to pain. Therl is .Iwfys oJh enough of .rntafon and pain attending the operation without unnecessarUy increasing it. To allay thh irritation, wl appl" cafons may be used, first in the form of WBrm water, and afte - wards by a pou tjce of linseed meal; and this latter will also secure a gradual but free evacuation of the abscess. Following closely upon the heel of this will be the first steps of the "healf process; not .ndeed, but that everything thSs far has been f process of heahng. All that the surgeon can have done was to g.ve assistance to a natural process. But very soon he" ing n a More percept. He manner commences. The pLltice 3 had been apphed should be discontinued, not to V,/ again used, unless from some cause, the pus should begin to collect; under uch c r cun>stances, a poultice may to advantage be at least appi ed at night and removed in the morning. ^^ We arc now on the boundaries of another subject,-that of the healmg process, which has to receive a separate consideration Suffice .t to say here, that nothing can be done by the surron to' make a part heal; it is a natural process, and all Lt can be don .so keep the part in such a position as will allow nature to work wuhout embarrassment. To accomplish this, all that i, neoesia y tV Yr" "' ™' """^ P'"'™' " ^y water-drcssing. ^ The,econd form m which pus is met, is where it is diffused « ::: mt^^ fr':v "° """- °f '^-p- ^-j -densfd tissue. The lymph which has .legeneratcd into pus occupies the tssue in small quantities; it is distributed in thLcIluTarTaoes Bc^eneration takes place simultaneously in several of These Sometimes, as it collects, several of them will coalesce. Bu s„ ct" T r °' ™""™''™^ ""I'te an abscess, in every rosp ct. A single opening will not secure a discharge of the pus hi it m ' """J-V™" ?»">"' constitutional cause; so much so, that It may he looked upon as a variety of infiammation. The 100 PRINCIPLES OP SURGERY. "*l*< ' 1 1 1 I I i i treatment is the same as that pursued in certain forms of erysipe- las. ( Vide that disease.) Pus, which forms upon a mucous membrane, may in many respects be regarded as mucus in an altered state. The blood which normally circulates in the part, and from which the mucus is secreted, coming thereto with unusual rapidity, gives rise to the phenomena of inflammation. Transudation, at first arrested, soon takes place in increased quantity ; but now, instead of mucus, it possesses rather the characteristics of pus. Or it may be, that while some of the fluid forming upon the surface is decidedly pur- ulent, other portions retain the nature of mucus. The treatment to be observed is obvious. There is too much blood going to the part ; this is due to some irritation. The first consideration is to effect the removal of the irritating cause, what- ever it may be : whether a poison, as in gonorrhceal conjunctivitis; or continued motion, which so frequently keeps up inflammation of the eyes; the cause must be removed. Then, the blood circu- lating normally, the pus will gradually cease to form, and the function be restored. If the inflammation have continued for a long time, the membrane may have become so changed, that, although the cause is removed, the pathological state will remain for an uncertain period of time. Mucus as a product of inflammation requires no separate atten- tion. Every principle as to pathology and treatment has already been considered under " Pus upon the surface of a mucous mem- brane." Blood is the only remaining product of inflammation. Inas- much as it demands no special attention in the way of treatment, it need not here be discussed. d I OS 'Hi DISEASES ARISING OUT OF INFLAMMATION. 101 CHAPTER XII. Diseases arising out of Inflammation — Passive- 1 rn„„« ♦• t. , Treatment, Local and General 2 rv. t l' ^<'°^^«*^°'^ 5 Results- Treatment. ^^ ^^'°°'" Inflammation; Products- There are certain conditions frequently seen in connection with, or arising out of, the inflammatory process, which have generally been considered in connection with it, and which are called remote products of inflammation. These conditions possess distinctive features, in which can be seen the morbid, prepondera- tmg There is more of the pathological than of the physiological. The inflammatory process, such as we have endeavored to trace and whose footsteps we have closely followed, has been, in the main, on physiological grounds. And all along the way, we have seen evinced the most judicious and successful arrangements of nature to effect a cure. But we now must turn into another path, in which nature s efforts seem to a great extent abortive, in which physiolog'at""' ^'^^^"^-^^^^^ *^« P^*»-^«g-l -Persedes the This plan, although novel, will, I think, simplify the matter for ho student-an object I have steadily in view; for I hold that in the medical profession there is more to learn than can well be ,acquii-ed, and that the road ought to be made smoother and smoother by each traveller as he passes along. The diseases arising out of inflammation are: 1. Passive Congestion 2. Chronic Inflammation. 3. Chronic Abscess. 4. Pyemia. 5 Softening. 6. Ulceration. 7. Sloughing. 8. Gan- grene. 9. Induration. 10. Hypertrophy. 11. Atrophy. It IS impossible to draw a distinct line of demarcation between healthy inflammation and unhealthy-between healthy products and those which are otherwise. Hence it was, that induration, hypertrophy, and atrophy received attention in connection with healthy inflammation, however at times they do present more the characteristics of disease than of healthy action. Passive Congestion.-In this disease, there is too mucb hlnorl ;. 102 PRINCIPLES OP SURGERY. the part affected ; not because there is too large a quantity sent, but because it cannot flow therefrom in a normal manner. Here is a condition widely different from that which has been described as active congestion. The vessels which are engaged belong rather to the venous system ; the blood within them is venous. Causes. — Two general causes may be specified : 1st, obstruction to venous return ; 2d, a toneless condition of the vessels and parts generally. The obstruction may exist immediately at the part, or it may be more remote. Taking the foot for example, if it be the seat of passive congestion, the cause thereof may be found close by, at the ankle, or at the knee, or even at the pelvis. Many causes of mechanical obstruction may be enumerated — such as external pressure, in the form of a garter around the leg ; or a tumor may press upon the vein so as to retard the flow. The gravid uterus may press upon the pelvic portion of the vein ; or a cirrhosed liver may diminish the calibre of the vein. Any one of these may be a cause of passive congestion of the limb. The congestion may result from a relaxed condition of the part, or a dilated state of the capillaries. Not unfrequently, inflamma- tion of the acute kind is succeeded by passive congestion in the part, the inflammation having been the cause of the dilatation. The congestion may thus be due to some local defect or disease ; or it may arise from some constitutional evil, with or without some local exciting cause. Whatever may have been the cause of the passive congestion, the phenomena by which it is characterized are quite unlike those of active congestion. Symptoms and Diagnosis, — As the pathology differs from that of active congestion, so do the symptoms. To distinguish between them, the surgeon has only to remember the following symptoms and diagnostic marks. In the first place, the history of the case is widely different. Then the influx of blood, in the passive form, is more general, and the swelling is more distributed. It produces what may properly be called an enlargement — instead of a swell- ing — which will from time to time be diminished, or will disappear. The pain is not acute, and sometimes is intermittent. Instead of redness, there is often an absence of the ordinary color; some- times, however, it is increased, but the redness is of a darker hue than is seen in the active form. There may at times be a sensa- tion of unusual heat, but nothing like that burning sensation which DISEASES ARISING OUT OF INFLAMMATION. 103 belongs to the active form. The function of the part is more or less deranged; this necessarily ensues upon the dilatation of the venous capillaries. The progress of the blood through them is very slow, and consequently the arterial blood cannot flow into the part, even to supply nutrition. Function is thus deranged, and ultimately vitality of the tissue is impaired. That continued passive congestion does impair the vitality, is shown very often in chronic ulcers of the legs. ( Vide Ulcers.) If from any cause the tissue IS mjured, the powers of nature fail to repair it as in health. Passive congestion may be called a local affection ; at least, for some time, it gives rise to no constitutional symptoms. There is nothing like irritative fever, such as is seen in active congestion. If, however, the disease continue for a long time, general weak- ness, failing appetite, and sleeplessness, may be expected to result. Itesults of Passive Congestion.— The principal result is effusion of serum. The watery state of the blood, its sluggish movements, as well as the weakened state of the tissue, favor transudation through the coats, producing dropsy or anasarca. Softening of the tissue is another result. ( Vide Softening.) And the tissue may undergo also other deteriorating changes. Treatment.— In no case of disease is the principle that it is necessary to remove the cause so apparent as in this. If there be any obstruction to the venous flow, it is of paramount importance to have it removed ; and then, if the congestion be not of long standing, restoration will soon follow. Again, if the disease is connected with a toneless condition of the tissue, endeavor to ascertain what was the cause thereof; and then, to effect its removal, understand whether the fault lies in the tissue of the part, which therefore does not possess the power to appropriate from the blood to maintain ordinary repair, or whether the blood itself is deficient in the necessary vital elements. If a satisfactory conclusion can be arrived at relative to these questions, the course of treatment to be pursued will be surely indicated. Speaking generally, the treatment will be both local and general. The bloodvessels are dilated, and will be benefited by external support. In case of venous congestion of a leg, a bandage ap- plied in the morning, before swelling takes place from the blood gravitating, will prevent its taking place, and often, after a time, 104 PRINCIPLES OP SURGERY. !llt' mu i .1 ili .1 even effect a cure. The bandage must, of course, be applied from the foot, so as to make the pressure equal. An elastic stocking may be advantageously used instead, thereby obviating the neces- sity of the daily attendance of the surgeon. Yet a nurse may be taught to apply it. Position is another important means by which the congestion may be controlled. As blood will gravitate to the part, so it may be made to gravitate from it. Bathing and friction must not be neglected. The constitutional treatment must be tonic, of which, prepara- tions of iron will be found the most serviceable ; also the iodide of potassium. In the treatment of passive congestion of the spinal cord. Dr. Brown Sequard highly recommends belladonna, and ergot of rye. The former, he has found by experiments on the lower animals, has a very decided effect upon the unstriped mus- cular fibre. It may be given internally, or applied externally in the form of a plaster. I have used it to great advantage in pas- sive congestion of the leg. In the treatment of chronic sores, I use the extract, to which water is added, so as to form a lotion. In some cases I have added Tinct. Ferri, by which the lotion was evidently made more potent. ( Vide Carbuncle.) It is hardly neces- sary to say that due attention must be paid to diet. Chronic Inflammation. — So called, often after acute inflamma- tion has existed in a part. It may be gradually superseded by a pathological condition, which, although commonly known as chronic inflammation, possesses very few of the features of inflammatory action. Indeed, when such features do show themselves, they may be regarded rather as a returning to the primary action. The chronic disease seems from time to time to create inflammatory action — perhaps even produced it in the first instance. Causes. — Are general and local. In every case, a general or predisposing cause may be said to have been in operation. Some- times two or more predisposing causes have acted conjointly. These gojieral causes may be some morbid condition of the blood, or of the tissue ; either may have been of long standing, or of recent existence ; and they may be hereditary or acquired. The more potent the general cause or causes, a less exciting cause will be adequate to produce the disease. Chronic inflammation bears almost the same relation to passive congestion as true inflammation DISEASES ARISING OUT OP INFLAMMATION. 105 does to active congestion. In one case, the action is governed in a great measure by physiological laws; in the other, it is all abnormal— pathological. In the one, efforts to heal are manifested at every step ; in the other, these efforts are absent, or are of the most futile kind. Local S^jmptoms.— The local symptoms of acute or healthy in- flammation are pain, heat, redness, and swelling. Now, if we examine the local symptoms of chronic inflammation, which are analogous to those of the acute, we shall find that they are indeed but the analogues of healthy inflammation. The pain is rarely great, as the swelling is slow in taking place, and the nerves are never made acutely sensitive, ffeat is never increased to an ap- preciable extent. Rednesn . not generally well marked ; it may be present, and, when it is, the hue is much darker ; there is not that bright ^rterial color which is seen in acute inflammation. The swelling is generally greater, not, however, always so. It is more diffused, and is due to effusion of serum. The resemblance between the constitutional symptoms of chronic and acute inflammation is even less. Inflammatory fever, with its various characteristics, is never seen. The excretions are not arrested. Where fever is present it will be in the form of hectic. There may be great debility, due to the disease itself, or to some pre-existing condition of the constitution, which, indeed, may likely have been the cause of the disease. ' Products of Chronic Inflammation.— M would naturally be sup- posed, from the pathological state of the part, serum is the prin- cipal product. With the serum, however, fibrin is often poured out ; but it is limited in quantity and deficient in vitality. Its power to organize is far less than that witnessed in the fibrin of acute inflammation ; and, when it degenerates into pus, it is also below par ; it is not laudable pus. The liquor puris is in excess when compared with the cell con- stituents, while at the same time the cells are wanting in the cha- racteristics of pure pus. I have said that at times the disease will give place to action of an active kind, during the continuance of which the features of true inflammation will become more prominent. Now, at such times, fibrin, in larger quantities, and with more plasticity, will be ef- fused, and will assume a higher state of organization. In some 106 PRINCIPLES OP SURGERY. Ill J.V ^ talis 1^1 ' J "ill cases these periods of active disease ■will be of frequent occurrence, or it may be that, simultaneously, chronic action may exist in one part, and active disease in another. The result of this will be that fibrin of a more organizable character will be eifused ; and, in con- sequence of the very chronic disease which is coincident, it is en- abled to assume a high state of development, that is, for a material such as it. It is in such cases of chronic inflammation that a tis- sue or organ is seen to become enlarged. The adventitious mate- rial becomes incorporated with the natural, constituting false hy- pertrophy. Sometimes, again, while this process of organization is taking place in one part, in another the lymph may be degene- rating into pus. The irritation in one place leads to the continued formation of pus ; in another to the existence of false hypertrophy. These widely different proceedings, although coincident, will indi- cate how abnormal is the action ; how far separated from healthy action is chronic inflammation, so called. The occasional attempts to cure but show how incapable is nature, unaided, to accomplish the work. Treatment of chrome injlammation may conveniently be divided into general and local. Sometimes the local disease will demand immediate attention ; but, while such is being given, the constitu- tion will also require particular attention. In most cases, how- ever, the order will be reversed, the constitution must receive the first attention. After it has been brought into as healthy a state as can be, then local treatment will be more likely to have effect ; yet, in the mean time, the local symptoms should be palliated. In all cases the treatment must be supporting. Whatever may be said in support of depletory measures in acute inflammation, no ground can be found upon which to base such treatment in the disease now under consideration. Tonics, and often stimulants, will be diligently used. Diet of the most nutritious and digestible kind will be given. The local treatment bears a closer resemblance to that of the acute. Counter-congestion will not prove so beneficial ; but local depletion will generally be serviceable. It draws away the venous blood, and relieves the distended vessels and the intervascular sub- stance. Blisters are of more certain value ; by their use a large quantity of the serum will be drawn off, likewise giving relief of an important kind, inasmuch as serum constitutes the principal CHRONIC ABSCESS. 107 product of the disease. Of still greater value in many cases is the formation of a discharge, as by the issue or seton or moxa. The benefit of these is strikingly exhibited in chronic inflammation of the knee or hip joint. In these diseases, a blister kept running for a lengthened period, or a continued discharge maintained for a long time, will, by diverting nature, attract from the seat of dis- ease the superabundance of blood ; so that the tissue may there- after recover itself, other circumstances being favorable. In all cases rest to the part must be strictly secured, which alone will often be sufficient to effect a cure. (Hilton.) ] CHAPTER XIII. Chronic Abscess — Results — Treatment — Sinus or Fistula — Treatment. Cause. — Chronic abscess is a very common result of chronic inflammation ; it is called chronic, however, because the pus col- lects very gradually, as well as very stealthily ; generally without pain or other symptom to warn the patient, or tell the surgeon of its existence. A chronic abscess may result from the acute, as well as from chronic, inflammation. Sometimes the inflam- mation having subsided, there will exist, as a product, a quan- tity of coagulated fibrin ; this may subsequently become a source of limited irritation, leading to the gradual formation of pus. Again, tubercular matter may have been deposited in a tissue and have become a source of slow suppuration. And again, a com- paratively slight injury may have produced effusion of a quantity of lymph, with or without a little blood, which, although coagu- lated, failed to become organized ; and which, after a little, gradu- ally degenerated into pus. Pus. — The -pus of a chronic abscess is never laudable. It will have character given to it by any constitutional evil that may exist, but it is always thinner, more watery ; the liquor puris being in excess, while the corpuscles are deficient in that vitality which is seen in pure pus. Symptoms. — The symptoms differ widely from those of acute immi 108 PRINCIPLES OP SURGERY. I % «' m^W abscess ; yet enough resemblance exists to warrant the use of the term abscess. In acute abscess there is always pain, sometimes of the most excruciating kind ; but, as before said, there may be none to mark the commencement and increase of the chronic ab- scess. The reason is plain ; the pus, forming gradually, does not cauf^e that sudden pressure, so that the parts may accommodate themselves to the forming material, which could not be done if the pus were suddenly collected ; and thus irritation, pain, and inflammation do not come in a train. The extent to which the body or a single part may become accustomed to the presence of a new formation, such as a tumor or a collection of pus, when the growth takes place slowly, is very remarkable. The tissues en- croached upon give place, will first be pushed aside, and afterward undergo absorption ; so that but a feeble, or perhaps no warning voice is heard, to tell of what may be a grave malady, leading to destruction of important parts. Diagnosis. — Very often a large abscess will form, or a tumor grow to a large size, and its existence be unknown, or at most but sus- pected, until it shows itself externally. And when an abscess is dis- covered by the eye it is not always easy to diagnose it from a grow- ing tumor, or a chronic hernia, or an aneurism. The location of a hernia is only likely to be where protrusions can the most easily take place ; and an aneurism can only exist in the course of an artery ; and so far safe assistance is obtained in making a diag- nosis. And upon these circumstances and the history of the case the surgeon will have principally to depend. When pus ap- proaches the surface the sense of fluctuation will afford great help ; but it must be remembered that fluctuation is sometimes present in an aneurism, particularly at its first formation. It would be a frightful mistake to cut open an aneurism ; and should the surgeon feel disposed to pursue the treatment of opening an abscess, and yet have some misgivings as to its nature, he ought by all means to wait. In this connection I am reminded of a case which came under my notice in the country, in consultation. It was an obscure swelling in the abdomen. The physician, under whose care the patient was, had diagnosed an abscess, and wished to make an incision through the intervening tissue. This proce- dure was objected to by two others in consultation. The patient ultiiuatclY died, whcn Vk j^Oii vlOrtcTil FcVcalcu XiXdX tu€ tUuiOI naS CHRONIC ABSCESS. 109 produced by an encephaloid growth of the kidney. Had the phv. sician, who was one of some forty years' practice, aade his inci- sion where he proposed, he would have cut through the omentum and colon. Frognoais.—mil necessarily depend upon the region in which the abscess is located; the tissue involved; the original cause; the constitution; whether afflicted with any special disease; the age; and the surroundings of the patient. Results.— Resolution may take place, or the pus may find its way through the tissue and be discharged. That resolution may be possible, the source of the constantly collecting pus must be dried up— the cause of its formation must be removed. There is always, .ur^-ounding the pus, a well-developed pseudo-membrane • this IS formed m part by condensed cellular tissue, and in part of organized lymph. It, after a time, is well supplied with blood- vessels. The lymph which separates from the blood in this sur- rounding false membrane, quickly degenerates into pus, and is added to that within the walls. The amount of pus thus formed will, of course, depend upon the degree of irritation. The mem- brane IS called the pyogenic membrane. Now, supposing the pus ceases to be formed, can that within the membrane be removed by absorption ? The belief was held for a long time that it could not; at least such was believed by many, and such was taught when T was a student. But the teachings of Hilton, in his recent lectures, are so plainly to the contrary, and are so well supported by Che re. ord of several cases, that no doubt can be entertained as to the ability of nature to remove it. The same membrane which had seemingly secreted pus, assumes a new office,— that of absorbing the pus; and as liquef active degeneration is consum- mated, the work of removal may he completed, and finally the walls of the abscess will be collapsed, join together, and become united by adhesion, thus completing the process of resolution. But the work does not always progress uniformly. Oftentimes the cause of suppuration will recur, and for a time pus may again be dege- nerated. This may occur many times before the abscess is finally resolved. "^ In a good majority of cases, perhaps, the contents of the chro- nic abscess gradually finds its way to the surface of the body. The process by which thiH is done is identical with that described ; 1 i . 110 PRINCIPLES OF SURGERY. I it £2 mfrtin.t.ivfi • thfl hiat.Olirv PYEMIA. 115 must be used, and the parts divided. But it must not be forgotten that this division of the tissues secures the grand desideratum, rest, and allows the opened sinus to heal by granulation. Could that rest be secured without the division, there would be all the differ- ence which exists between healing by adhesion and that by gi-anu- lation. CHAPTER XIV. Pyemia— Causes— Treatment— Softening— Ulceration— Sloughing— Gangrene — Treatment. Pathologi/.— This is a diseased condition of the blood, and is attended with profoundly evil symptoms, and too often followed by fatal results. Some product of inflammation becomes intimately admixed with the blood, by which that fluid is Mterallj poisoned ; and which, in turn, involves the whole system in disease, often, as I have said, unto death. It was formerly understood that pus was the material which had found its way into the volume of blood. But there seems to be some reasonable doubt respecting this question. There are only two ways by which pus could enter the circulating blood : by ab- sorption, or through the veins when accidentally divided ; or when it has formed within it. Respecting the first, we have learned that pus-cells are too large to be capable of passing through the coats of the absorbents ; and that, when purulent matter is removed by absorption, a prerequisite to its taking place is the breaking down of the pus-cells. Moreover, it is a fact to be remembered, that large quantities of pus are often absorbed without any constitu- tional effects whatever presenting themselves, without any sign of pyemia. The worn out, or perished cells, are eliminated without any perceptible evil. We look here, then, in vain for an explana- tion of the problem. Again, it has been supposed that when veins are divided there is an open way for pus to enter the blood, should it form in that part ; lorgetting, as a writer- has said, that if such a way were open I ; 5'! -m , i: V- 1 , ft 1 1 m Hi ft^^i : uM y k H 116 PRINCIPLES Of SURGERY. ■I -' U i.'f i I' I for pus to enter, by the same way blood would certainly escape ; yet, in cases of pyemia occurring in connection with wounds, there is no sign of hemorrhage. Probably the fact that pyemia very frequently follows phlebitis, has led to the conception that pus has directly entered the circulation. But the objection referred to seems to be fatal to the theory. But may not pus be formed in connection with inflammation around the coats of a vein, in con- sequence of which a separation of fibrin from the blood takes place within the vein ? Here, again, actual observation has shown that such is very unlikely to occur. The primary effect of the inflammation is the formation of a clot of fibrin around the vessel and within it ; and when inflamma- tion extends and suppuration ensues, even within the vein, it will be found that the clot extends along its course, so that a barrier of clotted fibrin always exists to prevent the entrance of pus into the blood. Likewise, when a vein has been divided, the clot will close up the wound, and very likely occlude the vessel to a greater or less extent. The formation of these clots in inflammation does not seem to be due entirely to the inflammatory action. To beget this disease there seems to be some peculiar condition of the blood, or its fibrin, which renders it easy of coagulation. There is a deficiency of vitality, which is manifested by a speedy coagulation ; and, subsequently, an equally speedy disintegration of its sub- stance. And here seems to be the most plausible explanation of the disease. Here is its pathology. The clot does not disintegrate in a body ; but its boundaries, which are constantly washed by the venous current, break away particle after particle, until the whole mass is floating in the circulating blood in the form of minute particles of dead matter, which may continue to undergo decom- position. It is this material, thus introduced into the blood, which affects so disastrously the vital fluid, which acts as a rank animal poison to it and the whole system. Thus it will be seen that pyemia is not due to the admixture of pus, but to a more noxious agent ; that, while it is derived from the fibrin, yet it is not a de- generation of that substance into pus, but an actual death and dis- integration. Perhaps it is not in every case an actual death; but at least it is a degeneration far more degrading than that of pus. Virchow says, "It is a puriform, but not a purulent substance." PYEMIA. 117 Causes of pyemia may be divided into predisposing, and local, or exciting. Among the predisposing causes are other diseases of the blood, such as prostration from organic diseases, as in lung and kidney affections, diseases of joints, exhaustion from surgical complaints, accidents, amputations, shocks, parturition, unhealthy occupation, and over-indulgence in food. ^ Local causes most frequently are some injury, by which the vein tissue is much involved ; severe lacerating wounds, of the leg par- ticularly. Anything, indeed, which causes inflammation of the veins. It is a common sequence of gunshot wounds. During the progress of the American war, pyemia has been of very frequent occurrence. Whilst sojourning in the Army of the Potomac, after the battle of Chancellorsville, and afterward in the Lincoln Hospital, at Washington, I had the opportunity of wit- nessing the course of not a few cases. No doubt camp life, espe- cially to the recently made soldiers, and the excitement as well as the toil of forced marches and of battle, constitute very potent predisposing causes of the disease. And very active exciting causes of the malady I conceived to be, from careful observation, the protracted, painful, and often ruthless examinations made, to find balls, which were supposed or known to be imbedded in the tis- sues, and the injudicious efforts made to recover them. Examina- tion by the finger was unhesitatingly resorted to and continued for some time. As a result of this there could not be otherwise than laceration of tissue, a breaking up of fibrinous adhesions, which nature had made in her anxious efforts to heal, and which then would speedily degenerate or die, thereby producing the ma- terial which we have seen leads to the disease. I could account in no other way for the fact that patients who had been placed on the operating table with no single unfavorable symptom " for ex- amination," and who had been subjected to a long-continued and extensive examination, terminating sometimes in the abstraction of a ball, often without discovering it, would the same evening have a chill, and two days after have all the symptoms of pyemia, and upon the third or fourth day would die. I was convinced, in my own mind, that it would be better for the patient were the ball never searched for, unless in cases of comminution of bone. Resulting from this blood-poison may be expected, in most 118 PRINCIPLES OF SUnaERY. cases, secondary deposits in the capillary structure. The detritus of the clot which has become mixed with the blood, will fail to pass through these small vessels, but, becoming lodged will set up a low form of inflammation, followed by the fornjiation of numer- ous small abscesses. It is, of course, in the venous blood that the morbid material first floats when it leaves the site where the clot had formed. It therefore passes immediately to the heart, and thence into the lungs. Here, then, are the first capillaries through which the debris attempt to pass; and it is here where the secondary deposits by far the most frequently occur. Having passed through the lungs, the next structures in frequency to become the site of deposit are the brain, liver, kidneys, and joints. (Syst. Surgery.) In connection with the secondary de- posits, or arising therefrom, will be seen an asthenic action in the whole capillary structure of the body, characterized by an oedema- tous condition. I have observed this more particularly in the lower e;ctremities, which resemble anasarca, only that there is less pitting on pressure. It would seem that the coats of the minute vessels lose their tone, and consequently exudation of serum and fibrin is favored, into the cellular structure. Symptoms and Diagnosis. — Symptoms of pyemia are, as a gen- eral thing, well marked; consequently, the diagnosis is never difficult. The history of the disease is important to assist in the diagnosis, inasmuch as the disease comes on after some injury or operation. If a wound is suppurating, it will be seen, as the disease is established, to cease discharging, and to become dry. Soon there- after, the skin and the secretory organs generally will cease to act ; but afterwards there will be a clammy moisture of the skin, and diarrhoea may set in. The disease is ushered in by a chill, which will be repeated from time to time. The pulse will be quick and uncertain, and compressible. The tongue will have a typhoid appearance ; indeed, many of the symptoms are the same as cha- racterize typhoid fever. In addition to these symptoms, others may present themselves, depending upon circumstances peculiar to the case. Treatment. — The local treatment will consist in the application of warm fomentations, or poultices, with the view of re-establish- iner the discharee and preventiner. at least of limitins. the entrance PYEMIA. 119 of the poison into the circulation. When the secondary deposits give rise to local inflammation, the treatment will be on general principles. , The constitutional treatment will be directed to the elimination of the blood-poison, and to sustaining the strength, which will rapidly decline. The skin, kidneys, and bowels should, as far as possible, be kept in a healthy state of action. Medicines cannot be found which possess any specific power to neutralize the poison. Such only should be given as will tend to aid in the elimination of the morbid material, or give tone and strength to the stomach, that nourishment may be advantageously administered. Stimu- lants ought from the first to be freely and frequently given. Everything, indeed, will depend upon the ability of the stomach to bear nutritious food and drinks, as well as judiciously admin- istered stimulants. Pathology — Softening. — We have elsewhere seen that softening of tissue, in connection with inflammation, is one of the many eflForts constantly made to cure, at every step of the inflammatory process. This is more particularly seen in connection with the formation and pointing of an abscess. This softening has been likened to that which accompanies or precedes parturition, by which the soft parts are prepared for the transit of the child into the world. And certainly the two processes are much alike, nature seeming to be adequate for the requirements of both cases. In parturition, the more complete the softening — the relaxation — the more speedy the labor, and the less suffering. Likewise in inflammation : when there is softening and yielding, and therefore swelling, the pain is less, and the danger diminished. So far, softening may be regarded as a physiological action ; but in many cases it becomes a disease. The softening may be too great, and more extensive than is requisite to subdue the inflammation. This may arise from a previously dilated or weak condition of the part, or of the whole system. Improper treatment is not unfrequently the cause of undue softening. Position, or any application that induces passive congestion, may become a cause of softening. I have in a great many instances seen long-continued poulticing, and other relaxing applications, lead to disastrous softening. Cer- tain tissues are more subject to softening than others: as the brain ; spinal cord ; bone ; synovial membranej &c= itm .fl t iu^^H • ; 1 • f ■ , 1 120 PRINCIPLES OP SURGBET. i!' Ii't •! 1] Results. — Degeneration will inevitably result from softening {vide Diseases of Joints), ^and the tissue will often become much thickened. Again, ulceration is a frequent sequel. These, then, are the results of softening : degeneration, thickening, ulceration, also absorption; besides, the system may become affected, leading to exhaustion and death. Treatment of pathological softening will consist, mainly, in re- moving the cause ; to do which, a distinct knowledge of the patho- logy will be essential. Relaxing applications must be discontinued, and everything which may induce passive congestion or pressure must be removed. The constitution will be treated according to circumstances. Ulceration is akin to softening, or may be considered a further step in the same pathological changes. It is desirable to have a distinct meaning attached to the term ulceration. Some confusion I have found to exist, in consequence of the term "ulcer" being employed synonymously, when its proper use is in connection with quite a different thing, although the two may coexist. An ulcer, it may be stated here, is a sore — a solution of continuity upon a surface, which nature is attempting, successfully or otherwise, to heal. If the effort is successful, it is a simple ulcer; if unsuc- cessful, it becomes an unhealthy ulcer. But ulceration is always a pathological action: it signifies destruction — actual death of tissue ; only, that instead of a large portion, a perceptible quan- tity, perishing, it is by particles. Molecule after molecule softens, dies, and is steadily carried away by the absorbents, and eliminated from the system. In health, there is a balance main- tained between decay and the building up of tissue ; if, however, the decay is greater than the repair, then there is an > xcess of molecular death, and there will be a diminishing of tte ?issr:e. Sometimes this occurs in a whole organ, and constitutes s:trop'iy. When it takes place in a part, it is ulceration. Like softening, it often comes under the surgeon's notice as a curative operation. ( Vide Pointing of Abscess.) Ulceration is sometimes rapi If the tissue be predisposed in consequence of natural weakneta, or from an injury, by which its vitality ia iri:v;aircd, molecular death will more readily and quickly follow any exciting cause. Again, the application of a poison PYEMIA. 121 may hasten molecular death; also, when it has entered the system, it may constitute a predisposing cause. The causes, then, are predisposing and exciting, both of which may act together. The treatment of ulceration is obvious. Ascertain the cause, and remove it ; or if that be impossible, endeavor to lessen the effects. When the process of ulceration has been stayed, healing ought to supervene ; but very generally the system— the blood— ;s impaired, and disqualified for supplying proper reparative ma- terif.1. Attention will therefore be directed to the general health, as well as to protecting the part where destruction has taken place. BougJnng.— Closely allied to the ulcerative process, is slough- ing. In this, however, the destruction of tissue is more rapid and extensive. It perishes, not by atoms simply, but in larger por- tions, though not in a mass, as in gangrene. Sloughing is often seen to follow a severe bruise. A crushing force has mechanically disturbed the physical substance, and the vitality of every atom is quite, or almost, crushed out, the coats of the vessels no longer possessing the power to discharge their functions. The blood passing to the part does not permeate it, although it gives to it a quantity of the watery element. There is but the faintest resem- blance between this process and that of inflammation ; it is this which alone distinguishes sloughing from gangrene. Sloughing may also be caused by some violent poison : as, for instance, when syphilitic poison of a virulent kind comes in con- tact with the glans penis. Its effects are often immediate, like a corrosive poison, before absorption can possibly have taken place. Any one who has walked a syphilitic ward will have seen instances where in a short time the whole of the glans, and even more of the organ, has sloughed away. No doubt, absorption begins to take place ; but the vessels, in the very act, receive their death- poison. Continued pressure, with undue heat, especially in a constitution weakened with disease, often causes sloughing, as well as gangrene. Instances are to be seen in the form of bed-sores, where the patient has been confined to bed for some time— more particularly from exhausting fevers, or other like affections. In every case, when the system is below par the effect of the exciting cause will be greater. } I ii F I! II f'i'pii time before. Hence the fact that gangrene is at once chronic and dry or shrivelled. The latter is more frequently seen in the aged. The terras idiopathic and traumatic are also sometimes used, but do not require any special interpretation. Treatment of Gangrene. — The remarks made respecting slough- ing will, in many respects, apply in connection with the treatment of gangrene. The part -hich has perished must of course be separated from the living tissue. To do this nature always sets promptly to work and hastens to complete it. The process of separation is supposed to be accompl,ished by, 1st, softening taking place in the tissue still living, and which it may be supposed had not escaped altogether that which caused death in the contiguous tissue. The state of gangrene seems to accelerate the adjacent softening. 2d. Following the softening is ulcerative absorption. The line of demarcation is gradually fixed, and the separation is slowly consummated. While some tissues are easily separated under such circumstances, others are slow to yield to the ulcerative process. It is a question of some importance whether, during the process of complete separation, any of the dead substance is ever removed by the absorbents. That such may take place might reasonably be inferred from the fact, that for some time after the other tissues are quite divided, vessels remain unsevered ; and, although blood finds no tubes to traverse in the dead substance, the powers of absorbing may continue. In this way it is possible that a thin stratum of the gangrenous substance may be removed. Yet it is more probable that the division is made at the expense of the living tissue. When, therefore, there is an extensive surface of gangrenous substance in contact with living tissue, as the greater part of a limb, the sooner the gangrenous mass is separated the less danger is the system exposed to. On this ground alone it will be seen that surgical interference may become necessary. Although nature earnestly works to rid the body of the mass, she may bo poisoned before the work is consummated. But, in case of a limb being the seat of the disease, there is another reason for interference. In the first place, as wo shall see hereafter, the process of separation in the bone is very slow ; and finally, when it is consummated, the stump is by no means fitted fur uutivu uurvice. Tliu rule, thurufuru, ict, iu wait uiilii uaiuru '\ VARIETIES OP INFLAMMATION. 1«5 declares, in terms that cannot be misunderstood, where life still remains ; and then, by the knife and saw, relieve her of the weary work, and at the same time secure a serviceable stump. In those cases where the gangrene is situated on other parts of the body than a limb, and where amputation may not be per- formed, a different procedure must be adopted. Much can be done to hasten the division and removal of the mass, and to pre- vent the entrance, by absorption of the poison, into the system. Often, continued poulticing will, by assisting the softening, and by producing a degree of inflammation along the boundary of the ter- ritory of the still living tissue, create suppuration, which will have the effect of establishing physiological absorption ; that is, the absorption that may take place will be of the living material rather than of the dead. By so treating there will be a greater loss of structure, but it will be attended with less danger to the constitution, and will be more speedily accomplished. In connec- tion with poulticing there must be the strictest attention to clean- liness, and disinfectants should be called into requisition. ^ The constitutional treatment will be regulated by the rules spe- cified in treating of sloughing, and the remedial measures will have to be more assiduously employed. CHAPTER XV. Varieties of Inflammation-Phlegmon-Anthrai-Ohilblains-FroBtbites- Burns. Varieties of Inflammation.— Vndcr this head I intend to treat of the various forms of inflammation in which are manifested phenomena at variance with those which characterize acute, or, as I prefer to designate it, healthy inflammation. Inflammation may be divided into two great classes,— the healthy and the unhealthy. Of the healthy I have spoken, and as well of Its products and certain diseases arising out of inflammation. It 18 of the unhealthy I design now to speak. -vuci uiviB iil 1 8,5; ' 138 PRINCIPLES OP SURGERY. w- ■ Lm J»'i ic body. At the best, now and then, there is but the slightest dis- play of life in the matter. There is a total absence of blood- vessels in its substance, as well of nerves and absorbents. If you examine with the microscope a portion of the tubercular matter, the proof is conclusive that vitality is absent. There is no perfect cell, such as belongs to healthy fibrin. The broken-down walls of aborted cells may be seen ; and now and then, soon after the de- posit, a whole cell may be discovered, when the disease is not fully developed. But in this cell can never be seen a single sound, life-enduring nucleus; instead, there may be recognized the cell filled with granular matter, derived from the fruitless attempts to conceive offspring. But what is this disease of the fibrin ? Why is it thus disposed to separate itself from the blood to which it belongs ? Why has it assumed a low standard of vitality ? Why does it so quickly die when it has parted from the blood ? The above questions have often been asked and answered, or attempts have been made to answer them. The fibrin of the consumptive blood, like a species about to be- come extinct, is incapable of resisting anything which tests its strength. Efforts are made to display vitality, but they are gene- rally abortive. In whatever way the fibrin of the b'ood is elabo- rated, the old race seems to have deteriorated, and is being suc- ceeded by a race still lower in the scale of animal life. The offspring is puny and sickly, although numerous, and is incapable of discharging the duties which belong to it. The current of its usefulness is turned aside into abnormal channels, only to destroy. The deterioration of species, the gradual decline and final cxter- minutioti of individual families of the human race, is a subject of interest and importance, and has engaged the attention of many scientific men. With th is subject the questions under consideration are intimately connected ; the solving of one problem will explain the other. As the causes which lead to the destruction of indi- vidual races may require the lifetime of generations to consummate the effect, so with consumption. It may be that it is a law of animal life that decline and death shall como to races, as to indi- viduals, and that they shall be wrought by changes in the elements of the fabric, aiuilogous to those which are apparent outwardly in Xne race itSCU. X>ut nv wnvrsc Dasjucca U in lO ct-lrn. i^.-t -ti?7*-t*-7v «"•* SCROFULOUS INFLAMMATION. 139 the causes thereof, who so often finds that malady is the inevitable result of a violation of physiological laws, is disposed to seek for such causes of deterioration in the human frame, and in the non- observance of physiological laws. The belief cannot be shaken that the aggregate of human life might be lengthened, and that life might be made less painful and better fitted to discharge its high duties. We cannot believe, that, live as we may, the extinc- tion of races must come. Causes. — With respect to the causes of scrofula, there is reason to believe that a want of cleanliness of the skin is one, at least, of them. The skin may be considered an excretory organ, which throws out upon its surface effete material, that ought to be re- moved therefrom. But in how many instances is it allowed there to remain, the skin being unwashed for months, perhaps for years. The matter is constantly being reabsorbed, again to enter the system. We have seen that the glands are often sufferers in scrofulous disease, and may we not look upon that fact as sup- porting this hypothesis ? Not that the effect upon the fibrin is immediate ; on the contrary, it may be a long time before the disease is fully engendered, for if the other excretory organs be in an efficient condition, the fault of the skin may be in pitrt com- pensated for. A second cause which is given is the frequent removals in the human race from one clime to another, and the consequent changes of diet and various other influences connected therewith, which affect the life. In all ages, these changes have taken place. It is not alone the emigrant of modern days going to a new country to try his fortunes. In olden time, the invading army went forth to conquer a new territory with a climate unlike that of their native land, and the army was followed by a peopling kinsmen, who re- mained to live and to die in the uncongenial clime. And in recent years, the over-peopled countries of Europe have sent hither to the United States and Canada thousands after thousands to find homes and finally their graves. Not only the American continent is being possessed by Europeans, but as well colonies in every part of the globe. Thus we sec, that from one cause and another the human race has ever been flitting; ever, since Adam took his sor- rowing depiirturo from the garden of Eden ; and as aninuils in lO'rVrr life may not Tviih impunity be transferred from one oounlry i:ni f S) -f. 1 i; j:, , 1 i bXI^^I !:■: M ■ 1 t . 1 H t : 9 140 PRINCIPLES OF SURGERY. to another, so it must likewise be with the higher animal, man. The effect of the evil might not immediately present itself; the individual who exposed himself to the climatic change might not feel the effect even during his life. It might be, the second or third generation had come before the disease were fully developed. Although man would seem, to a great extent, to be capable of adapting himself to all climes, to all conditions of life, to almost all kinds of diet, yet there is a limit to his powers of resistance and of recuperation. When two or more causes are acting simul- taneously, the limit will be sooner reached. On the contrary, ■when many of the laws of life are not exposed to violation, the infringement of one may not bring an early punishment. But it m.ust not be forgotten that in not a few cases emigration seems to prolong individual life, and to render that life a more healthy one. Under certain circumstances it is undoubtedly the case ; and I wish it to be distinctly understood that I have not undertaken to show that emigration is necessarily a cause of de- terioration ; and that the emigrant is necessarily doomed to decay, and his family in time to d'e out. I wish to assert quite a differ- ent thing. The causes I have attempted to explain of scrofula, due to emigration, I trust act not on all ; nay, I am sure they do not ; perhaps only on a minority. I find in the London " Lan- cet," of February, 18i)8, the following startling statements from the able editor : " In spite of some fashionable theories of the day, we are disposed to agree with that school of anthropology which maintains that the races of men can permanently maintain them- selveo and thrive in those countries alone to which they originally belong. To point to quarters of the globe at present peopled by races foreign to the land, and apparently flourishing commercially as facts opposed to our doctrine, would be met by the reply, that annually into these countries have been and still are imported thousands upon thousands of emigrants, representing the best blood of the colonizing stock. That to form any satisfactory conclusion this constant replenishment must be arrested, and a sufficient length of time allowed to elapse to enable to see how the foreign race could propagate and maintain itself in its adopted climo. We believe it would fail, and gradually vanish and die out." (I) It would be an unpleasant thing to contemplate that our children were destined to extermination unless thev returned to the land SCROFULOUS INFLAMMATION. 141 of their forefathers. Against ^ny such strong assertions I would enter my humble protest. The editor of the "Lancet," as well as other Englishmen, in casting their eyes across the Atlantic upon the North American continent, have been unable to see aught buta mighty republic. The inhabitants of British America have always sunk into insignificance, been quite hidden by their frontier neighbors. I make this remark to add that in Canada are to be seen quite remote descendants of two of the most promi- nent people of Europe, the British and French, and, I am prepared to assert, with no marked signs of physical degeneration. The French of Lower Canada, even under many adverse circumstances, have fully retained their ancient bodily vigor, and can compare favorably with the present inhabitants of old France, while their number has increased. Yet their ancestors, many of them, emi- grated to New France two hundred years ago; and, since the colony became a part of Britain, no "replenishment" has been received from the old stock. Turning to Upper Canada we find a fact no less important and quite as antagonistic to the theory that native Americans are doomed to dio out. In consequence of the American Revolutionary war, some twen- ty-five or thirty thousand United Empire Loyalists were forced or induced to seek a home in the Canadian wilderness. Many of these were descendants of those who had first peopled New Hol- land along the banks of the Hudson. A large number of these United Empire Loyalists settled along the St. Lawrence and the Bay of Quinte. In the main, indeed, almost altogether, until very recently, these old settlers have intermarried. Now and then an emigrant might settle among them, but it was an excep- tion. The great-grandchildren of those American pioneers now live on the old homestead, and are found scattered over the whole province. And although I have no positive data upon which to base my assertion, yet, from careful observation, I have no hesi- tation in declaring that in physical development, in slight mor- tality among the children, in length of life, in powers of endurance, not to say in bravery and patriotism, they cannot be excelled by any class of emigrants. I have deemed it necessary to make these, in some respects, ..,jin.. xvtiiuri.=, icat, iHt viuw 1 nave veuiureU to express that ii' 0- f m ililiSl 142 PRINCIPLES OF SURGERY. emigration is one of the causes of the scrofulous disease, might seem to corroborate the theory advanced by the editor of the '* Lancet." Emigration is one of the causes, perhaps not so much because of emigration as in consequence of the emigrant not being able to adapt himself in diet and in other respects to the new climate. So much with regard to the primary causes of scrofula ; two or more of which may operate together. Whatever the causes, how- ever, when the disease is once engendered, it does not stop with the individual, but is transmitted down to his children's children. As surgeons we may have only to treat the local manifestations of the constitutional disease ; yet it were well to understand what are the measures most likely to afford constitutional relief. The following, perhaps, are the most important remedial measures to which attention ought to be paid : 1st. Good, easily digested food. 2d. Daily ablution of the whole body, always avoiding the slightest chill. 3d. Keep the organs of digestion and excretion in a healthy and efficient condition. If these few, but essential points, were attended to, not only might the individual never be actually at- tacked with disease, but perhaps his children might also enjoy the same immunity, although neglecting these rules. Perhaps it is not saying too much to express the thought that, if due attention were thus paid to these physiological laws, the disease might in time be eradicated from the human race. Two general ways have been given in which the local disease may become established. 1st. It may be diffused through the tissue. 2dly. It may be in the form of tubercle. There are seve- ral forms of tubercle. It may be like a millet seed in size, scat- tered through an organ {miliary) ; or it may be in much larger bodies. Again, it may be, although in bodies, infiltrated. Then the tubercle, whatever its form or size, may be either gray or yel- low. The tubercular matter may have been yellow from the first, or it may have been gray at first, and subsequently have become yellow. The only difference between them is, that in the yellow there is a quantity of fatty matter. It is the more common opinion among pathologists that the tubercular matter is at first gray, and that it subsequently becomes impregnated with the oil globules. Again, there is the encysted tubercle, which arises from the mat- ter SCROFULOUS INFLAMMATION. 143 gether, and thus forming a cyst. Still another way in which the matter is found to collect is in layers, one deposit after another taking place. This is the lamellated tubercle. The form of the tubercle will to a certain extent depend upon the nature of the tissue in which it is effused^ the closeness of the texture, and the readiness with which it yields to pressure. But why this effusion or deposit of tubercular matter ? Why, instead of natural nutrition, is there this unnatural transudation ? Why does the fibrin thus separate from the blood to become a foreign body ? The diathesis existing, one of two causes may act ; or they may act together to produce the deposit. First, any tis- sue, naturally weak, may have bloodvessels so weak, so destitute of tone, that the blood cannot circulate therein in a normal man- ner. It will move in a sluggish manner ; and the coats of the vessels being lax, the diseased fibrin will the more readily transude, the more quickly coagulate and die. In the second place, any irritation or injury to a part, or, what is understood by catching of cold, a sudden morbid impression by which the blood is arrested in its course, may lead to the same effusion. When deposit has taken place in a part, it, acting as a foreign body, is itself a con- stant source of irritation, which will tend to cause still further effusion. Terminations.— '^&ime will endeavor to remove this deposit, as she does every other foreign body. They may, if the deposits are not large, be removed by absorption ; yet such a result, after de- posit of true tubercular matter, is very rare. Sometimes the de- posit parts with its more fluid portion and dries up ; it will then become calcareous, and finally be surrounded by a cyst. In such a state it may not cause any irritation ; but in the larger number of cases it eventuates in softening, not only of its own substance, but also of the surrounding tissue. When softening has taken place, it will constitute one form of abscess, and will thereafter follow the ordinary course ; which will depend not a little on the tissue involved, as well as the extent to which the deposit had been made. In those cases which come more especially under the notice of the surgeon a favorable issue is more likely than when they are medical cases. But even when the deposit has boon made in the •-!.g,.-, « vuFv i/j n,c cHui 13 ui naiure ig noc so rare u» is commonly i •f I , i| * m' , ii ''h \ I, * 1' 3 'Si ■ I'.r Iff k - 11 h !: 144 PRINCIPLES OF SURaERY. supposed. Three ways are given by Bennet, in which the disease, when in the lung, may be turned toward a cure. " 1. By the gradual transformation of the exudation into cretaceous and cal- careous concretions. 2. By expectoration and absorption of the exudation, the collapse of the ulcerated walls, and formation of a cicatrix. 3. By the ulcerated walls becoming covered with a smooth membrane, remaining open, and constituting chronic cavi- ties, which have occasionally been mistaken for dilated bronchi." And further, " that one or all of these modes of arrestment may be detected in the same lung." But too often the extent of dis- ease precludes the possibility of either of such favorable termina- tions. The local treatment of those cases which are surgical will de- pend upon the stage at which the surgeon is called. Hopes may be entertained of its dissipation, if it be not too large, or of long standing. When an abscess has resulted, it will receive the ordi- nary local treatment. If a lymphatic gland be involved hope- lessly, it has been recommended to allow the abscess to remain unopened, not in the attempt to procure absorption of the con- tents, but to secure entire destruction of the gland by the inflam- matory process, which otherwise would remain a long time before it could be expelled by ulceration and sloughing. As a general thing, however, the abscess ought to be opened early. The tissue to be expelled may, if necessary, be got rid of by caustic, which is by some strongly recommended. The constitutional treatment will precede, in most cases, as well as accompany, the local. CHAPTER XVII. Gonorrhoeal Inflammation. The gouti/, the rheumatic, and the diphtheritic varieties of in- flammation will also be omitted in this work ; so that I now come to the gonorrhoeal inflammation. It will bo remembered that inflammation may le divided into specific and non-specific. Gonorrhoea is one of the specific forms, being due to a specific cause. The poison is created by prostitu- GONORRHCEAL INFLAMMATION. 145 tion. The excessive, irregular, and unnatural irritation due to lawless sexual intercourse begets a diseased condition of the mucous glands of the vagina, and in consequence there is secreted an abnornal fluid, which is highly irritating, and which in time will cause inflammation of the mucous metnbrane of the part. The pus resulting from this inflammation is capable, when brought in contact with a healthy mucous membrane, of causing a similar inflammation; hence its specific nature. Commonly, gonorrhoea is confined to the mucous membrane of the genital organs, but in the female it may extend to the rectum. The eye sometimes be- comes affected. It may be conveyed to that organ by the hand or by a towel, and, according to some authority, by the air, the pus-cells becoming dry, and then while floating in the air are car- ried to that organ. Inflammation, of the urethra in the male and vagma in the female, may arise from other causes, and in most respects the symptoms be the same; therefore, by simply looking at a case of inflammation (urethritis), the surgeon cannot be sure as to the nature of the cause. There will, however, generally be other circumstances connected with the case, from which cor- rect conclusions may be drawn. Inflammation of the male urethra may be produced by an in- jury; by riding on horseback; also from sexual connection when there are other discharges from the vagina than the gonorrhoeal. Sexual intercourse during menstruation may produce urethritis. The woman with whites, or ulcers of the vagina or of the uterus,' may cause her husband to have it. I have, at the time of writing this, a clergyman under my care who has inflammation very closely resembling gonorrhoea, which is attributable to ulcers on the OS uteri. Thus it will be seen, that although inflammation of the urethra may always be justly regarded with suspicion, yet other causes are quite competent to produce the disease. Further than this, true gonorrhoea may be contracted in other ways than by sexual intercourse. The virtuous may contract it, and even be Ignorant as to the cause and nature of the disease. A very common way is from sitting in a water-closet, upon the seat of which the poison has been left by a previous occupant. In this way a female as well as a male may receive the disease. The length of time requisite for incubation varies very much, from a day or two to a for^n'-?}'* ti*--i- — mi i ^ - J K.X t«u m a, loriRignt. iTiuuu «iii uepena upon the 10 r li ifH V 'I i 146 PRINCIPLES OF SURGERY. virulence and quantity of poison deposited upon the mucous sur- face. The resulting inflammation has well-marked symptoms, and as a general thing it is a healthy attempt to dispose of a poison ■which is obnoxious to the part. The first indication of the disease in the male is a redness of the glans penis, especially at the orifice of the urethra. The glans, and perhaps the whole penis, is a little swollen, though not in a state of erection. When the disease is fully established, and the surface of the membrane is made tender, the passing of urine causes a distressing smarting pain. Probably if it were not for this periodical contact of the urine, the disease would run a more definite and speedy course ; that is, the action would continue only until the poison had been carried away in the discharge, whereupon healing would take place. But the urine feeds a flame which another cause has kindled. Gonorrhoea, although a venereal disease, is strictly a local dis- order ; and although it may give rise to other serious diseases in the parts, it never involves the constitution beyond what may be due to inflammatory fever, and exhaustion from continued irrita- tion. Besides the passing urine, there are causes of irritation, which will assist to continue the diseased action; inflammation tends to cause erection of the penis, and this will lend some assist- ance to other causes. Sometimes the erection of the organ is embarrassed in consequence of a spasmodic action of the engaged parts, and sometimes from the eff"usion of lymph external to the urethra, which will prevent a regular filling of the tissue with blood such as takes place at the time of erection. In consequence of this irregularity, the organ is often bent with the end down- ward, sometimes almost at a right angle. This is a cause of great distress to the patient. The inflammation commences at or near the orifice of the urethra; but it extends along the membrane, generally, an inch or two, and may even to the bladder. Probably it is at the point of termination of the aflected membrane where the bending takes place. This is called chordee. It more fre- quently comes on during the night, while the patient is sleeping, and is very likely provoked by the warmth of the bed, or by lascivious dreams. But the unnatural irritation incident to the disease is a common cause of erection during the waking as well as during the sleeping moments. The principal product of the inflammation is pus of a greenish aONORRH(BAL INFLAMMATION. 147 color and offensive nature. As before said, lymph may be effused external to the urethra, and give rise to chordee. But a more calamitous result may ensue, in the form of a stricture. The plastic material thrown out around the urethra may coagulate after a little, and at the same time contract, so as to diminish the size of the canal. This stricture may be very narrow, like a girdle ; or it may be quite broad ; but several attacks of inflam- mation will be necessary to form one so extensive. When a stricture is formed, it will be generally the effects of protracted disease, or perhaps of injudicious attempts to arrest the discharge at an early date. The degree of constriction varies ; it may be but slight, or it may almost close the channel. Although at first very little, if the irritation continue, the lymph will also continue to be effused and to be organized, by which the stricture will en- croach more and more upon the urethra. Sometimes, indeed, the passage may become so far closed that the passage of urine is impossible, when the most disastrous results will follow. A not uncommon complication of the inflammation is metastasis to the testicles. I have repeatedly seen orchitis produced by strong injections into the urethra at the commencement of the disease, by which the discharge was suddenly stopped. But it may arise purely from sympathy. Treatment of Gonorrhoea.— The indications for the treatment of gonorrhoea will be quickly comprehended if the cause of the dis- ease is considered aright, and as well the cause of the continuance of the inflammation. No attempt should be made to abort the disease. Not only may orchitis be the result of such attempt, but the inflammation may thereby be increased. It may, perhaps, be arrested for a little ; but generally it will break out with increased violence. It is possible to destroy the poison, and prevent in- flammation, by injection, if it be used before the disease is fully established; but the surgeon is not likely to be consulted before that, and if he were, it would in most cases be impossible to diag- nosticate the coming disease. In suspicious cases, an injection of some mild material might be given as a precaution. The disease fully established, it must rather be controlled than stopped. In- deed, there is a certain amount of poison which must be thrown off in the discharge ; and as long as the discharge continues to be thick, and of a crreenish vpllnw fhovo. \a TPo°t i;i^^i^ _«: — +!--„- ! N 'lij , IH j ' i .J7 1 . ** I if 1 , '■ M «'in K t - ^H p [ ' ^ wQ w* I ^ 9^9 !»*' "! ^^9 i^^ t -Swi r' < ^ I k9 w\\ a [;' i 11 . \ 1 1 ; . ^flH 1 ; M^l 148 PRINCIPLES OF SURGERY. and consequently the disease may be imparted to another person. This poison disposed of, it may be taken for granted that the dis- charge would cease, were it not for the acid urine which in passing creates so much pain. The chief thing, then, to which the attention of the surgeon must be directed at first, is the administration of such medicines as will render the urine less irritating, and the enjoining of those rules as to diet and drink which will tend to the same end. To neutralize the acid condition of the urine, alkalies must be admin- istered. Stimulating diet and drink should be most steadily avoided, and bland food and drink exclusively adhered to. Meat must be abstained from as a general thing, at first, and farinaceous food used instead. As a drink, nothing can be more useful than flaxseed tea, to be taken as often as may be done. To fulfil the above indications as to medicines, I have been in the habit of using the following prescription. It is one which I had the opportunity of testing and seeing tested, during a period of four- teen months, while House Surgeon to the Seaman's Eetreat, New York, where there were a large number of cases constantly in hospital. I have no hesitation in giving it a strong recom- mendation: I^. Bal. Cop. Sviij; Spts. Etheris Nit. Svi; Tine. Opii Camph. gij ; Liquor Pot. 3j- M. ft. mist. A tablespoonful to be taken three times a day. But I would not recommend the exhibition of this during the first stage of very active inflammation. Copaiba, and also cubebs, are more beneficial after the more active symptoms have subsided, and when the discharge has lost the peculiar thick greenish ap- pearance. These medicines are somewhat stimulating, and have a particular affinity to the urinary organs ; and it is when the dis- charge is beginning to be chronic, the membrane being in a morbid state, that copaiba particularly is found to be promptly beneficial. During the first stage the disease should be treated antiphlogisti- cally. Injections will, under proper circumstances, prove service- able. At first they should be astringent ; subsequently they may also be useful. Sulphate of zinc is a useful medicine for injection, and so is the nitrate of silver. The latter may be used at ten grains to the ounce, being employed only once ; or it may be more safely used at two or three grains to the ounce. The strong solu- tion has been recommended to cut short the disease, but I cannot «; , SYPHILITIC INFLAMMATION. 149 advise its use. The milder solution is often serviceable when the discharge is maintained by the acid urine. The raw surface is by it supplied with a coating, and thereby protection is afforded. The disease very often degenerates into a chronic discharge — glee% which may continue for a long time, with occasional exacerbations. There may be but little pain attending gleet even when voiding urine. The discharge is thinner and much lighter in color. Of course the patient is anxious to be rid of it as he was of the disease at first. At this time it is doubtful whether the discharge pos- sesses the power to cause disease in another when brought in con- tact with a mucous surface. If the medicine in the above given prescription fails, and the discharge is in the form of gleet, the tincture of iron may be tried with a fair prospect of being useful. Diligent inquiry ought to be made as to whether any special ex- citing cause is allowed to operate, such as venery, or lascivious thoughts, &c. The painful chordee may sometimes be allayed or arrested by taking a few grains of camphor at night. There are other general principles concerned in the treatment, of which no special instruction need here be given. CHAPTER XVIII. Syphilitic Inflammation— Pathology— Question of Duality— Hard Chancre- Its Treatment— Soft Chancre— Its Treatment— Buboes— Treatment of Bu- boes-Constitutional Treatment of Syphilis, Syphilis is a specific disease, which is at once prevalent among mankind and a disgrace to humanity. It is a venereal disease, resulting from excessive or indiscriminating sexual intercourse. It is one of the scourges made by the gods from a pleasant vice. It is not my intention to investigate the question as to th^: way in which this disease originated, nor the time at which it became a fully developed disease. It is sufficient for our purpose to know that the disease was the result of illegitimate sexual commerce. It is a matter of more importance to understand the probable or cer- tam way bv which tbfi maladv ia Tif^vnoinataA ir«~ -a.-hl^-n if i- I' ll -It PRINCIPLES OF SURGERY. met with, it is a foregone conclusion that it has heen contracted from another person, — that it has not been recently generated and developed. Gonorrhoea may be generated at any time under certain circumstances ; but syphilis is supposed to be a disease of ancient birth, which has been transmitted down from generation to generation; perpetuated by sexual contact in most cases, nourished by vice and unrestrained passion. It may naturally be supposed that nature would be ever making her efforts to eliminate the disease from the system; but, notwithstanding such efforts, constant prostitution, with, the accompaniments of filth, imperfect food, and strong drink, suffice to keep the disease in living vigor, so that it is handed down none the less virulent by the vitiated and polluted. They constitute the vehicle of this fearful and dis- gusting poison as it passes along from age to age, and from one generation to another. The disease, as already intimated, is generally communicated at the time of sexual intercourse from one to the other. But it may be communicated by other means ; and this is an important fact, one which may involve the life-interest and happiness of a whole family. It would seem, from recorded facts given to us by recent as well as by older writers, that the syphilitic disease may be communicate-^, not only by contact of the sexual parts, but also when the pus from a suppurating chancre is placed in contact by other means with the mucous membrane, or the skin from which cuticle has been removed, as for instance by the hand or by the clothes. There is a school of French syphilographers who hold that this is the only way by which the syphilitic disease can ba communi- cated, — that the pus from a suppurating chancre, the primary sore, is the only vehicle of the poison. M. Ricord says, '* I have for many years had a number of nurses at the Hopital du Midi ; and I have often given them children to suckle who were sent to me from the Maternity with secondary affections. Never, as far as my observation extended, were these nurses infected. "On the other hand, nurses clearly affected with secondary dis- ease have been able to suckle infants, which were sent as being affected with syphilis (but who only had had some simple eruptions of eczema, impetigo, or porrigo), and never were these children, whilst under my inspection, infected." SYPHILITIC INFLAMMATION. 151 On the other hand, there are a large numher of writers, in- cluding many of the leading observers, on this disease, in France, Germany, England, and America, who maintain that while the disease is by far the most frequently communicated through the pus derived from a primary sore, yet it may under certain circum- stances be imparted by one with secondary sores or eruptions. But in such cases, the disease resulting is the same as the second- ary to which it owes its parentage ; in every case, like begets like. (Dr. Waller.) According to others, secondary sores may produce the primary chancre after long incubation. Venereal sores, or chancres, are by some divided into syphilitic and non-syphilitic ; that is, into those which will infect the consti- tution, and those which are simply local and which possess no power to poison the system — at least no power to enter therein. It is only those which give rise to constitutional, symptoms that they designate true syphilitic sores, notwithstanding the non- syphilitic are contracted in the same way, and are due to the same cause. But the question of duality in syphilitic poison is yet unsettled; that is, whether the chancre which is followed by constitutional disease is a distinct affection from the one which does not produce syphilization. Before proceeding to discuss this question, it is well to remark that the genitals, which of course are the usual seat of the primary sore, though they may be found on other parts of the body (I have seen them on the lips of sailors), may have sores upon them due to other causes, as excoriations from intercourse with one af- fected by non-specific ulcers of the vagina or uterus. But an individual has been exposed to venereal sores ; these, or the pus thereof, have come in contact with the healthy body ; a day or two thereafter, or perhaps a week, a sore begins to form, often at first a vesicle. There is inflammation, and speedy ulceration. The length of time necessary for inocu- lation will depend upon the virulence of the poison, and the susceptibility of the part to become diseased. The extent of the sore will depend upon the same causes. The ulcers thus formed are divided into two kinds, — the hard chancre and the soft chancre. The former is followed by syphilization ; the other is not. 'yiii k ill -p 4| W*& I'l mm rf 1 W: 1 1 152 PRINCIPLES OF SURGERY. m^ W hf' '.1 QJ i ^1 The hard chancre, as its name implies, is characterized by well- marked induration. It is generally a small ulcer, with hard, ele- vated edges, cartilaginous in appearance and consistence, having a grayish color. It may be so small as to escape notice, and hence it is that now and then syphilization takes place without the individual having been aware of the primary disease. There is little or no discharge from the sore, which at the same time manifests little or no disposition to heal. In fact, the poison, constituting a peculiar irritation, has produced what is called ad- hesive inflammation of the most decided kind ; the lymph eifused, which ought to act a part in ejecting the poison and in repairing, takes on an intense action, and in coagulating acquires the carti- laginous condition. Now, it is a question of great practical importance whether the hard (also called the Huntcrian) chancre is an indication of con- stitutional disease. It has long been thought, by some investi- gators and thinkers upon the pathology of syphilis, that the formation of the hard chancre is a salutary operation of nature, by which the poison is, so to speak, locked up in the part, and thereby prevented from entering the system. The poison, being applied to the part, ct-eates inflammatory action, and the resulting effusion, quick to coagulate, embraces within the mass the obnox- ious elements ; and although its power for evil might not be ren- dered thereby nugatory, yet as fast as its influence extends, so far and so quickly will the adhesive barrier be formed. But this beautiful theory cannot be said to have a solid foundation. More recent observation and investigation would seem to support another theory, antagonistic to that. It is declared, by those who hold the later view, that the hard chancre, with its adhesive inflammation, so characteristic of the disease, is an unmistakable evidence of constitutional contamina- tion ; that the disease has already entered the system. Wo have seen that there are three general circumstances which may deter- mine adhesive inflammation, or suppurative inflammation: these are, "the state of the blood," "the seat of the inflammation," "the degree of inflammation." Now, it matters not whether the cause be one or the other, or even if two are acting together; there must always be a space of time between the cause and the effect. And it can hardly be otherwise than that, while the poison w. SYPHILITIC INFLAMMATION. 153 is acting to cause adhesive inflammation, it is also penetrating to the adjacent tissue ; so that, although a barrier of hard fibrin is formed, it is too late to close all the avenues to the system ; it is, in reality, closing the door after the beast has been stolen. Thus we see that adhesive inflammation cannot prevent syphilization ; that before the hard chancre has had time to form, the poison has passed beyond the power of any restriction it might place to it, although it may not yet have actually found its way into the system. But we will suppose that suppurative inflammation follows the application of the irritation. The lymph, instead of making at- tempts to develop itself, immediately degenerates into pus and escapes— is thrown off. The benefit is obvious. Not only is the lymph quickly got rid of, but likewise the poison, which would have been locked up had the inflammation been adhesive, is also ejected. More than this: when suppuration is established in a part, there is naturally a determination of blood thereto. The absorbents are not so active ; perhaps are inactive. Consequently, there is a current outward instead of inward ; and so far, there is a vehicle for expulsion of the poison, not only of that which may have been upon the surface, but also of that which may have en- tered to the neighboring tissue. In the latter kind of inflammation, which is attended with suppuration, the sore being bathed with pus, we have what is designated the soft chancre. This ulcer does not differ in appear- ance from one that has been caused by other than a specific disease. It is larger than the hard chancre ; and, unlike that also, there is generally more than one. Around the primary sore there are likely to form, after a while, several more. Tlie sore is well- defined at its borders, looking as if it had been cut out; this is the only peculiar mark in its appearance. Now, it is an important fact that syphilization rarely, if ever, follows as a result of the soft chancre, although it cannot be qucKtioned that it is quite as much due to a specific disease as the hard is. From these facts it has been inferred that there are two kinds, at least, of syphilis; that one kind is characterized by a hard chancre, followed by constitutional symptoms, and the other kind by a soft chancre, which is not followed by further disease. But the correctness of these conclusions may certainly be ques- I ii! H 154 PRINCIPLES OF SURGERY. '.»* tioned. There are three circumstances, as just above stated, which may control the changes which take place in lymph subsequent to its effusion. We have seen that after the application of the poison the inflammation may be either adhesive or suppurative. Now, it would seem that the poison so acts upon the part that the inflam- matory lymph exhibits a decided tendency to coagulate, and pro- bably this is the natural effect of the poison in every case ; but in certain cases, may it not be (and I only offer it as a plausible view) that another controlling influence, adverse to the first, comes into operation, very likely arising from the state of the blood, by which the lymph is made to degenerate into pus ? The conclusion which I wish to draw from the above is, that the syphilitic poison is always the same, but its effects upon the system may be modi- fied by the state the system is in at the time the poison is brought in contact with the body. That it naturally causes adhesive in- flammation, hut under certain circumstances this tendency is coun- teracted. That when it acts alone, and causes the hard chancre, inoculation is the result; but when from any other cause the soft chancre is produced, the poison is ejected and no syphilization ensues. When, therefore, a Hunterian chancre is met with, it cannot be inferred that the constitution is already affected, and the hard sore is the effect of constitutional disease ; but that there is imminent danger of such constitutional affection — that the poison is being held in the most suitable state to secure syphilization. In connection with this question, it requires to be mentioned that swelling of the glands at the groin, and the formation of buboes, is more generally an attendant of the soft chancre than of the hard. This fact, although at first it may seem to oppose the view advanced, in reality supports it. It is not at all irrational to suppose that, although the venereal poison is mainly expelled by the suppurating sore, yet the lymphatic glands may be called upon to stay tlie entrance of a very limited portion — a duty which they faithfully perform, even at the expense of their own integrity. The poisonous material even here causes inflammation, foUowed by suppuration, and so the pus and poison escape together ; while on the contrary, in the case of the hard chancre, the syphilitic poison has only the effect of causing induration of the glandf^, and thereby incapacitating them for their natural duty, so that the SYPHILITIC INFLAMMATION. 166 system becomes contaminated. To repeat: in the case of the soft chancre, the most of the syphilitic poison is cast out by the suppurating sore, and what little may be taken up by the absorb- ents is arrested at the first system of glands ; consequently, these glands take on a similar suppurative action, whereby is disposed of that limited portion which had so far obtained an entrance to the general system. Treatment of the Runterian chancre will depend, undoubtedly, on the view which may be held relative to the question just dis- cussed. If adhesive inflammation is regarded as an indication of constitutional disease, then the local treatment will be simply directed to the healing of the indolent sore ; but if, on the con- trary, it is to be considered a sign of local deposit of the poison, of which a portion may or may not have been absorbed, and that the indurated lymph is holding the poison in a manner which may favor its absorption, whereas if this lymph were to degenerate into pus it would conduce to the expulsion of the poison, then the efforts of the surgeon will be to obtain an action in the part which will result in suppuration, and thus turn the current outward and secure the ejection of the morbid element. Taking the riew that in the hard and grayish substance, which constituted the chancre, there is a quantity of poison, the proper course would be to apply a caustic, so as to destroy the whole of the substance, and thereby much of the poison itself. Nitric acid, or nitrate of silver, will do the work effectually. It may be neces- sary to apply the caustic a second time ; and it should be repeated until the characteristic hardness is no more observed. The caustic application will have the effect of producing suppuration as well, and so far conduce to the required end. But if the constitution has become affected, if the poison has already produced syphili- zation, the indurated condition may be expected to continue, not- withstanling any local treatment. In such cases it will often be found necessary to exhibit such medicines as will change the nature of the fibrin upon the chancre. To do this the most effectual drug is mercury ; yet this medicine cannot be thus referred to without the accompanying remark, that its administration is attended with danger, and may be the cause of serious complications. This will hereafter be particularly referred to. But in those cases where the constitution is not involved, mercury is contra-indicated, irre- K \\ E'i ^)} %' m fjij.. fi ' 'i S: 1 1'^. k ,; ■t! A irf^ tri .It , jrjn spective of the evils likely to follow its use. It will in reality favor syphilization by softening the hardened substance of the chancre, and thereby setting the poison free, to be taken up by the absorbents. To repeat, then, the treatment of the hard chancre will in the first place be directed to the sore alone. Caustic ap- plications will be made to it with the view of destroying the coagu- lated and indurated fibrin, and at the same time the poison which may remain in the part. If the one application does not change the character of the sore the caustic must be repeated, until either the sore is altered in appearance or it becomes certain that the constitution is already involved. When the fact is established that the peculiar hard soi-e is due to constitutional poison, and not simply to the localized poison, which is seeking .an entrance to the system, then the treatment must be directed chiefly to the consti- tution. The course will be that which is followed when secondary symptoms have presented themselves. So far as the chancre is concerned, the patient will be anxious to have it healed. Under such circumstances mercury may be cautiously administered to break up the chancre. Treatment of the Soft Chancre. — Local applications alone are necessary. The nature of the application will depend upon the character of the sore, for all soft chancres are not alike. The sore may be confined to the surface of the part, or it may involve the sub-tissue. Sometimes the poison seems so virulent that it induces ulcerative action or sloughing, or even gangrene. This may not be altogether due to the character of the poison, but rather to the state of the part, or the system of the individual. A part which is filthy is more likely to suffer. A person whose habits are irregular, who is intemperate, whose blood is vitiated from excess, may have " phlegmonoid suppurating sores," or ulcerative inflammation, or sloughing, or even gangrene in the part which has been exposed to the syphilitic pus. When the sore is quite on the surface, and even when the sub- jacent cellular tissue is but little involved, the treatment will be comparatively plain. But when the cellular tissue is more deeply concerned, something decided may be requisite. The application of caustic is commonly recommended. When applied it should be most thoroughly done, otherwise it would seem to be attended with some little danger. It should be so done as to destroy the whole SYPHILITIC INFLAMMATION. 157 of the tissue in which the poison may reside ; because sometimes a soft chancre unexpectedly takes on the character of the hard, indicating the greatest danger of constitutional infection. And the use of the caustic will in some cases be followed by this change. However, we may venture to suppose that were the poison entirely reached, induration of the sore would not ensue ; that it is the presence of the poison in the tissue which, influenced by the cauterization, leads to the unfortunate result— the forma- tion of adhesive lymph. It must be continually borne in mind that the soft chancre will not be followed by constitutional infection so long as it remains such, but that it may become a hard chancre when exposed to such influences as will beget adhesive inflammation. Suppuration should be promoted, for thereby it may be hoped that the poison lodged m the part will be discharged. To destroy the tissue the nitric acid should be employed ; its action is thorough, and is not par- ticularly likely to be followed by a change in the nature of the sore. ^ When the syphilitic sore is attended with ulceration, or slough- ing, or gangrene, the treatment will necessarily be prompt. What- ever may be the cause of the destruction of tissue by the poison, whether it be due to the vitiated state of the individual from whom the poison is derived, or to the one who has received it, the treat- ment will be of the most decided kind. The poison is causing destruction of tissue. The first, the only step indeed, is to promptly destroy the tissue in which it is producing its destructive eff"ect8. Here again the nitric acid will prove the best. (Vide Ulcers.) Treatment of Buboes.— It will be remembered that the soft, non-infecting chancre, is the most likely to give rise to swelling and suppuration of the glands at the groin. It would seem that a certain quantity of the syphilitic virus is taken up by the ab- sorbents, but that it passes not beyond the first glands. Being detained by them it creates inflammation, and finally suppuration. When the pus, in the form of an abscess, escapes from this bubo, all the virus that has entered the body is cast off. But, in the case of the hard chancre, these glands do not nlways cscnpe. They do not become inflamed ; but they will bo found indurated and somewhat enlarged. The lymph eff-used in the gland quickly nnn^u- 158 PRINCIPLES OF SURGERY. ' r mlf ill I lates. As a general thing, when this condition of glands exists, the constitution is already involved ; constitutional syphilis will ensue. It is thought, by some recent writers, that the avenue by which the virus enters and infects the system is not by the lym- phatic system of vessels, but directly through the blood circulating near the chancre. This may be regarded as an unsettled question. When the glands at the groin are found hard and painless, as it indicates constitutional disease, the treatment will at once be directed to the system. The use of mercury will no doubt hasten . the dispersion of the indurated mass. The tincture of iodine is very often used. I cannot say I have seen, as a general thing, any benefit from its use. But I have found the application of belladonna to be followed by prompt and marked benefit. These indurated glands may remain for months without giving any spe- cial trouble, except so far as it exercises the fears of the patient. The treatment of the suppurating gland will in no way differ from that of ordinary acute abscess. The pus should be let out as soon as detected. If the patient manifests a tendency to pros- tration, generous diet will be much required. Constitutional Syphilis. — We have learned that the constitution in many cases becomes infected with a blood poison. The subtle element, introduced at the part where the chancre forms, finds its way into the volume of blood, and sooner or later, according to circumstances, it is so multiplied or becomes so developed that a formidable and destructive disease pervades the who. .tem. And the disease thus established may remain, notwithstanding all treatment, for a lengthened period of time ; sometimes it seems to be incurable. The symptoms may from time to time disappear, under the use of certain drugs ; but too often they reappear, or a new phase of this Protean malady presents itself. Period of Incubation. — The duration of time between the re- ception of the virus and the constitutional display of symptoms is not always the same. They may appear in three or four weeks, or as many months may elapse before the so-called secondary syphilis is established. SymptomR. — The constitutional disease is ordinarily initiated by a slight irritative fever, and disturbance generally of the functions of the body. Soon thereafter will appear a characteristic erup- SYPHILITIC INFLAMMATION. 159 tion upon the skin. The mucous membrane may also be affected, ■which will be 'ndicated by soreness of the throat. Varieties due to Adhesive Inflammation. — And here, I venture to think, is an indication of nature to which particular attention ought to. be paid. The syphilitic poison in the system is not there allowed to remain, with no effort to eliminate it. Instead, we see an early attempt to cast it off. It seems to be through the skin and mucous membrane that this work is undertaken. And it is the presence of this syphilitic virus, passing through the skin, that produces this exanthematous eruption. This shows how in- tensely poisonous it is. Its presence at once begets irritation, and often inflammation. The inflammation maintains the peculiarity exhibited in the primary sore. It is always adhesive. The con- sequence is, that the poison, in greater or less quantity, is detained here and there. We see it in minute points in the eruption, but it will be found in larger portions at times, not alone in the skin, but, later in the disease, in other structures of the body. This variety as to mode and quantity of virus begets an equal variety of secondary, not to say tertiary, symptoms ; and we have the roseola; lichen; syphilitic tubercle; syphilitic lepra; syphilitic psoriasis. (Henry Lee, Syst. Surgery.) In all of these there is the adhesive inflammation, which by its very action interferes with the eliminating process. As before said, one of these conditions may disappear, to be followed by another. Varieties due to Suppurative Inflammation. — But the inflamma- tion arising from the virus is not always adhesive. It may be so for a time, but at last it takes the suppurative form. Pustular eruptions as the first constitutional symptom very rarely occur, yet sometimes they do appear. At a later period, the fibrin is more likely to degenerate into pus. Arising therefrom may be seen syphilitic impetigo, or syphilitic ecthyma. (Cazenave, Syst. Surgery.) Sometimes serum only is effused, and there is formed syphilitic herpes, eczema, &c. (Lee.) These varieties of eruption, tubercles, and pustules, may be found upon the skin or mucous membrane, but perhaps more frequently on the skin. Tertiary Symptoms.— But the action may not be alone suppu- rative, but also ulcerative. The virus at first provokes adhesive inflammation. The half-organized fibrin which results may after a time not only perish, but likewise involve the adjacent natural ill. ^M fm "; ' ■'■"V ;'Jt lil H y : I If I 160 PRINCIPLES OF SURGERY. tissue. In this way great and extensive destruction may take place, constituting the so-called tertiary symptoms. Liability of certain tissues to become involved. — The disease re- maining in the system for some time, there are certain tissues and structures which are more frequently the seat of further deposit. The iris is very often affected, forming syphilitic iritis. This, however, is commonly included among the secondary symptoms. The poison not being removed from the outer membranes, the subcutaneous and submucous structures will gradually become involved ; then the deeper fibrous tissues, as the periosteum and the bone ; also the joints, and the testicles. The tertiary symptoms, then, are characterized by a more ex- tensive destruction of tissue than before effected. The skin will ulcerate or slough in much larger quantity, especially about the scalp. The mucous membrane of the mouth and throat may be destroyed to a distressing and alarming extent, even so as to pre- vent deglutition and produce death. At the same time, the perios- teum may be, in places, very much thickened by half-organized lymph, constituting syphilitic nodes; or the bones may be in- volved, leading to necrosis, or caries. Again, the joints may be the seat of chronic inflammation and degeneration ; also the testi- cles may be immensely enlarged, or destroyed by atrophy. Treatment. — Having now traced the disease in its onward pro- gress, and endeavored to give the more prominent symptoms of the various forms of constitutional affection, the question may be asked, whether anything can be done to arrest this fearful malady, at least to palliate it? The fact has already been stated that nature seemingly endea- vors to get rid of the destructive virus, but that in these efforts she is hindered by the adhesive inflammation which the poison begets. In the first place, when an individual has been the sub- ject of an indurated chancre, he ougLt to commence at once a course of most regular life. Inasmuch as the skin seems to be the channel by which the poison is to be eliminated, it should be daily cleansed by washing and thorough rubbing. And even when the eruption presents itself, the bathing ought not to be dlscon- tinned. As well, attention should be paid to all the rules of diet and hygiene. With respect to the administration of medicines to cure the SYPHILITIC INFLAMMATION. 161 disease, it may be remarked that no little difference of opinion exists; and when such is the case, some doubt may be felt as to whether any one medicine has yet been discovered which has the power to cure this disease. The drugs which stand first are mer- cury and the iodide of potassium. SarsapariUa has enjoyed a high reputation as a curative agent; but I speak from experience and the concurrent testimony of not a few, when I say it possesses no pecuhar virtues as an antidote to syphilitic poison. Mercury, in one form or another, is regarded by some as an antidote to the virus. I will give the words of a recent writer (Henry Lee-Syst. of Surgery.) He says: "There is one n^di- cme alone-mercury-which, through good report and evil report in spite of the strongest prejudices of some against its use, and the no less adverse influence of others who have employed it to an unjustifiable extent, has maintained its general reputation "From within a short time of the recognition of syphilis as a specific disease to the present, mercury has been extensively em- ployed m its treatment; and during the whole of that time the majority of surgeons have regarded it as the most efficacious of all known remedies. It must be admitted that mercury has been often injudiciously given, and that it consequently has done much harm It has nevertheless maintained its reputation, and it may be safely affirmed that general experience has proved that no remedy exists possessing so great a power to extinguish the vene- real poison as mercury. The iodide of potassium, to which allu- sion has been already made, possesses in an eminent degree the power of removing some forms of secondary eruptions, but does not, according to my experience, either prevent the occurrence or the recurrence of the disease in the same way as mercury '' There are three different ways of administering mercury It may be given internally, in pills or solution ; it may be introduced into the system through the skin, in the form of ointment ; or it may be employed as vapor, also, applied to the skin " Mercury versus Iodide of P«^«««m/«.-Notwithstanding this high authority, I^vould respectfully submit that full justice is not clone to the iodide of potassium, as a curative agent. It must be conceded that a drug which has the power, " in an eminent degree of removing some forms of secondary eruptions," must possess some specific virtue. It is not argued by the above-mentioned II B' ill li ] J.i y'f -.'ifclfja ijl i I ; I ,1 i ^ ! t -w n mmmmmmfmmmmium 162 PRINCIPLES OF SURGERY. Pi eminent writer that it merely suppresses a disease, which after- wards exhibits increased virulence, but that it does not "prevent occurrence or recurrence of the disease in the same way as mer- cury." Now, the various secondary symptoms which are pre- sented must be regarded as efforts of nature to eliminate the virus ; and if a drug has the virtue to remove these symptoms, it must to a certain extent prove an antidote to the poison— at least it assists in its elimination. And if the medicine be continued diligently for a sufficient length of time, I must say, I think almost or quite as much benefit will be experienced by the patient as would be obtained by the use of mercury. But that is not all. Iodide of potassium is not likely to produce evil effects upon the system ; whereas the exhibition of mercury, even when judiciously used, may be productive of disastrous results. Mercury is recommended as the most efficacious medicine in all stages of the disease ; to prevent, as well as to cure. If we are expected to look upon mercury as a direct antidote to the poison —as a medicine which possesses the power to annihilate the virus I submit that the evidence is wanting to substantiate such a view. That mercury has the power to break up the spots of ad- hesive inflammation, is well understood. Herein would seem to consist the only virtue of the drug; because, when that is effected, a chance is afforded for elimination. But, as we have seen, the iodide of potassium enjoijs the same reputation, though to a less extent. Taking all in all, must it not be regarded as a safer mode of treatment to faithfully try, in the first place, the iodide of potas- sium, and then, should it fail to accomplish what is required, after due trial, resort cautiously to the more potent and at the same time dangerous drug— mercury ? The aforementioned writer recommends, as far the best mode of using mercury, calomel fumigation. " None is attended by so little mischief to the patient's constitution," a most important consideration, "and none is followed so seldom by a relapse." "Mercurial inunction," he says, "is a very efficient way of using mercury ; but it is dirty, laborious, and often little suited to the taste of those who require its aid." The following is the plan of fumigation practised and recommended by this writer. It can be well recommended to those v/ho wish to employ the drug : " It ■ f 'i SYPHILITIC INFLAMMATION. 163 the apparatus) consists of a kind of tin case, containing a spirit- lamp In the centre, immediately over the wick of the lamp, is a small circular tin plate, upon which the mercurial powder is placed. Around this is a circular depression, which is half-filled with boil- ing water. The patient places this on the ground, and sits over It, or near it, on a small cane stool. He is then enveloped, lamp and all, in a circular cloak, made expressly for this purpose by Messrs. Savigny. When a cloak cannot be procured, a double blanket answers the purpose very well. At the expiration of a quarter of an hour or twenty minutes, the calomel which is placed upon the lamp, the water, and the spirit, will have disappeared and the patient may then get out of bed. " During the time the patient is taking the bath, he may inhale the vapor for half a minute or a minute, on two or three different occasions, with advantage; and after the bath is over, he must contrive not to wipe off the calomel deposited upon his skin. Pa- tients are usually recommended to sit over the bath for two or three minutes after the lamp has gone out. They are then suffi- ciently cool to put their day or night shirt on, as the case may be without disturbing the calomel on the surface of the skin A portion of that which is left there becomes, by a slow process of imbibition, absorbed into the patient's system. "Amongst the poor, a less expensive apparatus is convenient. Halt a brick is directed to be heated to a dull red heat, and then placed m a pan having a little water in the bottom. On the top of the heated brick the mercury is placed. The patient then sits over the pan for twenty minutes, with a large blanket, reaching down to the ground, round his neck. It will be noticed that in all these arrangements, provision is made not only for the volatilization of the mercury, but also for presence of water in a state of vapor This is important; for practically, it is found that the mercurial action is more certainly produced and more steadily maintained when mixed with a certain quantity of vapor of water, than in dry air." These modes recommended by Mr. Lee are the least objection- able ways of using the drug, and it may be that the desired effect can be secured without exposing the constitution to those terrible etiects sometimes seen. This treatment is followed at all stages of * !! li '-■j f '!1- *i 'A 164 PRINCIPLES OF SURGERY. the disease, whether it be the primary indurated chancre, or ulcer- ative destruction of the tertiary symptoms. For treatment of syphilitic ulcers (tertiary symptoms), see Ulcers. CHAPTER XIX. Erysipelatous Inflammation — Causes. Varieties: 1, Simple; Symptoms — Treatment: Local — Constitutional. 2. Phlegmonous; Pathology — Treat- ment. This is the last form to he noticed. One of its chief charac- teristics is a tendency to spread, both by continuity and contiguity. It may extend along the skin or the mucous membrane, or to the subjacent cellular tissue. The inflammation is the result of a blood poison, which has been gradually developed in the system. It is probably due to the introduction of some decaying matter, either animal or vegetable. It is a disease in many respects like pyemia, and no doubt may be generated in the same way as that disease; or it may be the result of son-.e extraneous substance which has found entrance to the bloody often by inhalation. A period of incubation passes, during which there is no doubt a pro- cess of zymosis, and by which the poison attains to its power to create a local inflammation. It is not improbable that the local manifestation is an extraordinary eff"ort of nature to eliminate the poison, at least when the' disease ib upon the surface of the body. Otherwise, it may be regarded as truly a disease of the tissue, because that tissue, being weak, or irritated, or injured, could no longer resist the fatal influence of the poison which had been de- venped in the blood. Synptoms. — This affection is characterized by the various phe- nomena of inflammation, although they are very much modilicd. Stagnation of blood takes place very quickly ; the coats soon arc dilated and paralyzed, and seem to be (iuitc incapable of resi.sting the pressure made by the blood circulating therein. The result is rapid transudation of serum and liquor sanguinis with the coloring ERTSIPELATOUS INFLAMMATION. 165 natter of broken-down red corpnsclea, which are dying very ra- S VI """'"''' °' *'' '■*■»''«'"' i" the transudation wh, h g.vos ,0 the part that intense redness which is also charac teristic of the disease. ft,^...._The causes, already referred to, may be divided into predzspostng and e:ccitmg. Anything which vitiates the system or impairs its vitality, thereby making it more susceptible when exposed to the morbid influences, is a predisposing cause. Of the excting, there may be mentioned infection, atmosphere, epidemic With respect to the first, it must be remembered, a^s a flct^^f co" SKlerable practical interest, that the disease may be conveyed from one individual to another, and in various ways.' It can be carried rom one house to another ; and in the hospital, from one ward to another. The vehic e may be the surgeon, the aurse, a bandage. affl cted with the disease. This shows with what care the attend- ants upon such should proceed; how necessary it is to destroy everything that has been used about the afflicted, and to thoroughly cleanse the hands before approaching another patient. The pofson emanating from an erysipelatous sore is sometimes also conveyed by the air to a healthy so.o, and changes it into an erysipelatous ont. A times, there is an epidemic of erysipelas; it will prevail in a locality for a time, and then disappear. 7>/..W.«*.-Various divisions of erysipelas arc given by writers. I may be made into idiopathic and traumatic; also symptomatic. J he first form belongs more especially to the science of medicine, an. the second to surgery. The most nsoful division is into simple '^^d phlegmonous; and these may be said f embrace every form of the complaint, however caused, and whet t it be idiopathic or raumat.c^ The simple is confined to the skin or mucous mem- brane. The phlegmonous involves tho cellular or deeper struc But there are other kinds mentioned : kinds which have received heir distinctive names on account of some prominent or prevatiin« feature. These it will be sufficient to mention. They are • aj mtous,hccamoor oedema; cellular, where the c. iilar tissue is pnncpally aflocted ; biliotis, in which there is derar.gement of tho bil.ary apparatus; erratic, characterized by a disposition to move Irom one part of tho skin tn nr..,f},„.. _..„1j... _' .. , - 1 II 1 '^ 11 '■I 1 , ' ! i * 1 f m 1 i ^ il HI 166 PRINCIPLES OF SURGERY. coming periodically, without any adequate cause ; hospital, due no doubt to want of cleanliness, bad ventilation, or other neglect of hygienic rules. Symptoms of erysipelas may be divided into local and general. The constitutional symptoms of the simple and phlegmonous are the same, with this difference : that in the phlegmonous they are more decided in their nature — are better marked. The local symptoms are the same as in healthy inflammation, viz. : pain, heat, redness, swelling. The first is sharp and sting- ing — a sensation something like burning. There is generally exacerbation at night. " The inflamed part is hot and painful ; at first, a stinging or itching is felt, which soon becomes a sharp, smarting, and burning sensation, with acute pain on pressure. The pain is not so intense and unremitting as in phlegmon, nor is it attended with throbbing." (Lawrence.) Redness is always a prominent feature, and sometimes is very bright, in consequence of which it has been designated the rose. It is not due simply to an increased quantity of blood in the part, but to a common infil- tration of liquor sanguinis and the coloring matter of the blood. A peculiarity of the redness is that it has well-marked borders ; the line of demarcation between it and the healthy skin is distinct. If pressure be made upon the part, the redness momentarily dis- appears. Swelling, as a general thing," in the simple form, is not present ; but sometimes there are small vesicles over the reddened surface. This generally indicates a serious attack, and a danger of extension by contiguity to the subcutaneous structures. Constitutional Symptoms.— In the first place, there is a fooling of lassitude, with headache ; then, considerable depression, per- haps great prostration. Tho whole of the alimentary canal is disordered. Commencing with the mouth, it is found dry; the tongue is furred, or coated, and exhibits a tendency to bocomo brown ; the stomach is at first somewhat nauseated, and food is distasteful, and digestion seems impossible ; tiie bowels are gene- rally constipated ; the liver is sluggish, perhaps congested, wliich will be indicated by pain in that region. When the liver is thus involved, the disease becomes the bilious erysipelas. Fever, with dryness of the skin, is at times very considerable ; not, however, 80 great as in the healthy form of inflammation. The course and termination of simple erysipelas will depend ERYSIPELATOUS INFLAMMATION. 167 somewhat on circumstances, but generally it runs its course to a favorable issue. In those cases where a tendency is manifested to extend to the deeper tissues, the result is less likely to be favor- able. The disease, although inflammatory, yet being due to a blood poison, which for elimination requires time and suitable con- ditions of the organs of secretion, cannot, like ordinary inflamma- tion, be cut short. It must run a certain course ; and while such IS being done, the products before mentioned exhibit a quick ten- dency to aifect the tissue in which they are infiltrated. The effused material is strongly impregnated with the erysipelatous poison, and softening and ulceration speedily follow this abnormal inflam- mation. In the truly simple form, the products are very limited and consequently the eff-ect upon the membrane is very slight. But very often the simple form becomes phlegmonous ; in such cases, the products are more remarkable and injurious ; and the , result to the constitucion will be correspondingly great, causing very great prostration, and, if the system be weak, terminating in Treatment of Simple Hrf/atpelas.— The disease may not be aborted, or brought to a termination by treatment, like as in acute inflammation, although it may be somewhat abbreviated. The principal -point in the treatment is to control the inflammation ; to hmit it to the part already involved ; and should products result, give due attention to them. The strength of the patient must be maintained, by suitable means, until the poison shall have been eliminated. If the local inflammation can at all be regarded as an eff'ort at ehmination, and that the poison is concentrating in the part for that purpose, it can be readily understood that no eff'ort ought to be made to disperse the inflammation, inasmuch as the disease may disappear in one place only to appear in another, and where it will be less tractable— less easily controlled. 1 have seen some cases of idiopathic erysipelas of the face, in which powerful means were adopted to cut short the inflammation, and which, having accomplished the object aimed at, was followed by metastasis to the brain, terminating in deatli. Whether the above-ranntioned theory be correct or not, there can bo no doubt that to control the local manifestion is the utmost that should bo sought for. The disease is prone to snread bv rnntlnnifv • t" «>*pn ih\~ n Mi III 168 PRINCIPLES OF SUKGEEY. abundant experience has shown that a solution of Nit. Argent, will prove highly efficacious. The application should be made not to the surface of the inflamed part, but to the tissue around it, allowing a distance of something like an inch to intervene between the affected portion and the part to which it is applied. The caustic so alters and disorganizes the integument, that those changes necessary to the inflammatory process cannot take place, and thus a barrier is formed, beyond which the disease will not be able to spread. The circle of coated skin must be complete ; for if the slightest space be untouched by the solution, along it the redness will extend, and, when outside, thence spread on every hand. The solution of silver ought not to be applied to the part which is red, as it is very likely to cause the disease to extend to the deeper structures. To prevent the disease from extending to the subjacent tissue by contiguity, and to abate the existing inflammation, various appli- cations ha > e been recommended. It must not, in using any appli- cation, be forgotten that the inflammation is not to be directly arrested, but rather the cause should be removed, and that there- after the disease will naturally incline to stop. To limit the dis- ease, sedatives and astringents may be advantageously employed. Cooling lotions are often beneficial ; and, on the contrary, warm applications may give great relief, more especially when there is much tension of tissue by eff'usion of liquor sanguinis. Tincture of iron, or sulphate of iron, may be applied with very decided benefit. The iron acts as an astringent, and, as well, seems to have a specific effect upon the poisoned fluid in the part. It ap- pears to supply vitality to the blood : at least a greater degree of vitality is exhiL.ted by it. Possibly the iron acts directly upon the poison which is concentrated in the part, and destroys it, cur- ing the inflammation, and at the same time the cause of it. Oleaginous applications are now and then comforting to the irritated nerves. The presence of air seems to cause some of the irritation, and if it be excluded the pain will be lessened ; hence it is that oil aff'ords relief. Flour may prove likewise beneficial. Collodion has also been used. The tincture of iodine has been highly recommended ; but it ought by no means to be used indis- criminately. When the irritation is great — the action running high — the iodine will only augment the already too great action. ERYSIPELATOUS INFLAMMATION. 169 As an application, it is more particularly useful in the oedematous form, when there is a want of acute action, there being passive congestion instead of active. In the more serious form of this simple erysipelas, when vesicles are seen upon the surface, and extensive effusion seems to be taking place, the more prompt and suitable treatment is to make small punctures, so that the blood, almost or quite stagnating, may escape. Constitutional Treatment. — Sanitary rules must be duly ob- served. The primae viae, being generally deranged, will have to receive attention. If there is indigestible food in the stomach, an emetic to remove it will be well. The liver, always torpid, should be aroused to action by a full dose of calomel and jalap. To treat the disease itself — to destroy the poison in the system— I know of nothing more useful than the tincture of iron, in doses of from fifteen to twenty-five drops every three or four hours. The powers of life must be sustained by stimulants and by beef tea. With respect to alcoholic stimulants, there is a difference of opin- ion. The late Dr. Todd was a strenuous advocate for its use. He contended that brandy not only acted as a stimulant, but also as an antidote to the erysipelatous poison. According to the cases adduced by him in his work on "Acute Diseases," his success in the treatment of erysipelas was very great. But other authority, equally- high, declares that the disease can be governed without much, if any, alcoholic stimulants. From not a little observation, I feel no hesitation in off'ering the opinion that, in the worst forms of the disease, nothing can take the place of alcohol, administered in one form or other. If plenty of beef tea can be taken, the stimulant may be unnecessary ; but otherwise, brandy will be re- quired to sustain the powers of life. Phh'(/monou8 Injlammation. — It has already been observed that by this is meant those cases where the sub-integumental tissues arc involved. The disease may at first have been simple, and then have merged into the phlegmonous. The tissue affected may be the cellular tissue, or perhaps the meninges of the brain. It is by far a more serious and fatal form of the malady. Our atten- tion will be more particularly directed to the cases where the cellular tissue is the seat of the inffamination. At the very first sight, it will be seen to be a more grave and serious affection than 1' SI m^', 170 PRINCIPLES OF SURGERY. i!t the simple form. The characteristic redness is not so bright, but it is deeper in hue. In the simple there is little or no swelling ; in this there is a good deal, which is more diffused. To the red- ness there may be a distinct line of demarcation, but the swelling is not circumscribed. Into the cellular tissue is at first determined a large quantity of the vitiated blood. Rapid distension and paralysis of the vessels follow, attended by free effusion of liquor sanguinis of a low grade. Very soon there is a complete stagna- tion of blood in the part, while the cellular spaces are distended with fluid, colored with the haematine. Following, will soon be found a degeneration of the ill-conditioned fibrin into pus corre- spondingly low. There will be no collection of pus here or there, the matter b^ing distributed through the cellular tissue. While these morbid steps are being taken, one after another, the swelling is gradually increasing ; and, in accordance with the general rule, the pain is consid^ 'able, sometimes very great. There is a ten- dency to speedy ulceration and destruction of the engaged struc- tures ; sometimes there is even sloughing. These more formidable symptoms in the part are attended by equally prominent constitutional symptoms, Avhich approach to the typhoid kind. All of the constitutional derangements specified in the simple are here present in an intensified form. The disease is generally ushered in with a well-marked rigor, which may be re- peated. The tendency to prostration is constant and often alarm- ing, especially when there is delirium. The result and final termination may be the most serious. The inflammation is very likely to spread and involve the deeper struc- tures, and to extend along the subcutaneous cellular tissue. The constitution is in danger of succumbing to the combined effects of the blood poison and the local disease. The resources of the surgical art will be required to give prompt and decided assistance. Treatment of Phlegmonous Inflammation. — The surgeon's at- tention will be at once directed both to the local affection and the constitutional malady. The danger of ulceration, ani soughing of the tissue, must be constantly regarded. The pain iS distress- ing. It is due to triiti-adation of morbid lymph, vlMch, may be, has degenerated into purf. To relieve this, the hr^' efforts will be made. In very many cases, I have seen the besr ^ Tects result ERYSIPELATOUS INFLAMMATION. 171 from swathing the part in flannel wrung out of water as hot as can be borne by the hand. It is a sedative, and relaxing to the over- distended tissue. Sometimes, on the contrary, the heat increases the pain, when of course it ought at once to be discontinued. The only course now is to make free incisions completely through the diseased structures. Let them be short cuts, but as numerous as may be necessary to secure a free discharge of the effused lymph, or pus — whatever fluid may be in the tissue. Thereafter, hot fomentations will do good service by alleviating the pain due to cutting, and by promoting the escape of the blood, lymph, and pus in the part. These incisions are necessary, to save ulceration and sloughing. No matter where the seat of the disease, the knife must be used. The scar resulting will not be so unseemly as that deformity which would otherwise result, not to speak of the dan- ger to which the life would be exposed. When the face is the seat of disease, the hesitation to use the knife may be great ; but it must not be forgotten, that when the swelling subsides, the wound will very much diminish, so as to very materially lessen the scar. The general treatment must be the most vigorous, supporting the strength by often repeated stimulants, so as to keep the tongue moist. The essence of beef should be given as freely as possible. The other forms of erysipelas which were referred to do not require any separate notice, in this work, with respect to treat- ment. In every case the disease is the same, only that in some cases the constitutional poison is more active, more virulent ; and that in some individuals the constitutional or local weakness causes complications. When these varieties of the disease present themselves, the treatment will be modified to meet the require- ments of the case. I I 'a M;,y TDX^TSXOlSr II. THE HEALING PROCESS, AND DISEASES OF THE HEALING PROCESS. CHAPTER XX. The Healing Process, Ordinary and Extraordinary ; Kepair of Tissue- Material for Repair — Fibrin. Perhaps there is r o subject in the whole range of the surgical science which can supply so much food for pleasant thought, in its investigation, as the healing process. . Indeed, the surgical science, I venture to say, is based upon its principles. In the course of our examinations of the phenomena of inflam- mation and its results, we have caught many glimpses of the ready efforts of nature to repair, of the wise steps she is ever taking to secure that end, and of the varied modes by which she brings forth her resources for its accomplishment, whenever and wherever they may be required. After inflammatory disease, just so soon as it has subsided, and physiological action can supersede the pathological, the simple but many-phased operations of nature begin to display their wondrous doings. While we have had many glimpses, now and then we have had clearer views of her all- suflicient power. From the time fibrin begins to increase in quantity and vitality, aa the eff'ect of inflammatory action, and the dilating capillaries begin to show a sacculated condition — increasing often to prolonga- tions—until healing by granulation is in full activity, to repair a broad or deep breach (which has been made by disease), continued and successful eff"orts to heal are ever manifested. So striking are these displays during what is generally considered only a morbid process, that the thought cannot be repressed that the inflamma- tory process should be regarded rather as one of many ways to heal — that it is a first and necessary step to the attainment of a great object. In other words, healthy inflammatory action is a THE HEALING PROCESS. 173 process entered upon to throw off a morbid material, local or general ; or to prepare a way to expel and carry off a foreign substance, the presence of which is inimical to the health of the part, and which precludes the possibility of restoring the part, which has departed from its normal condition. We have already seen {vide Chapter I), and it is a well-known fact in physiology, that the body is subject to incessant decay ; that every tissue of the body is mutable. The individual parti- cles have a life of their own, which is very brief compared to the life of the whole body ; and this life may be shortened by use. This never-ceasing "wear and tear" of the body would soon un- dermine the human structure, were not repair as constantly taking place. Thus it is, that, day after day, ordinary repair is made in every tissue of the body. Now, it would seem that the healing process is but a modification of ordinary repair, and that it may be designated a process of extraordinary repair. By it, nature displays her power to meet the varied contingencies which wait upon mortal man. There is not only ordinary decay of tissue, but there is from time to time a more palpable destruction of tissue. . By the process of inflammation, or ulceration, or slough- ing, or gangrene, or from a wound or mechanical injury, a breach may be at any time made. While such destruction is uncertain as to frequency and extent, yet the body is never exempt from danger ; at no period of life does it enjoy immunity from these accidents. And for the well-being of the 'body, for its preserva- tion, it were quite necessary that preparation should have been made to meet the wants when they might be felt; to effect extra- ordinary repair, when there should occur extraordinary destruc- tion. It is this which is manifested in the healing process. Repair in Lower Animals.— It is not only interesting, but in- structive, to notice the fact that the provision to restore parts exists in the lower forms of animal life to a very great extent. It has been fully ascertained (Paget) that this extraordinary power to repair is exhibited in an inverse ratio to the degree of development which characterizes the animal. That is to say, when much strength and vitality is required and exhausted in the de- velopment of the body, there will be a corresponding want of power to effect extraordinary repair when called upon to do so. On the contrary, when the powers of development are low, there Mlij 174 PRINCIPLES OP SURaERT. '^ is, to some extent, a compensation in the ability to restore lost parts. Thus, while in man a limb may not be restored -when separated from the bc^y, the hydra, when divided into many parts, has in each portion the pcvof to reproduce all the parts from which it has been separated. Animals, then, whose powers of develop- ment are low, and which are, seemingly as a consequence of that want, more exposed to injury and death, have supplied to them an equivalent by which death and extinction of the species are averted. The ability to restore is in man comparatively lim'ted. la the young, however, it exists in a much higher degree, gradually de- clining as life advances and growth and development progress. The less the power which has been expended in development, the more quickly and the more extensively can nature do repair. So far is this true, that the child, while in utero (as there seems to be convincing proof), can in some cases have restored a finger or toe, when either has been lost by intra-uterine accident ; a power to repair never known in the child after birth. Again, cases are recorded where a whole limb has been amputated in utero ; and although not altogether restored, there was found, growing from the stump, fingers or toes, as the case might be. And it is a fact of great practical value, that in childhood, and during adolescence, the healing is both speedy and more extensive ; while in middle age, and especially in old age, the process is often tardj and imperfect. It was thought expedient to thus call to mind the physiology of ordinary repair, and to make these preliminary remarks relative to the subject to be considered. The Special Agent for Repair. — We may now proceed to dis- cuss the question. What is understood by the Tloaling Process? What is this process, by which restoration is sect, red and ' ost tissue regained ? Physiology explains to us the process of ordinary re- pair, called nutrition ; by it we learn that the blood coursing through every part of the body washes away the debris, and at the same time supplies the necessary elements to form new struc- tures. This fact furnishes the surgeon with light, to more success- fully examine the method by which healing is carried on. Is the material for ordinary repair the same as that which is demanded for extraordinary repair ? In the first steps of healing, i#-.-| THE HEALINfJ PROCESS. 175 the material seems to be quite dissimilar from that appropriated in nutrition, although derived from the same source. It is from the blood that is obtained the great primary agent employed by nature to heal, and that agent is undoubtedly the fibrin. It is the fibrin which performs this most important duty, second only in import- ance to nutrition and growth. Whatever other purpose the fibrin may serve, this is the principal object, seemingly, for which it exists ; and it is a function sufficiently high, so that those who have been wont to regard fibrin as the pabulum of the tissues, have no reason to think that in losing that status it has sunk into insignificance. Can it be thought unlike the doings of nature to suppose that she specially prepares a material for extraordinary repair— for restoring parts more palpably destroyed? Judging from numerous facts and data in the possession of our profession, one does not hazard much in venturing the opinion that this is the principal, if not the sole, use to which this element of the blood is intended to be put. This view has forced itself upon my mind, and it is in accord with physiological and pathological facts. The fibrin is an ele- ment of the blood which primarily was capable of entering into the process of nutrition ; but not being required, it is left to un- dergo a change by which it is made to occupy a grade somewhat lower in the scale of vitality. We cannot suppose that the supply of food, and that part of the blood which is the most highly vital- ized, and intended for the nutrition of tissues, will always be just coequal to the demand ; nor can we admit that the supply in health is ever below the requirements of the body. Consequently, we may reasonably suppose that there is often, or always, found in the blood of the body more material for nutrition than can be made use of. The elements of the blood, like the tissues of the body, have their day F growth, development, maturity, decline, and of death. When the tissue's food has reached its highest state of vitality, it is fitted to form a part of the most delicate organ in the frame. But should it not be required,— and we have seen that m all probability there is commonly more than the tissues do want, —then degeneration sets in, and that portion will have passed the meridian of its life, and thenceforward cannot possibly take a part in ordinary repair, but may, if required, take a part in extraordi- nary repair. Not, it is true, to be assimilated to the tissue ; but '■.11 !tfi 1 1 I* V PI i h 176 PRINCIPLES OF SURGERY. to constitute a temporary structure — a scaffolding, whereby the permanent and the natural edifice shall be built. I would liken the fibrin to refuse timber, which can always be seen strewn about a building in the process of erection. It has been rejected, not only because better were available, but because other and enough were more convenient. This material, thus de- clined, is regarded as a waste substance, and, in consequence of its being thus regarded, is subject to deterioration. Now, this timber, which has failed to form a part of the edifice for which it was prepared, may yet discharge an important duty by being em- ployed to construct a temporary stage, or scaffold, by which the permanent structure shall be completed. So the fibrin. Yester- day, under another form, it was perhaps qualified to enter into the formation of tissue. To-day, in the decline of life, it is no longer fit to accomplish so high a purpose ; yet not so degenerated but it may answer a temporary use in the work of extraordinary repair. Several facts seem to support the view advanced ; two particu- larly : first, the very small quantity of fibrin in the blood when the body is in a state of health ; second, the well-known fact that fibrin increases in a part as soon as the inflammatory process com- mences — that it is elaborated in excess immediately upon a pros- pect presenting itself of it being required to restore the part. And there are other facts which serve to corroborate the theory, which will become apparent as the healing process, in its several forms, is duly considered. We have seen already that even the inflammatory process may be looked upon as a means to secure an important end, — the heal- ing process. But when inflammation is really established, what are the marks by which we can trace the footsteps of nature in the great work of healing ? An early product of the inflammation is liquor sanguinis, the fibrin of which stands ready to commence the work of repair the very moment an opportunity presents itself; not only this, but its presence seems to do much, at t'mes, in ar- resting the disease. The serum having separated from the fibrin, the latter begins to coagulate and to contract. By this means, the tissue in which the inflammation is seated becomes fixed to a degree, and the part is thereby placed in a state of rest, so essen- tial to arrest the inflammatory action, and to allow the healing to commence. This is more particularly observed, as before men- ilili FIVE METHODS OF REPAIR. 177 tioned, m serous membranes. In the abdomen, for instance, the viscera constantly moving in the discharge of function, or under the influence of disease, will, as a consequence of inflammatory adhesions between serous layers, become fixed, more or less thereby arresting the morbid action. And it can scarcely be doubted that in every part of the body, when the fibrin stiffens in inflamed tissue, it, by securing rest, has a beneficial effect, although m a less marked degree. Even when a portion of fibrin degene- i-ates into pus, and an abscess is formed, fibrin will be found around the pus in a coagulated state, so as to form a barrier, that the pus or debns may not enter the system. And if, in connection with the abscess, an artery be endangered, the fibrin will form an extra covering or coat to the vessel, to preserve the coats from harm. And should the process of ulceration extend to the arterial tissue, and the tube be penetrated, it will be found that, before this could occur the artery within had been closed by a plug of fibrin; and thus hemorrhage is averted. When we come to consider the sub- ject of wounds, it will be seen that fibrin is the effectual agent by which a divided artery is permanently closed; and likewise in aneurisms it is by it that a cure must be made. It was necessary to thus refer to these several modes by which fibrin is known to act m furthering or effecting a cure in inflammatory disease. We aj-e now prepared to examine the healing process, as presented in the restoration of tissue actually and palpably destroyed mm CHAPTER XXI. ^7o^T^Vl f P^''"-I™'"«'i^^'^e Union-Primary Adhesion-Granula- tion-Second Intention, or Second Adhesion-Under a Scab, CicatrizaSon -Requisites for Granulation. ' ^'^''"^^a-io" According to Paget, there are five ways by which the healing may ake place; but we shall learn that each is a modification of he others and that, in each, fibrin is the great agent by which the work is accomplished. ^ b y wxucu 12 iv'^i 178 PRINCIPLES OF SURGERY. 1. Immediate union. 2. Primary ad- 4. Second ini.ntion, or secondary ad- The five methods are : hesion. 3. Granulation, hesion. 5. Under a scab. Immediate union may take place between the surfaces of a wound when there has been a very smooth cut ; when the tissue has been divided by the sharpest of instruments ; and when nei- ther bruising nor tearing has in the slightest degree attended the wound. If a part thus divided be immediately placed in a state of absolute rest, the bleeding having entirely ceased without external aid, and the surfaces having been brought accurately together, so that each tissue sustains the same relation it did before division, nerve against nerve, vessel against vessel, an immediate union may take place, and the blood very soon be found traversing the vessels which had been severed. There will be no perceptible bond of union between the surfaces thus brought and retained together. For a brief time, there is undoubtedly a stratum of fibrin ; but, the part being at rest, and the tissue uninjured, and the slight irritation caused by the cut departed, the fibrin is not required, so that before it can become solid by coagulation, it is carried away by the absorbents. The wound is rapidly and perfectly healed. This process is of rare occurrence ; but that it can and docs now and then take place, there is no doubt, and that sometimes exten- sively. The following case, recorded by Paget, is instructive. It is of "a woman thirty-three years old, whose breast and several axillary glands were removed for cancer. Iler general health seemed good, and all went on well after tiie operation. The flaps, which were of course very large, had been cnrefuUy laid down, strapped with isinglass plaster, and well attended. They appeared to unite in the ordinary way, and there remained only a narrow space between these retracted edges, in which space granulations arose from the pectoral muscle. Three weeks after the operation, these were making good progress toward cicatrization ; but erysi- pelas and phlebitis ensued, and the patient died in four or five days. '" I cut off the edges of the wound, with the subjacent partH, expecting to find the evidences of union by organized lymjili, or possibly blood. But neither c^ ""ited, and the Htute of the parts cannot be better described than by saying that scarcely the least indication remained of either the place vhere the flap of the akin n FIVE METHODS OF REPAIR. 179 was laid on the fascia, or the means by which they were united It jas not possible to distinguish the relation which these parts he d to each other from that which naturally exists between sub- cutaneous fat and the fascia beneath it." " With the most careful imcroscopic examination, I could discover no lymph or exudation- corpuscles Now, had there been a layer of organized fibrin be ween the surfaces, it could not possibly have been, in so short a tune so completely removed. We are by this case enabled to mfer that two clean-cut surfaces, although foreign to each other, may also be united by immediate adhesion. When, however, the essentials, one or more, for immediate un.on are absent, then the fibrin, being required, forms a coating upon the surfaces of the wound, the serum having trickled away Under these circumstances, the wound having been closed, the glazed surfaces are brought in contact and glued, as it were, to- getner; and thus, union by adhesion, or primary adhesion, or mediate umon, as it may be called, will ensue. The interposed bond of union may be thin, or it may be thir which will de^ pond upon the degree of irritation attending the wound But sometimes the irritation of the part is so great, and of so ong duration, that more fibrin is poured out upon the surfaces than can become organized, and degeneration of at least a portion -ets in. Shortly the wound will have a coating of pus, the inter- position of which precludes the possibility of primary adhesion, ^u nature ,n no way disconcerted, at once takes a different step Although the wound may be gaping, and pus be flowing therefrom ye beneath the pus is still a covering of lymph recently poured out. a he irritation having ceased, this coa'ing of fibri.i assumes the work of repair. It is converted into yranulations, by the successive layens of which the cavity may be expected to close. But tins work of healing by granulation may be abbreviated, very often, by bringing the granulating surfaces together, and thus se- cunng secondary adhesion, or what Hunter called union by second intention. •' Healing by granulation, and subsequent secondary adhesion may not only follow a wound, but also after destruction of tissuJ fjom^ mflammatiou, or from any other cause. {Vide Healthy Again : sometimes, when part to be healed is lim itcu and II "1 180 PRINCIPLES OF SURGERY. * ii superficial, a portion of the fibrin upon the wound will, instead of degenerating into pus, become dry, so as to form a crust or scab. This crust serves to protect the part beneath from the air and other irritating substances, and thereby allows a quiet and rapid formation of a temporary structure, yet approaching in character to the natural structure. In this case, healing is procured by a species of growth which closely resembles the healing process in the cold-blooded animals. In order that this process may be car- ried on successfully, it is necessary that the serum of the liquor sanguinis should have a free way of escape, if it be not absorbed, through the superimposed scab ; otherwise it will, by its presence and by the pressure, interrupt the healing process, and cause quick degeneration of the fibriu into pus, constituting an acute abscess. Familiar instances of this may often be seen when the skin has been torn off the hand, and a scab has formed. In every one of the foregoing processes of healing, we have seen the fibrin acting a primary and principal part, and that it coagulates and becomes organized. It now becomes necessary to consider what is understood by this term ; to understand to what extent fibrin can and does, under favorable circumstances, become an organized structure, and the manner in which it is accom- plished. Organization of Fibrin. — The power of fibrin to become organ- ized has, with a show of good reason, been disputed. But tliat it possesses a degree of vitality, there can be no doubt. It will be remembered that fibrin consists of two elements: a fibi incus, and a corpuscular element. Now, when fibrin separates from the blood and is placed upon the surface of a part about to be healed, we find certain changes taking place in the constituents. The cor- puscles manifest a tendency to develop themselves — to grow. The shape becomes elongated, and sometimes they have a caudate form, or spheroidal shape. (Paget.) At the same time, the fibrin- ous portion exhibits a power to take on the form of fibrinous tinsuc, the cells being interspersed through the fibres. Tlie degri'o of vitolity shown by fibrin in thus coagulating will be found to vary. It is neccHsary hero to call to mind some facts dwelt uixtii in connection with the inflammatory process. Fibrin, when removed from the body, sooner or later shows a disposition to coagulate ; and this is properly considered the last act of life. It is truly the FIVE METHODS OP BEPAIK. 181 yorrnoHu, of the blood. (Simon.) Now, when the same takes place m the fibrm upon a wound, it is also, to a certain ex- tent, the last act of life_so far, at least, as the fibrin itself is e of viWlt f °' •"" *" "''''''^'"« «^™ --•™' ap- plies of vital.ty from another source, death and disintegration wo„ d very soon ensue. But in the successful accomplishmen of tic eal,ngproe.,s, ,t does obtain support from another sou ce wh,ch source ,s the blood itself. To have a supply of blood toTe advc„t.„ous m.ner, it i, necessary to have bloodvessels in h tracture, by wh.ch the blood „,ay circulate. It is necessary h re aga,„ call to m,nd the fact, that in active congestion the vesse be ome e ongated and sacclated; and that when inflammation follows, those sacculated portion, increase, until they are pro! by which the fibrin- ous glazing upon the surface of the wound, ns it is coagulating, provided witii 18 blood voHsols. Those ciipillary offshoots reach here and there into the coagulating ^ubHtanco and finally unite together to constitute a network, as in surfaces of a wound .s supplied with bloo,l, by which vitality m f XT la ^m Bi 1 ■Pffi ' w.% t '' ,' i M 1 1 ■ '=3 1 ». I ' ' 4-1 iiii f, 'li Uli 1 1 §. [jji,. 4 IP 182 PRINCIPLES OP SURGERY. sustained in the adventitious matter — the temporary structure; and by which the permanent tissue is to be built up. The same process takes place as well in other forms of healing, whether in secondary adhe- sion or in granula- tion. Wherever the fibrin is effused, there will be exhibited the same phenomena. The vessels are seem- ingly always formed , in the same way. Now, the adventitious matter, thus provided with bloodvessels, becomes thereby elevated toward the standard cf true tissue ; yet it is in one respect essentially and distinctly beiow it. It is want- ing, at least, in one grand characteristic of the natural tissues of the body : it cannot assi- milate to itself elements from the blood, by which its existence shall be per- petuated. The natural tissues, as we have learned, enjoy the power of begetting tissue like unto themselves, by which ordinary repair is con- stantly made, and, not- withstanding the w(?ar and tear, by which the inte- grity of the part is stea- dily niaintiiined. But this pseudo-tissue has no 3uch power ; at loast, if it has, it is in the most limited degree. If therefore follows that this new substance is doomed to polish ; that its constituent elements, as they die one after another, having lived their period of life, leave no similar elements to take their [daoo. In other words, there is not nutrition of the adventitious tissue. While it resembles ordinary tissue in being subject to wear anil tear, it cannot perpetuate itself. Particle after particle perishes. FIVE METHODS OF REPAIR 183 and is removed by the absorbents, until in the lapse of time it en- tirely disappears And while this want of power to beget tissue IS manifested in the pseudo-tissue, the natural tissue, in 4ich it is placed, displays that power to an exalted degree; so that, a. the false parishes and is removed, the true takes its place. In this way, the substance which, for a time, occupied the place of natural tissue, IS gradually removed by nature, and the natural tissue is as gradually restored. In some cases, the process is carried on very slowly. Much will depend upon the age of the individual. The younger he is the more rapidly will the work be accomplished. Even a lar.e cicatrix IS sometimes gradi^ally removed in the young. At first prominent and unseemly, it, as .onths and years roll away, per- ceptibly diminishes, until finally it fades. Sometimes the scar is so large that a lifetime is not suflicient to elFect the extinction : yet It IS ever decreasing. ^ Healthy Ulcer.-ln many cases, the fibrin is thrown out so rapidly and in such large quantities, that it fails to become or- ganized. It coagulates, but bloodvessels are not formed within It, and consequently its existence must be a brief one'. It will very soon degenerate, or actually perish. More generally, the n-ntation leads to this effusion, and it, failing to organize, dLne- rates into pus^ Under circumstances favJJ-able t'o heaiingM whole of ho effused fibrin will not degenerate into pus ; whU; the outer portion will thus degenerate, that which is immed/ately upon .0 tissue may be undergoing development. Not unfrequenUy, to irrita ion which led to the large quantity of effusion was th^ m, or perhaps other substances, coming in contact with the wound In such cases, tlie pus becomes an a. ^tant in effecting repair. It constitutes a covering, by which . air and other irritating sub. stances are kept from the sensitive healing surface inder the covering of the bland pus is a layer of fibrin, under- going changes similar to those wi.ich we have traced in adhesion. ''^> f'l-nn eonguh,tc-s ar.d contract; but it will be found that it •loos not evenly cover t!.e surface. In contracting, it has taken I -e toward mu.y .nitres, so as to give rise to little elevations^ jwth^^intervening depressions. In this way are formed granZ Into each of tliese little bodies will soon bo extended n.anill„r- \ '' . u i ! J i!:: 184 PRINCIPLES OF SURGERY. vessels ; and in a short time, veins, and arteries, and nerves are developed. The presence of nerves has never been discovered ; yet the extreme sensitiveness with which they are endowed indi- cates the existence of nerve-matter. Certainly, they are under the influence of the nerves, although one may not actually exist in the granulation. The phenomena of life is exhibited in granulations. They grow, undergo gradual development, and, having reached a certain stand- ard, they become the base for a second layer of granulations, which will be formed in the same way and developed by the same means, to be followed by successive layers. Thus,. in time, the breach is entirely filled. As each successive layer is formed, its area is somewhat diminished, so that, as the healing sore comes to the surface, it is gradually lessening in diameter. This is due to a general contraction at the base of the ulcer as the healing pro- gresses. There are a variety of circumstances which may jxiodify the healthy granulation, and shorten or lengthen the time neces- sary for its accomplishment. Cicatrization. — As, in the process of granulation, the surface of the sore approaches to a level of the integument, cicatrization commences. At the margin of the sore will be seen a bluish- white pellicle, gradually extending toward the centre. It is gra- dually developed into a pseudo-integument, to be in the course of time replaced by the natural. This cicatrization always com- mences and progresses from the circumference to the centre, until the whole of the granulating surface is covered, when cicatrization is complete. However large the sore, the process is always the same. Sometimes the covering will be seen to be simultaneously forming, from one or more points, islands in the central part of the sore ; but it will be found, upon close examination, that in these places had been minute portions of the original skin, from which cicatrization could commence. Esicntiah for Healing. — That the healing by granulation may commence and be consummated, it is necessary that there be not undue irritation. Inflammatory action must have entirely ceased. It has been shown, that in a given cape of wound, a slight increase of irritation may completely arrest the union by adhesion, and render necessary the more complicated process of healing by granulation. Now, a still greater degree of irritation will disturb ULCERS. 185 the process, w that healing „»n„„t at all take plaee, and perhao, convert the part .nto a state of ulcerative inL«™&? it ^ moved , ha the blood m the systen, and in the part should be in a phys,o og,cal condition. The part, at least, !houId be stead fast ly retamed in a state of «,, the air and other rritantset Somet,mes the above .eqnirements, however, are not met Na- proceed. In o her words, there may be a dueme of the hcalina process, prcsent.ng to the surgeon some one of the manyform 7f ulcers, or sores, which he is called upon to treat. Ulcers --i)e..a,,, ,/ the muling Process. -Vhovs may be di- vided mto two general kinds, the health, and the unhealtli hnolH . f^ ''^'''' ''P*^^' ^'^ '^''''^^ ""d^r the rules of healthy action, by granulation, the process described in the pre- ceding chapter The time occupied is not prolonged; the par when repaired, is stable. ^ ' ^ ' The unhealthy ulcer is one in which restoration fails to be ac- complished in the proper time, and in a stable manner J^^sesof Unhealthy Ulcers.-The cause of failure to heal may exist in the constitution, or it may reside only in the part. Local Causes.~l will speak first of the latter, where, owing to tain ; M^ , ' ^'"'"^ ""^ ^' ^'"''''y- I* -":- ^^ ^om- irri- tttt on ^.hich leads to excessive determination of Idood, and inflam- - ovy action. Perhaps there is not the necessary 'state ofrel I part whereupon the ulcer is situated is made to move, as upon a Innb; or, as often is seen, the function of the part keeps u{f a. I •m If* uV. < i:^ ^1 ',1^. ''115 186 PRINCIPLES OF SURGERY. much motion as will prevent the healing process. ( Vide Fistulse.) Improper position of the part, by which free circulation of the blood in the part is more or less interrupted, tending to venom congestion. The venous blood, which fills the dilated capillaries, cannot supply the elements necessary for healing. Improper dressing to the wound is another frequent cause of delay in heal- ing, very often converting a healthy sore into an unhealthy one. It is so very difficult to disseminate the true and simple principles upon which the process of healing is based, not only among the public generally, but also among the members of the profession ; and the fault, it must be admitted, lies at the door of the writers and teachers of surgery. If it could be fully understood that healing is alone the work of nature, and that to do her work she only asks to be let alone, and not to have the part placed in a state unlike the natural. Calling to mind the old but beautiful quota- tion, that "nature when unadorned is adorned the most," I would apply it here by saying that when a part to be healed is in a state of health, nature is most assisted when let alone. A healthy sore requires nothing but protection from the air and other objects of irritation, and to be kept moist and clean. Yet often will numerous bandages be applied, and the part will become heated and irritated by the discharge, which is not allowed to escape. There is always, in healthy granulation, more or less of serum escaping ; and this, pent up in the hea4;ed bandage, under- goes decomposition, forming a further source of irritation. Clean- liness, so important a consideration, is impossible under such cir- cumstances. Again, the application of ointments to healthy sores is a very common thing. Occasionally, pure lard may protect a sore from irritation ; but it is absolutely necessary to thoroughly remove it by soap and water once a day, otherwise it is sure to become an irritant. Often the lard, or the simple cerate, is im- pure, and, almost from the first, causes irritation. But even when it is not impure, it soon becomes admixed with the discharge from the sore, and very likely leads to chemical combinations which prove highly irritating to the sore and the tissue around. Although now and then unguents may serve to protect the sore, they should be strictly confined to the sore itself; for if the intognmcnt around is besmeared, it will be impaired in respect to function, and will not constitute a sound base from which shall grow and develop ULCERS. 187 '.! he g™„lat,o„8. Again, a healthy sore may beeome unhealthy fron, ,„kerent ^eakneu of He part whereon ft is located or the part „ay beeome diseased from the contact of .„™. rnZhVml nal, m eonsequenee of which the tissue which forms the baT , capabk of supplying, by assimilation, those element from Ae tiolf'anlr """ '' """"^ ™'° "" "*«-*' f™" ">» f°™a. urn „rtheT °"" °''" "-^ ^"f""^ »■''■»'' »"«■>- the seium of the hquor sangn.n.s that woald trickle away. Its nre one "Ind°" ""? "■' '■'"""«• ""<• "■"'"- »" ">»' had been done. And agam, a fcaS% sore u ,on^time> changed into an in Pnmatory „„., by the presence of the trunk of a nerve upo! Z surface, or very npnr in Jf Tf rv, u P "^ are involved Th.. ^ ' ""■""■""' P^'-ipl'ory ndrves are involved. The consequence is, very great irritation and in flammatory action of a persisting kind CbK,«««W Came, of mease in the Sealing Process -Such diseases as vtt.ate either the tissues or the blood will f L inter fere w.th healthy healing. Any general weakness, her dUa v or acqu,red-an impoverished condition of the blood, due to e. ul! hvmg or bad food-may suffice. The constitution ,krngd1™m any cause, ,f a solution of continuity occurs, from injury or in llammation, or destruction, the process of healing cannof 'ensue • or If It do, the work will be but slowly and imperfltlv pi formed' Again, there are certain diatheses, which not only giVe eha>™ L; ulcers, but are also frequently the eanse of the ule r. As 1 „" been elsewhere explained, tuberculous deposit and syphilitic p'ion cause. Afte. the local manifestation of the disease n attemnt is mJe to repair; but, the blood being deficient in vital f";?i nothmg besules protection from irritating substances, aLl ,luca- ia % ii %m 188 PRINCIPLES OF SURGERY. tion to cleanliness, with continued rest. Simpk water-dressing is the best application. The water should be neither hot nor cold. A fold of cotton, dipped in tepid water and gently applied, is suf- ficient to protect the part ; that is to say, the cloth preserves the covering of pus upon the sore, which is the natural protection. And this pus should never be removed. The sore must be kept clean ; but by this is meant the integument around the ulcer. The pus must never be wiped off the granulating surface, as may be often seen done. The constitution is not in any way aifected, and therefore re- quires no attention ; unless it be to preserve the sti-ength, under increased demands upon it. Treatment of Unhealthy/ Ulcers. — The first thing is to possess a distinct knowledge of the cause ; to comprehend exactly why the ulcer does not heal ; whether the cause is local or constitutional, or both. Then let the surgeon's efforts be directed to effect its removal. A sore that is filthy, and irritated from bandages and retained discharge, ought to be thoroughly cleaned with Castile soap and water, to be repeated at least once a day : an advice which it might seem superfluous to give ; but, on the part of many, there is such a forgetfulness with regard to this, or an antipathy to it, that it is very often, according to my own experience, neglected. The bandages should not be used a second time, but burned when removed. The part must be kept in a state of rest, and in such a position as will allow free circulation of blood. Attention to posi- tion will be more important when there is a tendency to venous congestion, and, as a consequence of it, a weak or indolent sore. In the weak ulcer, where the veins are dilated, decided benefit will often be derived from the use of adhesive straps and band- ages, by which external support is given to the vessels, and thus arterial circulation be favored. This is the great desideratum in the tveak sore : to procure pure blood ; to have it circulating freely in the part. If the blood itself is deficient in Vitality, of course constitutional remedies will be required; but when the paucity of blood is due to local causes, those alone will demand attention. In the weak sore, there is not only a want of power to heal, but, there being an effort to repair, the result of the effort is the forma- tion of granulations which are destitute of vitality. They are ULCERS. 189 pale and tall, instead of that florid -AnA fi.rv, teristic of the healthy The MT u ^PP^'^''^^^^ ^^'^'^<^- tut aeaitny. ihe sore is perhaps more than filled with ment. If touched, they are foand to be quite destitute of sensa .on, and are soft and yielding. The probe will easily broaVh™ down, and therefron, venous blood will freely escape Now ,tv often these unperfect g.anulations cannot be developed il!7 ur,ng ..ssue; and in „a„y cases, when it is aceolp fshed ,0"^ t.me wUI be required for the purpose. Consequentlr iUs oftef necessary to destroy the mushroom growth-this JhiX IT caned "proud flesh." The effort may'bele to brl; hrgrtu" lants, but this fad.ng, ,t will be necessary to destrov tb™ hi causfc generally the Nitras Argenti. A Liety ofTtiluirti'j „t::r"Tb::b T '■^''°™™^^^. - "- for'™ „f tr " ■ t ointment. The objection to unguents, before advanced, is perbans : rir:,.:;::: i rrs:;:^^ ^.^. --' *■ " .0 use them in the form 7ZCt:^2 Z^ ommonly ,„ „se I have to mention one particularly, wliici i " found exceedingly useful. It is a lotion of belladonna, led bv water and the extract. In some cases of obstinate weak and in iklent ulcers of the leg, I have succeeded in healing the soi-ttf everything else had failed. The lotion was appliedln'he mli:/ and then a bandage applied to the limb. When the caustic r^!' sorted to, it must be used sufficiently to destroy h whokor 1 le" morbid growth. Often, after the caustic, a poultice wi 1 be r^ quired to assist the process of separatio^ of the e^U Tl I" being accomplished, it may be expected that healthy triin, w commence from the bottom of the ,or» nf neo'ing will the previous weak g^ulattfrnrhav^ bTerrro^r"'!:' blood must be in a normal state, and properly supp "ed . t t pL. The Mniulcr requires nearly the same treatment as the ^ ■ ;• r I IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I liO IM 1^ m 12.5 2.2 IM 1.8 1.25 1.4 1.6 == === ^ < _ 6" ► V] 7). e c" > ^l. ■'> •> '^^??y^. /'^ /^ -<{l^ Q^i Photographic Sciences Corporation V ,v ■O' ^\ ^V o^ ";^^^^ 33 WIST MAIN STRHT WliSTIIt,N.Y. MSBO (716) S73-4S03 '^ fj. % i> % '^ ■II nil * .1 190 PRINCIPLKS OF SURGERY. week after week, with little or no variation. The bottom of the sore will present a coating of an ashy hue, which will have little or no sensation. Sometimes it will be sensitive in places. The margin is of a pale blue color, and often inverted, making the sore look as if the skin had been cut out with a stamp. This sore re- quires the same treatment as the weak kind, with this difference : that in the indolent, stimulating applications are more frequently of service than the caustic. There are no sickly granulations to be destroyed ; but sometimes it is necessary to destroy the base of the ulcer, the tissue being so morbid in its nature as to be incapa- ble of begetting any granulation at all. It is in this kind of ulcer that I have used to advantage the lotion of belladonna. Some- times, in the leg, just above the ankle, the integument around the sore is altered in character. Its color is of a brownish red ; some- what shrunken, yet smooth and glistening. The skin thus affected may extend around the whole limb. The part probably has been in that state for years, and, if injured, is incapable of healing. It is exceedingly difficult to restore it to its natural state. Although the sore is made to heal, the skin obstinately remains the same, and the sores are liable to return. Attention to the general health, and avoidance of whiskey — which is a common cause of the affection — and also attention to cleanliness of the part, may after a time do much to restore the part to health. The irritable ulcer is distressing. It is caused either by some irritating application, or by the presence of nerves upon the sur- face of the sore. The periphery of the nerves, morbidly sensi- tive, keep up an inordinate flow of blood, which is inimical to the healing process. The nerves can be easily detected by passing the probe gently over the surface of the sore. If there be scattered over it the periphery of the nerves, it will be tender to the touch in every part ; and if it be the trunk of a single nerve, when the probe comes to it there will be a sudden flinching by the patient. The only way to effect a cure is to preserve the part from irritating applications, and apply something to soothe. Oftentimes cold water is the best. VVhen there is a nerve, or there are numerous little ones distributed over the part, they must be destro; id. When the nerves are not large, a solution of Nitras Argenti may be sufficient, or the solid stick may be necessary. But when there is a single trunk causing the irritation, Hilton recommends the i''"? ITLCERS. 191 contact ot a rough substance upon which the discharge has been Ilowed to remam. Conjointly, the blood is often in a gross sta o rom .mperfect food or intemperance. I„ the first plafe th i^ hZoT T "r;"'^''- ^" ''° "■''' » '-d >o/on wi, pro';; he most useful Afterwards, the treatment will be the salll! that recommended for the irritable. The ,crofulom ulcer, the mphiUtk, and the .hughma have 1«„ fnlly c«ns,dered elsewhere, (rv,. those suhje'cts Sspeo^ The Plageienic f^^osr.-This, of all the >ore>, is the most nro .f ction Of the par::::^, b t:^toTe:urs.%s .re two promment causes. 1st. The constitution is commonlv „ a very depraved state, from privation, exposure, ^.0! ::r,td nith. ^d. Some poison, an mal eenerallv offpn ^^^i-r,- in contact with a part, perhaps th'e ^^J^Z'!!^^::.^^:, tion. 1 he treatment is the same as for sloughing. * *h;t^::l.' , ra:^^:2'rt:s*" tt-' '"^»^^ °' "ja'Jiieaiation. J he sore which results from neal, but rather as an effort to eliminate a blood poison. (Simon \ The subject more properly belongs to the subject of tuj^r^ fertofl""™' """ """ "^ '"«°«- *•" '^several (.soases of that process; and while it will become the dutv of he surgeon to restore the part and the constitution to a s,.^ a 'it ""f ""l'" unnecessarily meddlesome. Helnot w 111 .'' t tS^ |M h ; i II f jDX-^xaxojsr XXX. EXTERNAL INJURIES — CONTUSIONS AND WOUNDS. CHAPTER XXIII. Contusions — Kesults — Treatment. Contusion. — By this is understood a bruising of tissue, pro- duced by a blow, or a fall, or a weight upon the part injured. The effect upon the tissue may be very slight, or it may be so great as to actually crush out the vitality. The part, in the for- mer instance, will quickly recover its vitality ; in the latter, it will become speedily gangrenous. Then, conditions ranging between the two may be followed by inflammation, ulceration, or sloughing. The degree of injury will not depend altogether upon the degree of force with which the foreign body comes in contact with the tissue, but as well upon the nature of the part involved. When a part struck is soft and yielding, other things being equal, the tissue will not be so much injured as when a subjacent bony structure exists, against which it will be more easily crushed. The coats of the vessels, especially the capillaries, are more or less injured, and a rapid transudation takes place from them. This fluid consists of serum, fibrin, and the coloring matter of the blood. The corpuscles, many of them, are broken down ; or per- haps the coats are so lacerated that a whole corpuscle can pass through the coat. It is this effusion, taking place so quickly, which gives that characteristic appearance called ecchymosis. If the tissue be lax, the effusion is greater ; as, for instance, when a blow is received upon the eye. In this case, the lax tissue around the eye-socket is crushed against the bone, and thereupon we have the immediate disagreeable discoloration. Consequently, the de- gree of transudation will not depend upon the severity of the iiyury, but rather the laxity of the tissue. CONTUSIONS. 193 The m^mptoms are always evident and characteristic. The diaa mm IS not difficult ; neither is the prognosis. ^' JiesuUs.--Discoloration.-.ms will persistently remain for a long time, as the coloring matter of the blood is no" easilC removed by the absorbents. When the vessels are to n andnu e blood IS extravasated, the time will be very protracted Lf!. ^l sorption is accomplished. The blood will i^ '^^l^^^^^^^ or partially coagulate. This is often seen at the^c rcuXence^^^^ The result „ay finally be suppuration, the formation of an aC' and ulumate discharge. On the contrary, a species of orlizat „n Treatment-Will depend upon the extent of injury which th. cover Its vitahty, or more tardily or whether if • Y^^^/^' nerish THa ^^L. j i •' ' ^nether it is doomed to pensh. Ihe steps pursued by nature must be the guide for th,. follow. v^angrenej, and healing may be expected to In slight cases of contusion, unless upon an exposed part but httle requires to be done Whpn thaZ ■ ^*P"^^« P^", but ^ wc uuiie, vvnen tnere is ecchvmosia imnn th^ -oved. It is by the absorLts hat the work ™ bTdo ' Above all, I have found useful the tincture of arnica d' no'; do somcthinaTn r : ^;'''''^'^'\ P'-essure made by collodion may Cold water may sometimes be used to advantage, but it mu«t be 13 Mm ill 194 PRINCIPLES OF SURGERY. i i applied with extreme caution. The tissue, already very much im- paired in vitality by the crushing, may easily be destroyed. Its use must be regulated by the heat and pain and redness in the part. If either or all of those be present, cold will be useful in preventing inflammation. Occasionally, sweet oil will, by soften- ing the distended tissue, be of use ; it will also soothe the irritated nerves. A poultice, applied cold, will now and then give sensible relief ; but when the blood begins to flow inordinately through the part, cold astringents must be substituted. I have, while writing this, under my care a patient with a crushed hand. It was caused by being caught between two cars in the eff"ort to couple them. The hand was caught sidewise. The metacarpal bones were all crowded and twisted together, and the hand actually burst open in the palm. The treatment has consisted in the diligent application of ice, rolled in cotton, and careful retention of the limb in a very elevated position. The result ha? been the most happy. When extravasation has occurred, and a clot of blood exists which produces pain and is likely to cause inflammation, it may be expedient to made an incision. After a time, the clot may begin to soften, when the escape will be easy, and thus inflammation averted. When an abscess results, it will be treated on the ordi- nary principles. If sloughing or gangrene ensue, the treatment will be for such. i '1! :'l CHAPTER XXIV. Wound8-Deflnition-Cla88ification-The several Dangers attending Wounds -Incised Wounds-Characteristics-Gaping-Hemorrhage-Artenal-Na- tural Hcemostatics. YfovNBS.— Sudden Solution of Continuity.— Definition.— kn injury resulting from the disturbance of the physical continuity of tissue. The definition given by Cooper in his Surgical Dictionary, and which is generally more or less adhered to, is as follows : "A wound may be defined to be a recent solution of continuity m tlic soft parts, suddenly occasioned by external causes, and generally attended at first with hemorrhage." This definition is objection- Hi : ^Lm^ WOUNDS. able ; because tbere may be \inm,la nf ti„ v lage, as well as of the Io(tZT\ ""* "' "" '^"■•«- n.ent, as a sabre, may dvM 1 T"""'' " """"^ m»tr„- Agai„,anaxe. ^bebur d „^ hTle ;1? °""' "" ^^f' soft structures, but the bo™ as well T„ ;/'"*"« "»' """^ '^« structures are wounded aH^as the softer " """' "" ''"■'" cause division of a tendon A f '"'^'^^"f taking place, may ^eingaisp,„ed,ca„s::ttud^„,^r:f ;i:"%t^^^^^^^^ ternal causes of iniuries whiVJi rv,o i. ^ ^^^ ^^® ^^' wounds as .ny ot.ilZl'rXT/.itT Xr"^'^ '^™1 is often made bv the s„r,,^n« v. """^®'^- '^t'" ^gam, a wound whStttiftioTr^-^^-^ -'^ ---' ^''''=""'. -0- of or^et'^^ wtihThe'rol?:" "V'^r'" °' *' ™'™-« Secmd DMmn.-Uto specific and ™„.,^,„%. i» wiib fh:r„„7T:t!tetr™ "-r rr -^ *^ ^°^^ M, of the „.*, of the «::'•;: """"* "^ "-^ '--'' »f '-e Fifth i)i„«,„„._i„t„ open and mbcMancom. fSvst q„r„ •, -Oayr of Wouna,.-PrognoA and ijCJ-In the'fi' . place, let us consider the degree of danri^TT "'''" various wounds, and the source of 1 T^ . '™^ """"'* iiasnon. and ^ro, J^^ ItJilfdetn Tthe «T, "'"°" "-^ the >iu of the Jcuni. The 1 rl ho woun'l ", ' "'' "^^ the greater the danger 2d Vhl J T ' "'"'"'" '"'"^"'' of the .t^re .ttw S" Zh """ ""^ '"^ '"'^"'""- i» «"nded, as the Wt, or thetnrXT" """""« '" ''^* , "I uie lung, the danger is imminent. • ■ t j 196 PRINCIPLES OF SURGERY. Again, a wound of the throat is critical, because of the necessity of using the part for breathing and deglutition. 5th. Another source of danger is when a large bloodvessel is divided. If the vessel be large, death may be the immediate consequence ; or if the loss of blood be very great, the evil effects may be lasting. 6th. The kind of wound modifies the danger. If a wound be bruised, or lacerated, or poisoned, the danger is much increased. When a part is, with the wound, affected in either of the above ways, nature will have more to do than simply to repair, as in the incised form; consequently, the danger is greater. 7th. The danger is greater when the constitution is suffering from any mor- bid diathesis, as the scrofulous and the syphilitic. 8th. In the aged, a wound is more likely to prove serious than in the young. Immediate cause of death when it ensues.— When death ensues from the wound, it may be in consequence of hemorrhage, imme- diately taking place, or some time after. It n.ay also be from an attack of tetanus; also of erysipelas, or pi/emia. It should be remembered that a healthy sore may be the channel by which ery- sipelatous poison, especially, may be introduced to the system, through the use of a contaminated sponge, or the unwashed hand of the nurse or surgeon. A sponge that h s been in use ought never to be applied to a fresh wound. Again, death may be due to hectic symptoms, which, after a time, may supervene from con- tinued discharge and irritation, in connection with loss of blood. Death may result from a part becoming gangrenous. The tissue around the wound may have been injured, and may subsequently die ; or a part may have been cut off from the necessary supply of blood, by division of an artery. In considering the subject of wounds, it will be convenient to take the first of the several classifications. Incised Wound.— In a pure case of this kind, the tissue is simply divided by a sharp cutting instrument, the tissue around being entirely uninjured. The surface of the wound is neither lacerated nor bruised : it is barely irritated. The instrument had necessarily possessed a thin blade, as well as a sharp edge, and the least possible force would be sufficient to cause a solution of con- tinuity. This is the simplest kind— the perfect type of an incised wound. A wound may be small or large. It may be extensive super- WOUNDS. 197 fioially or deeply penetrating. Both the extent, and the direction Titit *:;::' '"'"^-'"''™^'''-p''-^-idr::: ^^racteri^io of ,He incUei „ound, .„ yam, ,aping, Umor. The pain experienced from an incised ™nd is of a smarting or : 'rfirTtir to tt °T' '^ '"^ ■''""'"'^ °f the r:r to the air, the a,r to them being exceedingly irritating. The irri- tation may in part be dne to the instrument itself by which X he contact of air, or of foreign bodies. The more bonntifuHT the tissne i, supplied with nerves, the greater will be the Z^ "^ ffWis caused by the contraction of muscles, and by' the natural contractile power with which tissue is posses ed. Gap ng s always present; but the degree will depend, not upon th 'con ™n ' ';ir "'•"" P™"'^^"^ ""»■' *^ -i-ction of he wound. The gaping is greater when the cut is crosswise of the muscle, and less where it is parallel with the fibres. Th dcepe the wound the greater the gaping may be expected to be. ^ Ber^rrUge may come from an artery, or vein, or from capilla- divided The surgeon must distinguish between arterial and venous hemorrhage. It is not difBcult to do so. Blood from the artery comes m spurts at each contraction of the heart and art/ ries-"^.. ..ft ,. Th, „,„i^, „„„^ .^ a bright rdbl; xygenated. The venous blood, on the contrary. Issues witTf steady even Sow, and presents a much darker hue frtertal Bemorrhage.-It will bo advantageous to remember t in discussing this subject, we shall learn the nature of hemor fof b bT''™™" '"^'™' »P-'i«nMn the perrrm. ance of which, the surgeon intentionally divides structures of the in t'cil's" ':: ^ 'T,n "' '"""^' ""^ - -P"'"'^- and n excisions. Also we shall learn many of the principles reUtin^ e aneurism. Arterial hemorrhage is the mos' dangerous form^ I It come from several, or many smaller vessels, it will proveleTs dfcl to control, than when it comes from a ^e vessef H again, the surgeon, to properly comprehend what steps shall b^ aten to arrest the bleeding, must carefully examil the f o en! of nature-must learn of her who is an infallible teacher "^ >|.i i if 9 Hi! 198 PRINCIPLES OF SURGERY. rm M ibJhB^hh^ I H ' 1 ;'" I^^^^P ^.!i.:.! I^^^^^^^H' , •ii i Natural Rcemostatics. — It is a fact, known by any observer, that in many cases, hemorrhage, which at first seemed fearful, will in a short time be effectually arrested by nature alone. The surgeon can but proffer assistance — can but order circumstances which will constitute, so to speak, a starting-point for natural operations. Any one who has seen the knife in the hand of the surgeon, dividing the tissues in the performance of an operation, will have observed that the blood at first came rushing copiously forth, but that it gradually lessened, until, in most cases, it entirely ceased to flow. One minute, it would seem to the uninitiated, that the patient was bleeding to death ; at the next there would be barely an oozing. The mouths of the vessels from which the blood welled are quite closed. Now, by what means was this accomplished ? How can we account for this phenomenon? From careful investigation it is found that there are several im- portant steps taken, one after the other, but in quick succession, the result of which is the stoppage of the bleeding. That con- tractility of tissue, by which gaping of the wound is produced, affects the arterial coats, in common with the other tissues. Un- der this irritation the coats both contract and retract. It is a rare thing to see fully exposed the open mouth of the vessel, although bright red blood marks the spot; and the reason is, that it is drawn in from the surface of the wound — the coats retract. The contraction of the coats will lessen the size of the vessel, and in very many cases completely close the mouth, and so arrest the hemorrhage. This is favored by the absence of that pressure from within, which is regularly made by the ever-passing stream of blood. Of course this contraction and retraction are principally due to the muscular coat by which the artery is drawn in from its sheath. The result of this combined action of contraction and retraction is that the lips of the open vessel are drawn in, making it seem as if the middle coat were contracted more than the ex- ternal, and the internal more than the middle. The lips of the internal coat are in this way drawn towards each other, and in smaller vessels actually together, thereby stopping the flow of blood. When the coats are thus brought in contact they unite by adhesion, and thereby accomplish another step in the process of natural haemostatics. But when the contraction is not sufficient to close the vessel completely, the object may be attained by WOUNDS. 199 further aid, which nature, prolific in means, will be able to give Kemember ijiat the vessel is drawn from its sheath, leaving a space which is quickly occupied by blood (with perhaps an excess of fibrin in it). This blood will soon begin to coagulate and contract, and this ring of coagulating blood will, in a cer- tain number of cases, afford sufficient pressure from without to complete the work of closing the vessel. Sometimes the sheath is drawn away from the vessel by the contraction of the tissue around, in which case the space between it and the vessel is greater, and the quantity of blood to coagulate will be correspond- mgly greater. Not only will this clot form around the vessel, but It will manifest a tendency to extend over the mouth of the vessel • and. If the blood do not spurt out with too much force, this will be successfully done; and thus the artery will be sealed with a clot of blood which IS quite external. But when the artery exceeds a certain size, the force of the wave of blood will be so great as to prevent the formation of the clot over the mouth, and the bleeding will continue. A certain length of time" is always necessary to determine whether nature can accomplish the work or not. Here then are several means by which arterial hemorrhage is at first naturally arrested : First, there is contraction and retraction of the arterial coats, which tend to close the open vessel; then, the space between the vessel and sheath is occupied by coagulating blood, which by external pressure will further the process already commenced ; finally, the clot of blood may gradually spread over the mouth from which the blood was spurting, and so form a com- plete seal. This is the first stage in the process of natural haemo- statics. These steps, although admirable, ar^ not lasting; yet they are of sufficient duration to enable other and permanent ones to be taken. When the lips of the inner coat are in contact, adhesion will take place between them ; it is immediate union; but when the hps are not in contact their surfaces will be coated with fibrin which, perhaps, will constitute a bond of union. When, however' the outer clot of blood is slowly formed, there will be, when the bleedmg is finally arrested, a plug of fibrin formed in the orifice Now, whatever may be the way by which the mouth of the vessel IS closed there will immediately follow steps for organization in the fabrin. And, while this is being done the arterial tube will be i w ■ <. ! ^mmm^m M 200 PRINCIPLES OP SURGERY. gradually filling with a fibrinous clot, which will separate from the blood coming to the part. This plug of fibrin will form along the tube as far as the first branch given off from it. It will fill the vessel at the point where it is divided, but will taper to a point, making the whole cone-like in shape. By means of this clot the hemorrhage is effectually and permanently arrested. In time, the clot of blood, which acted an important part primarily, is detached, and cast off; but the internal clot assumes the form of adventitious tissue, perfectly seals the wounded vessel, and, finally becoming amalgamated with the arterial coats, there remains but a cord-like substance. Thus we see that in natural haemostatics fibrin is the necessary agent by which the action is completed. The clot in reality constitutes in the whole length, as far as it may extend, a bond of union to unite surfaces together. When it has served its purpose it will gradually decay, and be removed ; and so will the arterial tissue in the process of time. This is the second and last stage in the process of haemostatics. In order that the above described procedure may be commenced and carried on, it is necessary that the artery be not too large — that the blood do not flow into the part with too much force ; be- cause the rushing blood will not allow coagulation to take place at the orifice. Under such circumstances, it will be for the surgeon to give the assistance which art places at his disposal. There are two things, generally, which may be done, or attempted, either to place something against the vessel as a substitute for the external clot, until the inner clot of fibrin can have formed ; or to arrest or diminish the current of blood flowing to the part, with the ob- ject of allowing the external clot to form, which had been pre- vented by the force of the regular waves of blood. And this brings me to speak of the general indications in the treatment of incised wounds. TRKATMENT. 201 CHAPTER XXV. .ion^ .nd cold water applied wi„. ^a'S ll rTrarr; much increase the irritatJnr, t> u , . ^' ^^^^ unifo™ cold i^r.^rZTtXv^n ruJ^ ' ""' "'"• ^ ;.ud w.. L J»^r;^lrlTctr "";f :„,"! ■„ re™! "' """^'^ "^ ^ f°"» "' -"»" «>»'h, frequntly dipped pressure, either agamst the open mouth (direct pressure) or nnon the arterj above, where, in its course,' it can be convenient?; - ) < i' I if fflf 202 PRINCIPLES OF SURQBRr. *t !•» made (indirect pressure). The most speedy way in which pressure may be made, is by the hand. The finger may be thrust into the wound — as it often is, by the operating surgeon, when a gush of blood interrupts the proceedings — and be placed directly upon the vessel, the warm gushing blood being his guide. Oftentimes, the surgeon will be sent for, in hot haste, to visit one who has been seriously wounded — at least, the bleeding is frightful. The sur- geon will, in such cases, be called upon to display his presence of mind, where all is confusion; and his skill, when all eyes are turned to him. Numerous bandages will, no doubt, have been applied, and the bleeding may have ceased ; but the bandages, in every case, will have to bo removed, that the vessel or vessels may be properly secured. If there be no bleeding, all arrangements should be made before the bandages are touched ; but should the arterial blood be seen streaming through them, then the proper course is to use promptly indirect pressure, if it be possible ; or to tear the bandages away, and control the bleeding at the vessel's mouth. The flow of blood arrested temporarily, the surgeon can consider what further assistance or instruments he shall require. Sometimes the exposure of the wound to the air, with the irrita- tion and pressure of the finger, will prove suflScient to close the artery; or the pressure may have to be continued for a time. There are several ways of applying pressure; namely, by the hand, the compress, the roller, the tourniquet. There are several kinds of compress, which may be applied in various ways. Very often it is composed of a roll of cotton, or several layers of cotton. The compress may be put directly upon the bleeding part, or it may be indirectly applied. The compress properly adjusted, the pressure may be made by a bandage passed around the limb or body with suificicnt tightness; or adhesive straps may be employed instead. When direct pressure is contin- ued for a time, it is in reality intended to take the place of the external clot of blood, which would form at the mouth did not the current of blood constantly force it away; the pressure should therefore be continued until the inner clot of fibrin can have formed. And it will be understood that the pressure requisite will be just so much as may be necessary to overcome the force with which the blood comes to the part. There is a danger, into which I have seen many surgeons fall, nip TREATMENT. 203 of having the pressure too great, and of continning it too long a t.me. It .8 an .noised wound; and although the desiraMtyVf Ob a,„,ng un,on by adhesion is important, it\ never.hZ ^'uite But at the sal"; """"""" ™^ "' "^'''-S "'^ h-o-'age. *. compress he a,i„«dtrtraXbT:^Lrr:r In every case, however, if there is an error, let it be on th d^ of undue care to arrest the hemorrhage. When the prossur 1 .nd,reet, the object aimed at is to diminish the force of L arteria yet not partteularly mjurious. For further remaVks on indirlt premre-toumiquet-vide Aneurisms. tioff " A "sunt"""'"''' ■' ?' "^^' "'»'' °f ""'«- '» l-e men- t sue 'an^ T\ ""^ ?' ''^ """"■""""S "^ constraining the Colfl^l ^ '"'""^' °'-." ""'y "=' simultaneously in both ways Cold watc ,s commonly included among this class. A most valu- u r.i,c' uTod "'""■ '^ '"^ "^"' °' '™^- 1' -'» «'■-= "t upon he blood, causmg ,t to solidify very quickly. It mav be rt^tfit'T"?' '"t 1 »"» *-"-^ in'utcrLTcLr! rhag. , and .t may be appi.ed directly to a bleeding part bv a p.eceof cotton saturated in the lotionf There are f vaHc'.y of vegetace astr.ngents which may be employed, but it is uleces v oen^nerate them. I mention only'one more astringent! tht Imct. Fcrri-which I have seen arrest bleeding when other .neans had fai ed. Styptics may be used in conii ion w tl pressure, or other remedial measures The nuffl,.,ll ! omes^rcmedy, and a very useful one, I! ^bf m^liol Tw vl e, tl r-1 '° ™°«'""'^-' '' """"''"S '"itahlc materia upon which the flunl may rest and the fibrin solidify use to arreln "'°''"," P'"™,™™? *= -g""'' "bich the profession ° u Hr, r ''™:'*«':- I* '^ "»' »« ™»™only resorted to now am the days of barbannra, yet even now it is used by some and ».th success; but it should not be employed when a less nt'i,!ft,l -d starthng remedy can be used. A 'heated iron , p,d ed t' tS « „g part forms a charred covering; the artcrhd'tiss „ J "'«t around, ,s destroyed, and a. the .an,„ time dried up ; thereby 11 I 204 PRINCIPLES OF SURGERY. the vessel is temporarily closed ; there is formed a substitute for the external clot, and thereafter the internal clot may be able to form. But, inasmuch as the eschar will have to separate from the living tissue by a process of suppuration, there will always be a doubt whether the fibrinous plug will become affected, and degene- rate so as to open again the mouth of the vessel ; but, in many cases, the fibrin will be suflSciently organized to resist the influence of suppuration. The cautery should be heated to white heat, so that it will completely dry up the tissue , and, consequently, there will be less of suppuration as the eschar becomes detached, and the danger of secondary hemorrhage will not be so great. Nitrate of silver, as a potential cautery, is of great utility. It seems to act in two ways: first, by drying up the tissue, and thereby closing the vessel ; secondly, by inducing coagulation. It may be used to advantage in small wounds, where union by adhe- sion cannot be expected. The ligature is an agent for the arrest of hemorrhage, which demands a somewhat extended notice. It is as useful as it is old. Different kinds of ligature have, from time to time, been employed by the profession. The changes which have taken place have re- lated to the material of which it was made, and to its shape and To give a history of the ligature, although interesting, size. would not be of suflicient practical use to warrant its introduction here. The round ligature, made of well-twisted silk, somewhat waxed, is the one now very generally u^ed. The celebrated Hun- ter used a flat and somewhat broad ligature. The principles upon which this practice was based were erroneous, namely, that if the surfaces of the inner coat were brought together and there re- tained, union by adhesion would result, and the danger of suppu- ration within the vessel would be averted, — such as attends the division of an artery, and the subsequent sequestration of the ligature. He particularly aimed to avoid a division of the coats, and employed a ligature broad and flat, that the surfaces might he pressed together without dividing the tissue. But, unfortunately for this theory, it is impossible to apply a broad ligature without extensive detachment of the artery from its sheath, which would necessarily give rise to considerable irritation. And, more than that, the arterial tissue would bo deprived of its nutritious supply by this separation of the sheath. Irritation, inflammation, and ift TEBATMENT. 205 rappumtion wm necessarily follow outside the artery, and the process of adhesion within be thereby thwarted. This practice was pursued by Hunter in connection with aneur- rardialsire ' '' *" "^''" "" ™°'' '°"" *'""""=« »" «•"« The theory now held, and which may be considered a true one, as , has stood the test of many, many years, is that a ligatur Je Whed w,th as little irritation to the tissue as is possi! ble; and that every care should be taken to preserve the nutritious vessel Another essential point in the theory is, that the interna and »,ddle coats should be divided. To secure the above indica «ons the round l.gatnre is employed. The surgeon divides no more of the tjssue with the knife, than is necessary to reach the artery; and then, with the greatest care and gentleness, pas es the tenaculum around U. Finally, the ligature is tied aromd the vessel w,th sufficient firmness to divide the coats within, which he surgeon can know by feeling a yielding sensation, while the exter- nal coat remams unbroken. The coats within, immediately upon being divjded, contract and retract, so that they are drawn some istance from he seat of the ligature. Heroin seems to consis U, safety of the operation. That portion of the eternal coa which ,s embraced by the ligature, is doomed to destruction; and the work of Its sequestration will be attended by ulcerative in- m tation, the inner coats having retracted from the place where • ha. irritation exists, the formation of a clot of fibrin will duW Ukc place, which will not be exposed by the subsequent ulceration and separation of the ligature, unless it should be considerable In favorable cases the pus formed may be measured by drops. The advantages of the round ligature, it will be seen, are twofold- .1 can be more easily applied, and by being tightly applied h dmdes the internal coats so that they retract ffom Ac'plce irritation, where a permanent plug of fibrin is allowed to form. The ligature may be used to the open vessel in the wound, or T e operation for cutting down upon an artery for it, ligatb,^ toTvi„° 1 '" '" "■' '™""""' °f »«"""»»• With rC .1 to tying a vessel in a wound the surgeon should remember, in using the forceps or tenaculum, to make as little tra.'ti.m a- -....;". lii }. tl' i ! t|.1i I: 1 1 It 206 PRINCIPLES OF SURGERY. The artery should be only raised sufficiently to allow the application of the ligature. And when tying the knot, care must be taken to so hold the ligature that the vessel will not be disturbed in its bed. This is essential, that the sheath may not be separated. It is always desirable that only the arterial tissue shall be inclosed in the ligature ; but sometimes it will be so contracted, that some of the tissue around will necessarily be included in the mass. The larger the mass the greater will necessarily be the ulceration, de- struction, and obstacle to union by adhesion. After tying the knot, one end will be cut oiF, while the other will be allowed to remain hanging from a corner of the wound, so that it may be re- moved from the wound when it has separated by ulceration from the artery. The requisite time, for this work of nature, will de- pend upon the size of the artery and some other circumstances. The time given by most authorities varies from ten to twenty days, with the average being fifteen days. The existence of this ligature in a wound may be the only bar to a speedy union by adhesion, and the surgeon may be tempted to try at an early date to extract it. Any such procedure is attended with great danger of secondary hemorrhage. It is neces- sary to wait until the ligature is in all probability sequestrated. In removing it no force should be used whatever. The surgeon should make the very least degree of traction, and should it at once yield, it is well ; but if there be the slightest holding, he ' must at once desist. The danger consists in this : if the artery be disturbed before the inner plug is firmly established, it may be dislodged, and thereby the vessel be opened. From time to time the trial may be repeated until it is found to be separated. I have in mind a case where, after amputation at the shoulder-joint, an injudicious eflfort was made to extract the main ligature. In a few hours after, alarming hemorrhage came on ; the result was, that the wound had to be opened and the artery tied again. Occasionally the ligature, although quite detached, will be held somewhat firmly by the granulations. This can only be inferred, after a long time has elapsed. Torsion consists in seizing the divided artery, and drawing it slightly from the sheath, and then so twist it as to crush and lace- rate the coats. By referring to lacerated and contused wounds, it will be seen that in them the hemorrhage is not so great as in the • » r TREATMENT. 207 incised. The irritation of laceration causes a greater contraction Somefmes the seizing „f the vessel with the forceps, and hold- ing .t for a moment, will prove snffieient to arrest blading .l™^„.«re._Another agent yet to be noticed, is a form of teect.pressnre. It .s not as yet in general use ; bm is, no doubt of great value Dr. Simpson, of Edinburgh, has introduced it and commends .. highly to the profession. Certainly the principles .re most sound upon which the practice is based. I„ the ampu a- ..on of a large l.mb the ligature which is applied to the prrncipa, artery w,l very materially interfere with healing by primary adhe s.on and the process of sequestration of the ligature will !oL long fme delay a perfect recovery. In view of these facts it can b! readdy understood that if the ligature, the foreign body, could be reujeved th,s delay would not be so protracted. Now the ligature s ,ed around he artery to an-est the blood until the plug of fibrin as formed w,th,n; after this has been accomplishedf it is Z longer required; but there it must remain until the pro ess of »eparat,on by ulcerative inflammation is accomplished. This however, endangers the integrity of the inner clot. Could, thej^ ore the hgature be untied, or divided so that it might be ex. traded, the process of recovery in the stump would be hastened and secondary hemorrhage averted. Dr. Simpson proposes to subsftute for the ligature, a substance that m!y at a'nTtil b U en away ; and which, while in the wound, is even less Lra ing than the l.gature. A pm, of suitable size, is passed from the in tegument of the flap in which the artery is sftuated, and i? hen made to appear on the cut surface of the flap jus beside the artery; ,t ,s now made to bridge over the mouth of the vessel and of he skin. By this means pressure is made upon the vessel wh.l„ the vtality of the arterial coats is not at aU ie pard zed' When the artery has become permanently sealed by 6^1^ wi h n he pm can be extracted, and nothing remains to interL with the quick and permanent work of repair by adhesion. Not having had an opportunity of testing the practicability of Ins procedure, I can only say that the principles are sucli as commend themselves to the reflecting surgeon. Indee,!. I can j ■( I hi 208 PRINCIPLES OP SURGERY. hardly think that Professor Simpson (whose kindness to me, while in Edinburgh, I remember with gratitude), who enjoys a world- wide reputation, could be led astray by anything doubtful. I have now noticed the most important remedies for local use in the treatment of hemorrhage, every one of which is used with strict attention to the way in which nature travels to do the same thing. They are all designed to aid in the process of natural hcemoatatiea. Constitutional Means to Arrest Hemorrhage. — It is often neces- sary to resort to constitutional measures to arrest bleeding from arteries ; perhaps in connection with local treatment ; perhaps when it is impossible to successfully employ local remedies. Here again let us study the operations of nature, that we may learn the true principles of constitutional treatment. The phenomena of fainting from loss of blood supplies us the necessary lesson. Among other symptoms of fainting, is a very feeble pulse, indi- cating a diminished action of the heart, and a tardy flow of blood through the arterial system. Therefore it often follows, when the vessel is not large especially, that as soon as fainting occurs the bleeding ceases, and at all times the flow is diminished in force. Now, it not unfrequently happens that during the period of syn- cope, while the blood is flowing slowly and with little force, a clot will have opportunity to form in the orifice of the vessel, and with sufficient firmness to resist the volume of blood when it again comes in full force. While the blood flowed with natural force, this was impossible ; but when it came with lessened speed, the tendency to form a coagulum prevailed, and thus the hemorrhage became arrested. From this fact it will be learned, that when a person faints from loss of blood, he should not be hurriedly re- stored to animation, but rather he ought to be allowed to remain in a state so favorable to natural haemostatics, unless there should be danger of sinking. And when the patient does begin to re- cover, great care ought to be taken to have a gradual return to power of the heart ; inasmuch as a sudden action of that organ may — indeed, is likely to — dislodge the clot which has formed. Stimulants ought not, therefore, to be given, unless reaction is doubtful. From the above facts, we moreover learn that diminished action on the part of the heart, and the consequent tardier flow of blood, TREATMENT. 209 is favorable to the arrest of bleeding -NTa,, • involving „teHes whio. ^ZtlZX^'T. lT„t: chanical-of body and mmd-must not be forgotten. An assu ranee to the patient, when such can be »ivm t^ . u- • aUrming. will have a tranquniilg X"; ^.^ '"%" "I the^by upon the heart; and\erfeet'ret e „f hfd;;:tiat of the part where the wound e.i,ts, will materially oondu e t^the ormafon of the clot. For agents to eontrol the aetion of he heart, and to eeonre repoee, there partieularly are antimonT Seccnd<,r^ mmorrhage.-VfbiU speaking of arterial hemor r age, allna.on has been n,ade to the faet that, after a time tW b eedmg may reeur-there may be .eoondar^ hemorrhre the fibnnoue clot wuhin the vessel having been disturbed. ^' ..T;:Zl^'"'^'^ ""'""-^'-^^y "^ «"^ed into Ucal . f"""' f7»«— Are: 1. Inflammatory aetion, by which the .nernal clot, mstead of becoming organized, is made t" detene rate, thus openmg the bleeding channel afresh. 2. Uleerft on erhaps ,n consequence of injury to the arterial tissue, at the time he wound was received. 8. Inconsiderate meddlii^g with the ligature, before sequestration is completed ^ Oeneral, or Oomliiutimal Came,.-\re certain diseases of th. Wood, oharacterked by unnatural fin.dlf, „f ; ,.,'"', °' '"« Tu^ci. ■ ■ ■ , y ""'""nrai ouidity of its so id constituents The fibrin is incapable of permanent coagulation- it exTsts for ^ unpleasant a complication. When the bleeding aetuafly occurs same rules w,Il be followed as .re observed in prima^ hem„r: ^J; o:r :rdii:sir '- — - -^ ^- - - .he^r"' Tlfrr-^'" T' '^'"^ "-^ ^^t'^^"'^^ '' hea'- allowed to remain between 1^5/' ."'"' "''*'<"'" "■"« ^ •"rface or in the boC o/the wot? '" '° ""'""' ^'"'" " "" ta4X«fsul°Ts!"ff':'r T '" "™ '» -"- »»f' «P°nge mth water will generally be !t \\t.\ 212 PRINCIPLES OF 8TTRGKRY adequate to remove the clotted blood and dirt. Larger and firmer bodies can be extracted by the dressing forceps or the finger. Foreign bodies having been completely removed, the surgeon is prepared to attend to the Third indication in the treatment of wounds,— to approximate the opposed surfaces of the wound and retain them immovably in contact. It will be remembered that the separation, or gaping, is caused by the contraction of muscle, and the contractility of the tissue. These causes of gaping must be removed, or controlled. It is, therefore, of primary importance to relax those muscles by -which the gaping is produced, and by every possible means beget a state of quietude, so as to prevent any twitching, or irregular action of muscular fibre. The first things to be attended to are position and rest. The agents, besides, to be used, are bandages, compresses, adhesive straps, and sutures. Bandages prove serviceable in two ways : first, by giving sup- port, as when applied around a limb; and, secondly, by controlling muscular action. The benefit to be derived by applying a bandage, from the extremity, along a limb to the wound, cannot be too highly esteemed. In large deep wounds a compress placed on either side of the wound, and bound there by the bandage, assists very materially to bring the deeper surfaces of the wound together, as well as the superficial portion. The pressure made by the bandage must be uniform from the extremity, to prevent passive congestion. The bandage will slacken here and there in a day or two, perhaps in a few hours, and will require to be readjusted. When this becomes necessary, I have been in the habit of apply- ing a second bandage over the first ; as to remove the first for the purpose of tightening it would expose the wound too much to dis- placement. Adhesive straps are more particularly useful in superficial wounds, as they cannot draw together the surfaces at the bottom of a deep one ; and when employed for deep wounds it can only be for the superficial part. They should not therefore in such cases be used alone; as to bring together the lips of a wound, while at the bottom the surfaces remain apart, is not only useless practice, but an actual evil. The space at the bottom of the wound will become filled with liquor sanguinis, the fibrin of which will soon degenerate into pus, and thus an abscess will be formed. THIKD INDICATION. 213 »n,on of tho I.p8 „.y have actu.ll, takes place. AdhLe ZZ may do more than aet upon the lips of a wound if theXp" 'ed fghtly and entirely around the tab wounded, so^ to'make pressure at the deeper parts. Before proceeding to apply straps, the integument around ou^ht to be made perfect y dry, else they will not adhere firmly They ought to be cut m long strips, which will insure a greater probZ bihty of their adhering, and, as well, that rest of mfscTe so nece" Bary for immediate union. I have verv often «PPn „T • cut so short tlio* +1, 1 J ^ ®^®" adhesive straps rata ^ '" not possibly secure the above deside- to h^al"^' fr^^ "'?' *°° ^^^^' *^«^« <>"gh* -t the same time wound ''ZT''" *''"' *^ ^"^" *^^ ««^"^ *° --Pe from": wound. I ,s also important to have the straps fit snLly to the skm in their whole extent : to secure tl„'« ,-f -J ^^ fere with .hf union W adti^ Thf ';!"' r*^ 'f""'^ "'''■ found far n.ore serviceVe irVel' e. Xe ^T nt: woun^« «? .u ^''''*'® '" amputations, and very We wounds, as m these cases it mav fail nn«fl;Ki.r *^ . ^ sarv renosp of th^ *• \ . possibly to secure the neces- ^i^z^ t^oTi at:- :s:"^ -^ "»"- " ^^ ^»- ■ -( 214 PRINCIPLES OP SURGERY. Sutures.— There are several kinds of sutures. There are divi- sions based on the material employed and on the manner in which they are employed. First, as to the method of using sutures. There are the Interrupted suture, the Ur interrupted, the Twisted, the Quill. Speaking generally, the legitimate use of the suture is simply to prevent a sliding motion of the sides of the wound, and not to forcibly draw them together, and thus retain them. Other agents should be employed, which have already been given, to bring and hold the surfaces together. The surfaces of the wound being in contact, or nearly so, then a stitch introduced will assist to fix the parts, so that union can the more readily take place. But the gaping wound should never be forcibly closed by the su- ture alone, as it, by dragging upon the structures, will produce irritation and twitching of the muscles, while at the same time they will prove inadequate to accomplish what is aimed at. The number of sutures, and the depth to which they require to be placed, will depend upon the size of the wound. Speaking more particularly of the interrupted suture, it ought not to be intro- duced until the bleeding has entirely ceased, at least it should not be tied. Care must be taken to have the surfaces strictly in ap- position ; to secure this the suture will be, at first, introduced in the middle of the wound, and then on either side, as many as may be necessary ; but all should be introduced before one is tied. The central one should be first fastened. The knot must not be over the wound, but to one or other side. This is to avoid irrita- tion at the place where the bond of union is undergoing develop- ment. After the suture is tied both ends will be closely cut. The surgeon must not forget that it is only necessary to bring the sides together. I have very often seen the lips of the wound quite puckered from the suture being too tightly drawn. It is commonly recommended to allow the si- -^ ■■» remain for thirty or fifty hours, or until there appears a I'iU ' • 33 where the suture passes through the intej^ument. ^he presence of the foreign substance is offensive, «iid ^i1) iT^terfert with the bueccsf^^u! issue of healing by adhesion if allowed to remain for too long a time. Therefore, so soor as the wound is firmly closed, the suture o;tg> :. to be taken awaj I think it is more frequently permitted to xtuiajj) too long than too short a time. When they are ex- tractc-'l, they ought to be substituted by the adhesive straps. The THIRD INBIOAIlOlf. 216 necessuy of an early removal of the ,„t„re must not be over- oked, a, .t may lead to the formation of pus at the botlmo" The iy.,ted Suture.-Th, remarks made thus far have been more part,cu larly direeted to the interrupted suture, the proper u^e of wh,oh ,s to retain at rest the surfaces brought togethe" by other means. But in eertain kinds of wounds, the suLon wiu find .t necessary to use the suture to bring .og;thor theTurface n ,„ch cases to obviate the evil „hieh would result from the o" d,n.vy .uture dragging on the tissue through which it is passed J pu, prepared for the purpose, is introduced at some distance fl ... I.p of the wound, and made to traverse the deeper part of the wound to an equal distance from the lip of the opposite side The second step is to place a piece of waxed silk around one „d f .he p,n and then wind it around the two ends in the form of . figure e,ght. An assistant will hold the wound together while this wil ri T'Tl, "t" """ "P»'^''»" '» «-Pleted, tW wound w,l be firmly closed. The advantage of this, the twisted suture s sufficently flam. The pin fixes the sides of the wound and he s,lk crossed and bound around the ends, exerts pressure „1 fc surface of the part, by which the wound is retained :Z The twisted suture is principally used when there is » loss of n egument, or where there is much gaping. It is most frequently re orted to .n wounds of the face, when it is desirable to prevent .he^ex,stence of a scar. It forms a part of the treatm'enr^J The Quitted Suture.-The advantage of the quilled suture is m most respects, the same as that of L twisted It is gene' al w ™ed ,„ wounds and operations about the perineum, where th^ ^>'.sted suture could not be employed. It consists of ^ many n errupted sutures as may be necessary, and two substancr alut s,ze of a qu,Il, one placed on either side of the wound. The eTtheTf- "" 'r?'"""'' °"« ^■"' °f ^""l' » l»»Pea around 1 ,!. ^f '■/»'» ">« "'her ends are tied sufflciently tight ar and the body of the opposite side. By means of these bodfes x» mg the length of the wound, diffused pressure is mtde Id ^^™™' "' ""■" "•'«• "-y ^'^'=1' «'« ^"-"i fe kep *■■<: H n '■ j IB ' ■• in r .f il , 1 1 il ! iif 1 il 1 : !* ' III ,, 1 HI ' '' ^ m^m 1 clll SI Jfill H' M HIH M'l il HI 1 '{ V^^E^R* ^^^1 ' '(■■ jHI i.ill Hll f < i\ 216 PRINCIPLES OF SUEGBRY. Diviiion of Sutures, based on the material. — There are two kinds of sutures, as to the material composing it. One is of metal — iron or silver ; the other is of silk or hemp. The silk suture is of a more ancient use than the metallic ; hut within the last fifteen years, the latter has, to a great extent, superseded its use. The metallic suture is more cleanly, and less irritating, than the silk ; but its removal is attended with some diflSculty, and is likely to cause irritation, and disturb the process of healing. I cannot say that I have observed that extra advantage from its use for which it is so strongly recommended. Fourth indication in the treatment of wounds, is to prevent, or control, or subdue, inflammation. It should be well understood that no extraordinary flow of blood is necessary to secure the healing by adhesion. Healing is a physiological action, for which no excess of blood is requisite ; rather the congestion will subvert the process of healing, and lead to inflammatory action. The local applications consist in the use of cold water dressing, in connection with which, the same attention and the same precau- tions must be observed as are referred to in the treatment of in- flammation. It is a fortunate thing that cold applications tend both to the arrest of hemorrhage and the prevention of inflam- mation. Such constitutional measures will be adopted as are recom- mended in connection with the subject of inflammation. The surgeon, in treating incised wounds, seeks to obtain union by primary adhesion ; but it will occasionally happen that, either from constitutional defect or the absence of some essential local condition, adhesion does not follow his treatment. Whatever may be the obstacle to union, as soon as the fibrin, which should have served as a bond of union, has degenerated into pus, free egress for it must be made by the removal of the bandages and sutures. And if there be pain, indicating the formation of pus at the bot- tom of the wound, soothing applications, as a poultice, must at or ,e supersede the former treatment. Healing, thereafter, will have to take place by granulation or secondary adhesion. LACERATED WOUNDS. 217 re recom- CHAPTERXXVII. Lacerated Wounds : Characteristics-Treatment. Contused Wounds • Treat ment. Punctured Wounds : Characteristics-Treatment By a Wa«.rf wound is understood a solution of continuity attended with a stretching of the tissue around the wound from which Its vitality is impaired, or perhaps destroyed. The fo;ce by which the division of tissue is effected is generally indirect, in the same manner as the force applied by the hands is indirect which tears a piece of linen. The whole of the tissue, between the two points at which the power had been applied, was necessarily placed upon the stretch, and it was a chance circumstance which'^caused division to take p ace in one place sooner than in another; hence that^injured condition of tissue characteristic of the lacerated Characteristics.-.^},, wound does not present that even surface which IS seen in the incised; rather it is irregular, with ragged margins-uneven edges-perhaps hanging in shreds, or flaps The^aen, instead of being of a smarting nature, is more decidedly acute, or perhaps, on the contrary, altogether absent. In the former case, the nerves have been much irritated; in the latter, they have been benumbed or paralyzed. Hemorrhaged comparatively slight, as the laceration promotes the closure of divided arteries, and the coagulation of blood The coats more sneedily and effectually contract, while the rough and glazed prominences on the surface of the wound offer so many po.nts around which coagulation may commence. Consequently bVZT' "^ ^-go artery may be divided, and yet the bleeding bo speedily arrested by the unaided powers of nature. Cases ndeed, are recorded, where a large limb was torn off and n hemorrhage ensued. The gaping is by no means so great as in the incised. The Z.T':'t '"T --P-itates them for contraction that, although the wound is of equal size with the incited, the -r f f I 218 PRINCIPLBS OF SURGERY. ■ii gaping is much less. The absence of these two symptoms — bleed- ing and gaping — which are so well-marked in the incised, not un- frequently leads to the belief, on the part of the patient, that the wound is comparatively of little importance. In like manner, the inexperienced surgeon may be misled. The lacerated wound is more serious, because the injured tissue around the wound has to be restored in vitality before healing can commence. A lacerated wounJ may terminate in immediate union, if the tissue have been but slightly injured ; on the contrary, there may follow inflammation, or ulceration, or sloughing, or even gangrene. Much will depend upon the extent to which the vitality of the tis- sue is impaired ; also upon the recuperative powers of the system or the part. As a general thing, some portion of the tissue bor- dering the wound, which has been stretched, will perish, while other portions will gradually be restored to normal vitality. Na- ture, whose leadings the surgeon must here still follow, will take steps to ascertain how much of the affected structures will recover and how much must perish, and then will proceed to establish the line of separation between the living and the dead. This line will not be regular in its course, but it will be definite. The formation of the line will be followed by sequestration of the debris, either in the form of ulceration or sloughing. Simultaneously, the adja- cent tissue will be restored to health ; and immediately thereafter, healing by granulation will commence. Attending the separation of the destroyed tissue, will be a degree of inflammatory action. This is necessary to the separation. But care must be taken that the inflammation is not unnecessarily great. The surgeon cannot always be certain as to the termination of a lacerated wound. As before intimated, the wound may be more serious than appearances would seem to indicate. It can T^gver be known to what extent the tissue has suffered ; perhaps, while a part of the wound is lacerated, another part is simply incised, in which parts, adhesion may speedily ensue. On the contrary, a part may be bruised, which condition is quite as injurious as lace- ration. The character of the instrumont by which the wound has been inflicted will assist in determining the diagnosis and prog- nosis. A portion of the instrument may have a sharp edge, while another portion may be blunt ; or the cutting portion may have LACERATED WOUNDS. 219 been followed by the handle, which has forcibly torn the wound wider, or perhaps has bruised the tissue around Lacerated wounds are not equally serious in every part of the body. Cases are recorded in which very extensive lacerations of the scalp united very quickly. Treatment of Lacerated Wcund^.-ArrcBt the hemorrhage, re- move fo^gu bod.ea, and treat the inflammation; and then -the p. ho logy .ell understood, and the physiological action 'whl »■ be d splayed, properly appreoiated,_the duty of the nrgeon W.1I be s,n,ple and easy. As in the incised, so in the lacerllT the surgeon can but be the handmaid of nature and proper crcumstances are necessary, that the doomed pouZ «y e cast off and the living portion restored to a state of health U\ "T !''*' """' 'o «"«">•'' sequestration, the flo. of Mood does not requ„-e to be great; there must not he too much If the crculafou be too free, inflammation is favored, restoration .s delayed and destruction of tissue increased. I^flammatorv ac ,on w,ll however, undoubtedly hasten the separation "fZ des royed tissue; but it will likewise increase the amount of destrucon and the breach to he healed. There must be s„lu rauou; but the flow of blood need not exceed, to anTex en X natural quantity. To secure these essential circumstan e" tta .nd,ca.ed the surgeon has only to maintain the natural temper . e of the part and the ordinary circulation. Although the hroTtt" V:.""' '""""='' """"'^ '" ''""^ "iff"™' from that of he ncsed, the treatment required is essentially the same Cold water treatment ought to be adopted, as a generaUhing ;Tu; «. the tissue ,s wanting in that vitality which was present fn the .ncsed wound care must be taken that the cold beLt to great The only guide-and it is infallible-is to apply the water si -ti. cold and with sufficient diligence, to pTefe^t cIi ^ t „ slightest elevation of temperature ; and no more than ttat. J„ cxtnsive wounds, it will be necessary to administer medicines to Z; m" """^ "V^ '"'"^'- " ■'"' •'-" '-"".-emJed by ome, in those case, where the pain is great from the laceration of t n rve, to apply a cold poultice. In some instances, r i„f found to accomplish the same end, and at the same time it will ' 1 ■I '•\ 220 PRINCIPLBS OP SURGERY. 1 1 il more surely limit the inflammation. Sometimes, however, in ex- tensive tears, the tissue will have suffered so much, or the system experienced such a shock, that warm applications of water or poultice will be demanded, to raise the heat to the natural stand- ard. As soon, however, as this has been obtained, they must be discontinued; and when the action begins to be excessive, as it will, cold dressing must be employed instead. In these cases, the feelings of the patient will indicate, somewhat, the most suitable application. In every case, the patient's general comfort ought to be attended to. Repose of body and mind ought to be, if possible, secured to him. When necessary, local support should be supplied by straps, bandages, or splints. In a pure case of lacerated wound, no at- tempt should be made to bring the sides of the wound together by sutures. The sides ought to be approximated and firmly sustained, but not brought actually together ; unless, indeed, a portion of the wound be incised, and there be a fair prospect of adhesion of a part presenting itself. Attention to position is a matter of some importance, so that passive congestion may be averted. When the line of demarcation has formed, and there is a slough to be separated, the occasional use of a poultice may prove beneficial. Contused Wounds. — In this wound there is bruising or crushing of the tissue. It is caused by some body coming against the tis- sue with a force suflicient to cause a solution of continuity. Also a blunt instrument may produce it, which, although dividing the tissue, yet bruises it in its course. The difference, then, between a pure case of lacerated wound and a contused one, is this : in the former, the tissue has been stretched until its vitality has been impaired ; in the latter, it has been subjected to bruising until its integrity has been affected. The characteristics are nearly the same as those of the lacerated wound. The surfaces are irregular, the margins uneven. The pain is not great, perhaps absent, the nerves being bruised to numbness. Hemorrhage is not great; but in the bruised and jelly-like tissue around, there is more or less effusion of blood. The vessels do not contract so much as in the lacerated ; rather they are dilated, at least are unable to contract. The result iB, an escape of blood into the softened tissue. But, although the bloodvessels do not contract, the state of the tissue favors quiclc PBSCTOKED WOOKDS. 221 coagulation so that hemorrhage i, not great as a general thin.r Somefmea the blood will collect in thf tissue, thf p ne ff veslels a7e „fte?tt "" '"r"' '■"■ '"' "»■"''' ■"""»"- «f "e vessels, are often the cause of secondary hemorrhage. This unfor . nate comphcation is more apt to follow in the ptoess o "ker afon or sloughing, than in the lacerated form of wound Term,n ^''^^7 wo J in order t^trrrtLetbrr^ ""^''"^ '° ""•- '"' .he':r:rtro?rf::rr "' j™r ^ '»""» - --" sinus may result H aL°r f '•""' *'" "''*"»»' «"»' « pected in' due courfe t! otiThi T ^ «""'"^ "= ''■ «u.e as for the contused wound n' *''t'7'.™"' ""' b" the poultice, in order to kZtZt I ^^ " ^"""'''^' "> W^ » ;ng .ust oommencratZtttr %re:r:e"'r,r '''' free way of escape for the (l„r,I „,l, ' "' '" '"""»' a depth of the wound. ' '"""" P"' "'" ""'l""' » the oa.e bein'g diligeLuy Z:!::!''''"'' """" "' P™"""'^ -«' "« ' 4 I If ^!1 ■ 'I 'I irH 224 PRINCIPLES OP SURGERY. CHAPTER XXVIII. Gunshot Wounds: History— Division— Missiles— Velocity— The Kind of In- jury — Position of Body — Location of Ball. In considering this class of wounds it is well to include all solu- tions of continuity which are produced by explosion, by which a substance is projected, and which, coming in contact with the body, breaks the tissue. The history of gunshot wounds is not uninteresting. Much importance has always been attached to such on account of their associations; but in the present work, where practical points alone are dwelt upon, space cannot be given to the subject. Divisions.— A division of gunshot, wounds may be based upon the causes of the wound, thus : 1st. Those caused by explosion of powder alone. 2d. Those by the shot-gun. 3d. Those inflicted by a ball, which may be round, or conical. (In modern military practice the latter is more frequently met with.) 4th. From a grape-shot. 6th. By pieces of shell. 6th. Wounds produced by some material, which itself has been struck by a ball. 7th. In- juries due to spent cannon-balls, causing destruction of bone, or rupture of internal organs. Again, the wounds may be divided into such as are inflicted directly, and those which are indirectly made. That is to say, the missile which inflicts the wound may be directly or indirectly driven by the explosive powder against the body. There are seve- ral circumstances connected with this division, which may modify the character and extent of the wound, as well as the eff'ects upon the constitution. Another division is given in Holmes's System of Surgery, based upon the shape of the body which has made the wound. The round ball makes a wound mostly spherical. The modern conical ball produces a wound more of a cylindro-conoidal shape. Then there are wounds made by bodies of no particular form ; these are de- signated irregular. Such may be due to a bursting shell, or bits OUNSHOT WOUNDS. 225 [ind of In- of wood or atone, or iron, which have been struck off f . tures of that material. Air»;n .,» ™ *'""' ^*""^ body at the time th wouS i'. TT """"""^ ^^ '■"" ^e pieces of n.eney, or\: Zt,7 etn" ' ^ .f' "V^^^' " another individual. These unusual TrlXtd 1 " T are not cas.ly diagnosed. And when a.cove:er.t;t:S .etr^t-e-tsr:rfwirit^^ however, has a less Tod , 'gXTnThe'^-""^- l'^ "^'«'"> cannon-balls are eminenllv l!/ . ,'"' '"' " ^^e- But great or otherwise ^ destruchve, whether the velocity be the Lssians dulTthe wart VT"""^"'' ""' ''■"""'-' ^y Wets were found fbouub" 1^ arnTseSrorb f '^^'^ juries received from them h<.^r^ i. , ^eoastopol, but no m- fcovery, pec„li:r."ie's i: he chraclrff^'' "'*°"«'' ""^^ *» had not previously been satisf ctor y aocoun tdT "°™''' """"' to have probably resulted from them T, v,T' '"''P"'^'' that when discharged the dW^rlrV "" '''"''y' '""'ever, bullets were sufflcfentW tett ' T f™' """'"^''^^ '»' *« '« which was of very stlrdtm . ^te.^" T'°'"' ""''' With the troops against whom they ; rTdXeltd Dr 'I ""'"' his History of the Eastpm p„ -^ . ^*« uirected. Dr. Scrive, m .li.ryballs'^wereeied byrr'-"""''!"' "''° *''»' '°'=™- small cylinder of com,er 7 . ""'• ^'■"^ """''''"d of a "dmad'e up into tleX; of '"'""/ '^'"-"""S composition, discharged from „ mlstt On""!:;'''""'^ ''''"'i"' «° - '» b bums with violence Thte bail, w '"* '" f'°°' "'' ?'■">«"'« oonolasion of the si .e and it w T T' '''""™ ''" ""'^ ^e 'ha' a key was obtS o olToS If""' ^^ f/'^ '™"'=^' "hich could not be accon„..r TTu " '"«'"'^"' character, or fragments of shell." ^ *' ""''^ "^ ""'■-"y k-Uet^, ^^«e Influence of Velocitu A „ i. i much to do in giving challTM, ,'■''' "'«» ""™'"cd, .rfo^Vy has -e. XheLl, ttXCirrreSr^^^^^^^ Ifl ' ^ ii d'H - 1 mi Im 'f " ' »i 1 1 1 3 ^ J J « a w\ ■f.^ ,»i li . 1 ^^ffi 1 "P ifi -IJIl il . HI' ; 1 1 1 ;« ,i^^p ,J Iwl 226 PRINCIPLES OF SURGERY. death-errand for a distance of 1000 yards, will, in the first part of its course, prove far more destructive to tissue and to life than did the old rifle-ball, which could take no effect beyond 250 yards. And the musket-ball, being round, will, when going with its great- est speed, cut the tissue, without a serious amount of bruising or tearing ; but the conical ball, perhaps in consequence of its shape, but more likely from the boring manner in which it passes through the tissue, produces a great deal of injury to it. That is to say, extreme velocity in the round ball lessens the degree of danger, while in the conical ball it increases it, whether it strikes the soft or hard tissue. The following, as to the contrast between the effects of the old fire-arms and those in use at the present time, will be found interesting and instructive : " The velocity of motion of different projectiles is an important ingredient in the consideration of the several wounds produced by them The rates of motion imparted to missiles by the fire-arms of early times were probably-from the imperfect construction of the weapons, defective quality of gunpowder, and other circura- stances-as inferior to those of the musket lately in use as the velocity of musket-balls was to that of the conical bullets of the rifles in present use. In a table showing the velocities of certam moving bodies, published in 1851, the common musket-bullet is set down as moving at the rate of 850 miles per hour ; the rifle-ball of that time at 1000 ; the 24-pound cannon-ball at 1600 miles per hour But the musket-ball then could not be depended on to hit an object beyond 80 yards, the rifle 200 to 250 yards; while the present Enfield rifle is sighted to 900 yards, and the short Enfield to 1100 yards. The effects of different rates of velocity on wounds are seen in the variations which occur in proportion to the distance which the missile has travelled before inflicting the injury. A cannon-ball which, with but slight velocity of motion added to its weight, would knock a man over, at ordinary speed will carry away a limb without disturbing the general equilibrium of the body A musket-ball that would be arrested half way through a limb, is now replaced by a ball which, at like distance from the point of discharge, will pass through several bodies in succession - The increased velocity, or, in other words, greater force of modern projectiles, exhibits its effects in two directions: local y, by the greater destruction of tissues in the track of the projectile; GUNSHOT WOUNDS. 227 organized fabrio^hrJ^V:^ nirV 'f" P-''»» "^ the several miles per minute Z,. . ' '"'^'''"'"g »' the rate of of their viealif,. ""in-^ctr ' LTeTbT '"r""^/^^^''^^ wounds having healed bv simnll ?u ^ """'"• "' g"""!!"' not met ^tk tZ mZL T'-'^' •>»' «"* -^-Ples are Moreover, .hen eonsideri„!th 1 '?7 ^" °"«'"»' f"™- it wn, have to be aho J'tlt'^lrXc"!" tS'^: ''^- ^"1^' from modern weapons has Ud t„ '{ ™Parted to projectiles wounds. The great power of lit """"'■•/■•auge in gunshot b. the yieidi„g%,a,/;:if„~i:ir;:t"d''^'"^ ""■"■'"" structures, is no longer of avail „l, . •>? «ond,noas and other «re.arms, at their ust, rLrof s^::^ '™^"'"" '™"' "»»"- shroVttgt jriTtrer*'."^ "°"'"^' ^'"» «» •»« mentioned when referring tothelr'"'-'''' '"'™ "'^'^y '«<"' together with form, theroutoCrrifr"'""''^- ^°'' gredient m estimating this result ", " , "^ '» "> necessary i„. from their form, but also from ,1, 1 """"^ Wls.-par.ly firelocks from wWch they wl -e di cLr";*"^ ""'"'■■'™ "^ "■» degree of velocity ™P»Ld ^^^ t^it Tt iCrr^"' --' ™ply be turned away from the direc line • or f2„ T' """''' knock out a portion of thn ,l„ft -.7 /' ""« ""*' ™nl» »-- such as are still used in some °f, "'"""'"'!''' Pressure, than bullets, «f^o„sity,withresprr :;^\7;':-* Theinfluenee' wben lead is «sed,Ve " n t™^l tS v^f "' "^ T ' "''•«-'• w.th the Whitworth than the EnfieM Iff 1 «»o-third greater joctile is used (as when the lc..l s mi^rl th't ?■ """'"' ^"^ " as 17 to 4 at 800 yards W ,mU ,t ""^' "» P^otration 'bo fact is certain that c„„iea7b„t ■ """ "''""^^ ^ "<». mbly an overpowering ? c °„ tr " r l™ ^''''■''■"""■ost inva! eluded, with which they come 11 ""'''*.»"•»"'"■•«». bone in- ">ey come into contact m the human body, I !.' I i i ^ '' j Itfj i 1 ^^ffi' 1 i i ■ ■ 228 PRINCIPLES OP SURGERY. and are rarely met with flattened, or so much altered in form, as bullets not unfrequently were formerly under like circumstances." (Prof. Longmore, Syst. Surgery.) Another kind of injury is that arising from a spent cannon-ball. It is not due, as formerly supposed, to the concussion of the air, but to the weight of the ball, which rolls along with only sufficient momentum to overcome the force of gravity. A body lying upon the'ground will not arrest its progress, but the ball will roll over it. If it be a leg or arm, the bones will be crushed by its weight; or if it be another part of the body, life may be destroyed. The most extraordinary feature is, that the skin and other soft tissues are often entirely uninjured. Tissues that will yield under the weight will, as a general thing, escape. For instance, a ball roll- ing over the abdomen may produce rupture of the liver or other viscera, while the walls remain unaffected. Upon the velocity will also depend whether the missile lodges in the body, or completely traverses it and escapes. When the speed is limited in degree, the tissues of the body, especially the bone, will arrest the missile, causing it to lodge in the body. The modern Mini^ and Enfield balls travel with great swiftness, and consequently lodgment is not so common, relatively, as was for- merly tiie case. In a letter to the London Lancet, written after a visit to the military hospitals in and about Washington, in Decem- ber 1862, I wrote respecting this subject, as follows, speaking of a museum which was in preparation at Washington, consisting of dried specimens of wounded bone : " The bones, being thoroughly cleaned, are arranged with much skill on wires, so as to show the manner in which the ball had entered, the effects immediately pro- duced, and subsequently the efforts made by nature to repair the injury. By this means, it is clearly demonstrated that the Mime ball is but rarely turned aside by the bone; and that, although the ball is generally much battered, it will pass through even the largest bone, or, if the momentum be not very great, it will bury itself in the osseous tissue. In every instance, the bone was seen more or less comminuted, even where the ball had seemingly passed through the bone with considerable force. From looking at these specimens, it would appear as if the cone-shaped ball passed into the bone in a wabbling manner, and that thereby great destruction, characteristic of that ball-wound, is accomphshed. GUNSHOT WOUNDS. 229 located in a place most unexpected in « l . ""'' """^ would seem to have taken a vCt" .l? X'" ^f -^J"" !' is the round ball, mjy be attrihm.hL .T '' "'"'" " to turn it .side;^„t'it r2e ;:' X /ueTtr "■• v°"° '" .ion of the body at the ti.e thetrnters il'" ""^ """"^^ ^''■ stretched, of fle/ed ^rd ffe t Z ^ Td Th ?7 "^^'^ conflict the soldier will necessarilv h. .7, ' """""^ ** ble attitude, while the enemv ™ I « V-" ''"^ '=»'"'^'™- directions, St can be reTr/u: L rodX"'': 'T '''"T body be wounded in any part but he b.l ^ """^ *' reotion through the body or hmb A^t^ i ,7^ ?"'" '" """■^ <"■ burg there wfre a cert^ IbeV „t„t Xed "' ''"'"'"'"■ position. This was done durinTthr nl'ht d'l" T """"' "JXii^:: TLtosirr- r^r- " =' now and L„, when the head of i" .^ '^"""« *<' ''"y- ""<• slightest extent fron, the tlnl "f jf ""'"'"' "'"" '» *^ nan. The result wa, T , , ' "" " '"'S*' f" ""^ rifi<=- be.d,face,r:'and „li:onrecrt'''''r™ """'"^ '" *^ had traversed the neck obluel % t 7" ""''' ""^ '"" ■e. With the body, and^rrtr^raTardlt^ ^"'^" -"'• inflicted several wonnl n Sometimes the same ball had i 1 Nt! 230 PRINCIPLES OF SURGERY. while in the act of putting a cartridge into his musket. The ball had completely cut off his forefinger, then passed directly through the body of the hand, and again entering the back of the arm, about two inches above the wrist, had ploughed a furrow for a few inches, and then entering into the deeper part of the arm, had finally made its exit and escape a little above the external condyle of the humerus. Now, it can be at once understood from the fore- going, that when the ball, instead of making its escape from the body, remains within it, it will be exceedingly difficult to ascertain its locality. Not only may the ball be lodged in a part very re- mote from its place of entrance, but chance may have taken it in one direction, or perhaps the opposite. It will be impossible to tell its course unless its track can be traced externally, or the patient can call to mind the position he was in at the time he was wounded, and the direction the ball came; but then, even, it may be impos- sible to say whither it has passed. The difficulty of ascertaining the locality of a ball is increased by the fact that its own weight will often lead to displacement from the first place of lodgment. And, also, the contraction of muscles may cause it to move to some extent. Not only do balls lodge in the body, but also any one of the missiles which produce gunshot wounds ; such as pieces of shell, or stones, or bit of wood, or a button, or a piece of clothing, or even a comparatively large grape-shot. Several interesting cases are recorded in the System of Surgery, by Holmes, where a grape-shot had unexpectedly been found lodged in the body. And I have now before me one, not very large, which was excised near the spinal column between the scapula). It had entered behind the left shoulder and passed beneath the scapula. / SYMPTOMS OF GUNSHOT W OUNDS. 231 iTSi^t CHAPTEE XXIX. Sympton^s of Gunshot Wounds-Treatment: Local-General-Pn™.ry or Secondary Operations. S!/mpU,n,. of ff„,te Wounds.-Vo have to consider those tha. present themselves in the part, and those .hich affect the whole constitution. .)Il\^'""'-l ^"'"P'""' "^ '" "^-y aspects the same as those ™nds. The characteristics are, generally, much crashing of l.s»ue, and very often considerable tearing of the structures. The conical ball especially, boring its «y through the tissue i emnently destructive to it, vitality, and aIo„g%hc rtol of i course w,ll be found a lining, of tissue so injJed .hat it wU in e ably per,sh. The effects of the round ball upon the tissue dtLcXm'.'" ""-' "'^"'' "r»» '"» -'-"^ »f".e ban as"! Pam may be almost or altogether absent. It is characteristic of gunshot wound, that the pain does not altogether deprupn t'iZtJ'''"'' r '""'"°" '° "''"" -"- have' becnTx" po»ed but, to a great extent, upon the temperament of the indi- v.dua , and the state of mind in which he was at the time the wound was inflicted. So true is this, that the soldier m»rbe se mu ly wounded, and yet be unconsciou, of the fact. Wrought up to the h.ghct pitch of excitement by the engagemeri and th^ «~::: «i[rr ""-"'■ - '""''''™- --- ' -y i'::!' rece ved, and ,t.ll the recipient rush on in the bloody strife Wlnle on the other hand, where fear is predominant, thcTst rj^y from the enemy may cause the sensitive one to fall down "m^ pr«ed with the belief that a do«n balls have pierced him Aid Tf Xui'l'n ''•'T' "':'" ""'" ""' '■^'""^ » """•i» ^' « l?r. . ■""'"""• ^'■o -=i'-'=™»tances of c.n.„.|if„ mav b "ved a T""" '-'■"—• Whatever be the^'ca , , ^ Observed a good many woundcil on^a «,„ r .i. ... ,. ', - "- 7 —-''J VI lucui wun sngnt t ' 1 r * t y M j 232 PRINCIPLES OP SURQERT. wouncis, yet who suffered excruciating pain, while others experi- enced but little. Hemorrhage is not, as a general thing, very great. The fact that the wound is lacerated and bruised would promise the absence of bleeding. We have, however, the testimony of the experienced Guthrie, that hemorrhage is often considerable. But, while the primary hemorrhage, it may be said, is not com- mon, secondary hemorrhage is very likely to occur. The injured state of the tissues necessitates the process of ulceration at least. ( Vide Lacerated Wounds.) Attending this, will be, to some extent, the inflammatory process. This will often lead to the opening of vessels. The ball in its passage impinges on arterial coats, affect- ing their integrity; and subsequently, the process of ulceration sequestrates the injured portion and thereby opens the arterial tube, and bleeding is the consequence. Gaping is not very great in gunshot wounds. Oftentimes, on the contrary, the lips are inverl;ed, especially where the ball had entered, and where it emerged there is, at least, an absence of gaping, so that very frequently the orifice is seemingly less than the size of the ball. But although the wound at the place of entrance is often charac- terized by inversion of the lips, yet such is not always the case. After considerable attention to the matter, and careful observa- tion, I have to say that there is no regular order concerning the relative size of the orifice of entrance and of exit. I have fre- quently seen the wound where the ball emerged, even smaller than that made by its entrance. Sometimes the ball will travel some distance immediately beneath the skin, and its course will be marked by a somewhat livid mark. By passing the finger along the route a sensation of crepitus will often be experienced. Constitutional Symptoms. — The first is the well-marked shock. Sometimes it is slight, but more frequently it is very great. No doubt this is due in part to the circumstances of battle, and to the actual shock imparted to the nervous system. I have repeatedly asked those who had been struck with a ball, as to the nature of the sensation at the moment. As before said, some are not even aware of the fact, until weakness or helplessness, or the loss of blood acquaints them with it. Those who could call to mind the sensation when wounded, described it as something resembling ft SYMPTOMS or GUNSHOT WOUNDS. 233 generally. The prostration consequent thereupon, is sometime very grea and alarming. Of course when an infpo tant t™Z .8 involved, the shock will be correspondingly great. Other constitutional symptoms will supervene. These mav be due to loss of blood, or exhausting discharge, or locrirrTtation or want of rest, or imperfect diet or nursing. Then h re are a variety of complications which often present themselv , as fo^ instance, pyemia. ' ' ^ The;,™^„„„-, of gunshot wounds should always be exceediuBlv cautious, more especially when the shock is severe, or there is rea son to fear that deep-seated parts are involved ; a^d also f om the fact, just above stated, that serious constitutional complica" ns may supervene. "ipucttuons Treatment of ann,hct lr»«*,_The loeal treatment will be somewhat mod. led according as the wound partakes of the ha racer of the incised, the lacerated, the bruised, or the punctured t IS scarcely necessary to say that it is desirable to have tl« oreign body removed. With respect to balls which may have be removed^ Formerly, ,t was recommended to take no great ro* to effect their extraction ; but according to recent praftce Sjst Surgery ) But more generally the foreign body is a con- tmued source of irritation, pain, and danger. Thi, .ilV ° .r^nenaei «,/.„ tU position of the lall .' Wn; b : en i. L' not, , becomes a question how far efforts should be mad! 1 r„ U. whereabouts by probing. A wound may bo probed by T metalhc probe, or by the finger. According to the high author y i;°'r:%'?r'™,°'.'r''"^'' " ■» P-f-able'to u,e t « linger. But if the probe is handled with great gentleness a, tho probe ought always to be used, it is less likely to eaule rH „, o" and extend the depth of the wound. I cannot omit cxnre sTnl ° the ball ,s lodged are too often subjectci to rough examination M, w, the prol,,. and the finger. It is a question," ::": a.lvantage to bo obtaniod by probing 1, commensurato with the 11! iStI -iJl 234 PRINCIPLES OF SURGERY. risk of forcing the probe into unbroken tissue. Not a few cases came under my notice while in the United States service, in which pyemia and death ensued after the use of the finger to discover the ball, although the patient did not seem to be predisposed to such diseases. Before commencing to explore the track of a ball, the patient should be placed, so far as it can be known, in the position he was when wounded ; otherwise, the channel will be obstructed by the relative change in the position of structures. The ball will some- times be buried in the bone, in which case all efforts to remove it will prove useless ; and occasionally it will remain without causing any inconvenience or irritation. Should it produce irritation that will lead to a separation of it from the bone, then it can easily be extracted. The instrument with which removal is effected is very commonly the bullet forceps. Objection is, by some, made to these, because of the necessity of separating the blades to grasp the ball. Professor Longmore, of the Military School, Netley, recommends the extractor, consisting of a scoop for holding, and central pin for fixing, the bullet. There is a possibility of being too solicitous to extract the ball. Of two evils, the surgeon ought to choose the least ; and while the ball, as any other foreign body, ought to be removed, it should not be forgotten that the efforts to remove it may be productive of more evil than the ball would be if left to nature. Protracted and violent efforts cannot be recommended in any case. Before search- ing for a ball in the wound, careful examination ought to be made, with the hope of detecting it in some subcutaneous position, as in such cases it will be preferable to make a direct incision upon it. Very often, although not always, the patient will become aware of its position by pain or uneasiness in the part ; perhaps not at once, but after a few days. One case, which just comes up in my mind, I will give as an illustration. Sergeant C had been wounded in the leg, I think while advancing at the double-quick. The ball had entered to the front of, and a little below, the knee. It was a fortnight afterwards when he came under my care. In the mean time, the wound had been repeatedly probed in the efforts to find the ball, but without success. Believing, from the character of the wound, that the ball hud taken a downward course, I proceeded to carefully examine the leg on every side. Coming to the ankle, TREATMENT OP SUNSHOI WOUNDS. 238 a»d while pressing .he finger inward heneath the fendo-AchiUis near us attachment, he complained of soreness, and at the sal t,me I could d,stmctly feel a hard substance. The patient assured that th,s must be the ball, submitted at once toC u se f he kn,fe and a large Mini6 ball was extracted through the wound It had not caused so far, any inflammation. The bafl was shghtlv when the .0.. ml l^lTr^^lZZZ!' ^^^^^^^^^^^ no only more than a foot from the place of entrance, buUt w 1 at the opposite side of the limb. Moreover, the bill had blen S which? '" I""' '"*°'" "^^""8 -fl-™tion, a d : wound which was made to remove the ball healed in a few days dia/n sirThav r """' ""^ """'' "■"'* "» "^"^■" "' his diagnosis. I have known an incision to be made upon the exter- n. condyle of the humerus, with the belief that 1' was a bal Other foreign bodies, such as bits of eioth, or a button, wil be removed when discovered ; but the rules of procedure a e" „„ way different from those detailed in connecLn with punctured the principles are the same as those given before. It will be borne ,n mmd that the surrounding tissue has been much in Id and that time will be required to establish the line of divi "on be! tween the tissue which can recover and that which will perrh Conrntufonal Treatment of Qun.Lot Wound.-lTlZ &^t place,.t IS not unimportant to state that great care is essential^ removing a wounded man from the field. The surgeon rcalled a non-combatant officer, sometimes in offensive tonf; b h wil ngly goes on the battle-ground while the conflict rages, to relie e the distressed, to succor from death, while he has not the excite njent to sus,.i„ him which the officer in command e e f a few «n has. Under sueli circumstances, it will often be impossibll •ns bTtl " ''°°°''"' ■""" """ '" "™' '■■« l.on,„rrhag , P haps by temporary means. There is commonly a place ff com ltd ^life': ''Tr' '""- ^''--y "p-tirns^hici,:: .In-ii, ■ ^'' O"'""". recommends a kind of wheelbarrow as the most suitable vehicle to use, and which can bo PI i I 8 H w. ' 1'IFi 236 PRINCIPLES OF SURGERY. I i* managed by one person. The surgeon upon the field will see the wounded comfortably placed upon the stretcher, taking a part to save any limb that may be injured from unnecessary motion. Inasmuch as there is generally prostration from the shock, and the work of restoration will be attended by nervous irritation and exhausting discharge, the powers of life must be from the first husbanded, or perhaps supported. If antiphlogistic measures be required, they ought to be adopted with caution. The question will often have to be decided, in a practical way, whether primary or secondary amputation should be performed. In a communication to the London Lancet in 1863, after having inspected some thousand cases of wounded, and heard the opinion of several surgeons, competent to judge, in the American war, I expressed the following opinion : "Although a strong advocate of conservative surgery in the broadest sense of the term, I became convinced, that, upon the field, amputation was less frequently resorted to than it should be; that while, in a few cases, the operation was unnecessarily per- formed, in many cases it was omitted when it afforded the only chance of recovery. The Mini^ ball, when it strikes a bone, pro- duces extensive comminution ; while all along the track where it has passed, in the soft parts, there is a good deal of destruction of tissue. Now, if absolute rest could be secured to the patient, in many cases nature would be adequate to effect repair ; but the cir- cumstances of war, the frequent and in many cases careless re- movals to which the wounded are subjected, preclude the possibility of recovery under the care of the most judicious surgeon. In very many cases, were primary amputations practised, the system, rid of a great source of irritation, would safely endure the subse- quent disturbance. Perhaps, in injuries involving the leg, and more especially the (knee and) thigh, such proves more generally to be the case." I saw not a few, upon whom secondary opera- tions were performed, and who subsequently died; but had the operation been resorted to at first, the life would have been pre- served. ii POISONED WOUNDS. 237 CHAPTER XXX. Poisoned Wounds-Three Varieties._(l) Dissecting Wounds-Symptoms- Treatment.— (2) Stings, &c. Poisoned Wounds.^Sipeaking generally, by a poisoned wound IS meant the introduction of a poison into the system through the wound at the time it is inflicted. But it is necessary to include under this term all wounds, or sores, or abraded parts, which may have been poisoned by the contact of the virus. And, even more than this, It IS desirable to include also those cases which, although the wound or sore is not directly poisoned, become so by the poi- son being otherwise imbibed by the system, as when the cuticle is very thm, or when a part is for a long time exposed to the poison, or when the poison is very virulent. Sources of Poison.~mson maybe derived from a mineral a vegetable, or an animal source. It is the last, where the poison IS of animal origin, that we have here to consider. This may arise from different sources. 1st. From dead animal matter, which is undergoing decomposition, or about to do so, as from the dissec- tion ot a body, or from making a post mortem examination. 2d From a healthy living animal whose bite, or sting, is naturally poisonous to the human system, such as bites of serpents, sting of bees, &c. 3d. From a diseased living animal, which may be com- mumcated l?y a bite, or by inoculation; of these we have hydro- phobia, glanders, &c. "^ Dissection Wounds—With respect to the first of these three classes, the most important is the Dissecting Wound. This poison may be rom the dead animal matter of the body which is being dissected, or examined; or it may be a poison which had been del veloped in the system prior to death, and which probably had caused It. In the latter case the virus is more potent, and the rosult more likely to prove fatal if the poison be received soon after the death, than it will after some time has elapsed. This is especially so m puerperal peritonitis. ]i 238 PRINCIPLES OP SURGERY. Division. — There are two general forms of dissecting wounds — • acute and chronic. The acute is rapid in its course, and mostly fatal in its termination. The chronic is generally mild in its na- ture, and, although tedious, not often fatal. Mode of Introduction. — The modes of introduction into the sys- tem are two — one general, the other local. The general cause may predispose for the local cause ; that is to say, the system may become gradually affected from long-continued dissecting, or ex- tended exposure to the poisonous air of a dissecting-room, which not only affects through the lungs, but also by the skin. And an individual with the system thus contaminated, if wounded by any instrument, will very likely have all the symptoms of a dissecting wound. It is not necessary that the poison should be introduced by a wound made in the dissecting-room. Any wound from any cause, or a local inflammation from any cause, is quite sufficient to give rise to the disease. The system being poisoned, and a part becoming injured, instead of the healing process being com- menced and carried on as in health, inflammation of a specific character ensues. A wound may be received while in the dissecting-room, and the poison actually coming in contact with the divided tissue, be at the time received into the system ; yet had there not previously been contamination, the local reception would not have led to the train of symptoms which follow. Indeed, many of the local symp- toms are often due to the previously poisoned state of the blood. Those students who most frequently contract the disease, are they who have for a long time been dissecting; while the one who has but recently entered upon that part of medical study, may cut himself, if in health, with impunity. In those cases where the disease was seemingly due to the imbibition of the poison through a recent wound, it will very often be found that some other pre- disposing cause had been in operation, and that the disease arose, not so much from the dissecting wound, as in consequence of con- stitutional depravity. A system vitiated by the existence of any poison, or weakened from any cause, is thereby rendered liable to attacks of this disease, if a wound happens to be inflicted. Under such circumstances the work of repair cannot proceed ; initiatory steps may bo taken, but they come far short. It is indeed, a dis- ease of the healing process. POISOHED WOUNDS. 239 The mectrng »„„„a, or a wo«nd in connection with the noi the s,ste/, the-intenfit*:;! ^I^^^ITZ " tare of the wound, whether incised, or otherw.s7 The di« I consequent upon the infliction and 'the healilg „f ^'^Li: ^ ^n"/ may be so slight that the disPicp ,-» i..,* • T , ^^^^ wound, But the .ore odious P-sXl IS T tc r^S contused wounds,-tho inflammation, and the nlceratioTll Z »»ppurat.on cause too n,ucl> irritatio; for healthT Zar'and turn the process ,nh, one of disease. It will be remembereT that eve„ m ordinary inflammatinn the. M^ ^ , "^^muerea, tnat even dicated b/inflananTat; f r Whe7a"n„"°°"" ■'''"'"'' "' '- it;t„Te::.-^---"^^^^^^^ e.el=.^r LCLtrCHoL^^^^^^^^^^ ^ ^ ^ whenitisthepertonelthrv 1 r"™''"-'^ i»feetious; peKtouitis isdr:rr:™it;;re::srpi^^^^^^^^^ nxiiiVd^d^f^rr^tr-^^^^^^^^ entirely subsidine lin„^r» :„ T inflammation, instead of of redness o Tn^ ;i '" ''! 7'' P-^aps with a good deal form around the w2 wl T ■ """ ^ """■" "'''"l^' -ay the disease incrcasis the'- '"""T" '"'™°'' P"""'-' ^s of tte .bsorbr I'nd Vt ndT;r: : 7e t "°"' T "■"°"- ness and swelling Th. „!„ i u ™'*'^'' °'' ^^«» lender- .i.edi.ch.r;:":"'';heKi\trs;ir "' •:"'°^«^''" "long the absorbent vessels Thl , ^ '" "" P""'*?' iiil m i!, 1 ; iM i *h'! ft pffi 240 PRINCIPLES OF SURGERY. has not been very virulent, nor great in quantity, and the consti- tution of the individual is in other respects healthy, so that the powers of nature were capable of overcoming the action of the poison. Bqt, even in these milder cases, time and judicious treat- ment are essential. The disease is chronic, but mild. When the disease is acute the symptoms are better marked, and quick in their progress. In the part wounded there is a low form, but a destructive inflammatory action. It soon extends up the absorbent vessels, and the glands become much inflamed, and sup- puration of a low order will quickly follow. The whole limb will become cedematous. Pain, which in the milder form was but little, is of a dull, but distressing nature. Redness with a livid cast is not confined to the track of the vessels. It is the arm which is generally aff"ected; and the local disease continuing to extend, passes the shoulder along the anterior and posterior parts of the thorax. Although the limb is much swollen and in places intensely red, yet if an incision be made the quantity of fluid to escape is very limited. The blood circulates through the tissues sluggishly at the first, and at last becomes stagnant. Perhaps, in places the tissue is undergoing changes which indicate its death. When such local symptoms as these present themselves the case may be looked upon as one which is very likely to prove fatal, notwithstanding all efforts of nature, aided by treatment. Constitutional Symptoms. — In the milder form of the disease the constitution is but little aff'ected; but it is far otherwise when the acute disease attacks a part. Then, of course, there are cases intermediate in degree, in which constitutional symptoms will be more or less severe. One of the first constitutional effects is a dulness of the spirits, a degree of lassitude, with loss of appetite. Then diarrhoea will come on. All of the excretions are exceedingly off'ensive. Not only the breath, but the exhalations from the skin, are strikingly putrid. It has been observed by many that the off'ensive smell bears a resemblance to the dead body from which the poison was derived. In the comparatively milder cases these symptoms may gradually wear away. In the severe, extreme prostration will supervene, with delirium, or coma. The bowels, sometimes, instead of being relaxed will be constipated. There is commonly in the worst cases, fever of a typhoid type, with occa- sional profuse perspiration. The tongue is at first pale and flabby, POISONED WOUNDS. 241 or perhaps coated, with a tendenov tn h wh.h completely orushe, „„t .he vkaHt/„ hXll *'' f"™"' Treatment of Bmecting Wounds -tI T ^T made "-^ a scalpel while diLo^gf;"!:".":'?''^ '"'™'' amiuation, but little attention ia relief V,rf ','""' '" to thoroughly wash tt,o „.,. "J"'""- i' '3 only necessary placing th! wound to Z I 'anTfT """""^ ''^^"'"^ "^ Although .here may be no bleed! IveTb """"''' ""''»8 "- the fluids around the wound .„7M' th. '°""'" "" "'"""" which may be located in thel!. \ u I™' """" "'<' ?»'»"". net had Le to r ya^a? ^hl.I '"'-"^ ^""^"'^ '«- that the system is afreadrimbrd "i h h' " •""" '" ""''"" poison is of a virulent Icind"^ Z b" si ps wmT™' " ""™ '"^ it will be remembered that 1 lad?,* ] "^ v "ooessary. And htely to prove serious .Wnt, ol". 'T' rr" '^ """- work of repair will be mnr„ , , ' ""'^ ''""use the ci»edwound^he wha;:i;::etr:ndt '::r- » '"^ »■ hkely .0 be washed out of the wotnd TK^ ' "™ '^ ""^^ aimed at is to tarn .he current h?^. I «™' "'•J"'" '" '»' ried into the system and „s iVfl f ° '"t"" ^-^ ^^ ■="" ingis to be fafored/by ba°.r;:h':,t: Ha™ wX"- if ^^■ i'ts't:Te::ird!r^^^^^ -und, with the vCof causbfbir;'""' T* " ''"'^^' '" *■>« however, doubtful. Whil c er,!in slt.T ' t ""■"'y °f *- »• blood flows therefrom .he vir. 1 7 T""'' "" "P"""'' ""'' veiling to the venouT^urren iT -^ t™b bl" ^ «"'"^"^ *^»- »PpIy a ligature tightly a"„„nd hi r'^f^u ^°""' '"''"'■'«' '» the woundfan,! thereby arreTtb ' \'''°'" •"'•"■'"'= ='''«™ may be .h^ vehic e of fhe^Ti ^::;T' °' '^""^ "»»"■ --ch hemorrhage. ^ ' '"' ""■" """=" '"""e degree of The cautery has been highly recommended by some h„. ,,, IS some reasonable doubt resnectin,, .h-. „ -^ ! ' "'*''<' When the constitution is , t aCt i P^P^'y "f employing it. of nitrate of silver may bv de^ T'""'"'' "'<"'PPli«'"io-' vi.™ Moposited, ,::!;x errLi^;:':;:,:.;" -t'^' 7 wen. But when the const.tution is already impregnated f if '(i ;4N 16 242 PRINCIPLES OF SURGERY. r s i! III! with the poison, the caustic can be of no possible use ; while it is sure to increase the local inflammatory action, which, we have seen, is calculated to intensify the general disease. Indeed, nothing should be applied that can increase the morbid action. Of cauteries, the nitrate of silver is the least objectionable, as it dries up the tissue, in a measure, and the subsequent separation of the eschar is not attended by the same amount of inflammation as that following the use of more destructive cauteries. Respecting constitutional treatment, but little need be said. It is, in the main, the same as that recommended for erysipelas. The diarrhoea and sweating are undoubtedly operations of nature, endeavoring to eliminate the poison. They should therefore be merely controlled, not arrested. As the faeces ought to be promptly removed, so ought the excretions of the skin. Washing and rubbing of the skin should not be neglected. See that the patient has plenty of pure air. Tonics and stimulants will have to form a portion of the remedial measures ; indeed, in the more severe cases, upon stimulants will depend the chance of recovery. In chronic cases, it will often be found advantageous to have a change of air, scene, and diet. The second class of poisoned wounds are inflicted by a healthy living animal. Of these it is unnecessary to speak. I am not aware of any animal at the present time in Canada, whose bite is particularly dangerous ; although the sting of some bees is, for a time, very painful. CHAPTER XXXI. Third Variety : Hydrophobia— Two Kinds— Dog-madness— Symptoms— Three Stages— Symptoms in Man— Course— Diagnosis— Pathology— Period of La- tency — Prognosis — Treatment. Hydrophohia. — The third class of poisoned wounds— \hQ only one of importance in this country— is hydrophobia; and the alarming frequency with which we hear of its occurring, and de- stroying life in the most distressing manner, calls for a careful consideration of the disease. HYDROPHOBIA. 243 yl oL Th ' rS "" """--'"i-l ty certain well-marked but the saliva !, T„ .t ^' • ""* " ""' '"<''f Poi™nou8, rt lie f p";„„ '^^f "-'«'»' »f 'be „,o»th resides the fata the absorbents. But any wonnd, it matters not'^ow made 1„^ sore any abras.on; even a thinness of the integumlt wi ,'suffi cen ly open a channel by which the saliva can, ff bTuehT L i!" ::!'ZTtZ''''''''' "J" f -"^ "■» poison i:tmV,"f:; me system. Cases are mentioned bv writers u-Jior« +v. r ™ contracted by a -bid dog licWn'g I^frc'e,; 1 1'^;' 'ri sm. 1 p.mples, or which had been cut by a razor JTT-\~'^T '"'"''' "' M'-ophoWa are men'tioned by writers ST. :Kt ^.Ti ';:-:.r "•■ -'•- •"•"■•- On^>n.-Hydrophobia is supposed to arise spontaneously in the f ti: brdrr'^v ■" *^' ""^ r *^ <■«- *« -f. *e > ui ratlfof t f Isea! rpVcWWi T T" '''T'' '^ "" S-- .he extremes of Jt IT^'/Z^H if Tnll '"d""^' likely to have something to do with it TTn^n+iofi a ^^/"o^e is also supposed to be provocate o the ;rB„:rf t" the origin of the disease is not understood "' Dog-madness. — Inasmuch no I'f ;a +u j .i 5^ disease to man, it is nt sly ,: Z^l^l^^SZ H~c;:H?er ■" "■"' ^■""■^•' -^ '-^ Atomst;:;ict same-'vertWd" " ""/°«' ""^ '^'"P'™^ "^ »»' "'"Js the r One of th'rr ""^^ «°" °" '° " »"'^'^ '•■"a' '-mina! One of the first symptoms, in the dog, is a decree of rest- ( i»i :iit \ ■ \&n 244 PRINCIPLES OF SURGERY. lessness, and suspicion of every body and thing; even his own master will be regarded with a perceptible degree of fear. In- stead of going as usual to his kennel, he seeks unusual places in which to lie. As the disease becomes developed, he will at times snap in the air, as if at flies. The eye becomes unnaturally bright and sparkling, so much as to seem reddish. It is not bloodshot ; but rather like that of a wild savage animal in the shades of night. The mouth and throat soon become affected, the secretions of the mucous membrane thereof being abnormal — thick and te- nacious. The efforts to dislodge this give rise to an unnatural barking. The following is taken from the System of Surgery, and is de- rived from the writings of Virchow. He describes the disease in dogs as consisting of three stages, and in the following manner: " The first stage is the melancholic, and is often unnoticed and un- recognized at itc onset ; still, there may be observed a palpable change in the natural condition ; alternations of depression and exaltation; restlessness, and change of place; sudden waking from sleep ; irritability ; deranged digestion ; anorSxia. The dog has often a greedy appetite, but sometimes leaves his food, or snaps at it. There is natural thirst, and no fear of water. After these premonitory symptoms have set in, the specific character soon becomes developed. There is great susceptibility in the cica- trix, when a bite or wound has been the antecedent ; a change of affection, character, and desires; a proneness to lap his own urine, and eat the fiieces of other dogs ; a peculiar idiosyncrasy to take all sorts of unwholesome and indigestible things, such as straw, paper, wood, &c. There is much sexual excitement, and eager licking of the genitals of other dogs. He seems friendly with the cat, but exhibits a marked change of affection toward his master. He becomes shy and backward, and avoids observation. The organs of deglutition and respiration become involved. There are spasms, and difficulty in swallowing, as if something was stick- ing in the throat ; alteration in the voice ; arrest of salivary se- cretion ; application of the tongue to cold surfaces, such as stone, iron, iic. Changes also take place in the motor system, for in all there is more or less debility and weakness. *' The second stage is the irritable and furiom. It commences generally in from one to three days, but may set in after twelve )'!» HYDROPHOBIA. 245 hours; it is seldom, however, met with after the eighth day Its course The paroxysms are strongest and longest at the onset commencmg with restlessness and irritability. He run ou of the house, attempts to bite, goes from place to place wiZut thou^t :^n "^^^^^^^^^^^ 'iTtLr '^''^ ^"'' \'' '-'- '-'-^ J .f ■ ,'"""""• " "8 this proneness to b to which rm aers this period so dsni»>rnii<: Ti,« hours and ofL """S*""'- The paroxysms may last several hours, and often even a whole day. Then follows a remission wh,oh „ very deeeptive, as all signs of disturbance subside b„^ the dog, aware of hi, unsociability, generally hides. The dilease .s often described from dogs who have been hunted, hooted and followed about m the street, and goaded on ,„ mad;ess and "n these severe symptoms are superadded, such as panting Ind flow . tust:^fT:'f b^t °' \""'^'' *i-.,'dread''of tat: th ust „g of the tai between the legs, starting of the hair, &c The h,ef and prominent symptoms of this stage consist in psy hieal and esthetic changes; there is a kind of'acute man a 'aifd del. mm, disobedience, no knowledge of his master, no avoidance of danger, sudden anger and snappishness, outbursts of wildness loss of general sensation and all sexual feeling. The chanr'n bXTn;; '^""^T •""■■ '"'™'' '™" °f voice betwen barking and howlmg, indicative of extreme distress; spelling of e fauces, tongue, and nose. The movement, of the body arc ash and hasty, and the hearf, impulse strong. The durationTf .his s age varies. It generally lasts three o'r four %, Cin" ni» the next and final stage; but ™ rare instance, it m/Z' nate suddenly in death, through a form of apoplexy. ^ wenke V„,r "T " ""7'"-'"^"'"- The paroxysm, now become weaker iind remittent; the animal emaciates rapidiv the coat mc he 1 es on one side in great prostration, but when rouseil is W Isnappish, and bite,; if able to walk, he totters and lag ™ a ong; t e eye, are sunken and dull, the mouth open am Iry e tongue hanging out and hard, the heart', action weak «^ r irTfr"'',*" '""""■« "'"--'• ^ ^-u,,™; r™ ?„ f T "'"" '''"'=" '■'•'"" "''»"»««"> or during a par- oxysm, in from five tn e "ht <1""" '— i- • - ^ I '" iU - wic nrsi ttitiick. This i' ! a kinu ■a ■ ! t 11 :w ; ■'■!?'? fill ,'i ; m ' 'h? 'U B. \?i ' 1 1 246 PRINCIPLES OF SURGERY. description is so important and truthful, that it could not be abridged. Frothing, to which so much importance is commonly attached, is due to the efforts to dislodge the tenacious mucus in the throat. Symptoms in Man. — We have now to notice the symptoms of the disease in man. They are local, and general or constitutional. The wound in most cases will have healed, perhaps been healed for weeks, when the first uncertain constitutional symptoms begin to appear. But now, as a general thing, the part which had been wounded takes on inflammatory action ; and if the wound has not healed, it assumes .the appearance of an inflamed ulcer. There is redness and pain, which gradually extend toward the body along the ("ourse of the nerves. In the part will sometimes form a vesi- cle, in which will be collected a drop of serum-like substance. At the same time, a group of similar vesicles will sometimes form under the tongue, by the foramen. The fluid in these is said to be highly poisonous. An Italian physician entertained the idea that if these were duly opened, the disease would be aborted ; but fre- quent experiments have proven the fallacy of his supposition. Nevertheless, it is recommended to carefully puncture these, and remove the concained fluid. The constitutional symptoms are very slow in their development. In most cases, the patient, for an indefinite time, feels an indefina- ble indisposition — a dread of impending danger. If he be aware of the nature of the wound which he had received, he will be un- willing to entertain the thought of hydrophobia, yet it will force itself upon him. The mind very often becomes unusually active ; the conversation will be brilliant and witty ; the imagination vivid and flighty. Sometimes, on the contrary, he is melancholy and dejected. This state of mind, and these uncertain symptoms, may continue for several days ; after which, the more characteristic symptoms begin to appear. Among the first signs will be those arising from embarrassment of the respiratory organs ; at the same time the glands of the mucous nienibrane will pour out a secretion more copious and viscid than natural, which, adhering tenaciously to the surface, urges the patient to make extra cftorts to expel it. These efforts are attended, in many cafecs, with an unnatural hawking noise. It is this which imagination has likened to the bark of a dog, and it has been supposed to be an attempt on HYDROPHOBIA. 247 thepart of the patient, while u„dcr the influence of the disease to imitate the dog which had bitten him. The paroxysms increase in frequency and severity, durine each of which the mouth opens and shuts convulsively, which g"ves the p. len, the appearance of one snapping at objects. BuTth s i not as has been supposed, an effort on the part of the subject to grati y a rabid desire to bite. It is only the uncontrollable'action of the muse es about the face and throat. Between the paroxysms the patient ,s fully sensible of his condition; indeed, Z^Zl the fit IS on, he IS quite aware of his state, but is impati;'t to resist the irregular action of the muscles. When the period of note of fte ?"'/," \'- '""""'' "^ "■» '"«»• ''^ -ill often give notce of the fact to his attendants. But the attack may be bought on suddenly, by any sudden alarm; and he is easily startled by an unusual sound or motion. At such times he wiU assume the attitude of defence, or as if about to deal a blow to some supposed foe. It is characteristic of this disease, in all .2 mas, to make use when alarmed, of the natural weapon of pro- tection to the body: thus, the dog will bite, the cat will scratch and me, the ox wil use his horns, and man will use his fists. The word hydrophobia indicates a fear of water ; and the popu- l«r belief ,s, that any animal suffering from this disease will neces- sarily have this, as the most prominent symptom. But the fact is, fear of water, or any other fluid, is not alway> present; and when her IS a dread of water, it arises from the insufferable pain which as been occasioned by efforts to swallow it. As the disease is oveloped, the tough, tenacious mucus, and the irregular action of imcTe ,? T-7 "-".^""""-S »f «-->". whilf at the same he wished-for fluid cannot bo swallowed, that causes the patient to shun the appearance of water, or any other fluid. E,™ the »onnd of water often produces feelings of great distress. Some- .....cs the mentioning of it will beget feeling, of extreme terror- and also he sight of tears. But the patient will, for a long iW .uc„e.,sfully try to swallow fluid, ; and when it become, distrtssi:;,' I w 11, a. If anxious to silow he has not the ,li,™,e. u.e the mof tormined effort, to swallow .Iraugh.s of water. Sometimes, in e,g , of the ,li,e^e, the thirst will be so great that the p„- litnt will, with heroic determination, carry a cup to hi, lipn, and ...Jf A- ii I * m i ) > i^:' \ V '' » 1-] 248 PRINCIPLES OF SURGERY. even succeed in gulping down large draughts of water. At first he may be unsuccessful, the cup being involuntarily drawn away ; but after repeated efforts, the fluid will be swallowed, although mortal terror is in his countenance. There will be, from first to last, occasional periods of fever and headache. There is often a pain shooting from the wounded part through the body, like that of rheumatism, and centring in the region of the heart. The penis is often in a state of erection, and there may be priapism, and seminal ejections. Vomiting is a com- mon symptom, and entire loss of appetite ; but sometimes the pa- tient will be able to take food. Restless and easily excited at first, he becomes, toward the last, entirely wakeful, as if in utter despair, and is often exceedingly rageful. The urine is passed with frequency, and at last involuntarily. As the disease ap- proaches toward the paralytic stage, all of the symptoms are intensified, until, — the strength of the patient being exhausted from the unnatural excitement, the terror, and the want of nou- rishment and drink, — depression, delirium, and paralysis super- vene. " The pulse becomes small, quick, and irregular ; the skin bedewed with clammy sweat ; the eyes dull and sunken, and the pupils large ; and death takes place, either from asphyxia during one of the convulsive attacks, or from exhaustion. The patient, however, may die quietly, sinking into a state of repose, with abatement of all the symptoms ; in one case being able to eat and drink, and expiring immediately on suddenly waking." (Sys- tem of Surgery.) Its Course, — The disease will generally run its course in two or three days ; it may, however, extend over a week, or eight days. As intimated above, the patient will generally die from exhaustion, and the duration of the disease will depend upon the powers of the patient to withstand the depressing effects of the disease. Sometimes death is hastened by some complication, as the arrest of the function of the lungs by congestion or paralysis. Occa- sionally, apoplexy suddenly closes the dreadful scene. No two cases, probably, will be found to possess just the same features; but the disease may with propriety be divided into three Stages. The first of which has the premonitory symptoms; the second is characterized by irritation and rage; the third by a ten- dency to paralysis. (System of Surgery.) HTDKOPHOBIA. 349 Z)M^n«,._The only diseaseB with which hydrophobia may po s.bly be confounded are te.an„, and hysteria. To distinguish n from tetanus .t ,s only necessary to notice the character i the spasms In hydrophobia they come on in paroxysms, while in tetanus the contraction of the muscles is consLt. Instead of the irregular action about the throat, there is continued lockjaw. Hydrophobia ,8 sometimes simulated in hysteria. Fear of water .s commonly supposed to be the characteristic symptom of the d-sease, consequently the hysterical patient has this as the chief or„rb / f J'"' °' ™'" '' "='y «-"• "» tte other symp- m of hydrophobia are absent. The history of the case, as weU as he various circumstances existing in connection with it will be phTbia " ^ ^^°'"' " '™ ^""' " 'P"™"' ~«^ "f hydro! Pathologi,.-The manner in which the system, some time after the bite, becomes aifccted, and the disease is established, is a question concerning winch much has been written, and with regard to which here seems yet to be some difference of opinion. The poison is in- re uced into a part of the body. Attending the wound there is no ymptom nor other indication of its deadly nature. The imme! latc -u'ts of the ite of a mad dog are in no way differentrm h se inflicted by a dog not mad. The usual course is pursued by nature to heal the wound ; restoration is, in most cases, as quickly and perfectly effected as in a wound not thus poisoned. Cicatriza^ .on 1, complete, the function of the part is in all respects per- fectly restored. After an indefinite, but generally prolonged *rt 'b TT" f "'■'"'' ■' '"'^ ''^y^' "■" 00-titutiofai effect begm to show themselves; then, and not till then, the part wounded also manifests certain peculiar symptoms. What are the stops between the cause »n,l the effect, which are so silently taken ' I» It possible to trace the chain of morbid links which stretches over the interim of silence? Is the poison taken „p b^ the al Jbents; does it pass directly into the blood; and there, In course of tunc become developed, as for instance in small-pox! Or Zs .t act from the first upon the nervous system ? Some pathologists hoi I one view some the other. The local and genera sympfoms quo" liofs' "' '" ""•"■' "' P"''"'" '•««''"« »« ">e above Hi inf ? ' H ^ ^ji ■MS A. • '■ \ I'ii i-'i km ' ,1 5 'I u w il '. Mi \i m m 4 m i in^ 250 PRINCIPLES OP SURGERY. This disease diflfers very much from small-pox, and kindred dis- eases, in this respect, in that the period of latency is prolonged, and is unattended with any symptom whatever. This has led to the supposition by some, that a double zymosis takes place; first in the part wounded, by which the poison is increased or intensi- fied so as to cause it to be taken into the system, and then having gained admittance into the blood, a second development follows, by which in due time, the whole volume of blood becomes afi"ected. Probably, however, the other theory, that the virus acts solely upon the nerves, will prove to be the most in accordance with the nature of the symptoms. The virus is received into a part of the body. Its eff'ects are directly upon the nerves therein. Probably not creating, as Chelius supposed, a kind of quick running inflammation, but a dis- turbance somewhat analogous to it. In course of time, the length of which will depend, first upon the extent to which the poison is brought in contact with the nerve-tissue, or the intensity of the poison, and secondly, upon the strength of the constitution, and other circumstances, the disease of the nerves insidiously creeps along the nerve-trunk to the nerve-centres, and finally culminates in the spinal centre, or the medulla oblongata ; and still working out its poisonous effects, causes abnormal reflex action in certain nerves, those especially about the throat; and hence the charac- teristic symptoms of the malady. From post-mortem examinations it is known that the medulla oblongata is principally affected. It is generally found softened. This softening sometimes extends to the striated bodies. The nerves which are most affected are the eighth pair, and it would seem that it is the morbid communica- tion sent by these nerves, which produces all of the characteristic symptoms of the disease, such as the morbid condition of the mu- cous membrane of the mouth and throat, the abnormal secretion of the glands thereof, the unnatural condition of the tonsils; also the spasmodic action of the pharynx, the trouble in breathing, and the frequent paralysis of the lungs, the derangement of the stomach, &c. There is great congestion of the encephalon, as might be ex- pected from the terrific spasms of the disease. The blood is said to be more fluid than in health ; the red corpuscles are broken HYDROPHOBIA. 251 effects are •eating, as 1, but a dis- the length e poison is sity of the tution, and isly creeps culminates 11 working in certain he charac- aminations Fected. It extends to ed are the onimunica- iracteristic of the mu- ,1 secretion nsils; also breathing, ent of the gilt be ex- ood is said ire broken down, and the tissues are infiltrated by the unnaturally dark coloring matter. j "^la. Although much uncertainty exists as to the origin and mode of development of the disease, it is well known that it is propagated by inoculation through the agency of the saliva alone ''From experiments, it is proved that neither the blood, flesh, milk, seminal fluid, nor the breath, nor the secretions and excretions of the ab- dominal viscera, are capable of producing hydrophobia, although Mag ndie has endeavored to prove that the blood is contagious " (System of Surgery.) ^ Through the agency of saliva the disorder may be communi- cated by those animals before mentioned, among themselves, and herbivorous animals, to fowls, and to man. But the disease can- not be communicated at all by herhivoroua animals, and there is no case on record where the disease was communicated by one human being to another. There is, however, a case recorded by Magendie, m which it was communicated to a dog by saliva taken from a man just before his death from this disease. This dog bit another, and both of them died. With regard to the period of latency, it has been stated that the average time IS about forty days. But a few cases are recorded, in which the disease was developed in a much shorter time, while on the contrary, some cases are mentioned where the period ex- tended over years. The case of the Duke of Richmond is sadly mteresting, because of the fact that he was far away from home, ma half settled colony, and because that colony was Canada H.8 death occurred in 1819, and the disease "was attributed by his Gi-ace to having had a cut on his chin, made in shaving, licked by a dog five years previous to the appearance of the disease. But It IS much more probable that he was infected by a tame fox which bit him through the thumb six or seven weeks prior to his death. (J. F. South, Chelius' Syst. Surgery.) And, with re- pect to all similar cases, there is a reasonable doubt whether there had been so long a period of latency. This question is one some importance; for if the surgeon could assure one, who had be en bitten by a rabid animal, that having passed a certain time without any signs of the disease, he was henceforth in no danger It would be a great relief to him. And the fact, that we have not ) '' WM\ «"'?™ k 252 PRI>JCIPLES OF SURGERY. as yet, any very well authenticated cases, should warrant the sur- geon to offer much comfort to the anxious bitten one. Still more, there seems to be no doubt that now and then, an active imagination in connection with an exceedingly nervous per- son, may give rise to many of the symptoms of hydrophobia, and even lead to death, even when the dog which had bitten the person was not rabid. These facts make it desirable that all reasonable grounds should be occupied to relieve the harassed object of a suspicious bite. Prognosis. — The above-mentioned facts will receive their due consideration. It is an important fact, and one which ought to afford considerable comfort to the patient, that all of those bitten by rabid dogs, are not seized with hydrophobia. On an average only one in twenty go mad; and, when the anxious question is put to the surgeon, he may reply, that he stands a chance of twenty to one of not contracting the malady. Again, when two or more are bitten, the one first bitten is far more likely to become infected than those subsequently bitten. The saliva which is adhering to the mouth will be, to a great extent, wiped away in the first act of biting, so that when the next is seized, although perhaps more seriously wounded, there will not be present any quantity of poi- soned saliva to enter the wound. And again, when the wound is not attended with much bleeding the danger is increased, as the blood when it flows from the wound, may wash away the fatal virus. For the same reason, a small wound, which naturally has limited hemorrhage, is more dangerous than a larger one, other things being equal. Bites upon the hand, or '" .or other un- protected parts of the body, are ~nore to be leared than those which have been made through a garment. When the tooth has passed through a thick, dense material, as the leather of a boot, there is very little cause to fear any evil ; for the tooth would be completely cleansed of the saliva ere it reached the skin. All these points will be duly estimated by the surgeon, before he offers an opinion as to the prognosis. The most hopeful opinion should be expressed, and the ground upon which this opinion is based. When the constitutional symptoms present themselves, the prog- nosis in most gloomy. A few cases are mentioned in which reco- very, it is asserted, took place after characteristic symptoms had shown themselves ; but it is to be feared that In these cases the ima- HYDROPHOBIA. 253 gination had created the symptoms. What supports this uncom- fortable view is the fsiot thai- ;« „ii iu • "utum- a subseouenT tZV fj ' ^ ■-stances of reputed cures, a subseqneni trial of the same remedies has entirely failed uZZ^'^rl^' ""T '"'~^' '"""-"-^ '» ^^teates. hurry for, of all cries, there is none more alarming and electric than that a person has been bitten by a mad dog. He must need accede to the most urgent of requirements. To him will be turned many an anxious face. And the patient should be seen as soon as possible, in order to take the necessary steps to prevent if nossT rests of others, the surgeon ought to give the first attention to the animal supposed to be rabid. As we shall see, it is important to know whether the dog was actually mad. Inoiiries ou^ht to he made ; and if the dog has not been already des't " d care should be taken to preserve him alive, to see if if be reai^; Vd" tli This can be done in a judicious manner, without othei' incurring any risk. Dogs are frequently supposed to be mad when tl ^ "! not. Any sickness or indisposition is likely to be regarded by the apprehensive public, as that of hydrophobia; and no do„M many a poor cur ,s hunted, chased, and stoned, until he seems to be ,ke one mad; indeed, he becomes mad in a certain sefs and It fro hing mouth, will in self-defence attempt to bite a y'thing hat obstructs his path. The surgeon' ought first to determC ff he can, that the dog was really mad. The history o ^e cle my reveal the existence of doubt as to the nature of the dLase - ;s friends, ^^z ;:i^;:zT::z:^^z horrible suspense. If the person bitten be subject to nervoTs im pression, we have seen that imagination, although it cannot boRe to death. Still more, there are not wanting those who believe the d««.sc to be a disease entirely resulting from a busy imag nation Ccrtamly, there can be but little douut that it will at leaft aM in o't olw in T -'i ™" 1 ''''' '''''' " ™" '" coneld, ha" tien. tl e > TT. "^ ""= P"'"'"' ""' <■»■■ ""-■ ''»«fi' of th dd h ^^ *°'"1'"'™ - fi--'' oonsideration, and that its life required than a sight of the living dog after several days. I U h: I'. J .: :'li li 254 PRINCIPLES OP SURGERY. ^ And should the dog unfortunately die, it will be no worse for the patient. But even then, all hope is not destroyed ; many a dog dies with the symptoms of hydrophobia, due to other causes. Considering the very great influence the mind has upon the devel- opment, if not of the disease, at least certain symptoms of it, I have ventured, in the class-room, to suggest that if a dog like the one which had bitten the patient were shown to him, leading him to believe it the one by which he had been bitten, the disease might be averted. The terrible nature of the malady might jus- tify the deception. With respect to the patient, the great aim of the surgeon is to remove the virus from the wound before it can take effect upon the tissue or be absorbed. Those points referred to under prognosis will receive a quick but definite consideration, so as to estimate the probable degree of danger. Flowing blood tends to carry the poison out of the wound ; bleeding should therefore be promoted. By sucking the wound, which can be done with impunity if the lips and mouth are unabraded, it is possible to draw' out fluid con- taining the virus. A friend will generally be found to perform this important duty. When some time has elapsed since the re- ception of the bite, this mode of using suction will hardly sufiice. The various measures recommended to prevent the entrance of poison in dissecting wounds, may likewise be adopted. But exci- sion of the tissue around the wound is the most reliable step to be taken. The virus is probably confined to the superficial part of the wound. The tooth of the dog, as it pierces the tissue, will be effectually cleansed of the saliva as it passes through the skin; and as the blood begins immediately to flow (and if it continue to flow), the poison cannot have found its way to the deeper part of the wound. Under such circumstances, the excision of the super- ficial part of the wound may effectually remove the poison. To insure a complete removal of the tissue all around the wound, it has been recommended to make a ring around it, by the applica- tion of nitrate of silver, before commencing the incision. It is better to remove too much than too little of the tissue which may be contaminated. Even when the wound is upon the face, the question of deformity — of unseemly scars — will hardly be taken into consideration. It is a question, not only of life and death, HYDROPHOBIA. 2SS but Of a most homble death. The dog being really mad, the face hav»g been unprotected, the saliva of the ani™a/was freely be. smeared upon the face and the wound. The ehances, then^ are P 7" J^''; f»"« having been well cleaned, the tissue around must be effectually e«Ued : no matter if the ^ound be extensive lulillted it ^f t I "''' "' " *°«'"'' " =" f""' has been much mflated, It w,ll be safer to amputate the member at once. Some- tames the cautery ,s used, both actual and potential. The safer course .s to exc.se, and then use the nitrate of silver freely It I even reeommended to excise the cicatrix after the constftul -old symptoms have begun to appear. Respecting the propriety of such procedure, there is, however, some reasonable doubt Oo«mtut,onal Treatment.-T>unns the period of suspected la- te ey, constant efforts should be made to tranquillize the mind by rehevmg ,t of unnecessary apprehension. Unfortunately, when genera symptoms have shown themselves, but little can b done To palhate ,s the highest aim the surgeon can take. It is s ar ely necessary to enumerate the long list of antispasmodics and seda! t.ve» wh,ch have been recommended, but subsequently found wlnl mg m power to cure, although they may have power to give tern- porary rehef Among them are aconite, Indian hemp, musT camphor armca nitrate of silver, belladonna, hyoseyamus &c Strychma, also, has been highly recommended. Many of thes^ may control, somewhat, the distressing symptoms. The iniection result. Ice has been used, also, to the spine, with the view of ta "TcUtb" ^''"''' '"' " "-"^ P™-^ serviceable fir a me Ice w,ll be more grateful to the patient when given to hira to take m small p.eces; these he can often swallo;, with mos" comfortmg rehef. Marshall Hall, while pursuing his unwearied .use ofV ,^ 7 ,. '\""' '"'•^"""y "f '"■™"'i»g «s the final cause of death, and that the operation of tracheotomy would nrovc a cure. However, by such a course, only one symptom is relieved The disease always takes a steadfast course, whether one or mor<; way retard the fatal course of the malady. n i r ii *: ff.l i ' ill ^ 1 1 < f I 111 ^ , .1 J!'lij.,B'it 11 256 PRINCIPLES OF SURGERY. In conclusion, I have to refer to the proposed cure by salivation. A case is recorded by a Dr. Legget, of Maryland, who declares that he successfully treated a colored girl, agod twenty, of unmis- takable hydrophobia, by the administration of calomel in drachm doses. Having first abstracted blood to the amount of Sxxxij, he administered the drug about every six hours. Under this treat- ment, the paroxysms gradually subsided in force and frequency. The ground upon which he based the treatment, was that "the increased flow of saliva appears to be a conservative effort of the vis medicatrix to eliminate the poison from the system^ through the glands engaged in its secretion." So far as I know, this remedy has not been fully tested. But it is to be feared that it, like so many others, will fail when again employed. Yet it is to be hoped that the advance of pathological science will hereafter enable the profession to conquer this distressing malady. CHAPTER XXXII. Tetanus : Symptoms— Stages— Pathology— Diagnosis— Treatment. Tetanus — Varieties. — There are two kinds of this disease, the Idiopathic and the Traumatic. It is the latter which the surgeon ,i8 called upon to treat. By tetanus is understood a tonic contrac- tion of one or more of the voluntary muscles, commencing almost always in the region of the neck, especially the muscles of the jaw. Hence the cognomen lockjaw. It is essentially a nervous disease, in which the nervous centres, especially the medulla oblongata, assume a function decidedly morbid. Its Nature. — It has generally been supposed that in traumatic tetanus some irritation in a certain part, commonly where a wound has been made, acts upon the nerves therein, creating a morbid action, which action is, after a time, communicated to the nervous centres ; there in turn to establish an unnatural condition, which will be manifested by morbid reflex action,— the phenomenon above- mentioned, that is, an incessant contraction of certain muscles, which will continue for an indefinite period, but often until death TETANUS. 257 terminates the disease. This has been the general view but of late the question has been raised whether f^o would exhibit a condition so aTnorJl It^^^^^^^ '''''"^ so frequently fatal, if the^e were nn^.' ' a termination rangement, o'r pred'ispo^ ioirdisetse '^Zf^TT^'''' t tetanus arises without any appa ent l^erntl '""'T^'' X xf , ^ «ppt,o„ may produce the disease, there n,„st have previous yerid some spec,flcd,sease of the blood, engendered perharby thTde velopment of some poison akin to that which gives riL to oyll certain e.ects upon trhtlltltrr trnditZ::; remain m a latent state for an indefini e time A. , ,T ^^^ .here is an expression of disturbant t rnifestd t ^"S . tetanus. Now, nliopathic tetanus is comparatively a ZiMlZ' Md rare y terminates fatally; at least, 'under tv„r:;":r form may be recovered from, the traumatic rarely does rTt ::rttiicr^~^'~^^ toe but quickly extends to the muscles of the body When ,Z , >vutn inose ot the back alone are enira<^Pd th^r^ ic 17 illt. I ' y. I 'f! i*'l5 llil I, . I fi 258 PRINCIPLES OF SURGERY. Opisthotonos. Sometimes the disease attacks the muscles of one side, and then it is called Pleuroathotonos. And sometimes in its intensity, the disease affects all the voluntary muscles of the body, so that it is immovable— rigid. Here we have essentially tetanus — the disease in its perfect type. Causes. — The causes, to repeat somewhat, are local and general, or predisposing and exciting. The general cause is some weakness or poison developed in the systqm. That weakness is a cause, is seemingly shown by the fact that the bleeding, or accidental loss of blood, sometime before the attack, will intensify the complaint. The local causes are wounds or injuries, especially such as involve dense fibrous structures, which have a free supply of nerves. In these cases the nerves themselves are generally lacerated, or otherwise very much irritated. There are certain irritants which seem particularly to possess the power to light up the disease, the embers of which had been laid. The rust of a nail, the accretions upon an old pin, are among the most active ones. Exposure to ex- treme heat and cold, are said to be exciting causes of the disease. Structures subject.— W'UWg the disease is most likely to occur in connection with wounds of a fibrous structure, it may also fol- low wounds of the face, neck, joints, spermatic cord, as well as of the fingers and toes. Period of Incubation.— The length of time between the recep- tion of the wound and the commencement of the disease, is said to vary very much, indeed, from a quarter of an hour to a month. There are cases mentioned in Chelius of both kinds. When the disease presents itself, the wound may be yet in an inflamed state, or healing, or suppurating, or a cicatrix may have formed. Stages— Symptoms of each.— The disease may be divided into three stages (Chelius), with corresponding symptoms. In the first stage the muscles about the neck only will be affected. There will be a sense of stiffness like that which accompanies a common cold. The larynx and muscles of the tongue are unable to act freely, i,ftU8ing the voice to appear unnatural. The efforts to swallow cause often great distress, and sometimes terror, especially when it is water, as in hydrophobia. It is these symptoms— the changed voice and difficulty of swallowing, which have produced, some- times, difficulty of distinguishing the two diseases apart. Their is an absence of inflammatory symptoms, but sometimes there TETANUS. 259 are shootmg pai„8. In the part wounded there may be unhealthv aeon, or .t may remain unchanged. After a time the slifCa of the muscles about the neck asanmes the form of lockjaw and the second stage ,s mtroduced. The mouth, now, cannot b opened unless w,th great difficulty, cither by the patie;t or surgeon The t:Z: Th ' ^"tJ"^"""^ '"™ •'°™ " '"earners he mouth The eyel.ds are sometimes firmly shut, the iris con trac ted, the eyeball fixed, and there is an acute ensib i'; t„ l.gh . Th,, contracted state of the muscles of the fac 'il a most unpleasant expression to the countenance, which ometimes becomes h.deous. The muscles of the abdomen are generXZ next to become affected, and the intestinal canal, S ott ^ X dommal v.sccra participate in the affection; and here is conte" quently, retention of stools, and of the nri. , This const'inrot .almost always present; and it was asserted b. ACrXylZ th,s eons„pat,o„ was the determining cause of the malady '0!^ s..pa„on generally precedes the tetanic convulsions, and Ab rnethv of the present day is. that ^r^:^:!:7Z:x:[::: Ihc effect of the morbid condition of the nerves and no, » or a link in the chain of causes. At this rL of the die":; .here ,s more pam experienced; sometimes severely a the low" :::;;et;ossr""^'™-' '"«-'•"- The Ih-rd stage is introduced by ,ome difficulty of brcathinir- he muscles of respiration begin to participate in the pa , oJ c«-muMy the contraction is so deci.lcd that death at one. lu! " b.v the arrest of the respiratory function Oftener .U • ' and continued distress of breatl,i„„ iLl, I " «''''"' 0...-I hy the disease ex.::, ^o ,h hean' 1:T'"'11' con,n,c,ion of muscles about the fhroa s so gr at ^CuTl ™nont ,s arrested, and thus death will be pro .c bl Ip :!' isT ./•"""« «!'« "hole course of the dis, «e, the intellect !»,ii Vfl i: ii. -I'fl ji Jim ■Hi Kii 1 260 PRINCIPLES OF SURGERY. Pathology.— Post-mortem examinations have not revealed very much. The nerves and their sheaths, extending from the wound toward the spinal cord, are sometimes found inflamed. In the substance of the brain and spinal cord, but little, if any, change can be detected. They are sometimes congested, occasionally softened. (Chelius.) The membranes, however, are always found congested, especially those of the cord; possibly though, the gravi- tation of the blood after death, may assist in producing the latter condition. Effusion of watery fluid between the membranes is not uncommonly seen. Recent observations show that the medulla ob- longata is generally softened. As yet there is not sufficient data to establish any hypothesis. Dta^wom.— Hydrophobia is the only malady for which tetanus may be mistaken. But if the history of the case and the charac- ter of the spasms be studied, there cannot be a mistake. In addi- tion, the diagnosis will be assisted by noticing the condition of the mucous membrane of the mouth and throat. In hydrophobia there is an undue viscid secretion; in tetanus such is not the case. Prognosis.— In the traumatic form, it is always unfavorable. But few cases of recovery are recorded. The danger is always in proportion to the acuteness of the attack. If trismus only be present, and there be no tendency to increase in the intensity of the symptoms, then there is hope. This hope will brighten, as day after day passes away with no increase in the severity of the symptoms. South says " if seven days pass away, in any case, there is great hope of recovery." Treatment.— The pathology of the disease, so far as understood, must be the basis upon which to found judicious troatmont. It is essentially a nervous disease. The blood may be in an abnormal state, or other morbid conditions may exist, which have led to the malady. But when the disease is before the surgeon, he finds the nervous system principally affected. All along the nerve- tracks-from the scat of the wound to the spinal centres, and m those centres themselves, and then along the nerves procoed.ng to supply the muscles, which in this disease become affected, at many points and in a degree more or less intense— may be foun