THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY THE NEW SYDENHAM SOCIETY. INSTITUTED MDCCCLVIII. VOLUME LXXIII. LECTURES SURGICAL PATHOLOGY AND THERAPEUTICS. A HANDBOOK FOR STUDENTS AND PRACTITIONERS. « BT De. THEODOR BILLROTH, PEOFESSOE OF SUEGEEY IX THE UXIYEESITY OF VIENNA. TRANSLATED FROM TEE EIGETE EDITION. VOL. L LONDON: THE NEW SYDENHAM SOCIETY. ilDCCCLXXYII. 559 Bioniedicd] Library too 4/:/ CONTENTS, LECTURE I. INTRODUCTION. PAGE TJie relation of surgery to internal medicine. — Necessity of a practi- tioner's having acquired both. — Historical remarks. — The method of study of surgery pursued in the German universities . . . i LECTURE II. CHAPTER I. SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Mode of origin and appearance of these wounds. — Various forms of incised wounds. — Symptoms during and immediately after the act of wounding : pain, haemorrhage. — Different kinds of haemorrhage : arterial, venous. — Entrance of air through wounds in veins. — Paren- chymatous haemorrhage. — Haemorrhagic diathesis. — Haemorrhage from the pharynx and rectum. — General consequences of severe haemorrhage 22 LECTURE III. Treatment of haemorrhage: (i.) Ligature and transfixion of arteries. — Torsion. — (2.) Compression, compression with the fingers, choice of places for compression of the larger arteries. — Tourniquet. — Acu- pressure. — Bandaging. — Application of the tampon.— (3.) Styptics. — "General treatment of suddenly-occurring ansemia. — Transfusion . 35 593170 PAGE VI CONTENTS. LECTUEE IV. Gaping of the wound. — Union by plaster. — Suture. — Interrupted suture. — Twisted suture. — External changes perceptible in the united wound. — Removal of the sutures. — Healing by the first intention LECTURE V. Inflammation. — The more minute processes in healing by the first inten- tion. — Dilatation of the vessels in the neighbourhood of the wound. — Fluxion. — Different views regarding the causes of fluxion . 67 LECTUEE VI. Changes in the tissue during healing by the first intention. — Plastic infiltration. — Inflammatory new formation. — Development of the cicatrix. — Anatomical indications of the process of inflammation. — Conditions under which healing by the first intention does not occur. — Union of parts that have been completely separated . 78 LECTUEE VII. Changes visible to the naked eye in wounds with loss of substance. — Minute processes in healing by granulation and suppuration. — Pus. — Cicatrisation. — Views as to " inflammation." — Demonstration of preparations illustrative of the healing of wounds .... 94 LECTUEE VIII. General reaction after injury. — Traumatic fever.— Theories respecting this fever. — Prognosis. — Treatment of simple injuries, and of the injured 117 LECTUEE IX. Combination of healing by primary and by secondary intention. — Deep wounds. — Open treatment of wounds. — Lister's method. — Cocco- bacteria septica. — Union of granulating surfaces. — Healing under a scab. — Diseases of granulations. — Cicatrices in difl'erent tissues — in muscle ; in nerves, and their bulbous dilatation ; in vessels, organ- isation of thrombus. — Arterial collateral circulation , . • 131 CONTENTS. Vii LECTUEE X. CHAPTER II. ON SOME PECULIARITIES OF PUNCTURED WOUNDS. PAGE Punctured wounds, as a rule, heal quickly per primam. — Needle pricks ; needles remaining in the body, their extraction. — Punctui'ed wounds of nerves. — Punctured wounds of arteries. — Aneurism, traumatic, varicose, aneurismal varix.— Punctured wounds of veins. — Bleeding 169- LECTUEE XI. CHAPTER III. ON SIMPLE CONTUSIONS OP THE SOFT PARTS. Causes of contusions. — Kervous shock. — Subcutaneous rupture of vessels. — Rupture of arteries. — Ecchymosis. — Absorption. — Termi- nation in fibrinous swellings, in cysts, in suppuration, in sloughing. — Treatment . . c 183 LECTUEE XII. CHAPTER IV. CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. Mode of occurrence of these wounds ; their appearance. — Slight haemor- rhage in contused wounds. — Early secondary haemorrhage.— Gan- grene of edges of the wound ; influences which effect the slower or more rapid detachment of necrosed tissue. — Indications for primary amputations. — Local complications in contused wounds. — Decom- position. — Putrefaction. — Septic inflammations. — Contusions of arteries ; late secondary haemorrhage 197 LECTUEE XIII. Advancing suppurations originating in contused wounds. — Secondary inflammations of wounds ; their causes ; local infection. — Febrile reaction in contused wounds, secondary fever, suppurative fever, fever-rigors, their causes. — Treatment of contused wounds ; immer- sion, ice-bladders, irrigation ; critique of these methods of treat- ment. — Incisions, counter-openings. — Drainage. — Cataplasms. — Open treatment of wounds. — Lister's method. — Prophylaxis against secondary inflammations. — Internal treatment of the severely wounded. — Quinine. — Opium. — Lacerated wounds, subcutaneous tearing of muscles and tendons, tearing out of limbs . . «213 Till CONTENTS. LECTUEE XIY. CHAPTER V. ON SIMPLE l'RACTURES OF BONES. PAGE 'Contusion and concussion of bones, various kinds of fractures. — Symp- toms, method of diagnosis. — Course and phenomena recognisable exteriorly.— Anatomical character of healing process and callus- formation, — Sources of the inflammatory process of ossification, histology 238 LECTUEE XY. Treatment of simple fractures.— Reduction.— Time of applying the dressing. — Choice thereof. — Sulphate-of-Iime dressings, starch dressings, dressings with splints, permanent extension ; position- apparatuses. — Indications for removing the dressing . . . 260 CHAPTER VI. ON OPEN FRACTURES AND ON SUPPURATION OF BONE. Difference between subcutaneous and open fractures in reference to prognosis. — ^Varied character of the cases. — Indications for primary amputation. — Secondary amputation. — Course of the healing process. — Suppuration of bone. — Necrosis of the ends of fragments 270 LECTUEE XYI. Development of granulations in bone. — Histology. — Separation of sequestra. — Histology. — New-formation of bone around the separated sequestra. — Callus in suppurating fractures. — Suppura- tive periostitis and osteomyelitis. — General conditions. — Fever. — Treatment ; perforated dressings, closed, cut-open dressings. — Antiphlogistic means. — Immersion. —Lister's method. — Behaviour of splinters of bone. — After-treatment 279 LECTUEE XYII. APPENDIX TO CHAPTERS V AND VI. 1. Retarded formation of callus and development of pseudarthrosis. — — Causes often unknown. — Local conditions. — Constitutional CONTENTS. IX PAGE causes. — Anatomical conditions. — Treatment; internal, operative measures ; criticism of methods employed. — 2. Obliquely-united fractures; rebreaking, bloody operations. — Abnormal development of callus 293 CHAPTER VII. INJUEIES OF THE JOINTS. Contusion. — Distortion. — Massage (Shampooing).— Opening of the joints and acute traumatic articular inflammation. — Varieties of course and terminations. — Treatment. — Anatomical changes . . . 302 LECTURE XYIII. Simple dislocations — traumatic, congenital, pathological luxations. — Sub- luxations — etiology — difficulties in reduction. — Treatment. — Reduc- tion. — xlfter-treatment — habitual luxations — old luxations. Treat- ment — complicated luxations — congenital luxations . . .3] LECTUEE XIX. CHAPTER VIII. GUNSHOT WOrNDS. Historical remarks. — Injuries from large missiles. — Various forms of gunshot wounds from musket balls. — Transport and care of the wounded in the field. — Treatment. — Complicated gunshot fractures 329 LECTURE XX. CHAPTER IX. BUENS AND FROST-BITES. I. Burns, grade, extent, treatment. — Sunstroke. — Stroke by lightning. — 2. Erost-bites, grade, general freezing, treatment. — Chilblains . 3.44 X CONTENTS. LECTURE XXI. CHAPTER X. THE ACUTE NON-TRAUMATIC INFLAMMATIONS OF THE SOFT PAETS. PAGE General etiology of acute inflammation. — Acute inflammation: — i. Of the cutis : a. Erysipelatous inflammation ; h, furuncle ; c, carbuncle (anthrax, malignant pustule). — 2. Of the mucous membranes. — 3. Of the cellular tissue. Hot (acute) abscesses. — -4. Of the muscles. — 5. Of the serous membranes, sheaths of the tendons, and subcutaneous mucous bursse 358 LECTURE XXII. CHAPTER XI. ACUTE INFLAMMATIONS OF THE BONES^ PERIOSTEUM, AND JOINTS. Anatomy. — Acute periostitis and osteo-myelitis of the long bones : symptoms, terminations in resolution, suppuration, necrosis, pro- gnosis, treatment. — Acute ostitis in spongy bones ; multiple acute osteo-myelitis. — Acute inflammations of the joints. — Hydrops acutus ; symptoms, treatment. — Acute suppurative inflammations of joints : symptoms, course, treatment, anatomy. — Acute articular rheumatism. — Arthritis. — Metastatic inflammations of the joints (gonorrhoeal, pyaemic, puerperal) 389 APPENDIX TO CHAPTERS I— XL Retrospect. — General remarks on acute inflammation , . . .412 LECTURE XXIII. CHAPTER XII. OF GANGRENE. Dry and moist gangrene. — Immediate causes. — The process of separa- tion. — The different varieties of gangrene according to the remoter causes. — i. Destruction of the vitality of tissue from mechanical or chemical causes. — 2. Complete arrest of the afilux and reflux of the blood, — Incarceration. — Continued pressure. — Decubitus. — Over-tension of the tissues. — 3. Complete arrest of the supply of arterial blood. — Spontaneous gangrene. — Ergotism. — 4. Normal gangrene in various diseases of the blood. — Treatment . . . 423 GENERAL SURGICAL PATHOLOGY AND THERAPEUTICS. LECTÜEE I. INTPtODüCTIOK The relation of surgery to internal medicine. — Necessity of a jjrac- titioner's having acquired both. — Historical remarks. — The method of studu of surgery jmrsued in the German univer- sities. Gentlemen. — The study of surgery, whicli you commence with these lectures, is in most countries at present rightly regarded as a necessity for the medical practitioner. We consider it a sign of progress that there is no longer the same separation of surgery from medicine as was formerly the case. There is in fact only an apparent distinction between internal medicine and surgery, the separation is artificial, although founded on history and on the great and ever increasincr extent of medicine o-enerallv. You will often notice in the course of these lectures how very much surgery has to take into consideration the internal and general processes in the body, also that external and internal affections are in all respects analogous, and that the whole difference is in the fact that in Surgery the local alterations of tissue are mostly patent, whilst we only judge of the local afiPections of internal organs from the functional disturbances. The effects of local disturbances on the condition of the system in general, must be as accurately understood by the surgeon as by one whose attention is principally occupied with diseases of the internal organs. In short the surgeon must be a physician also in order to form a correct and safe judgment as to the condition of his patient. On the other hand the physician who puts surgical cases A 2 INTRODUCTION. on one side and only attends to the treatment of internal complaints^ must have some surgical knowledge if he would avoid making the most unjustifiable mistakes. Independently of the fact that the country doctor does not always have a colleague within reach to whom he can hand over his surgical cases, the life of a patient may at times depend on a rapid and correct diagnosis of some surgical disease. When blood is spouting from a wound, when a foreign body has entered the wind-pipe and the patient is threatened with immediate suffocation, then is the time for surgical interference, and that quickly, or the patient is lost. It may happen in other cases that a physician without any knowledge of surgery may do much harm by his incapacity of forming a judgment as to the importance of a disease ; he may allow the complaint which at first might have been easily relieved by surgical aid, to become incurable and thus by his want of knowledge cause unspeakable injury to the patient. It would for this reason be most unjustifiable should a physician perversely persist in the idea of only practising internal medicine, still more unjustifiable would it be for you even to think of neglecting the study of surgery : to say, " I will not operate, as there are so few operations in general practice, and personally I am not fitted for it V' As if surgery consisted in operating only ! as if surgeons only needed skilful hands in order to do their work properly : I hope to present you with a better view of this branch of medicine than that represented, which is unfortunately only too popular. As surgery has to deal chiefly with palpable injuries, it certainly has a somewhat easier position with regard to the anatomical diagnosis, but do not estimate this advantage too highly ! Quite apart from the fact that affections requiring surgical treatment are often deep-seated and hidden from view, much more is expected from a surgical diagnosis and prognosis and even from the treatment than is expected from the therapeutic action of internal remedies. I do not deny that internal medicine may in many respects possess greater attractions just because of the difficulties which it has to surmount in the localisation and recognition of disease, difficulties often so successfuly vanquislied. Yery fine mental operation is frequently neccessary in order to obtain a clear idea from the complexity of the symptoms and the results of the examination. Physicians may point with pride to the anatomical diagnosis of diseases of the heart and chest, since by their indefatigable spirit EELATION OF SUEGERY TO INTERNAL MEDICINE. 3 of inquiry they have been enabled to give as accurate a repre- sentation of the changes in the affected organ as if they were present to the eye. How marvellous it is to be able to get a clear idea of the diseased condition of deep-seated organs^ as the kidney, liver, spleen, the intestines^ the brain and spinal cord, by means of an examination of the patient and the combination of the symptoms. What a triumph to be able to diagnose diseases of organs, of whose physiological functions — the supra- renal capsules for instance — ^we have not the slightest idea. This somewhat indemnifies us for the fact that in internal medicine we have more frequently than in surgery to confess our powerlessness respecting the operation of our mode of treatment, although the treatment of internal complaints has_, owing to the progress of anatomical diagnosis, become more certain and more definite as to its object and the results attainable. The attraction of the finer reflective qualities of our imagination and intellect to the sphere of internal medicine is, however, abundantly compensated by the greater certainty and clearness of diagnosis and treatment in surgery, so that both branches of medical knowledge not only appear perfectly equal, but what is done in the one is as glorious as that in the other. And we must not forget that the anatomical diagnosis — I mean the knowledge of the patho- logical changes of the diseased organs — is but a means to an end, that is the cure of the disease. To find the causes of the morbid processes, to fortell their course correctly , to conduct them to a favourahle issue or to check them, these are the peculiar prohlems for the physician, and these are equally difficult of solution in internal as well as in external medicine ; scientific research and refined empiricism are the means at our command for the solution of this 2yrohlem. One thing alone is required of the pure surgeon more than of the pure physician : the art of operating. This, like every other art, requires mechanical skill; operative skill depends upon accurate anatomical knowledge, on practice and on natural talent. This talent for operating may by constant practice, be successfully cultivated^ if there be medical aptitude as well. Remember how Demosthenes overcame the difficulty of speaking ! — Owing to this practical part of it, though essentially necessary, surgery, in its narrower sense was so long separated from medicine ; historically we can trace how this separation arose^ how more and more it 4 INTEODÜCTION. continued to make itself practically felt and only in the course of the present century was it looked upon as unsuitable and was put on one side. In the word " Cliirurgery '^ we find expressed that originally the practical part of the art only was meant^ for the word '^ Chirurgery '^ is derived from y^tio and epyov ; the literal translation being " hand-work/' or as it was called in the favourite pleonasm of the middle ages "the craft of Cliirurgery." Little as it is the design of these lectures to give you a complete sketch of the history of Surgery, it still seems to me of importance and at the same time interesting to give a hasty glance at the development of our science and of the position we held_, from which you will understand many of the various existing regulations affecting the so-called medical staff in different countries. A more copious history of surgery can only be useful to you later, when you have already obtained some insight into tlie value or otherwise of certain systems, methods and operations. You will then find the key in the historical development of our science, particularly in respect to operative surgery, for much that is at present surprising and for much concealed knowledge. Much tliat is absolutely necessary for its comprehension, I will explain to you in speaking of the various diseases ; at present I will only bring forward some of the prominent events in the development of surgery and of the surgical status. Among the nations of antiquity, the healing art was essentially connected with religious culture. It was looked upon among the Indians, Arabians and Egyptians, as well as among the Greeks as a revelation from the Deity to the priests, which spread by tradition. Philologists have not all been agreed as to the age of the recently discovered Sanscrit writings ; at first they were believed to have originated about looo to 1400 years b.c., at present they believe for certain that they were written in the first century of the Christain Era. The Ayur Veda (*'Book of the art of life ") is, as regards medicine, the most im])ortant work in Sanscrit, and was composed by Siisrutas ; this work most probably first appeared in the time of the Roman emperor Augustus. The art of healing was considered in its entirety, as is evident from these words : " Only the association of medicine with surgery forms the perfect physician. The physician who is deficient in the knowledge of one of these branches, resembles a bird with but one Aving.'^ Surgery at that time was beyond doubt by far the most advanced department of HISTORICAL EEJIARKS. 5 the healing art. Much is spoken of a vast number of operations and instruments, but it says very truly that " of all instruments the hand is the best ;" the treatment of wounds is simple and appropriate; and most surgical diseases were already known. Among the Greeks the aggregate of all medical knowledge was concentrated in Asklepios (^Esculapius), a son of Apollo, and a pupil of the centaur Chiron. Many temples were built to Jilsculapius, and among the priests of these temples the healing art was transmitted by tradition; in the different temples arose different schools of ^Esculapius, and although every one who entered the service of the temple as a priest of ^Esculapius, had to take an oath which has been preserved to our own time (though its genuineness has in more modern times become very questionable), that he would only teach the art of healing to the successors of the priests, it yet appears from various circumstances that besides the priests there were other physicians. From what occurs in one part of the oath, it even seems that then, as at present, there were physicians who occupied themselves solely as specialists with certain operations, for it says : *' J^ever will I cut for stone, but will leave it to those men whose business it is."'' We first obtain more accurate information as to the different kinds of physicians in the time of Hippocrates ; he was one of the ^Esculapians, was born on the island of Cos about 460 B.c., lived partly in Athens, partly in Thessalonian cities, and died at Larissa 377 b.c. We might well expect that medicine would be scientifically treated at a time when the names of Pythagoras, Plato, and Aristotle, shone in Greek science; and, in fact, the works of Hippocrates, many of which have been preserved to our time, excite our deepest admiration. The clear descriptions, the perspicuous arrangement of the whole material, the enthusiasm for the healing-art as a science, and the keen critical observation which we find in the works of Hippocrates transport us, even in this department, with admiration and reverence for ancient Greece, and show plainly that it was not merely a credulous repetition of tra- ditional medical dogmas, but that there was already a scientifically and artistically formed art of healing. In the Hippocratic school the art of healing formed a complete whole ; medicine and surgery were united ; but the medical practi- tioners were divided into various classes. Besides the uEsculapians there were others, educated physicians as well as the apprenticed medical assistants, gymnasts, quacks, and miracle-mongers; the b INTEODIJCTION. physicians took pupils to instruct in their art; and from some observations of Xenophon, we learn that there were already army- surgeons, especially in the Persian wars ; they had, together with the soothsayers and flute-players, their position in the neighbour- hood of the royal tent. It is natural that special attention would be paid to external injuries at a time when so much was thought of corporeal beauty as among the Greeks ; consequently, the study of fractures and dislocations was particularly cultivated among Hippo - cratic physicians ; while, at the same time, we have accounts of many difficult operations, and of a great number of instruments and other apparatus. As regards amputations they certainly seem to have been very backv^'ard ; probably most of the Greeks would sooner have died than have prolonged life in a mutilated condition ; only when the limb was already dead, " gangrenous,^' was it removed. At that time the doctrines of Hippocrates could not become further developed, as increased knowledge of anatomy and physiology was necessary ; there certainly was a weak attempt in this direction in the learned school of Alexandria, which flourished for some cen- turies under the Ptolemies, and through which, after the victories of Alexander the Great, the Grecian spirit spread, even though but for a time, into a part at least of the East ; the Alexandrian physicians in the meantime soon lost themselves in philosophical systems, and only slightly promoted the progress of the healing art by original anatomical observations. In this school the art was first divided into three separate parts, dietetics, internal medicine, and surgery. With Grecian refinement the Grecian healing art came also to Eome; the first Eoman physicians were Greek slaves ; the freedmen were permitted to erect baths, and to practise their art in the public baths ; here for the first time barbers and bathers appear as our rivals and colleagues, and this association was long injurious to the medical status in Home. It was only gradually that the philoso- phically educated possessed themselves of the writings of Hippocrates and the Alexandrians, and then practised the healing art them- selves, without however adding anything of importance to it. The great want of original scientific production is shown in the ency- clopsedical reproduction of the most varied scientific works. The most celebrated work of this kind is the " De Artibus" of Aulus Cornelius Celsus (from 25 — 30 b.c. to a.d. 45 — 50 in the reigns of the emperors Tiberius and Claudius); eight books of this, ''De Medicinä," have come down to our time, from which we have HISTOEICAL EEMAßKS. 7 learnt to know the condition of medicine and surgery at that time. Yaluable, however, as are these relics of ancient Rome, they only, as already mentioned, place a compendium before us such as is often written at the present day ; it has even been contended that Celsus never practised as a physician ; this, however, is very impro- bable ; at any rate, we must allow Celsus to be judged from the character of his writings, and the seventh and eighth books, which treat of surgery, could hardly have been so clearly written by any one who understood nothing of his subject practically. From them we see that surgery, especially the operative part of it, had made no inconsiderable progress since the time of Hippocrates and the Alexandrians. Even at this time Celsus speaks of plastic operations and of the herniae, and describes a method of amputating, which is still occasionally practised. One paragraph in the seventh book, in which he describes the qualifications of a perfect surgeon, has become very celebrated, and as it is characteristic of the thoroughly sound spirit which reigns throughout the book, T will give it to you;': ''Esse auttim cJiirurgus debet adolescens, aut certe adolescentim propior, manu strenua, stahili, nee unquam intremiscente, eaque non minus dextra ac sinistra promptns, acte oculomm acri claraquey animo intrepiduSj immisericors, sic, ut sanari velit eum, quem aceipit, non ut clamore ejus motus vel magis, quam res desiderat, properet, vel minus, quam necesse est ; secet : perinde faciat omnia, ac si nullus ex vagitibus alterias adfectus oriretur" The surgical instruments found in Pompeii, which was destroyed a few decades after Celsus, demonstrate that the mechanical improve- ment in these operating implements was already at that time consi- derably developed; the forceps, nippers, knives, scissors, specula, catheters, &c., which have been preserved in the museum at Naples, are very neatly made of bronze, and are very suitable for their several purposes. It made a peculiar impression upon me, when I saw before me this two thousand year old surgical armamentarium of a Eoman colleague, differing but slightly in the form of the more ordinary instruments from those of our time. Ars longa, vita brevis ! As one of the most brilliant among the Roman physicians we must reckon Claudius Galenus (a.d. 131 — 201); eighty-three ■undoubtedly genuine writings of his have come down to us. Galen again returned to the principles of Hippocrates, inasmuch as he proclaimed observation to be the basis of the healing art; he also 8 INTEODÜCTION. promoted the advance of anatomy very considerably : he mostly used the bodies of apes for dissection and examination, more rarely human bodies. Galenas anatomy, and the whole philosophical system to which he reduced medicine, and which at length stood higher with him than observation itself, were accepted as alone cor- rect for over a thousand years. His importance in the history of medicine is immense. Surgery in particular he advanced but little, indeed he practised it but little, as in his time there were special surgeons, partly gymnasts, partly bathers and barbers, among whom surgery was principally handed down by tradition according to the rules of their craft, while internal medicine was then and continued for a long time in the hands of the philosophically educated physi- cians who were acquainted with and indeed commented on the surgical writings of Hippocrates, of the Alexandrians, and of Celsus, though they occupied themselves but little with surgical practice. As this is only a superficial sketch, we may now pass over several hundred or even a thousand years, during which time surgery hardly made any progress and to a certain extent even retrograded. The Byzantine period of the empire was especially unfavourable to the development of the sciences, there was merely a brief revival of the Alexandrian school. Even the most celebrated physicians of the later lioman period, as Antyllus (in the third century), Oribasius (a.D. 326 — 403), Alexander of Tralles (a.D. 525 — 605), Paulus of ^gina (660) accomplished com- paratively little for surgery. Much had been done for improving the position and scholastic education of physicians : there was a Gymnasium under Nero, an Athenseum under Hadrian, scientific institutions in which medicine also was taught, and a special Schoko Medicoriim under Trajan. Military medical service was maintained among the Eomans, there were also special court-physicians " archiatri palatini " with the title ^' Perfectissimus,''-' '*' Eques "' or Comes Archiatrorum,''^ as in our time the Germans have Hofrathe, Geheimräthe, Leibärzte, Ordensritter, &c. We have to thank the Arabians that medicine did not quite degenerate with the decline of science in the Byzantine empire. The immense elevation attained by this nation under Mahomed after the year 608, contributed to the preservation of science. Throudi the Alexandrian school and its branches in the Orient, the schools of the jN^estorians, the Hippocratic art of medicine HISTORICAL EEMAEKS. 9' ATitli its later improvements reached the Arabians. Tliey cultivated it and brought it, thougli in a somewhat altered form across Spain into Europe again, until their power was finally destroyed by Charles Martel. Among the most celebrated Arabian physicians whose writings have been preserved to us, as well as being of the most consequence for surgery, are Rhazes (850 — Q32), Avicenna (980 — 1037), Abulcasem ( x 1106), and Avenzoar (x 1 162) ; the writings of the two latter are of most importance for surgery. Operative surgery suffered considerably from the aversion of the Arabians to shedding blood, which was partly founded on the precepts of the Koran. Instead of the knife the actual cautery was employed to an extent which to us seems hardly credible. The distinctions between surgical diseases became more defined and the certainty of diagnosis improved con- siderably. Scientific institutions were already much cultivated by the Arabians ; the most celebrated being the School of Cordova ; in many places there were also public hospitals. The education of physicians was no longer chiefly a private aS'air, but most medical pupils had to complete their education at scientific institutions. This also exercised an influence on the western nations ; next to Spain, Italy w^as the chief place where the sciences were cultivated. In South-Italy arose a very celebrated medical school, that of Salerno, in the lovely city so beautifully situated to the south of Naples in the Gulf of Salerno ; it was probably founded by Charles the Great in 802, and stood at the height of its glory somewhere about the twelfth century ; according to the most recent researches this w^as no monastic school, but all the teachers were laymen ; there were also lady-teachers who took an active part in literature ; the best known of these is Trotula. There was little or no orighial research, but the writings of the ancients were followed. This school is also interesting from the fact that it is the first corporation we find having the right to grant the titles of " Doctor " and " Magister."^ — Emperors and Kings began to take more aud more interest in science and founded universities. In Naples in 1224, in Paris 1205, in Salamanca 1243, in I^^^ia and Padua 1250,. and in Prague in 1348, universities w^ere established and the right of conferring academical degrees granted to them. Philosophy was the science most in vogue and medicine retained for a long time her philosophical garb at the universities ; at one time Galen's system was followed, at another the Arabian, at another the modern 10 INTEODUCTION. inedico-philosopliical_, and all observations were recorded according to these systems. This was the chief obstacle to the progress of the natural sciences, a species of mental shackle, from which even the most noted men could not wholly divest themselves. The anatomy composed by Mondino de Luzzi in 13 14 is but little different from that of Galen, in spite of the author^s relying upon the dissection of human bodies. As regards surgery no real advance had been made. Lanfranchi (X1300), Guido of Cauliaco (in the beginning of the fourteenth century), Branca (about the middle of the fifteenth century) are a few noteworthy names of celebrated surgeons of that time. Before turning our attention to the flourishing condition of the natural sciences and of medicine in the sixteenth century, we must take a brief survey of the mode of classification of medical men in their respective positions in the times of which we speak, as this is important for its history. In the first place there were philosophically educated physicians, partly laymen and partly monks, who taught medicine at the universities and other learned schools, that is, they commented on the writings of antiquity on anatomy and surgery as well as on special medicine ; these men certainly practised but had little to do with surgery. — A further seat of the sciences was in the cloisters ; the Benedictines particularly paid a great deal of attention to medicine and also practised surgery, although the superiors disliked seeing it, and occasionally a special dispensation for an operation had to be applied for. The regular practising physicians were partly resident and partly travelling. The former as a rule had been educated at scientific schools and only obtained the right to practise on certain conditions. The emperor l\ederick II, in 1224, introduced a law by which these physicians were obliged to study logic (i. e., philosophy and philology) for three years, medicine and surgery for five years, and finally had to practise for some time under the supervision of an older physician, before obtaining the right to practice on their own account ; or as an examiner lately remarked of the physicians who had just graduated, ^^ before being let loose on the public" Besides these resident physicians, of whom a great part were either doctor or magister, there was a large number of "travelling physi- cians," a kind of " travelling student,''"' who exercised their calling for money, travelling from one market to another in a cart in HISTORICAL EEMARKS. 11 company with a clown or merry-andrew. This species of so-called charlatans, who played an important role in the dramatic poetry of the middle ages, and even at the present day is greeted on the stage with uproarious applause by the public, led a wretched existence at that time ; they were looked upon as dishonorable, like the pipers, jugglers, and public executioners. Even now these charlatans are not quite extinct, although in the 19th century it is not at the fairs that they follow their occupation, but in the drawing-rooms as miracle-mongers, especially as caacer-doctors, herbahsts, somnam- bulists, &c. If we inquire as to the relation between this mixed company and those who practised surgery, we shall find that this branch of medicine was occasionally practised by almost all of them; there were, however, physicians practising surgery in particular, who associated themselves into guilds, and formed honorable civic corporations. These first received their practical knowledge from a master to whom they were apprenticed, and later partly from books and partly at scientific institutions. These persons had the prin- cipal share of operative surgical practice in their hands ; they were mostly resident, but some of them travelled about as herni©tomists, lithotomists, and oculists. Later we shall become acquainted with some first-rate men among these old masters of our art. Besides these, the bathers, and at a later period the barbers, as with the Eomans, practised surgery and were legally empowered to prac- tise "minor surgery;'' i.e., they might cup or bleed, and treat fractures and dislocations. Among the different grades of physi- cians disputes naturally arose as to their various privileges, which were hardly ever accurately defined ; this was particularly so in the large cities, where all descriptions of doctors were established. It was especially the case in Paris. The surgical guild there, the " College of St. Come,-" wanted equal rights with the associates of the medical faculty, more especially they aspired to the baccalaureate and hcen- tiate. The " Corporation of Barbers and Bathers" again wanted to practise surgery in all its branches, just as the fellows of the College of St. Come. In order to annoy these latter, that is the surgeons, the associates of the faculty supported the wishes of the Barbers, and in spite of occasional mutual compromises the disputes continued, one may even say, that they still continue, wherever there are chinirgi puri (surgeons of the first class and barbers) and medici purl. It is only about ten years since this class distinction has been abolished 12 INTRODUCTION. in all German states bj granting degrees neither to chinirgi piiri nor to medici puri, but to physicians who practise medicine, surgery and midwifery simultaneously. In conclusion, as to the external rank of physicians, we would remark that in England alone there still exists a tolerably defined line of demarcation between surgeons and physicians, chiefly in the cities, while in the country the " general practitioner" practises surgery and medicine together, and at the same time keeps an apothecary^s shop. In Germany, Switzerland, and in France, it often happens that, owing to circumstances, a physician practises more surgery than medicine ; the male portion of the medical staff, however, consists legally only of physicians and their assistants, or barber-surgeons, who, on passing the legal examination, are licensed to cup, bleed, &c. This regulation has been finally adopted in the organization of the army, in which the so-called company, surgeon with the rank of sergeant-major, formerly had a miserable position under the battalion and regimental physicians. Quite recently perfect freedom in medical practice has been established in the German empire ; that is, every- one who likes may give medical advice and take payment for it; those who have passed the state-examination alone have the right to the title of ^' medical practitioner " (praktischer arzt) ; the sick public is now at liberty to choose whether it will consult the one or the other. If we now resume the thread of the historical development of surgery, we must, as we now enter upon the period of the " Renaissance '' in the sixteenth century, before all things remember the great advance which was then accomplished in nearly all the sciences and arts by means of the reformation, of the invention of printing and of the awakening genius of criticism in educated countries. The observation of nature began again to assert its rightful position and to free itself, though but slowly and gradually, from the fetters of scholasticism. The search after truth again assumed its right to be regarded as the essential nature of science ! The Hippocratic spirit was re-awakened. Above all things it was the revival, we may almost say the re- discovery of anatomy and the subsequent continually progressive development of that science, which levelled the ground. Yesal (1513 — 1584), Miopia (1532 — 1562), and Eustachio (x 1579) became the founders of modern anatomy; their names, like many others, are already known to you from the names of HISTORICAL REMAEKS. 13 different parts of the body. The sceptically critical attitude which was assumed towards the prevaihug Galenical and Arabian systems was chiefly owing to the celebrated Bombastus Theophrastus Paracelsus (1493 — ^554)^^^^^ observation was recognised by him as the chief source of medical knowledge. When, at length, William Harvey (1578 — 1658), discovered the circulation of the blood and Aseli (1581 — 1626) the lymphatic vessels, the old anatomy and physiology had to give way completely and to make room for modern science, which thenceforth steadily progressed down to our own time. It was a long time, however, before practical medicine could free itself in a similar manner from the constraint of philosophy. Systems were raised upon systems ; and the theories of medicine were again and again varied to suit each prevailing fashion of philosophy. We may say, that it is only since the great advance of pathological anatomy in the present century that practical medicine has obtained a firm anatomico-physiological basis, on which it now almost entirely moves, and which forms a powerful pro- tection against all philosophical medical systems. But with this anatomical direction there are the dangers of exaggeration and one-sidedness. Later we shall have to speak of this occasionally. We will now give our exclusive attention to the scientific deve- lopment of surgery from the sixteenth century down to our own time. It is an interesting feature of that time that the advancement of practical surgery proceeded more especially from the incorporated surgeons, and less from the learned professors of surgery at the universities. German surgeons had mostly to get their knowledge at foreign universities, but some part of it that they worked out was entirely original; Heinrich von Pfolsprundt, a member of a German ecclesiastical order (born at the beginning of the fifteenth century), Hieronymus Brunschwig (born 1430 at Strassburg, of the race of Salern), Hans von Gersdorf (about 1520), and Felix Würtz (x 1576), surgeon at Basel, are the first of any note; we possess writings of all of them ; Telix Würtz appears to me to be the most original of them, he had a keen critical mind. Of greater attainments were Fabry von Hilden (i 560-1 634), a physician at Berne, and Gottfried Purman (1674-1679), surgeon in Hal- berstadt and Breslau. These men, whose writings show a high scientific inspiration, fully understood the value and the absolute necessity of accurate anatomical knowledge, and promoted it to the 14 INTRODUCTION. best of their ability by their writings and by private instruction to their pupils and assistants. Among the Trench surgeons of the sixteenth and seventeenth centuries, Ambroise Pare (15 17 — 1590) is pre-eminent. Originally only a barber, he was, on account of his great services, admitted to the membership of the surgical corporation of St. Come ; he was actively employed as an army surgeon, often had to take long journeys as a consulting surgeon, and finally resided in Paris. Pare advanced surgery by what was for that time a very keen criticism on treatment, especially having reference to the chaotic mass of doubtful remedies. Some of his treatises on the treatment of gun-shot wounds, for instance, are thoroughly classical ; by the introduction of the ligature for bleeding vessels in amputations he made himself immortal. Pare may be placed as the reformer of surgery, side by side with Yesal, the reformer of anatomy. The works of the men we have named, including those of others more or less gifted, held an influential position in the seventeenth century, and only in the eighteenth do we find any fresh advances of importance. The contest between the members of the faculty and those of the College de St. Come still continued in Paris, the most prominent individuals of the latter accomplishing far more than the professors of the faculty of surgery. This was at length practically recognised in the year 1731 by the foundation of an ^^ Academy of Surgery" in every respect equal to the medical faculty. This institution soon attained^such a height, that for nearly a century the whole surgery of Europe was regulated by it ; nor was this an isolated case, but was a part of the general French influence, of that universal intellectual dominion which at that time French science and art had deservedly acquired by the eminent services it had rendered. The men, who at that time stood at the head of the movement in surgical science, were Jean Louis Petit (1674 — 1766), Pierre Jos. Desault (1744 — 1795);, Pierre Francois Percy (1754 — 1825), and many others in France. In Italy, Scarpa (1748 — 1832) did more than any one else. Already in the seventeenth century surgery was considerably developed in England, and in the eighteenth century attained great eminence under Percival Pott (171 3 — 1768), William and John Hunter (1728 — 1793), Benjamin Bell (1749 — 1806), William Cheselden (1688 — i752), Alex. Monro (1696 — 1767) and others. Among these John Hunter was the greatest HISTORICAL REMAEKS. 15 genius, equally celebrated as an anatomist and as a surgeon ; his work on inflammation and wounds still forms much of the ground- work of our present views on those subjects. Compared with the lustre of these names, those of German surgeons of the eighteenth century must modestly retire into the background, honest and earnest as were their efforts. Lorenz Heister (1683 — 1758), Joh. Ubich Bilguer (1720 — 1796), Chr. Ant. Theden (17 19— 1797) are relatively the most important German surgeons of that time. Greater progress in German surgery was first made with the com- mencement of the present century. Carl Casp. v. Siebold (1736 — 1807) and August Gottlob Richter (1742 — 1812) were distin- guished men ; the former was professor of surgery in Würzburg, the latter in Göttingen; of the writings of Eichter some have retained their value to the present day, particularly his little book on ruptures. Here on the threshold of our century, you again see professors of surgery occupying a foremost place, and henceforward they maintain their position, because they really exercised their pro- fession practically. A predecessor of old Eichter in the professorial chair of surgery at Göttingen, the celebrated Albert Haller (1708 — 1777), at once physiologist and poet, one of the last encyclo- psedists, says : '^ Etsi cJiirurgicB cathedra per septemdecem annos mihi concredita fuit, etsi in cadaveribus difficilli7aas adminis^ trationes, chirurgicas frequentjsr ostendi, non tarnen unquam vivuni hominem incidere snstimii, 7iimis ne nocerem veritus" We can hardly imagine this, so immense is the revolution that the short space of a hundred years brings with it. Even at the commencement of our century the French surgeons still remained at the helm. Boyer (1757-^1833), Delpech (1777 — 1832), but particularly Dupuytren (1777 — 1835) and Jean Dominique Larey (1776 — 1842), exercised an almost unlimited, but, at the same time, enlightened absolutism in their art. Beside them arose in England the unassailable authority of Sir Astley Cooper (1768 — 1841). Larey, the constant companion of Napoleon I, left a large number of works ; at some future time you will read his memoirs with great interest. Dupuytren did most service by his highly intellectual and sound clinical lectures. Cooper^s monographs and lectures will fill you with admiration. Translations of the writings of the French and English surgeons we have mentioned had the immediate efi'ect of stirring up German 16 INTRODUCTION. surgery; and very shortly there appeared original work of the most thorough character on this subject. The mpii who gave life to this national resurrection of German surgery were^ among others, Tincent von Kern, in Yienna (1760— 1829), Joh. Nep. Eust in Berlin (1775 — 1840), Philipp von Walther (1782 — 1849) ^^^ Munich, Carl Eerd. von Graefe (1787 — 1840) in Berlin, Conr. Joh. Martin Langenbeck (1776 — 1850) in Göttingen, Joh. Priedrich Dieffenbach (1795 — ^847), and Cajetan von Textor in Würzburg (1782 — 1860). The nearer we approach the middle of the present century, the more do the rugged boundaries of nationalities (Jisappear from the domains of surgery. With increased means of communication, every scientific advance is spread over the whole civilized world with a speed that could never have been anticipated. Numberless journals, national and international congresses, individual inter- course of the most varied kind, have brought about an active interchange of ideas of surgeons with each other. The schools, which in the older and narrow^er sense of the word were attached to certain prominent men or groups of such men at some particular locality, are at an end. It appears as if a generation of surgeons, on whose great services we of the present time look with respect, -were just dying out. I mean men like Stanley (1791 — 1862), Lawrence (1783—1867), Brodie (1783— 1862), Syme (1799— 1870) in Great Britain; Eoux (17^0 — 1854), Bonnet (1809 — 1858), Leroy (1798—1861), Malgaigne (1806— 1865), Civiale (ti867), Jobert (1799— 1868), Velpeau (1795 — 1867) in Prince ; Seutin (1793— 1862) in Belgium; Valentine Mott (1785 — 1865) in America; Wutzer (1789 — 1863), Schuh (1804— 1865), Franz von Pitha (1810 — 1875)) and others, in Germany! And from our own generation also we have to mourn over some bitter losses, beyond all others the irreparable death of the highly-gifted and inde- fatigable investigator 0. Weber (1827 — 1867), of the eminent Pollin, one of the soundest of modern Prench surgeons (11867), of Middeldorpf (1824 — 1868), the celebrated inventor of galvano- caustic operations ! Among the living there are still many who might be mentioned, on whose shoulders rests the present generation of German surgeons ; but as it is hardly agreeable to any one to become historical during his hfetime, I forbear to quote any more names ! One important event however in the modern history of surgery I METHOD OF STUDY. 17 must not leave unmentioned^ that is^ the introduction of remedies to allay pain. The nineteenth century may well be proud of the discovery of sulphuric ether and chloroform, which may be prac- tically employed as anaesthetics in all kinds of operations. The first communication came from Boston in the year 1846, to the effect that a dentist named Morton had been induced by his friend Dr. Jackson to employ inhalations of sulphuric ether for the pro- duction of complete anaesthesia during the extraction of teeth, and with the most brilliant result. In 1849 ^^^^ ^^i^^ more effectual chloroform was introduced into surgical practice, in place of the ether, by Simpson, late professor of midwifery in the University of Edinburgli (181 1 — 1870), and, notwithstanding many and various experiments with other similar materials, chloroform still holds its ground to the present time, beyond the most sanguine anticipations. Thanks ! a thousand thanks to these men, in the name of suffering humanity. AYitli regard to my former observations respecting German surgery, I will in conclusion only add that it now stands in a position at least equal to that of other nations. It is nevertheless clearly desirable that every physician should enlarge his experience and observation in other countries. From a practical point of view^ England, America, and Germany, seem to me to be of greater importance for surgery than any other countries. Erom the time of Hunter to the present time English surgery has had something of grandeur and style about it. The surgery of the nineteenth century in Germany owes its greatest rise to the circumstance that it has endeavoured to unite all medical knowledge in itself on the basis of a sound anatomical and physiological foundation ; the sur- geon who succeeds in this, and in addition also masters completely the entire mechanical part of surgery, may boast that he has reached the highest ideal point in the whole of medicine. Before we enter upon our subject I will premise a fe«^ remarks on the study of surgery as at present it is or ought to be carried on in our universities. If we retain the four years usually allowed for the study of medi- cine in German universities, I would advise you not to begin surgery before the fifth half yearns session. There is very frequently an eflort among you to endeavour to get over the preparatory lectures as soon as possible, in order to get quickly to the practical part. This is B 18 INTEODUCTION. . certainly somewhat less the case since in most of the high schools courses have been established on anatomy, microscopy^ physiology, chemistry, &c,, in which you are practically occupied ; never- theless, there is always over-eagerness to enter the clinical wards. It is, in truth, one way of gaining a certain amount of experience from the very commencement, and it appears much more interesting than worrying yourself with things whose -connection with practice you cannot as yet rightly comprehend. But you forget that a certain amount of practice in the school of observation has to be gone through before you can extract the really useful from your experiences. If any one just released from the control of school were at once to enter a hospital as a student, he would in this novel situation be like a child entering the world to collect experience for life. Of what good is the experience of the child in respect to its future worldly wisdom, and to teach it the art to live among men ? How late it is before we find the true value of the most ordinary ob- servations of our daily life. And in the same way it would be very slow and tedious to work empirically through the whole development of medicine, and only a very gifted, restlessly energetic man could do any good in this way, after having passed through the most varied phases of error. We must not rate " experience" and " observation" too highly, if by them we understand no more than the laity ; it is an art, a talent, a science, to observe critically, and to draw from these observations correct conclusions as our expe- riences ; this is the strong point of empiricism. The public only recognises experience in the vulgar, not in the scientific sense, and values the experience and observation of an old shepherd as highly as, sometimes even higher than, that of a physician. But enough; if a physician or any one else parades his experience and observations before you, just notice what kind of intellect is possessed by the narrator. In making this attack upon natural empiricism I do not mean to assert that you must necessarily get a perfect theoretical knowledge of medicine in its entirety before commencing practice, but you must bring with you into the wards of the hospital an intelligent acquaintance with the fundamental principles of the scientific investigation of pathological processes. It is absolutely necessary that you should have a general idea of what you are to expect at the bedside ; you must also be acquainted with your implements before seeing them used or handhng them yourself. In other words, you must know the outlines of general pathology, the- METHOD OF STUDY. 19 rapeutics, and materia medica, before commencing your bedside study of patients. General surgery is but a division of general pathology, and should therefore be studied before attending clinical surgery. At the same time you must, if possible, get a clear insight into normal histology, at least the general part of it, and you should study pathological anatomy and histology, together with general surgery, some time during the fifth session. General surgery, which we are about to discuss in these lectures, is, as already mentioned, a part of general pathology, but stands in a far nearer relationship to practice than the latter. It is the doctrine of wounds, inflammations, and tumours of the exterior of the body and of those parts that are treated externally. Special or anatomico-topographical surgery has to do with the surgical diseases of the different parts of the body, at the same time taking into consideration the most varied tissues and organs according to their locality. While, for instance, we only speak here of wounds in general, of their mode of healing, and of their general treatment, in special surgery we discuss wounds of the head, chest, and abdomen, and we then have especially to attend to the simultaneous participa- tion in the injury of the skin, the bones, and the viscera. Were it possible to pursue one^s surgical studies for many years at one of the larger hospitals, and at the same time to combine with them an accurate clinical examination of each individual case together with persevering study at home, it might perhaps be unnecessary to treat of special surgery systematically in lectures delivered for the purpose. But as there is a considerable number of surgical diseases which even in the largest hospitals are never seen in the course of many years, a knowledge of which, however, is absolutely necessary to the physician, lectures on special surgery are by no means superfluous when they are brief and concise. One often hears it said. Why should I hear lectures on special surgery and pathology ? I can read them up far more comfortably in my own room ! That may be the case certainly, but unfortunately it is only too seldom done, or not until the final sessions, when the examination threatens. This reasoning is also in other respects false ; the viva vox of the teacher, as old Langenbeck in Göttingen used to say (and he had, in truth, a viva vox in the highest signification of the word), the winged words of the teacher always are, or at least ought to be, more impressive and effectually stimulating than what we read ; and what must render lectures on practical surgery and medicine part- 20 INTRODUCTION. cularly valuable for you are the demonstrations of diagrams^, preparations^ experiments, &c., which accompany them. I set the greatest value on demonstrations in connection with medical instruction, as I well know from my own experience that this kind of instruction is the most stimulating to the attention and the most permanent. Besides these lectures on general and special, surgery you will have to go through the operative course on the dead body ; this can be put off to the final sessions. I always liked students to take this surgical operative course in the sixth or seventh session at the same time as the special surgery, so that I could give them opportunities of performing some operations, occasionally amputations, in the hospital, under my superintendence. It gives confidence in your future practice if you have already performed operations on the living subject during the period you were engaged in study. It is a great advantage in the smaller universities that there the teacher may become well acquainted with every pupil and know what he can trust to the skill of any one individual. This is unfortunately impracticable in the larger hospitals on account of the circumstance of their size. Avoid the large universities, therefore, at the com- mencement of your clinical studies. Attend them rather in the later period of your apprenticeship, and when you are already in practice return later from time to time and spend a few weeks in them. After hearing general surgery you commence attendance in the surgical wards of the hospital, in order that in the seventh and eighth sessions you may as a practitioner publicly give an account to yourself of your knowledge in special cases and accustom yourself to concentrate your knowledge rapidly, to learn to distinguish the important from the unimportant, and, above all, to learn how to apply it in practice. By this means you will be enabled to recognise the flaws in your knowledge, and by persevering industry at home be able to fill in the gaps. If you have in this manner got through the legal period of study, passed the examinations and enlarged your medical horizon for a few months or a year at various large hospitals either at home or abroad, you will then be so far educated that you will be able to form a correct judgment of surgical cases occurring in practice. If, however, you wish to quahfy yourself as a special surgeon and operator you are still far from your object;, you must then repeatedly practise operating on the dead body, act METHOD OF STUDY. 21 as assistant for from two to four years in the surgical wards of a hospital, study surgical monographs indefatigably, write cot cases industriously, &c. ; in short, go through the whole of the practical course from the very beginning. You must also thoroughly under- stand the hospital service and the duties of the nurses; in fact, you must practically learn everything, even the most insignificant things, that in any way pertain to the patients, and even learn to be able to do them yourself occasionally, so that you may obtain a complete command over the medical staff entrusted to you. You see that there is much to be done, much to be learnt, but with perseverance and industry you will accomplish it all. Perseverance and industry, however, are necessary for the study of medicine. *^ Student " is derived from ^' to study,"*' and you must study diligently. The teacher will call your attention to what he considers the most necessary; he may stimulate your energies in various directions ; the positive that he gives you, you can take home in black and white, but in order that that positive may quicken and bear fruit in yon, that it may become your own intellectual property, that you can only bring to pass by your own mental work ; this mental work is the true study. If you simply maintain an attitude of passive receptivity you may -certainly gradually acquire the reputation of being a very learned man, but unless you have the power of reproducing and giving life to your knowledge you will never make a good ^^ medical prac- titioner.^'' Let what you observe penetrate your inmost soul, let it so warm and replenish you that your thoughts constantly refer to it, and then you will find true pleasure and dehght in your intel- lectual labours. How strikingly Goethe observes in a letter to Gchiller, '^ Pleasure, delight, interest in things, these are the only jeahties ; all else is vanity and disappointment.''' LECTURE IL CHAPTER I. SIMPLE INCISED WOUNDS OE THE SOET PARTS. Mode of origin mid appearance of these wounds. — Various forms of incised wounds. — Symptoms during and immediately after the act of loounding : pai7i, Immorrhage. — Different hinds of Jice- morrliage : arterial, venous. — Entrance of air through wounds in veins. — Parenchymatous hmmorrhage. — Hemorrhagic diathesis. — Hmnorrhage from the pharynx and rectum.'— General conse- quences of severe hmnorrhage. The proper treatment of wounds is to be regarded as the first and most requisite qualification for the surgeon, not merely on account of the extreme frequency of their occurrence, but also because in operating we so often purposely make wounds, and not rarely under circumstances in which the operation is for a complaint that can hardly be considered dangerous to life. We are therefore so far responsible for the healing of wounds, as, according to expe- rience in general, we are enabled to form a judgment as to the danger of an injury. We will now commence with the discussion of incised wounds. Injuries produced by strokes with sharp knives, scissors, sabres, rapiers or axes, present the characters of clean-cut wounds. Such wounds are mostly known by their sharply defined regular edges, in which we see the smooth-cut surfaces of the unaltered tissues. Should the above-named instruments be blunt, they may still cause tolerably clean incised wounds, if the blow was given rapidly, whilst if slowly, the penetration of the tissues would give the cut edges a rough contused appearance; occasionally the kind of injury only becomes apparent during the process of healing, for wounds caused by the rapid movement of a sharp instrument heal more easily and MODE OF PRODUCTION. 23 quickly, for reasons to be hereafter stated, than those caused by a blunt, slowly penetrating knife, scissors, sword, or such-like instru- ment. It is but rarely that a completely blunt body causes a wound having the same characters as an incised wound. This may happen from the skin splitting from the force of a blunt body, particularly such portions of it as lie close to the bone. You will not unfrequently observe, for instance, that scalp-wounds have quite the appearance of incised wounds, though caused by a blow from a blunt body, or from striking the head against a stone or beam, or something of that kind. Similar clean-cut lacerated wounds of the skin occur on the hand, chiefly on its palmar surface. Sharp edges of bone may also divide the skin from within outwards, making it look as if it had been cut, as, for instance, when any one falls on the crista tibiae, and the skin is cut through by it from within. We can easily understand, too, that pointed splinters of bone penetrating the skin may also cause wounds with clean-cut edges. Finally, the point of exit of a gunshot wound, that is, of the course of the bullet through the part struck, may under certain circumstances be a sharply defined slit-like aperture. A knowledge of these circumstances is of importance, because you may by chance be asked by a judge if a certain wound in question was caused in such and such- a manner, with this or that instrument, and your reply may give a decided turn to the evidence in a criminal case. We have hitherto considered such wounds only as are caused by blows or strokes. But by repeated cuts the edges of a wound may get a jagged appearance, and in this manner the conditions for its healing be essentially changed; of such wounds we will say nothing at present, they must be classed with contused wounds in regard to their healing and treatment, unless by paring their jagged edges they can be artificially converted into simple incised woundsc The direction in which a cutting instrument is held in relation to the surface of the body at the time of its penetration makes on the whole but little diff'erence, if it be not so slanting that portions of the soft parts are cut off in the form of more or less thick flaps. In these flap-wounds, or sliced wounds, the breadth of the bridge connecting the half-separated portion with the body is of great importance, as it depends upon that whether any circulation of the blood can still continue in the flap, or whether it has entirely ceased and the severed portion must be regarded as dead. Cuts are the prin- 24 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. cipal cause of these flap-wounds, but they are not uncommonly due to a tear or laceration ; they occur frequently on the head, where a too violent tug at the hair may tear away a piece of the scalp. In other cases a portion of the soft parts may be completely cut out ; we then have a wound with loss of substance. By penetrating wounds we understand those by which one of the three great cavities of the body or a joint is laid open ; they arise most commonly from a stab or a shot, and may be complicated by injury to the viscera or bones. By the general terms longitudinal or diagonal wounds we refer, as may be readily understood, to the long or transverse axis of the body, head, or extremities. Diagonal or longitudinal wounds of the muscles, sinews, vessels, or nerves, are naturally such as divide the fibres in a transverse or longitudinal direction. In a person wounded the symptoms more or less immediately caused by the act of wounding are pain, hasmorrhage, and gaping of the wound. As all the tissues, not excepting the epithelial and epidermic, are supphed with sensory nerves, pain is at once caused by the injury. This pain varies considerably according to the supply of nerves in the part injured, and according to the susceptibility of the indi- vidual to the sensation of pain. The fingers, lips, tongue, the neighbourhood of the nipple, the external genitals, and the anal region, are looked upon as the most sensitive parts. The nature of the pain felt from a wound, as for instance of the finger, is probably familiar to each of you from personal experience. Cuts of the skin are decidedly the most painful, an injury to the ■ muscles or sinews is far less so ; injuries of the bones are always extremely painful, as you may convince yourselves by inquiring of any one who has suffered from a broken bone ; and we are informed that when amputations were performed without chloro- form the sawing of the bone was the most painful part of the operation. The intestinal mucous membrane, as we may occasion- ally observe in men and animals, is hardly at all sensitive if irritated; and the portio vaginalis uteri is almost insensible to mechanical and chemical irritants; sometimes even the application of the actual cautery, which is used to cure certain affections of this part, is not felt by women. It appears that very few if any sensory nerves are associated with the nerves which need a specific irritation, such as those of the special senses. SYMPTO:\[S — PAIN. 25 The relation between the sentient tactile nerves of the skin and the sensory nerves, if there be any essential difference between them_, is still an undetermined question. In the nose and tongue we certainly have sentient and sensory nerves lying side by side, so that in both organs there may be a sensation of pain as well as the special sense belonging to each organ. On cutting through the nervus opticus there is perception of light, but no pain to speak of. We have no recorded observations as to direct injury of the auditory nerve. Although tlie white substance of the brain contains many nerves, it is yet without feeling, as may be seen in many severe injuries of the head. The division of nerves of sensation or of compound nerve-trunks is at any rate the most painful of all injuries ; the laceration of the dental nerve in tooth extraction is an instance that may be familiar to many of you ; the division of thick nerve-trunks must cause overpowering pain. Sensitiveness to pain seems to vary somewhat in different indi- viduals. You must not, how^ever, confuse this with the external expressions of pain as shown in various degrees, and Avith the psychical power to stifle these expressions, or at least to retain them within bounds ; this, anyhow^, depends on the strength of will of the individual as well as on the temperament. Men of active temperament express pain, as well as all other sensations, more vividly than phlegmatic men. Most men say that the crying out, as well as the instinctive firm tension of all the muscles, especially of the masticatory muscles, biting or grinding the teeth together, &:c., renders the pain more endurable. Personally I have never found that it allayed it in any w^ay, and look on it as imagination on the part of patients. Strong will in the patient may do much to suppress all signs of pain. I have a vivid remembrance of a woman in the Güttingen Hospital, at the time I was a student there, who had the whole of the upper jaw removed, on account of a malignant tumour, without chloroform, during which severe and excessively painful operation, in which many branches of the nervus trigeminus were cut through, she did not utter a sound of pain. Women, as a rule, bear pain better and more patiently than men. But the exercise of psychical strength required, not un- frequeutly causes subsequent fainting or a high degree of physical and psychical relaxation, of longer or shorter duration. I have seen 26 SIMPLE INCISED WOUNDS OE THE SOFT PARTS. strong men, of determined will, who suppressed every indication of suffering, though the pain was severe, but soon afterwards dropped senseless. But, as I before remarked, I believe that many men feel pain far less intensely than others. You will most probably meet with people who, without any exercise of an energetic will, show so little sign of pain, after painful injuries, that we can only sup- pose that they actually feel pain less acutely than other people ; I have mostly observed this in dull stupid men of lax fibre, in whom all the nervous symptoms following the injury were also remark- ably slight. Sudden fright occasionally causes temporary anaesthesia ; timid men, but especially children, may be so stunned by suddenly shouting at them, that we are enabled to perform small operations quickly, which otherwise they would never have consented to. The quicker a wound is made and the sharper the knife, the less is the pain ; so that, in the interest of patients, we lay great stress, and rightly too, upon using the knife with certainty and rapidity in all small and large operations, particularly in making the incisions in the skin. The sensation in a wound immediately after an injury is a peculiar burning one ; we can hardly call it anything else than the feeling of being wounded, smarting. Only when a small or large nerve is compressed by something or another in the wound, or is lacerated or in any way irritated, we get, immediately after the injury, severe pains of a truly neuralgic character, which if they do not soon cease spontaneously, must be allayed by removal of the local causes after careful examination ; or if this cannot be done, or is ineffectual, by the administration of narcotic remedies, other- wise the patient may get into a highly excitable state, which may be kept up until it increase to maniacal delirium. At the present day inhalations of chloroform are universally employed in order to avoid pain in operations. The mode of using this remedy, and the prophylaxis and treatment of the dangers caused by chloroform, you will learn more quickly in the hospitals, and afterwards remember better than if I were to give you a detailed account of it here. In the lectures on operative surgery this will be more fully discussed ; I will only just mention that recently sulphuric sether has again come more into use than during the ten previous years, during which time the number of deaths from chloroform had increased owing to its enormously extended employment. At ANESTHETICS HYPNOTICS. 27 present I use exclusively as an ansesthetic a mixture of three parts of cliloroform with one part of sulphuric aether and one part of absolute alcohol, and I have an impression that the narcotism produced is less dangerous than that from chloroform alone. In England during the last few years bichloride of methylene has been much used and warmly recommended, particularly by Spencer "Wells ; it is said to act as quickly as chloroform and to be less dangerous. Local anaesthetics which are intended to numb pain temporarily in the part to be operated upon, as, for instance^ by the application of a mixture of ice with saltpetre or salt, have generally been quickly given up again, or, rather, have never been extensively used. More recently these attempts have awakened a more active interest, for it seemed as if at length a really efficacious method for producing local anaesthesia had been discovered. An English physician, Eichardson, has constructed a small apparatus by means of which a spray of aether can be blown against the skin, whereby, after a time, such an amount of cold is generated at the spot on which the spray is directed that it is deprived of all sensation. After receiving this aether from England I satisfied myself of the perfection of its action. In fact, in a few seconds the skin becomes as white as chalk, and absolutely without sensation to the extent of this whiteness, but this effect hardly extends through a moderately thick cutis ; and if, without further consideration, the spraying be continued against the cut surface until this is com- pletely anaesthetised, in consequence of the intense cold we have, on the one hand, the misfortune that we can no longer distinguish the hard frozen tissues from each other^ and, on the other hand, the knife becomes covered with such a coating of ice that it will no longer cut. Consequently local anaesthesia, even in this perfected form, can only be employed advantageously for patients in a few minor operations. My former apprehension, that the subsequent process of heahng would be essentially interfered with, in con- sequence of the application of such intense cold to the tissues, has proved to be incorrect. For allaying the pain and as a hypnotic immediately after extensive injuries and operations there is nothing better than a dose of about one third of a grain of muriate of morphia ; the patient is quieted, and though he may not always get sleep he at any rate feels less pain from his wounds. Morphia can also be used in the form of subcutaneous injections. If with a very fine syringe, to 28 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. which a pointed lancet-shaped canula is so attached that it can be easily pierced through the skin_, we inject a solution containing one sixth to one third of a grain of muriate of morphia, this produces its narcotic effect at first locally on the nerves irrigated by it, and afterwards on the brain as the morphia solution becomes absorbed into the blood. This mode of using morphia has latterly been most highly commended ; such an injection is generally made either directly before or after an operation, or after an acci- dental injury, usually in the immediate neighbourhood of the injured part, by which means the pain is at once relieved. Most of the syringes in general use for subcutaneous injection contain about fifteen minims^ of fluid ; we prescribe for patients, when ignorant as to how they are affected by morphia, ten parts of muriate of morphia to a thousand parts of distilled water, and inject a syringe full of the solution ; many individuals require twice this quantity or more in order to obtain the desired soothing effect. If we prefer in- jecting only half a syringe full each time, so as not to have to order a repetition of the medicine too frequently, we must double the quantity of morphia. In larger quantities than 5 per cent, this salt of morphia only dissolves in warm water; the injection of large quantities of fluid as well as of too concentrated solutions causes pain to patients. Particular attention must be paid to the cleanli- ness and careful washing of the syringes. Quite recently hydrate of chloral in doses of 3*00 — 5*00 grammes (in half or a whole glass of water) has been used internally as an ana3sthetic ; its narcotic effect was discovered by Liebreich in 1869. The action of this remedy is chiefly intensely hypnotic ; it is, how- ever, rather uncertain; it cannot supply the place of chloroform, but as a new narcotic it is a decidedly valuable acquisition to our therapeutic treasury. Tinally, we can employ cold locally as a remedy for the relief of pain in the form of cold compresses or bladders of ice applied to the Avound ; we shall speak of this again when we come to the treatment of wounds. In a clean cut or punctured wound the second immediate symptom is hsemorrhage, the quantity of which depends on the number, size, and kind of vessels divided. We speak here solely of hoemorrhage from tissues that were perfectly sound before the occurrence of the injury, and we distinguish capillary, parenchy- ^ Oue g-ramme is equal to about fifteen grains. SYMPTOMS CAPILLARY AND ARTERTAL HAEMORRHAGE. 20 matous, arterial, and venous haemorrhage; these must be considered separately. Different parts of the body, as is well known, vary considerably as to their supply of blood-vessels, the greatest differences being chiefly in respect to the number and size of the capillaries. In a given portion of the skin there are fewer and smaller capillaries than in a portion of equal size in most of the mucous membranes ; the skin, too, contains more elastic tissue and muscles as well, so that (as we feel and see in the cold and in the so-called goose-skin) the vessels are more easily compressed than in the mucous membranes, which are deficient in elastic and muscular tissue; simple wounds of the skin therefore bleed less than wounds of mucous membranes. If the tissue be healthy_, capillary haemorrhage will cease of itself from the compression of the open mouths of the vessels by the contraction of the injured tissue. But in diseased parts, which cannot contract^, bleeding from the dilated capillaries may be very considerable. Haemorrhage from arteries may be easily recognised,, partly because- the blood spirts out in a jet-like stream, in which the rhythmical contractions of the heart are distinctly perceptible, and partly because the blood effused has a bright-red colour. This bright-red colour of the blood, however, changes to a very dark hue when there is- deficient respiration; so that in operations about the neck, for instance, performed on account of danger of suffocation, and in very deep narcotism from chloroform, quite dark, almost black blood may spirt out of the arteries. The quantity of blood effused depends either upon the diameter of the completely divided artery or upon the size of the openhig in its wall. You must not, however, imagine that the size of the jet of blood from an artery corres])onds exactly to the diameter of the vessel ; it is usually much smaller, because an artery contracts at the divided part and so diminishes the size of the opening ; the large arteries, however, as the aorta, carotid, femoral and axillary arteries, possessing but few muscular fibres, show hardly any perceptible contraction, at least in the calibre of the vessels. In very small arteries this contraction of the divided vessel has such an effect that occasionally, owing to the obstruction to the flow of the blood caused by the increased friction, the stream neither spirts nor pulsates ; and this friction in the smaller arteries may be so con- siderable that the flow of blood soon becomes excessively slow 30 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. and impeded towards the divided ends, until at length it rapidly coagulates and the bleeding ceases of itself. The smaller the diameter of the arteries, owing to the diminution of the total quantity of blood in the body, the more quickly the bleeding ceases without its being necessary to arrest it artificially. Hereafter you will frequently have opportunities in the hospitals of observing how strongly the blood spouts out at the commencement of one of the larger operations, and how towards its termination the hsemorrhage is considerably less, even when the arteries divided are absolutely larger than those cut through at first. Decrease in the quantity of blood in the body may thus lead to spontaneous arrest of haemor- rhage, though at the same time the weaker contractions of the heart must also be taken into consideration. In fact, in internal hsemorrhages which are inaccessible to direct artificial aid we make use of a rapid abstraction of blood from the veins of the arm (venesection) as a hsemostatic; the artificial production of the condition of general ansemia, (naturally only done in cases in which the internal hsemorrhage has not already caused it) is in such cases looked upon as a remedy for internal hsemorrhage, however paradoxical this may appear at first sight. Hsemorrhage from cut wounds of the great arterial trunks of the body, neck and extremities, is always so serious that artificial arrest of the hsemorrhage is absolutely necessary unless the opening in the arterial wall is extremely small. If, however, an arterial trunk in one of the extremities be lacerated without any wound of the skin, then certainly, owing to the pressure from the surrounding soft parts, the stream of blood from the artery may be checked ; such injuries give rise later to further after-consequences, to which we shall direct your attention on another occasion. Bleeding from the veins is characterised by the continuous flow of dark blood. This is chiefly the case in veins of small and medium calibre. It is rarely very profuse, so that in order to obtain a sufficient quantity of blood when bleeding from the subcutaneous veins at the bend of the elbow it is necessary to check by compression the flow of blood towards the heart. Were this not done only a little blood would flow from these veins on their being punctured ; the further bleeding, however, would cease spontaneously, unless somewhat kept up by muscular action. This is chiefly because the thin walls of the veins collapse instead of gaping like a divided artery. Owing to the valves, the blood does not easily flow SYMPTOMS — VENOUS H^MOREHAGE. 31 back from tlie cardiac extremity of a divided vein as long as there is no insufficiency of the valves ; we very rarely have to deal with valveless veinSj such as those of the portal system. Haemorrhage from the large venous trunks is always most dangerous. Haemorrhage from the axillary, femoral, subclavian or internal jugular veins is in most cases fatal if assistance be not speedily rendered ; a wound of either of the innominate veins may be looked upon as absolutely mortal. Blood does not flow in a continuous stream from these great venous trunks^ but shows very decidedly the influence of the respiration on the circulation. I have several times seen the internal jugular vein wounded in operations on the neck ; during inspiration the vessel collapsed to such an extent that it might have been mistaken for a band of fibrous tissue, while during expiration black blood welled out as if from a spring, or rather like the bubbling up of water from an artesian well. In veins which are contiguous to the heart there is, besides the excessive and rapid loss of blood, another circumstance that heightens the danger considerabl}', namely, that during a deep inspiration^ when the blood regurgitates towards the heart, air occasionally enters the vein with an audible gurgling sound and is carried into the heart; instant death may be thus caused, but such is not necessarily always the case. I cannot here enter more fully into this extremely remarkable phenomenon, which, as regards its physiological action, does not as yet appear to me to have been satisfactorily explained. You will again have your attention called to this in books and lectures on operative surgery. You will also be told that on the opening of a large vein in the neck or axilla a gurgling noise is heard, and the patient immediately becomes unconscious, and that only in a few cases can he be again brought to life by the instantaneous em])loyment of artificial respiration and other restorative remedies. The probability is that, owing to the air-bubbles penetrating as far as the medium-sized branches of the pulmonary artery and lodging there, the further progress of the blood to the vessels of the lung is suddenly checked ; owing to the stoppage of the pulmonary circulation the flow of blood to the left side of the heart ceases ; the entire aortic system receives no blood, consequently the brain gets none ; sudden and total cerebral anaemia is thus most likely the immediate cause of the sudden death. I have never experienced anything similar to this, although I have known air enter the internal jugular vein and seen frothy blood 32 SIMPLE INCISED WOUNDS OP THE SOFT PAETS. escape ; this liad no perceptible effect on the general condition of the patient. It appears that animals vary considerably as to their relative susceptibility in respect to the entrance of air into the vessels ; if with a syringe you pump only a small quantity of air into the jugular vein of a rabbit it soon dies, while you may some- times pump several syringefuls of air into a dog without observing any effect. Besides the varieties already mentioned, we distinguish the so- called parejicJipv^atous Immorrhage, which is sometimes incorrectly identified with bleeding from the capillaries. In the normal tissues of an otherwise healthy body parenchymatous hsemorrhage does not come from the capillaries, but from a large number of small arteries and veins, which owing to certain circumstances do not contract and withdraw themselves into the surrounding tissue, and are con- sequently not compressed by them. Hsemorrhage from the corpus cavernosum penis is an instance of this kind of parenchymatous hsemorrhage, and it occurs similarly from the female genitals, in the perineal and anal region, and in the tongue and spongy bones. These parenchymatous haemorrhages are very common in diseased tissues, and they not unfrequently occur as so-called secondarij limmrrliages after injuries and operations; of this we will speak later on. One thing should be mentioned here, and it is that, according to the most authentic accounts, there are people who bleed so freely from every small insignificant wound that they may bleed to death from a scratch on the skin or from the vessel in the dental pulp after extraction of a tooth. This constitutional disease is called the hsemorrhagic diathesis (haemophilia), and people subject to it are called in Germany bleeders (hsemophilistsj, from the Greek words aljua and ^tXoc- The essential nature of this complaint consists, probably, in an abnormal tenuity of the walls of the arteries, which is, in most cases, congenital, but may, perhaps, gradually arise from pathological degeneration, with atrophy of the coats of the vessels. Conditions of abnormal pressure arising from the relatively too great narrowness of the large arterial branches may occasionally be the cause of such apparently enigmatical hsemor- rhao-es as those to which Yirchow has latterly drawn particular attention. This dreadful malady is often hereditary in certain families, especially among the male members ; women are less fre- quently afflicted with it. Not wounds alone cause bleeding in suck HJEMOREHAGIC DIATHESIS EFFECTS OF LOSS OF BLOOD, oo people, but simple pressure even may give rise to subcutaneous h?emorrhage ; bleeding of a fatal character may also occur spon- taneously, as from the mucous membrane of the stomach or bladder. It is not even after the more serious wounds, where medical assistance has been rendered immediately or within a short time of the occurrence, but principally after shght injuries, that in such people these continuous heemorrhages take place that are so diihcult to stop, which, as already remarked, points partly to diminished contractility or complete absence of muscular tissue in the vessels, and partly to deficient coagulability of the blood. The latter has certainly not been confirmed from observation of the blood effused, as, in those cases where attention was directed to it, it coagulated just like the blood of a healthy man. That the state of the blood must be taken into consideration with respect to this disposition to haemorrhage, is clear from the circumstance that leucocythoemic individuals (in whom the number of white blood corpuscles is considerably increased, while that of the red is dimi- nished) often bleed profusely from small wounds. A rapid and excessive loss of blood soon causes very perceptible changes in the whole body. The face, and particularly the lips quickly become very pale, and the latter turn bluish; the pulse becomes smaller and at first diminishes somewhat in frequency. The temperature falls most strikingly at the extremities ; the patient readily faints, especially if he sits upright, he turns giddy, he has a tendency to vomit, there are flashes before his eyes, singing in the ears, all things seem to swim round him, he collects all his strength to hold himself up, then all sense is lost, and finally he swoons away. "We explain these symptoms of fainting by supposing rapid cerebral ansemia. This soon passes off in the horizontal position ; people often faint after a very small loss of blood, as a rule, more from horror and disgust at the sight of blood than froai loss of power. One single fainting attack of this kind is thus no index as to the quantity of blood lost, the patient soon comes to himself again. Should the hsemorrhage continue, the following symptoms sooner or later make their appearance. The face be- comes more and more blanched and wax-like in appearance, the lips of a clear, pale, blue colour, the eyes dim and glassy, the tempe- rature sinks still lower, the pulse gets smaller, thread-like, and extremely frequent, respiration incomplete, vomiting sets in, the patient faints repeatedly, gets constantly weaker and more anxious C 34 SIMPLE INCISED WOUNDS OP THE SOFT PARTS. and restless,, at length persistently unconscious^ and finally there are convulsive twitchings of the arms and legs, which are renewed on the slightest irritation, as by the prick of a needle for instance-; this condition may pass on to death. Great dyspnoea, gasping for breath and at the same time a subjective feeling of heat with great restlessness are among the worst symptoms ; but even then we must never despair, as we may still often be of service, although life is apparently extinct. Young women especially can bear enormous losses of blood without immediate danger to life ; you will have opportunities later for observing this in the lying-in hospital ; children and old people least of all bear much loss of blood. In very old people great loss of blood, though not immediately fatal, may result in an incurable collapse, terminating in death days or weeks afterwards ; this admits of a very easy explanation ; the amount of blood lost is at first replaced by serum, and as the form^a- tion of blood-corpuscles probably takes place very slowly in old people, the greatly diluted blood is not sufficient to nourish their tissues, which at that time of life are extremely torpid in their interchange of materials. Should the patient come to after a severe haemorrhage, he chiefly feels excessive thirst, as though the body were dried up, and. the vessels of the intestinal canal absorb greedily the quantities of water that are drunk ; in strong healthy men the cellular constituents of the bl(X)d are soon replaced (from what sources we certainly do not exactly know) ; after a few days we observe very little of the former ansemia in an otherwise healthy, strong, and young individual ; and he also soon feels nothing of the former exhaustion of his strength. LECTURE III. Treatment of haemorrhage : (i). Ligature and transfixion of arteries. Torsion. — (2) Compression, compression with the fingers, choice of places for compression of the larger arteries. — Tourniquet. Acupressure. — Bandaging. — Application of the tampon. — (3) Styptics. — General treatment of suddenly -occurring anamia. — Transfusion. You now know, gentlemen, the different varieties of hsemorrliage. Now, what means have we for arresting hsemorrhage more or less severe ? The number of remedies is great, and yet we only employ a few of them, those alone which are the most certain. Here you have at once a field of surgical therapeutics, the requirements of ■which depend on assistance rendered quickly and with certainty, so that the result may not be doubtful. But the employment of these remedies requires practice ; coolness, quiet, absolute certainty as regards operative skill, and presence of mind, are the first requisites in cases of da]igerous haemorrhage. In such situations the surgeon may show what he is capable of. Eemedies for stopping the effusion of blood are divided into three principal classes: (i.) The occlusion of the vessel by tying or twisting it : ligature or tying, and torsion; (2.) compression; (3.) remedies, which cause rapid coagulation of the blood, styptics (from }, to contract, to harden). The ligature may be used in three different ways, either by applying a ligature to the isolated bleeding vessel, or by transfixing, that is, surrounding the vessel, together with the neighbouring soft parts, or by applying a ligature in the continuity of the vessel, that is, tying the artery at some distance from the wound. These various modes of ligation are almost entirely used for arresting arterial haemorrhage. The ligature is rarely required for venous hcemorrhage ; only in the very large venous trunks is it 36 SIMPLE INCISED WOUNDS OF THE SOFT PAKTS. occasionally indicated ; we avoid it however, if anyhow possible,, as the consequences may be dangerous : later on we will inquire in what the danger consists, and at present only speak of the ligature of arteries. Let us take the most simple case ; one of the smaller arteries is spirting in a wound, you first take a pair of so-called sliding forceps, seize the artery transversely if you can, and as much isolated as possible, then push home the shder of the forceps and the bleeding is completely stopped. These sliding forceps are best made of German silver, as this metal rusts less easily than iron. There are many different varieties of forceps, which all have the one thing in common, that, wdien they are closed they remain fixed in this position ; the mechanical means by which this closure is efi'ected, vary greatly ; the simpler the mechanism the better. It is interesting to examine the various phases of development that this instrument has passed through since the time of Ambrose Pare, before attaining its present state of simplicity and perfection. More recently small spring clips have been occasionally used to compress bleeding arteries ; they are certainly very serviceable if strongly made. Besides these forceps, one can also make use of small curved, sharp hooks (Bromfield's artery tenaculum) in order to draw the artery forwards, but this is far less practical, as the blood naturally continues spirting during the subsequent application of the ligature. Having seized the artery securely, the next thing is to make the closure eft'ectually permanent, this is done by the ligature. Convince yourself, however, beforehand, that you have not included some branch of a nerve with it, as the simultaneous ligature of a nerve may not only cause severe continuous pain but dangerous constitu- tional nervous symptoms as well. Tor tying arteries we use silk thread, twine or catgut of varying thickness according to the size of the arteries ; the threads must be good, strong ones, that they may not break when tightly tied. The forceps, which remain attached to the extremity of the artery, should be slightly raised, and the thread is best applied round the artery from below, making first a simple knot and tying it tightly just in front of the branches of the forceps, and then securing it with a second knot. Now loosen the forceps, and if the ligature i& properly applied, the bleeding must cease. The knot must be fastened firmly and securely by pushing the ends of the thread forward and stretching them steadily with the points of both fore- TEEATMENT OF HAEMORRHAGE LIGATURE. 37 fingers. This is especially necessary when very deep-seated arteries have to be tied. If the threads are good, two simple knots placed one over the other are sufficient. You should practise these little manipulations beforehand on the dead body or on living animals. If the ligature holds securely, you must, if you have used silk or twine, cut the one end short off and carry the other end out of the wound by the shortest way ; after six to ten days, you can as a rule withdraw these threads from the wound. In wounds which you intend to unite completely and by first intention, it is best to Tise catgut (gut-strings, soaked in oil to render them supple) ; the knots, and loops become gradually absorbed, and it is only very rarely that they are thrown off later by suppuration. We cannot always succeed in isolating the spirting artery so as -to be able to seize and tie it ; occasionally it withdraws itself so strongly into the tissue, chiefly into the m.uscles and thickened cellular tissue, that it is impossible to obtain a hold of it detached from the surrounding parts. Under such circumstances it is diffi- cult to apply the ligature securely ; you are then very apt to include the points of the forceps in the ligature, as you cannot push the thread far enough forward. In this case the proper plan is to transfix the artery. After having drawn the bleeding part forward with forceps or a hook, you take a strong semicircularly curved needle held in a needle-holder, thrust it in close to and on one or the other side of the bleeding vessel so as to surround it from below, carry the needle out, draw the thread through with it and fasten the knot so as to encircle the entire end of the artery ; then tie it very tightly as we have described above ; in this manner some of the adjacent tissue will be included with the artery, and the mouth of the vessel closed at the same time. This transfixion is only to be looked upon as an exceptional proceeding, for the strangulated tissue either perishes or decomposes in the wound if the hgature has completely destroyed vitaHty in the tissues, or if the ligature has been imperfect, it sets up jintense inflammation ; both may complicate the process of healing. That we must guard against tying any visible branch of a nerve lying near the bleeding vessel is a matter of course. Middeldorpf s method of percutaneous transfixion is more summary still; you take a large strongly curved needle and simply thrust it, as in a case of haemorrhage from the radial artery for instance, on the cardiac side of the bleeding spot, deeply through the skin transversely to and beneath the artery, and 38 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. bring it out on the other side ; the thread moderately firmly tied, compresses the artery together with many other parts ; the thread remains for two or three days and is then removed. I cannot, however, recommend this method to you ; it should only be used in cases of exigency, and merely as a provisional remedy for arresting hsemorrhage. As long as the bleeding arteries are visible in the wound, the first thing to be done is to apply the hgature ; but in those cases where the arteries of the periosteum spirt out blood the appHcation of the ligature may be impossible, it is just as little applicable in spirting arteries of the bone; other methods are employed here, chiefly compression. If you have to deal with very large bleeding arteries, the proceed- ing is exactly the same, only you must be doubly careful to isolate the artery ; you must, after seizing the bleeding end scrape back the surrounding tissue by the aid of a small scalpel or anatomical forceps, and then tie it most carefully and accurately; in most arteries you must tie both the cardiac and distal ends if they lie exposed in the wound, for the anastomosis in the arterial system is always sufiiciently extensive to cause bleeding from the distal end through the medium of the collateral branches ; if not immediately, at any rate later. It may hajjpen that the wound from which severe haemorrhage takes place, is only very small, as from a stab or gun-shot wound. Guided by your anatomical knowledge you should know what large vessel has been injured by the wound in question. If you are convinced by the severity of the bleeding that the ligature is the only certain remedy to stop it, you then have the following alter- natives : — Either to enlarge the wound, to search for the vessel by careful clean dissection, while it is at the same time compressed above the wound, the limb having been beforehand emptied of blood by Esmarch's bandaging (of which later), and then to tie the ends of the divided artery, or while the bleeding vessel is com- pressed in the wound you search above it for the cardiac portion of the trunk of the vessel of that extremity and apply the ligature in its continuity. Accurate anatomical knowledge as to the situation of the arteries and practice are absolutely necessary in both methods of proceeding. Which of these these two methods you cht)ose, will depend upon which is likely to effect its purpose most quickly, and to cause the least additional injury. If you think that you can TREATMENT OP HiEMOREHAGE — LIGATURE — COMPRESSION. 39 easily expose the artery in the wound without causing any im- portant injury to neighbouring parts, choose this method as absolutely certain ; but if you consider this very difficult, if the artery, for instance, at the part injured, lies very deeply beneath layers of muscle and fascia, particularly in very muscular or very fat people, then apply the ligature in the orthodox manner to the trunk of the vessel in its continuity above the wound (towards the heart) . I shall not here enter upon the subject as to the choice of places for tying the vessels, these have for many, many years been thoroughly tested and universally accepted on theoretical and practical grounds. In operative surgery, in the manuals on surgical anatomy, and especially in the course on operative surgery you will be instructed on these points, but above all things you must exercise yourself in the practice of being able to find the arteries with certainty, of exposing them neatly, and of tying them according to the rules of art ; at the same time you cannot accustom yourself to too much pedantry and uniform technicality. Although the great value of the ligature is acknowledged by all surgeons of the present day, people have never ceased trying to discover simpler, and at the same time equally certain methods. I will here merely mention torsion of the bleeding arterial extremities as one method, which is employed to close the vessels mechanically and safely without a ligature until occlusion is effected by their walls growing together. With strong, very accurately-closing, sliding-forceps, you seize the spirting bloodvessel isolated from the surrounding parts, either transversely or in its longitudinal axis, draw it forwards for about half an inch and then twist the forceps and with it the artery about five or six times on its longitudinal axis ; I generally draw the vessel as far forward as practicable and then twist it till it breaks off. In this manner I have twisted bleeding arteries from the size of the smallest up to that of the brachial artery so effectually that the hsemorrhage was quite safely arrested. Should branches be given off just above the bleeding end of an artery, we find that the vessel is then not sufficiently moveable to employ torsion with certainty ; for this reason I have only once succeeded in torsion of the femoral artery. (2.) Compression. — Pressure with the finger on the bleeding vessel is so simple and so convenient a method of arresting haemor- rhage, if method it can be called, that we can only wonder that the 40 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. laity do not at once resort to it ; it is a matter of instinct with anyone who has been present at a few operations to immediately place the finger in contact with the bleeding vessel and hold it there. And yet how rarely do we find that people think of this most simple remedy in a case of accidental wounding. They prefer employing all sorts of useless domestic remedies, daub the wound €ver with cobweb, hairs, urine and every possible kind of filth, or fetch some old woman to staunch the bleeding with a charm. And no one present chances to think of compressing the wound ! The object of m.ethodical compression is twofold, provisional and permanent. Provisional compression, whicli is only made use of until it is decided how the haemorrhage in the case in question may most certainly be definitively arrested, is managed either by pressing with the finger the bleeding vessel in the wound firmly against a bone, the edges of the wound in the meantime being pressed firmly against each other ; or by compressing the cardiac portion of the trunk of the artery against the bone at a greater or less distance from the wound ; the fii'st, as we have already stated, if we wish to tie the trunk, the latter if it is desired to tie the bleeding end of the artery or to examine the wound more accurately. Where shall we compress the arterial trunks and how shall we most effectually carry it out ? To compress the right carotid artery you place yourself behind the patient, take the second, third and fourth fingers of the right hand, place them together and press the points of the fingers somewhere about the middle of the neck at the anterior border of the sterno-cleido-mastoid muscle firmly against the vertebral column, at the same time clasping the nape of the neck with the thumb, and with the left hand bending the patient^s head slightly towards the wounded side and somewhat backwards. You will then plainly feel the pulsation of the carotid artery. Tirm pressure is here very decidedly painful for the patient, as we cannot avoid pressing upon the vagus nerve and by the deep pressure of the fingers so much tension of the parts is produced that it afPects the larynx and trachea. On account of the free anastomosis between the carotid arteries, one-sided compression of a carotid for the arrest of haemorrhage from the arteries of the head or face is not very effectual, and to compress with perfect certainty on both sides takes up so much room, that in most cases we have to be contented with a diminution of the arterial volume by incomplete compression. TREATMENT OF HAEMORRHAGE COMPRESSION. 41 Compression of both carotids is always a painful and alarming manipulation for tlie patient, chiefly owing to the strong indirect pressure thereby exercised on the larynx and trachea, consequently it is seldom made use of. Compression of the subclavian artery may often be necessary, particularly in wounds of this artery in Mohrenheim^s fossa and in the axilla. In this operation too it is best to stand behind the recumbent or half-sitting patient, then with your left hand incline the head of the patient towards the wounded side (we will suppose it to be the right) and immediately behind the outer edge of the clavicular portion of the relaxed sterno-cleido- mastoid muscle firmly insert the thumb of the right hand, so as to compress the artery firmly against the first rib as it issues from between the scaleni muscles. Here too pressure is painful owing to the difficulty of avoiding partial compression of the brachial plexus, but the artery can be so completely compressed at this point that pulsation of the radial artery is arrested ; less physical strength is requisite for this purpose than dexterity and sound anatomical knowledge of the situation of the vessel. The thumb of the compressing hand soon tires, however, and loses sensation owing to the strong pressure, and so various instruments have been devised to replace the fingers. One of the most convenient is a short stout key, the wards of which have been wrapped round with a pocket- handkerchief ; then with the handle held firmly in the palm of your hand, you place the wards of the key on the artery and press it steadily asrainst the first rib. The brachial arterv owiner to its ])osition can be easily compressed. Place yourself on the outer side of the arm, clasp the upper arm with your right hand so that the second, third and fourth fingers are placed along the inner side of the belly of the biceps muscle about the middle of the arm or a little higher, then clasp the rest of the arm with the thumb and press firmly with the fingers against the humerus ; the only difficulty here is to avoid compressing the median nerve, which at this spot nearly covers the brachial artery ; by compressing the brachial artery we can easily stop the radial pulse, and we make use of this compression very advantageously, if, on account of a wound of the radial or ulnar artery, we wish to apply a ligature to one of them and at the moment have no bandage for enveloping and bandaging the arm accordnig to Esmarch\s method. In haemorrhage from the arteries of the lower extremities we compress the femoral artery at the spot where it first commences to bear this name, that is just below 42 SIMPLE INCISED WOUNDS OF THE SOET PARTS. Poupart^s ligament. We compress it here where it lies exactly in the centre between the spine of the pub es and the anterior inferior spine of the crest of the ilium, against the horizontal ramus of the pubes. The patient must be in a recumbent position ; compression is made with the thumb and is easy, as the situation of the artery at this point is tolerably superficial. The femoral artery can be thoroughly compressed against the bone as far down as near the lower third of the femur, but it can only be done safely with the fingers in very thin individuals. Although the more modern mode of compression, by simply, tightly encircling the limb after previously induced local ansemia, has rendered the tourniquet unnecessary, w^e must not let it pass quite unnoticed. By a tourniquet we understand an apparatus by which we press an elongated, oval-shaped piece of wood or leather, a pelotte or pad, by means of a twisting, screw, or buckle and strap mecha- nism, firmly against an artery and the artery against the bone. As long-continued compression of the brachial or femoral artery is excessively fatiguing, we can employ it as an auxiliary with these arteries. The kind which we use at present is the screw-tourniquet of Jean Louis Petit. The pad, which slides along a b^nd, is placed accurately on the spot corresponding to the artery, and immediately opposite the screwing apparatus, beneath which a few thin layers of linen are to be placed, to prevent too great pressure upon the skin. We then buckle the band firmly round the extremity, and by means of the screw we can now tighten the band and with it the pad till the artery below it ceases to pulsate. Should the orifice of an artery not be immediately discovered, in an amputation wound for instance, we may loosen the apparatus slightly by reversing the screw, so as to allow a little blood to flow from the artery, thus localizing its bleeding point ; then retighten the screw of the tourni- quet and apply the ligature to the artery. In this lies the great advantage of the screw. If the apparatus is well made and properly applied, it renders excellent service. The veins, and especially the subcutaneous veins, are certainly somewhat compressed by the band encircling the limb, but this is unavoidable ; the pressure, however, by means of the pad, acts chiefly upon the artery. You can easily improvise a tourniquet with a broad band and a rounded piece of wood, or with a roller of bandage and a short stick ; but if such an improvised compressorium does not firmly and effectually secure the artery, I would rather advise you to employ other and more certain TREATMENT OF HEMORRHAGE TOURNIQUET ESMARCH. 43 means of compression, of which we will speak directly. The con- venience of checking serious haemorrhage with the aid of the tourni- quet may tempt you to leave it on for a lengthened period^ till the htemorrhage had perhaps ceased spontaneously and so save yourself the trouble of the hgature. This would be a great error. Within barely half an hour, if the tourniquet remains on, the extremity below it becomes dark blue, swells up, loses sensation, and the cir- culation of the blood in the part may be entirely arrested, thus causing its death ; you would reproach yourself your whole life through for having made such a mistake, which might seriously endanger the life of your patient. The application of the tourniquet is therefore only admissible as a provisional remed)/ for arresting haemorrhage. To compress one of the larger arteries with the finger for a length of time till haemorrhage ceases spontaneously, is difficult of accom- plishment. Still, cases may arise where compression with the finger is the only certain means of stopping bleeding from some of the smaller arteries, as in haemorrhage from the rectum or deep in the pharynx, when other remedies have left you in the lurch ; here it is sometimes necessary to compress with the finger for half an hour or an hour, or even longer, as ligature of the internal iliac artery in the first instance, and of the carotid in the second, would be as dangerous as it would be uncertain for arresting the haemorrhage permanently. In order to avoid the danger which arises from damming up the venous blood by the constriction caused by the band encircling the limb, we can, before applying the tourniquet, tightly bandage the extremity from below upwards, so that the blood contained in it is forced out backwards. Formerly this was occasionally done with limbs which were just about to be amputated ; the haemorrhage was thus limited to an extremely small amount. A physician in Yicenza, Grandesso Silvestri, recommended an elastic bandage for enveloping the limb, and instead of the tourniquet the employment of thick india-rubber tubing, with which the extremity Avas to be several times encircled. Esmarch, without having any knowledge of this little known process of Silvestri, hit upon a similar method, and drew attention to the efficacy of it ; and since that time it lias very rightly been generally adopted. As a matter of fact we can per- form operations of long duration, without any €0*1151011 of blood, on limbs that have been first bandaged in this manner and then con- 44 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. stricted, the bandage being removed, but the india-rubber tubing remaining; the extremities can be made perfectly bloodless and maintained so for about an hour, without the vitality of the part being endangered ; after tying all visible vessels the elastic fillet is loosened and immediately the blood shoots back again into the vessels ; if previously divided arteries have been overlooked and they now bleed, they must be at once seized and tied. This method of making portions of the body quite bloodless and keeping them for a time in that condition is an immense advance in modern surgical 2yractice ; operations have thereby become practicable, which were formerly not ventured upon. Let us now pass on to those methods of compression which are intended for the permanent arrest of lisemoi-rhage. In modern times a new hsemostatic method has been recommended by Simp- son, late of Edinburgh, the highly gifted surgeon and obstetric physician already known to you tlirough his introduction of chloro- form, a method, that I cannot certainly acknowledge as a perfect substitute for the ligature, but which is in many cases of practical value ; it is the compression of the bleeding artery by a needle, acupressure. Acupressure may be performed in various ways. In a stump after amputation, for instance, you introduce a long insect-needle, such as is also used for sewing, nearly perpendicularly, either from above or below, into the soft parts at a distance of a quarter to half an inch from the side of the artery, then turn the needle hori- zontally, and carrying its point just over or under the artery, you bring it out again almost perpendicularly on the other side of the artery and at a point equally distant from where it was first intro- duced, so that the arterial orifice is compressed by the needle against the soft parts, or better still against the skin or a bone ; should this compression not be perfectly effectual, as would seldom be the case with the larger arteries, you must compress the artery against the needle by means of a loop of thread. In amputations I prefer making acupressure by torsion, acutorsion : I transfix the end of the artery after it lias been drawn forward; and then with the needle make a quarter, half, or whole turn in the direction of the radius of the amputated surface, until the bleeding stops, and then insert the point of the needle deeply and firmly into the soft parts. These needles can be removed after forty-eight hours, without recurrence of the bleeding. It was only the more extended TREATMENT OF HiEMOERHAGE — ACUPRESSURE. 45 experience of English surgeons as to the success of this bold proceeding that encouraged me to try it ; from its simplicity it is very practicable, and dexterously performed, leaves nothing to be wished for. That acupressure will entirely supersede the ligature, as Simpson prophesied, I. can at present hardly believe. In this haemostatic operation, which I have resorted to in most of my amputation wounds for some years past, I use long gold needles with large heads, because silver is too soft, platinum too dear, and other metals rust too easily. Quite recently small ligature rods have been used by Yon Bruns, by which loops of silk thread are placed round the artery after it has been drawn forward, the loops are then drawn tight, and retained there ; these rods with the threads are removed, as was the case with the acupressure needless, after forty-eight hours ; I tried this recently on the femoral artery with complete success in an amputation of the thigh. In venous hsemorrhages, or in hsemorrhage from a large number of small arteries, especially in the so-called parenchymatous haemor- rhage, bandaging secundum artem or the tampon must be employed with the aid of bandages, compresses and charpie. Tightly plugging or rather cramming the bleeding wound with charpie and a cord- like application of a bandage would be just as injurious for a permanency as a tightly applied tourniquet. Total anaemia, bloodlessness of an extremity may be continued without danger of its perishing, for an hour or an hour and a half, but not longer. If you have haemorrhage from an arm or leg, that you want to arrest by compression ; if, for instance, large quantities of blood are being effused from a much dilated, diseased vein, or if the bleeding is from a number of very small arteries, you should bandage the extremity from below upwards after having previously covered the wound with a compress and charpie and placed several layers of folded linen (graduated compresses) lengthways on the extremity along the course of the principal artery. It is well, if to this application, which is called Theden's bandage, you add a splint, so that the extremity may be at perfect rest, for muscular contraction may easily set up bleeding again. These involutions, carefully applied, are chiefly used on the field of battle in gunshot and punctured wounds, and are of considerable efiicacy ; we can, by their aid, arrest haemorrhage from the radial, ulnar, posterior and anterior tibial and even from the femoral and brachial arteries. This 46 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. bandage does not make the extremity totally bloodless, but only lessens materially the quantity of blood circulating in it. Bleeding from small or medium sized arteries can be permanently arrested by such a bandage, if it be left on for six or eight days. Also in hsemorrhage from the thorax, as on account of parenchymatous bleeding after removal of a diseased mammary gland, compression may be employed by laying compresses and charpie on the wound and keeping up a certain amount of pressure by applying bandages to cover the dressing firmly round the thorax. Such a bandage, however, if it is to be really effectual, annoys the patient extremely ; it is on the whole always better to tie the bleeding arteries properly, even though there should be a great many of them ; you, as well as your patient will be the better for it, as you will not be so easily annoyed and disturbed by the secondary hsemorrhage that is especially liable to occur after this operation in consequence of hasty bandaging and imperfect compression. There are some parts of the body where compressive bandages are useless, as in hsemorrhage from the rectum, the vagina and from the depth of the nasal cavity. It is here that the tampon or plug finds its application. There are many descriptions of tampons, especially for hsemorrhage from the vagina and rectum, the following is one of the simplest : you take a four-cornered piece of linen, about a foot square ; by means of tvv^o or three or the five fingers of the right hand placed together in the centre of it, push it sufiiciently high up into the vagina or rectum and fill the space left vacant by the withdrawal of your hand with as much charpie as you can get in, so that the vagina or rectum is fully distended internally and strong pressure is thereby exercised on its walls. Should the bleeding cease, you leave the plug till the next day or somewhat longer, according to circumstances, and then remove it by gentle traction on the linen which serves as a sack for the charpie. You can also make a large ball of charpie or linen tied together with thread, leaving a long string attached for the purpose of withdrawing the mass ; but as a plug of this kind Is at one time too small and at another too large, I prefer the first method, where the linen bag having been introduced can be filled to any extent that may be required. If the hsemor- rhage comes from the portio vaginalis uteri, as sometimes happens after an operation on this part, it is certainly far safer to expose the portio vaginalis by holding back the posterior vaginal wall with a TREATMENT OF HiEMOEEHAGE — TAMPONS — EPISTAXIS. 47 large Sims' speculum and applying a tampon firmly and directly to the bleeding spot, for the mass of charpie which is necessary to fill the vagina of a woman who has borne several children_, so that no more blood shall pass through or by the side of the plug, is incredibly large, and the pains which she suffers in consequence are very severe. In profuse haemorrhage from the nose, which generally comes from the posterior part of the inferior meatus and certainly not uncommonly from the posteriorly situated cavernous tissue of the inferior turbinated bone, plugging the nose in front is entirely insufficient and useless ; the bleeding continues and the blood either runs down into the pharynx or flows out of the other nostril, the patient in the meantime pressing the velum palatinum against the wall of the pharynx and so shutting off the upper part of the pharyngeal cavity. It would tlien be necessary to think of plugging the cavity of the nose from behind and this can easily be done by- means of Belloc's sound. This exceedingly convenient instrument for the purpose consists of a tube or canula about five inches long, the end of which is slightly curved ; in the canula is a steel spring stylet of much greater length, having a perforated button or knob at one end. You prepare beforehand a thick plug of charpie having a string or thread attached ; this plug must be large enough to fill the posterior nares. To use this apparatus, you pass the sound, with the stylet drawn back, into the inferior meatus, push it quite to the back of the nares, and then press the stylet forwards, so that it makes its appearance in the mouth below the velum. You now fasten the string securely to the button or to the hole in it and then drawj the canula and stylet back again out of the nose ; the string tied to it as well as the attached plug must follow and when you make steady traction on the string the plug becomes tightly pressed into the posterior nasal orifice ; if the bleeding now stops, as is usually the case if the plug (which must not be too long, otherwise the end of it might encroach upon the larynx) was not too small, you cut off the thread or string and leave the plug in the nose till the following day and then withdraw it from the nose by means of the string left attached ; which is so much the more easy, as it is generally thickly covered with mucus and is consequently smooth and slippery. As this instrument is not always at hand, you can make shift with an elastic catheter or a thin piece of whalebone, or something of that kind, by passing it into and through the nose, seizing the end with the finger behind the velum palatinum, and drawing it into the 48 SlMrLE INCISED WOUNDS 0¥ THE SOFT PAETS. mouth in order to fasten the thread and plug to it. The use of such a substitute demands however more skill and dexterity than the use of Belloc's sound. (3.) Styptics are remedies which act partly as astringents to the tissues and partly by causing remarkably rapid and firm coagulation of the blood. The number of remedies recommended is very large ; but we shall only mention those which have furnished successful results under various circumstances. Cold not only excites the walls of the arteries and veins to con- tract but makes the other soft parts contract also and thus com- press the vessels ; the current of blood gradually experiences greater obstacles and may even stagnate entirely should the part be com- pletely frozen. The effect of cold as a hsemostatic remedy appears to me, however, to be very much exaggerated ; I advise you, there- fore, not to trust too much to it. Cold may be applied as follows : — in the first place we can inject ice water on the bleeding wound or into the vagiim or rectum, into the bladder through a catheter, into the nose or into the mouth; the mechanical irritation of a forcible stream of water is added to that of the cold ; or you may apply pieces of ice directly to the wound, or introduce them hito cavities, or they may be swallowed, as in cases of haemorrhage from the stomach or lungs ; or finally you can fill a bladder wdth ice and apply it to the wound, where it may be kept on for hours or days. The absolute rest, which must be observed in every case of ha3morrhage, as well as the diminution of the diameter of the arteries in consequence of the loss of blood that has already taken place may probably often have a greater influence in checking bleeding than the employment of ice, to which alone the good effect is attributed. I would not dissuade from the use of cold in cases of moderate parenchymatous haemorrhage, but in bleeding from the larger arteries, you must not expect too much from it, and do not waste too much time over it, as in this case " time is blood — blood is life." It is the same thing with regard to the local astringent remedies in general use, vinegar, alum solution, and such like, that also cause contraction of the tissues and so compress the vessels ; they may be all very well for checking capillary bleeding from the nose, but you cannot expect any great results from their use. The red-hot iron, ferrum candens, causticum actuale or the actual TKEATMENT OF HEMORRHAGE ACTUAL CAUTEEY. 49 cautery, acts by cliarring the ends of the vessels and the blood, and by the hard eschar thus formed the escape of blood is prevented. If you take a wooden-handled iron rod provided with a small knob at the one end, and having heated the knob to a white heat, hold it in the immediate neighbourhood merely of the bleeding part, a black eschar is at once formed; occasionally indeed the tissue flames up even from the radiated heat alone of the white-hot iron. A red-hot iron pressed on the bleeding spot has the same effect, but is apt to adhere to the resulting eschar and tear it ofi". These cautery irons are generally heated to the required temperature in a chafing dish by means of bellows. The actual cautery may under some circumstances be a very convenient haemostatic ; it was formerly the most celebrated styptic before the ligature was known. The Arabian surgeons used to make their amputating knives red-hot, a proceeding that even Tabricius Hildanus commended, although he preferred burning the orifices of the spirting arteries separately with a fine-pointed hot iron, in which he must have had an amount of dexterity that we may well envy. In more recent times a method has been invented which must be noticed here : it is the use of platinum for operating, made red-hot by a galvanic battery. This was introduced into Germany by Middeldorpf ; it is known as galvano-caustic, and in certain circum- stances may be used with advantage; it only acts styptically, however, where the platinum is at a moderate red heat ; at a white heat platinum wire can cut through the soft parts like a knife, but at the same time they bleed freely. You can understand that a cautery iron properly shaped for haemostatic purposes as found in the surgical wards is not always at hand in actual practice ; BiefFenbach, the most ingenious German operator of this century, as well as one of the most original of men, once arrested a severe haemorrhage that set in after extirpation of a tumour on the back by means of the tongs, which he rapidly heated in the fire ; he was alone at the time, in a miserable dwelling and had no other remedies at hand. A knitting-needle fixed in a piece of wood or in a cork and heated in the candle may in some circumstances be used as a cautery. One remedy which may not only be put on an equality with the actual cautery in its effects, but occasionally surpasses it, is the Liquor Terri Sesquichlor. ; this forms with the blood such a firm, leathery, adherent coagulum that it is admirably suited for a styptic. To use it take a roll of lint or charpie, saturate it with D 50 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. the Liquor Ferri, and having previously wiped off all blood with a sponge, press it firmly on the wound for the space of from two to five minutes : you will thus arrest tolerably severe arterial hsemor- rhage. Should the first application prove ineffectual, try it a second or third time; this remedy will rarely fail you if you combine compression with it, but it makes an irritable corrosive slough, behind which decomposed pus mixed with gas-bubbles is not uncommonly formed ; so that you should not employ this styptic without urgent necessity. The application of German tinder and blotting-paper to bleeding wounds is an old popular remedy ; German tinder becomes firmly adherent with the blood to the wound if the bleeding is but slight, but without simultaneous compression it is ineffectual in anything like severe hsemorrhage ; occasionally it does good service and many surgeons esteem it highly. Dry charpie, firmly pressed on the wound, has, according to my experience, the same effect. I have a few times lately used the Penghawar Djambi, and can corroborate the statement that in large quantities and firmly pressed on the wound it acts really styptically, better than charpie j if it be as effectual as Liquor Terri, I leave undecided, but it makes less of a mess about wounds, although remaining firmly adherent to them for several days. Penghawar Djambi is composed of the light-brown soft hairs from the trunk of Cibotium Cuminghii, a tree-fern indigenous to the East Indies. Other styptic remedies are oil of turpentine and aqua Binelli, in which creosote is the principal effective ingredient ; in the use of the former remedy only have I any personal experience and I can highly recommend it to you ; when a student in Göttingen, it used to be particularly commended by one of our lecturers. Professor Baum, and I employed it once in a doubtful case with such striking success that I have a sort of veneration for it. It is in reahty a very heroic remedy, not only because the application of oil of tur- pentine to a wound causes very severe pain, but also because it excites strong inflammation, not in the wound alone but in its vicinity as well. I will relate the case to you in which I used it. A young, weakly woman some months after her confinement suffered from extensive suppuration behind the right breast between the mammary gland and the fascia of the pectoral muscle ; several incisions had already been made through the breast and by the side of it in order to give free exit to the large quantities of matter that were formed ; TEEATMEXT OF HJ^lMOERHACrE — STYPTICS — TURPENTINE. 51 but tlie openings soon closed again, and tlie old ones had to be enlarged or new ones made, as healing did not take place in the suppurating cavity. After one of these incisions that I had carried down rather deeply, severe haemorrhage set in, blood welled up continuously from the bottom of the abscess, without my being able to find the bleeding vessel ; I first of all filled the cavity with charpie and bandaged over it ; the blood soon came through the bandage. I removed it and injected ice-water into the difi'erent openings and the bleeding moderated ; again I applied a firm compressive bandage and the bleeding seemed arrested ; I had hardly got to my room in the hospital before I was hastily summoned by the nurse^ because the blood was again soaking through the dressing I had applied ; the patient had fainted, looked as pale as a corpse, and the pulse was very small. The dressing had to be immediately removed ; I now introduced pieces of ice through the different openings into the cavity beneath the breast, but the bleeding did not cease. The patient passed from one fainting fit into another, the whole bed was full of blood and ice-water, the woman lay unconscious before me with cold extremities and dim glassy eyes, and the nurses were indefatigable in their efforts to resuscitate the patient now bleeding to death, by holding ammonia to her nose and rubbing her forehead with eau de Cologne; I, at the commencement of my surgical career, not yet inured by practice to coolness and presence of mind in scenes such as this of which I had been the originator — I shall never forget the situation ! I was already thinking it would be inevitably necessary to quickly amputate the entire mammary gland, search for the bleeding vessel, and tie it, when I decided to make another attempt with turpentine. I soaked a few wads of charpie in the oil, pressed them in the cavity of the wound, and the hcemorrhage stopped immediately ; the woman recovered rapidly ; owing to the turpentine, which was removed after about twenty-four hours, very violent reaction was excited in the cavity of the abscess, the walls of which were thrown off ; a subsequent active growth of granulations effected in three weeks a cure, which physician and patient had for mouths perseveringly but vainly endeavoured to obtain. How haemorrhage is arrested by oil of turpentine and creosote solution I cannot tell you, as they do not produce particularly firm coagulation of the blood ; probably owing to the intense irritation caused by them, a peculiarly energetic contraction of the divided orifices of the vessels ensues. 52 SIMPLE INCISED WOUNDS OP THE SOFT PARTS. On the whole you will seldom see styptics used in the surgical wards ; they are rather favourite remedies with physicians, to whom, the application of the ligature and the transfixion of arteries is an unaccustomed affair. Where it is possible to tie and compress you should avoid styptics. In the face, neck, or perineum we may advantageously make use of the more efficacious styptics when there is parenchymatous hsemorrhage, if it makes no difference as to whether the wound suppurates or not ; but if the hsemorrhage be excessive and if styptics have left you in the lurch, the subsequent application of the ligature is far more difficult, as wounds often get into a horrible mess from the styptics employed. From the use of medicines recommended as internal styptics you have nothing to expect in surgical practice. Absolute rest, keeping cool, narcotics, laxatives in cases of congestive haemorrhage, may now and then prove extremely serviceable as auxiliaries, but their action is too slow for the hasmorrhages with w^hich we have to deal in surgery. The general state of weakness resulting from profuse haemorrhage is naturally most effectually combated by stopping the bleeding, but whilst thus occupied, those who are placed at your disposal to assist you may be employed in attempts to revive the patient during the repeated fainting-fits by means of smelliug-salts, sprinkling with water, &c. Only when the haemorrhage is arrested may you turn your attention to this point ; you may then give strong wine, rum or cognac, hot coffee, warm soup, a few drops of spirits of sether or acetic aether, and at the same time ammonia and such like should be given to the patient to smell. Artificial warmth, which is very effica- cious, should be quickly supplied by covering the bleeding patient with thick blankets that have been warmed before the fire. It is also very effective to envelope the extremities in elastic bandages in order to drive the blood contained in them into the interior of the body, as the extremities can dispense with blood for a longer time than the brain, the heart, or the lungs. Up to the present time it has never happened that a patient has bled to death in my hands, but I have met with several cases in which one, two, and five hours after large operations with considerable loss of blood the patients have been seized with dyspnoea and spasmodic convulsions, and have died, evidently in consequence of the great loss of blood ; for such cases there is one extreme remedy, namely, to inject blood from a healthy person into the bloodless patient. This operation^ which is called TRANSFUSION OF BLOOD. 53 transfusion, is tolerably ancient ; it originated in the middle of the seventeenth century, and after people had for a time marvelled at the strangeness of the idea it was laid aside and derided, till, however, at the end of the last century it was again withdrawn from the darkness of oblivion by English physicians, and more especially by their obstetric physicians ; after Dieflfenbach had made some attempts, which he soon abandoned, to reintroduce transfusion into Germany, Martin, in recent times, has more especially the merit of having directed attention to this operation as a life-saving one, whilst Panum has treated the subject experimentally from a physiological point of view in a thoroughly fundamental manner. The instru- mental apparatus consists of a knife, forceps, scissors, and a small narrow canula with a glass syringe to fit it, the latter to hold about 140 — 200 grammes (about 5 — 8 ounces) of fluid. You bleed a healthy strong young man from one of the veins of the arm in the ordinary manner tobe hereafter described, and receive the blood, at first to the extent of about 140 grammes, in a rather deep vessel which should be placed in a wash-hand basin filled with water of the temperature of the body ; the blood flowing into the vessel is kept whipped with a twirling- stick till the fibrine separates. While this is being done, the most distinctly perceptible subcutaneous vein at the bend of the patient's elbow is to be freely exposed by an incision through the skin ; then two silk threads are passed beneath the vein, the lower one is drawn together without closing it entirely, so that no blood may escape from the subsequent fine obHque incision made by the scissors in the vein ; the canula is pushed up into the now gaping opening of the vein, and the upper thread crossed over it without tying it in a knot; some blood must be allowed to escape through the canula so as to fill it and expel the air. In the meantime the assistant has finished bleeding the healthy man and filtered the whipped (defibrinated) blood through a fine cloth ; then the syringe having been first warmed is filled with the blood, inverted and the air entirely driven out. The syringe is now firmly fixed in the canula and the blood very slowly injected. Experience has taught that it is unadvisable to inject more than 140 — 280 grammes of blood, and that even this completely suffices to reawaken vitality. The syringe must never be entirely emptied and you must stop directly the patient shows any signs of dyspnoea. Having completed the injection you remove the threads and the canula, and treat the wound as in venesection. It has long been a 54 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. vexed question whether the blood to be injected should be deprived of its fibrine beforehand or not. Panum^s experiments have con- clusively proved that fibrine is not necessary to the restoration of vitality in cases of "blood-substitution/' i.e. transfusion, and that with the greatest care we may even cause injury by the introduction of coagula. The supply of blood-corpuscles as carriers of oxygen appears to be the essential restorative principle in this operation. Possibly transfusion has still a great future in store ; but it has become very doubtful if it will ever be of any value in those cases of extreme anaemia that arise from other and occasionally unknown causes; we draw these conclusions from the results of Panum's excellent experiments, according to which the blood itself does not nourish, but is only the principal channel and medium for distributing the nourishment. The experiments made by Neudorfer in the last Italian war on the wounded who had become ansemic in consequence of profuse suppuration have had no permanent results. Hueter has of late paid much attention to the subject of transfusion ; he prefers and urgently recommends whipped and filtered venous blood to be injected into an artery (such as the radial or posterior tibial artery) , in the peripheral (distal) direction, as was once formerly done by Yon Graefe ; as Hueter has clearly demonstrated that this arterial transfusion is performed almost more easily than venous, this method deserves the preference, chiefly because the danger of embolism in the pulmonary vessels is thus with certainty avoided ; no abnormal symptoms made their appearance in the hand or foot of those operated on by Hueter either during or after transfusion ; but I am very doubtful if in many cases we should succeed in introducing a canula into the above-named small arteries in a patient bleeding to death, we should then have to choose the brachial artery. The enormous rise in the temperature of the body, the appearance of bloody urine, cyanosis, dyspnoea, and other symptoms which arise after and occasionally even during the operation, plainly indicate that it makes a considerable inroad on the physiological activity of the organism. On the whole I am but little prepossessed in favour of this operation, which has always hitherto been unsuccessful with myself and my assistants, but must confess that it is extolled by many physicians as having very good results. More recently still direct transfusion with Iambus blood (the first and oldest form of this species of operation) has been again revived ; fatal cases have TRANSFUSION OF BLOOD. 55 occurred during this operation as well as during direct and indirect transfusion with human blood. The statements which have been made with regard to cases of successful transfusion of lamb's blood are not such as to cause me at present to alter my opinion as to this operation. I cannot now discuss the treatment of the after-consequences of serious haemorrhages ; it will be evident to you that, as a general rule, the chronic effects, the defective formation of new blood, must be combated by dietetic and medical treatment of a strengthening and nourishing character. 56 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. LECTURE IV. Gaping of the wo2md. — Union by plaster. — Suture. — Interrupted' suture. — Twisted suture. — External changes perceptible in the united wound. — Removal of the sutures. — Healing by the first intention. After the hsemorrliage from a wound has been completely arrested and the surface cleansed by washing it with cold water, you should satisfy yourself as to its depth and the character of the parts divided, and in doing this you must notice particularly whether a joint, or one of the cavities of the body, has been opened, large nerve trunks divided, or a bone exposed or injured. You will then turn your attention to the third symptom in a recent wound, that is, the gaping of the parts. Skin, fasciae, and nerves will, when divided,, separate ; partly in consequence of their elasticity and partly because they are attached to muscles, which, being contractile, . become shortened directly they are injured, and whose cut surfaces therefore, especially in transverse wounds, are more or less widely separated from each other. We shall consider, in the first place, only those incised wounds where there has been no loss of substance, but merely a simple division of the soft parts. For such a wound to heal quickly, it is requisite that the two edges should be brought exactly together as they were before the injury, and to accomplish this we make use of strips of adhesive plaster or sutures. In wounds where the cutis is scarcely divided, as in the small incised wounds of the fingers so often occurring in daily life,. Enghsh sticking plaster is, as is well known, a good application. It consists of a solution of isinglass in water, mixed with a little rectified spirits of wine, painted over a piece of thin, but firm, silk or paper. The back is often painted over with tincture of benzoin, which communicates a pleasant odour to the plaster. As UNION OF WOUNDS — PLASTERS. 57 the plaster readily becomes loose under moist applications, it is often advisable to paint it over when dry with a brush dipped in collodion. Collodion is a solution of gun-cotton in a mixture of ether and alcohol. If this fluid be painted over the plaster and the adjoining portions of the skin, the ether very quickly evaporates, and a fine membrane, insoluble in water, remains behind, often puckering up the skin to a considerable degree. A further therapeutic use can also be made of this contractile action of the collodion by painting it on the inflamed skin either directly, or still better after previously covering the afi'ected part with thin open cotton gauze, thereby producing moderate, equable pressure. In using collodion to fasten the plaster, take care not to apply it directly to the wound, for this will not only cause unnecessary pain, but may also induce inflammation and suppuration, which are just the things we wish to avoid. If the cutis" be divided and the plaster has to resist a more considerable amount of tension in order to keep the edges of the wound in apposition, the English plaster is insufficient, and we then use the proper adhesive plaster. Of this we have two kinds, in addition to numerous modifications, and attempts have also been made both to improve it and make it cheaper. The emplastrum adhsesivum, the emplastrum diachylon compositum, our common adhesive plaster, consists of olive oil, litharge, resin, and turpentine. When liquefied by heat it is spread on linen, and used generally in strips ; these are laid over the wound, the edges of which are thus drawn together and kept in position. This plaster when freshly prepared adheres admirably, but it is apt to become loose if moist compresses are applied over it for some time. Yery sensitive skins become irritated by it if often applied, and some- times even after one application ; and in such cases we may have recourse to other adhesive plasters, the emplastrum cerussse (em- plastrum adheesivum album), which is prepared from olive oil, litharge, and white lead with hot water. This plaster adheres much less firmly, but it has the advantage of smearing the edges of the wound less than the yellow sticking plaster. A mixture of the two kinds of plasters in equal proportions lessens the objections, and combines the advantages of both. As a general rule, for large wounds we now avoid the use of adhesive plaster more than formerly, and in its place employ the 58 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. suture more frequently. When we wish to unite wounds by the suture^ we have, as a rule, the choice of two kinds — the interrupted suture (sutura nodosa) and the twisted suture (sutura circumvoluta) . There is some truth in the objection that by the introduction of a foreign body, such as a thread or needle, we keep up a constant state of irritation in the edges of the wound, but this cannot counter- balance the great advantage obtained by the certainty with which tbe surfaces of the wound are adjusted by means of the suture. Hence, then, with the exception of adhesive plaster, almost all substitutes for the suture in which ancient and modern surgery has exhausted itself, after having been very mucb in vogue for a time, have been thrown aside. The suture has not yet been supplanted any more than the ligature, and probably never will be superseded. There are certain portions of the body, such as the hairy scalp, the hands, and the feet, where we make a point of avoiding sutures, because any possible inflammatory processes which may occur, and which have often been attributed to the suture, are prone to assume a dangerous character; in my opinion, however, there is much prejudice at the bottom of this. Wounds of the head are especially prone to cause inflammation of the skin and subcutaneous cellular tissue; that this tendency is particularly increased by properly applied sutures, has not been proved statistically to any great extent. There are articles of faith of this kind handed down from teacher to pupil, from one handbook to another ; many of them are a sort of Hippocratic tradition full of practical truth; these I willingly respect : others are based on undeterminate observations and prejudices founded thereupon, and among these latter I class the prohibition to apply sutures to wounds of the head. On looking back to my own experience, I remember more cases in which inflam- mation of the skin followed wounds of the head where no sutures were applied, than where they were. It is extremely important, however, in applying sutures to wounds of the head, to take care not to tighten them too much, to recognise at an early period inflam- matory symptoms, and under such circumstances at once to remove the sutures. In applying sutures to flap-wounds we must provide for the escape of secretions by inserting drainage-tubes before we begin the dressing. The necessity for applying sutures is determined by the amount of gaping and the form of the wound ; they are required, for example, in flap wounds. We are never likely to take any unnecessary trouble in UNION OF WOUNDS — SUTURES. 59 introducing sutures unless urged by excess of surgical zeal, but sutures should be employed where, for the reasons above stated, sticking plaster is inappropriate or insufficient. For the interrupted suture we use surgical needles and silk thread or wire. Surgical needles differ from ordinary sewing needles in having a lancet-shaped ground point which pierces the skin more readily than the round point of the sewing needle ; besides this they are of somewhat softer steel than the English sewing needle, in consequence of which they do not spring so readily. They vary much in length and thickness, according as we wish to pass strong threads deeply where the edges are very tense, or only to use a fine thread to bring the edges into exact apposition. All needles, however, should have an eye of moderate size, so that time may not be lost unnecessarily in threading them. The needles may be either quite straight or curved in form. The curve should vary according to the localities where we wish to use the needles ; for example, fine, very much curved needles are necessary for applying sutures to the parts about the inner canthus of the eye ; large, much curved needles are used for sewing up a perinseum ruptured during labour, kc. The curve may be either in the whole needle, or only at the point : the variety is very great ; for sewing up the wounds that are generally met with in practice you need only a few thin needles, and a few thick ones, some straight, others variously curved. The thread is generally of silk, of varying strength and thickness corresponding to the needle. Formerly I always used soft red silk, which has long been employed for this purpose. In England, however, I met with a kind of undyed, strongly twisted silk, which, even when extremely fine, is so strong that wounds can be sewn up and their borders drawn together with thread as fine as a hair. This silk, moreover, imbibes so little moisture that it may remain for many days in the wound without swelling or irritating, and now I use only this so-called Chinese silk. Another material for sutures has lately been introduced from England and America, and that is, silver or iron wire. This must be exceedingly fine and soft. The iron wire must be very well annealed for this purpose. The use of this material was suggested by the long-known fact that pieces of metal, when allowed to remain in the body, often cause no suppuration, but the parts become healed up over them. It was thought, therefore, that the suppurations, which not seldom occur at the spots where the sutures have been introduced, might be avoided by 60 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. using metal, instead of the animal substance silk. It cannot, in fact, be denied that such suppuration at the points of suture is much less liable to occur with metalKc than with silk thread, but the experimental investigations of Simon have shown that the suppuration about sutures is mainly dependent upon the thickness of the threads. I can from my own experience confirm the observa- tion that very fine silk threads cause just as little suppuration in the track of the suture, and may become healed over just as well as metal ones. As a general rule I have not found catgut a very good material for sutures ; the portion remaining in the wound some- times becomes absorbed in three days, and the borders of the wound, unless by that time firmly adherent, are prone immediately to separate. We now come to the application of the interrupted suture. This is done as follows : — With a toothed forceps you first seize one lip of the wound, introduce a needle through the skin at a distance of about two lines from the edge, passing it into the subcutaneous cellular tissue, and bringing the needle out again into the wound ; now seize the other lip of the wound with the forceps, and pierce the skin from below upwards from the wound exactly opposite the first point of entrance, next draw the thread through, and cut it so that on both sides it is sufficiently long for a knot to be conveniently tied. Now make a simple knot, or, if the tensidh of the borders of the wound be great, a surgeon's one, draw it tight, and take care that the edges of the wound are in exact apposition, then make a second simple knot, and cut off both threads close to it, so as to prevent any long ends of thread getting into the wound. If you wish to use wire, you thread the needle with it as with the silk, bend the short end which has been drawn through the eye of the needle, and pass the latter through the parts as above described. If the wire is very soft we can tie an excellent knot with it just as with a silk thread, but the whole of this manipulation is much less pleasant with wire than with silk, and on closing the knot the border of the skin is easily displaced, or the wire may get twisted, so that the suture holds less securely ; this is very likely to happen with our German wire, which has not yet attained the softness of that made in England. The pleasantest metallic wires to use are those made of a mixture of gold and silver, and of platinum, of which marvellously fine, pliable, and at the same time firm wire UNION OF WOUNDS — SUTURES. 61 may be made. It would be, however, a ridiculous notion to wish to substitute these expensive articles for ordinary silk, with which. millions of wounds have been excellently healed, and doubtless will "be so in future. I pass over the many newly discovered appliances by which the wires can be fastened by knots or short twists ; they show that those who enthusiastically advocate the use of the metalhc suture have experienced many difficulties in fastening the knot. I first make a simple knot with the wire, then draw it together and make two or three quick, short, twists, and cut off Loth ends close to the twisted part. Where there is any tension of the borders of the wound, the finer the wire, the more apt it is to cut its way through, just as the silk does. I have seldom found the supposed objections to silk sutures sufiiciently great to make me often take the opportunity of substituting metal ones. These latter I have occasionally preferred to use ; of this I shall speak further when dealing with individual cases in the clinical wards. The usual fault that beginners make is to draw the sutures too tight ; they seldom apply them too loosely. In the former case, the borders of the wound, which almost always swell a little, become strangulated ; this strangulation is certainly seldom so great as to cause the death of the tissues involved, but it sets up a condition of inflammatory excitement in these parts which soon shows itself in deep reddening and very early suppuration in the track of the suture ; and unless we relieve this excitement by promptly cutting and removing the sutures the inflammation is very likely to spread, and the healing of the wound may be thereby very seriously inter- fered with. Straight needles may be best introduced with the fingers. Curved needles, however, especially when small and when the wounds are deeply seated, can be introduced with more ease and security by means of particular kinds of needle-holders. Of these there is a great quantity, but of them all I am accustomed to use only the one invented by Dieffenbach. It consists of a forceps with short thick blades, between which the needle is firmly and securely held, and then passed through the skin in the direction of its curve. This perfectly simple instrument is sufficient for almost all cases, and in a skilled hand is surpassed by no instrument of the kind for security in holding and introducing the needle. Com- plicated instruments are suitable for unskilful surgeons, says Dieffenbach, in the admirable introduction to his ^ Operative 62 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Surgery / the hand of the surgeon, and not the instrument, should operate. Practice and habit in the use of particular instruments cause one kind to be indispensable for one operator, and another for another. Thus, some find it inconvenient and troublesome to seize with the forceps the lips of the wound in order to approximate them, as I have just explained to you, though this method is far neater than holding them with the fingers ; to me this latter would be extremely inconvenient ; but it is quite allowable that every one should act according to his own manner and habit in the way which he finds most convenient. When I have to apply sutures at some depth, for example, in the velum palati, rectum, or vagina, I always use needles with handles. The number of sutures to be applied depends naturally upon the length of the wound ; as a general rule, sutures at a distance of one centimetre ('39 inch) apart are sufficient, but where very exact appo- sition of the edges of the wound and fine cicatrices are particularly important, as in wounds of the face, the sutures must be closer, and there should be strong ones deeply placed, at a distance from the edges of the wound, alternating with finer ones involving but a small portion of the edge (Simonis double suture). The second kind of suture, the twisted, also called the harelip suture, is made by inserting a long pin with a lancet-shaped point through the borders of the wound ; this is allowed to remain, and a thread of strong cotton or silk is passed round it, as I now show you. You take the thread with both hands, place it parallel to and immediately above the pin, transversely, therefore, to the wound ; draw the thread downwards over the apertures of exit and entrance of the pin„ so as to approximate the edges of the wound exactly (this is the so-called Nulltour) ; now you change the threads from hand to hand, and with the right thread in the left hand you pass round the left projecting end of the pin from above downwards, and you do just the same for the right end of the pin, with the left thread in the right hand ; now you change the threads again, and make three or four similar so-called figure-of-8 turns : then make a double knot, and cut the ends of the thread close to the knot ; lastly, with a small pair of cutting forceps made for the purpose, you cut off' both ends of the pin as may be required, to prevent them from pressing on the skin, but they must not be made so short as to cause any difficulty in withdrawing them at a later period. There is in addition a large number of other sutures, which for UNIOX OF WOUNDS — SUTURES. 6S the most part are only of historical interest, and which we here pass over ; in our chapters on special surgery we shall have to mention a few peculiar kinds of sutures, adapted for wounds of particular parts, such as, for example, the intestines. What now are the advantages of the twisted over the interrupted suture, and when do we employ it? These indications may be reduced to two factors, and the interrupted suture may be regarded as the simpler and more common. The twisted suture is employed,. 1, when the tension of the lips of the wound is very considerable ; 2, when the flaps of skin to be united are thin and unsupported, where the skin is very loose ; in short, where the borders of the wound have a great tendency to inversion. The pins remaining in position give, in both cases, a more secure and firm support to the sutures, the pin acts in some measure as a subcutaneous splint for the edges of the skin ; they are supported by it and are also held more firmly in position by the numerous threads on the outside. In many cases in which sutures have to be closely applied to the face, the interrupted and twisted kinds are used alternately; the latter serve to support the parts and resist tension, the former induce more accurate union of the borders of the wound already in position. "When the bleeding has been stopped, and the wound accurately brought together, all has been done that is at first necessary. Let us now notice what goes on in the closed wound. Immediately after the edges of the wound have been brought together, they usually appear pale in consequence of the pressure exercised by the sutures upon the vessels of the skin ; more rarely the borders of the skin are dark blue in colour ; this always indicates great impediment to the return of blood through the veins, the cause of this being the loss of a portion of the blood-vessels. It is evident that the division of a large number of capillaries may very greatly disturb the communication between arteries and veins, so that at some point in the border of the wound the vis a tergo may be insufficient for the venous current j this dark blue colour of the borders of the wound most frequently occurs when the skin is very thin, or in cases where much of the panniculus adiposus has been removed, the veins of the skin emptying the greater part of their contents into the veins of this tissue. If this blue colour does not soon spontaneously disappear, a small portion of the edge of the 64 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. wound dies, a symptom to which we shall return when speaking of contused wounds, in which it is of frequent occurrence. After a period varying from twenty-four to forty-eight hours, jou find the borders of the wound often slightly swollen, and sometimes bright red; these symptoms are certainly often absent, especially where the epidermis is thick ; but occasionally they spread, according to the extent and depth of the wound and also the tension of the skin, sometimes only two or three lines, and sometimes as many inches around the wound ; within this area, the usual so-called local reaction takes place about the wound, which becomes slightly painful, especially on being touched. All this may be best seen in children and women with a delicate skin. About wounds of the face we often notice extensive oedema, espe- cially of the eyelids ; this often frightens beginners, but it is usually unattended with danger. In a not inconsiderable number of cases, if the sutures have not been applied too tightly, not only is there no immediate subsequent change in the borders of the wound, but they remain unaffected until healing has taken place ; this is the most favorable and the ideal proper course, and one which is more and more frequently noticed with our improved methods of union and treatment. The process which follows injury of the tissues, and by which also union of the flaps of a wound takes place, cannot be referred otherwise than to that category of mixed morphological and chemical changes of tissue which are comprehended under the designation of inflammation ; and indeed, in such cases, we speak of a traumatic in- flammation, that is, of an inflammation caused by an injury (rpavßa) . If, in twenty-four hours, these local symptoms have not extended so as to exceed the limits just indicated, you may at once consider that the process is running a normal course. It is a marked peculiarity of traumatic inflammation that it is strictly confined to the borders of the wound, and does not spread without special cause. Erom the third to the fifth day, any slight redness, swelling, pain, and increase of temperature which may possibly have been present in the injured part, will in great measure, if not entirely, have disappeared. If the symptoms increase on the second, third, and fourth days, or if some of them, such as severe pain and great swelling, become very marked at'^this time, after apparent subsidence, or if they remain with increasing intensity beyond the fifth or sixth day, these are all signs that the healing process is not pursuing the UNION OF WOUNDS — SUTUEES. 65 wished-for normal course. This will be especially evident from the general condition of the patient. The whole organism is made to sympathize by the abnormal increase of the inflammation. At the end of this chapter^ we shall refer to this general reaction^ ^' the wound-fever.''^ At present we shall confine our attention to the condition of the wounded part. On the third day, often indeed on the second, you may carefully remove the pins of the twisted suture, supposing that you have also applied the interrupted kind. The best way to do this, is to seize the pin with Dieffenbach's forceps, which I have already brought to your notice ; you then withdraw it with a gentle rotation, while you fix the twisted threads by laying your finger lightly upon them. The threads usually remain as a sort of clamp upon the wound, to which they are attached by some coagulated blood ; they afterwards loosen spontaneously. By forcibly tearing away the threads you would unnecessarily strain the wound, and possibly tear apart the recently united edges. If at this time we carefully feel the edges of the wound, we shall find them, supposing that the oedema has already subsided, somewhat firmer than the healthy parts around'; this state of firm infiltration disappears in a few days. If you have applied many interrupted sutures, you may remove ■some of them that have little to hold, on the third day, others on the fourth and fifth days ; only at those parts where the tension is very great, you may, as an exception, leave the threads for eight days or more, or even allow them to cut their way through the edges of the wound, if there is any real use in keeping together the borders of the wound which may perhaps be still gaping in some places. If, at an early period, the extension of the inflammation exceeds the normal amount, earlier removal of the sutures is necessary, lest the irritation should be increased : not unfrequently blood decomposing or mixed with pus is found at the bottom of the wound, and is the cause of the unusual symptoms of irritation ; more of this by-and-by. In removing the interrupted sutures, the following small pre- cautions must be taken : cut the thread on one side of the knot, where you can most readily pass the thin blade of the scissors under it, without in any way stretching the wound ; then seize the thread at the knot with a dissecting forceps, and draw it out towards the side where it was divided, so as not to separate the edges of the wound in taking out the thread. 66 SIMPLE INCISED WOUNDS OE THE SOFT PARTS. Should you think^ after removing tlie sutures^ that the adhesion of the wound is still too weak to prevent the flaps from gaping, you may, by applying strips of English plaster, which you place trans- versely over the wound between the openings of the sutures, and fixing the ends (avoiding the wound) with collodion, give additional support for a few days ; this will suffice to prevent any strain upon the edges of the wound, such as unavoidably occurs in injuries of the face, from the movements of the muscles in expression. In from six to eight days the majority of simple incised wounds are sufficiently united to keep together without any further support ; indeed, in many cases, this occurs between the second and fourth day. If, in the course of the following days, the blood which may have coagulated about the wound be carefully washed off, the young cicatrix appears as a fine red streak, as a scarcely visible fine line. The process which we have just described is called healing of wounds by the first intention. In the course of the next few months, the cicatrix loses its redness and hardness, and finally becomes perceptibly whiter than, and just as soft as the skin, so that for many years it continues to be recog- nised as a fine white line. It often disappears almost entirely after several years. Some of you who leave the university with many very visible cicatrices on the face, may comfort yourselves with the hope, that they will be scarcely visible in six or eight years, when the Philistine visage will become you less than it does a student. Tem- pora mutanter nos et mutamur in Ulis ! THE INFLAMMATORY PROCESS. 67 LECTURE V. hifla^nmation. — The more ininute processes in liealmg hy the first intention.- — Dilatation of the vessels in the 7ieujhhourhoocl of the wound. — Muxion. — Different views regarding the causes of fluxion. Gentlemen^ — You are now acquainted with the changes visible to the naked eye, which take place in the wound while it is healing ; let us now endeavour to examine the processes that develop them- selves in the tissues from the time of injury until the formation of the cicatrix. For a long time attempts have been made to study and distinguish these processes more minutely; for this purpose wounds have been made on animals, and examined at different stages, but it is only the most exact microscopic examination of the tissue and direct observation of the changes after injury, that have enabled us to give a complete description of the healing process. I will endeavour to give you in a few words a distinct account of the results of these investigations, to which I have devoted much special study. The interesting results, obtained in the manner above alluded to, have essentially contributed towards accustoming us to understand by ^' inflammation" mainly that succession of changes which may be perceived in the tissues on microscopical examination. We have recently become accustomed to regard these morphological pro- cesses as the absolute essence of the process of inflammation, and even to attach the term " inflammatory process" to the accession and typical subsidence of these histopoetic processes. I should not like to diminish your interest in these subjects at present, but the prevailing current opinions make it necessary for me to remind you beforehand, that — as in all organic growth, and in every change and process for the maintenance of the tissues of the body — the form which this takes, the smallest as well as the largest, is always the product of the chemical and physical forces inherent in the actual Q8 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. material of the tissues ; the inflammatory process is, like every phy- siological one that occurs in the body, of a chemico-physical nature ; itself, we never see, even with the best microscopes; it is only the results of its action that are visible to us. These results, destruc- tion and formation of tissue, have much that is peculiar, especially in their typical course, but their limits are as wide as life and death ; the tissues may perish in an instant, or may be chronically diseased for years ; of two new formations of exactly similar structure, one may have sprung up in a few days, the other may have required several months for its development ; totally different causes may induce new formations of tissue having an extraordinary resemblance to each other. Were it not that I feared to confuse you, I would here enter more minutely into the difficulties which always present themselves whenever we treat of inflammation in general. Let me therefore now go at once into detail ; later on we will return to the description of inflammation as a whole. The changes which occur after injury of the different tissues are particularly manifest in the blood-vessels, in the injured tissue itself, and in its nerves. The influence of the nerves upon the in- flammatory process, and of this latter upon the former, is unfor- tunately still surrounded by so much that is obscure that we shall Slot consider it. We must at once dismiss, as at present unanswer- able, the question whether the finest nutrient (vaso-motor) nerves, which lose themselves in the various tissues (for the c[uestion at issue can only concern these) exercise any immediate influence over the processes which become developed in the injured tissues and in the vessels themselves ; the more so because up to the present time there are but few parts of the body in which the ends of the nerves have been recognised with certainty, while for other parts we are quite in the dark, and we have no kind of knowledge as to the manner in which the nutrient nerves act, and just as little as to the relations of the ends of the nerves to the capillary vessels. In the lectures on physiology and general pathology yoar attention will have been already called to the imaginable possibilities and probabilities on this subject. If, therefore, in what follows, we say little about the nerves, it is because we know nothing of their action in this special process, not because we wish to deny their influence. Let us take for an example the sim])lest tissue ; let us suppose a vertical section through connective tissue, with a closed capillary UNION OF WOUNDS. 69 system near the surface of the skin^ and magnified from 300 to 400 diams. Here you have a diagram of such a system. Fig. I. Connective tissue with capillaries. A diagram. Magnified 350 — 400. An incision is now made from above downwards into the tissue, the capillaries bleed ; the bleeding soon stops, the wound is accu- rately united, no matter by what means. Now, what are the prin- cipal changes that take place here ? The blood coagulates in the capillaries to about as far as the next branching — to the next point of intersection of the capillary network. Some coagulated blood almost always remains between the edges of the wound (Fig. 2) . Of the channels for the circulation in our diagram a few have become blocked up ; the blood has to accommodate itself to this, and escape by the existing by-paths around the wound. It is obvious that it does this under greater arterial pressure than before. This pressure becomes greater, the greater the obstruction to the circulation, and the less numerous the by-paths (of the so-called collateral circulation). The result of this 70 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. increased pressure is tlie distension of the vessels, hence the redness in the neighbourhood of the wound and partly, also^ the swelling. Fig. 2. Au incision made. Closure of capillaries by blood-clot. Collateral distension. A diagram. Magnified 350 to 400 diameters. This latter symptom has, however, another cause. The more the walls of the capillaries are distended the thinner they become ; even under ordinary conditions of pressure, with normal thickness of their walls, they allow blood plasma to pass through to nourish the tissues, and now under increased pressure more plasma than usual will pass through the walls, saturating the injured tissue, and becoming absorbed by the latter by reason of its capacity for swelling. You have here in a few words the explanation of the changes sometimes externally perceptible in the borders of the wound immediately after the injury ; the redness and increased warmth due to the rapid development of the collateral circulation by reason of which a greater volume of blood circulates through the vessels near the surface ; the swelling of the borders of the wound is caused by UNION OF WOUNDS — lEEITATION. 71 the distension of the vessels and the swelling of the tissues, which again produce slight compression of the nerves, and thereby some amount of pain. This, as it seems to me, exceedingly simple mechanical explana- tion would be of considerable value if it fully accounted for the entire subsequent course of the process, and could be applied to all inflammations which are not of a traumatic or mechanical origin. This, however, is not the case. Neither the great vascular dis- tension that occasionally occurs some time after injuries, and mani- fests itself in diffused redness about the wound, nor the capillary dilatation which exists from the first in inflammations of spontaneous origin, can be referred to mechanical impediments of the circulation. If the disturbance of circulation, due to the incision, is only incon- siderable, readjustment speedily takes place ; such so-called passive hypersemias stop short of *' inflammation." Their extension is very closely connected with mechanical conditions, whereas the redness in advancing inflammation often spreads beyond the immediate sphere of the mechanical impediment to the circulation ; only when the capillary distension is connected with conditions of irritation of the tissue, and eventually induced thereby, are we accustomed to make use of the term '^ inflammation.'"' There are various kinds of irri- tation which produce dilatation of the capillaries. Let us now take mechanical irritation. You see, for example, my ocular con- junctiva of a pure bluish-white colour, like that of every normal eye. Now I rub the eye freely, so that it weeps ; look at it again, the conjunctiva becomes reddish, perhaps with the naked eye you may see distinctly some of the larger blood-vessels, with the lens you will see also the finer vessels filled with blood. ^Viter, at most five minutes, the redness has entirely disappeared. Look again into an eye where a small insect has accidentally got under the eyelids, as is constantly happening ; the person rubs his eye, the eye weeps and becomes very red, the insect is removed, and in half an hour^s time you will probably see nothing remarkable about the eye. If such irritants were to continue to work, acute inflammation would be the result. We shall now only attend to the symptoms connected with the vessels ; these originate suddenly, and as rapidly disappear, because the irritation has ceased ; there was no mechanical impediment to the circulation. AYhat is the immediate cause of these sym- ptoms ? AYhy do not the vessels contract instead of dilating ? These 72 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. questions are as difficult to answer as the observation is easy to make, and to be repeated over and over again with the same results. The fact itself has been known as long as observations have been made ; the old saying, ^' JJhi stim.ulus ibi affluxus^' refers to this. The increased flow of blood is the answer which the irritated vascu- lar part gives to the stimulus. formerly, the process which induced this kind of redness was- called active hjpercemia or active congestion. Yirchow took up an older name, and brought again into use the term fluxion or congestion {Fluxiov, Walhing). You will now be in a position, assisted by your knowledge of general pathology, to recognise the fact that what is required here is to give a theoretic explanation of phenomena, which through all time have formed one of the most important objects of consideration, in medicine. Astley Cooper, a very celebrated English surgeon, whose works you will read with pleasure in time to come, when you. take up the study of monographs, a thoroughly practical surgeon, commences his lectures on surgery with the following words: *'The subject of our present lecture is irritation, which, as it is the- foundation of surgical science, you must most carefully investigate^, and clearly understand, before you can expect to be masters of the principles of your profession, or to be able to practise it witli credit to yourselves, or with advantage to those who may place themselves under your care." This will show you what part the questions now under considera- tion, which may possibly appear to you as superfluous amusements of the mind and imagination, have played at various times ; you will hereafter learn from the history of medicine that entire medical systems of the greatest importance, are based on hypotheses that w^re constructed for the explanation of these phenomena in thevessels,. and of this irritability and excitability of the tissues in general. This is not the place for an exhaustive account of the history of this subject, I will only remind you of a few hypotheses which have been lately advanced, with the already-existing knowledge of the vessels and parts visible by the aid of the microscope, with regard., to the production of vascular dilatation from irritation. You know from histology and physiology that arteries and veins,, before they pass into capillaries, have muscular fibre cells, partly transverse and partly longitudinal, in their walls; that these fibres are more scanty in veins than in arteries, altliough there are very. IRRITATIOX — DILATATION OF THE VESSELS. 7S great differences in this respect. Now, although it may be very difficalt to make direct observations as to the effect of irritation on these minute arteries and veins, it is very easy to see its effects on- the intestines, where we have essentially the same conditions, viz. a tube provided with longitudinal and transverse muscular fibres. But, irritate the intestine as you may, you will never cause dilata- tion at the spot where the stimulus is applied, but only a shortening or constriction, and consequent motion of the contents of the intes- tine, the rapidity of which will depend upon the frequency of the repetition of the contractions. But is it possible that dilatation of the capillaries should be induced by such increased rapidity of motion of the vessels and of the blood? Certainly not. In the *^ General Pathology ' of Lotze, the celebrated medical philosopher of Göttingeu, you will find a few remarks that are so trenchant, and, like all the chapters on this subject, so excellently illustrate the- brilliant genius and critical acumen of this author, that I shall make- use of the imagery he employs. His remarks are : " Pathologists- who seek to explain congestion by increased contraction of the arteries, assume the thankless task of the Danaides, they cannot produce the stopper which prevents the escape of the blood that is pumped in with so much difficulty. Overfulness results, if in the same space of time more is introduced and the same amount as- before escapes, or if the same quantity is introduced and less escapes. If we now suppose a portion of a vessel to contract more actively and at shorter intervals, it will have as little influence in causing^ increased afflux or diminished efflux of blood as the stamping of a person in a stream would have in regulating the amount of water.^^ This sufficiently refuted hypothesis, that the dilatation of th& capillaries resulted from a more rapid and energetic contraction of the arteries, was at least founded on known observations, but Lotze's own explanation, on the contrary, is so far from all analogy that we are unable to attach any value to it. Lotze's opinion is, that there is no objection to the assumption that the capillaries are affected differently from the arteries by irritation, that they may by nervous influence expand actively on irritation, by their molecules separating- from each other. This opinion is a thoroughly arbitrary assumption, and to some extent opposed to recent observations. It is well known that with the microscope we can follow the circulation of the blood,, both in the smaller arteries and veins, as well as in the capillaries in the web of the foot, in the mesentery, and in the tongue of the frog,. 74 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. or in the wing of the bat ; but the immediate effect of a slight che- mical or mechanical irritant does not show itself immediately in the capillaries, but first in a contraction of the smallest arteries, some- times also of the veins ; generally this contraction passes off very rapidly, lasting scarcely a second, indeed it often escapes observation altogether, and we then assume that the duration and degree of the contraction are too slight to be measured by our observation. This brief contraction is then followed by the dilatation, the immediate cause of which is obscure even on microscopical observation. We shall soon see that we get no help from this explanation ; but that the fluxion is the result of a kind of paralysis of the capillary walls, active as this symptom may appear. Even the most recent, ex- tremely interesting observations of Golubew, who had the kindness to show me that the capillaries of the nictitating membrane of the frog contract transversely when exposed to strong electric shocks, do not appear to me, as far as I have considered the matter, to be at present perfectly applicable to the question of fluxion. Virchow supposes that the excitement, the immediate cause of which may certainly be the contraction, is followed by rapid fatigue of the muscles of the vessels ; after a tetanic contraction there is relaxation, just as in irritated nerves and muscles, a view which may find some support in a communication from Dubois- ßeymond with regard to the painful tetanus of the muscles of the vessels of the head as a cause of headache on one side, a so-called hemicrania, since this supposed tetanus of the muscles of the vessels, dependent upon great excitement of the cervical portion of the sympathetic nerve, was certainly followed by their relaxation and great distension of the vessels, in short, by symptoms of cerebral congestion. But in this view, which, it is true, explains the relaxation or temporary paralysis of the walls of the vessels following the •contraction, and a consequent decrease of their resistance to the pressure of the blood, we must not forget, that it is by no means proved that the muscles of the vessels, once irritated and excited to rapid contraction, are indeed immediately paralysed, while this fatigue in other muscles usually occurs only after long repeated irritation. We should be obliged indeed arbitrarily to assume that the muscles of the vessels are particularly easily fatigued, but this is controverted by experiment. You know from physiology, that Claude Bernard has proved that the contractions and dilatations of the arteries of the head are under the influence of the cervical portion of the IRRITATION — DILATATION OF THE VESSELS. 75 sympathetic nerve, as I have already pointed out to you. If the upper cervical ganglion of this nerve be irritated, the arteries contract ; if the nerve be divided, dilatation, (paralysis) of the arteries and capillaries is the result. These experiments may, as far as regards the irritation, be again and again repeated without producing fatigue of the muscles of the vessels, provided that the electrical current be not too strong ; hence it may well follow, that we are unable to accept unconditionally the assumption of an immediate fatigue after a single irritation. Schiff, however, like Lotze, supposes that an active dilatation of the vessels is possible; he thinks that this necessarily follows from certain experiments ; the mechanism of this, however, is to me utterly incomprehensible, for there are certainly no muscles that can actively dilate the vessels. If the veins alone contracted strongly on being irritated, filling of the capillaries would doubtless occur as a consequence of the obstruction, and there would then be no difference between venous (passive) hyperaemia and fluxion. This assumption is, however, quite untenable ; for it is quite inconceivable that the veins alone should contract on inflammatory excitement. That the veins do contract on mechanical irritation you may see, for example, in the femoral vein of a thigh which has just been amputated, to which Yirchow draws particular attention, and this irritability of the walls of the veins certainly lasts longer than that of the nerves. Henle some time ago advanced the view that the phenomena of dila- tation of the vessels from irritation were directly caused by paralysis of their walls ; Lotze, on the other hand, opposes this view and asserts that it cannot be supposed that the muscles should all be paralysed in a man in a violent state of irritation, in whom all the muscles are tense and the face glowing red, but this objection does not seem to me to be very tenable, and Lotze^s other objection does not appear to me to hold good; he says, "how shall we account for the paleness, the contraction of the vessels that occurs in fright and terror ? Does that look like violent muscular action if redness in anger and shame can be the effect of paralysis ?" In my opinion, this proves nothing. In a terrified man, the muscles of the vessels may be thrown into a tetanic condition, which is usually rapidly followed by fatigue of the same muscles ; immediately after a great fright we generally feel the blood pouring into our cheeks, directly "we begin to breathe deeply, and recover from the shock ; we soon become red and, at first, indeed, redder than is pleasant, and certainly 76 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. it not unfrequently happens that the pallor in many men from fright is often overlooked, and only the subsequent redness perceived. This explanation^ moreover, may suffice for the paleness in terror^ as well as for the phenomena of " shock," of which we shall speak when describing the effects of crushing injuries upon the body. But apart from these objections, how can we imagine that the irritation of a nerve can produce an active, directly paralysing effect ? Physiology, in fact, makes us acquainted with such phenomena as, for example, the obstruction of the heart's action from irritation of the pneumogastric nerve, of the movements of the intestines from irritation of the splanchnic nerve, &c. We assume here the exist- ence of an inhibitory nervous system, which arrests the con- tractions of the muscles ; could not there also be such an inhibitory nervous system for the vessels, i. e. nerves, the irritation of which suppresses the tone of the muscles of the vessels, and thereby renders the walls less capable of resisting the pressure of the blood ? The whole theory of the inhibitory nerves is so exceedingly difficult to explain, that even a brief exposition of the probable possibilities of the process would lead us too far. I must therefore content myself with having called attention to the analogous physiological processes. Yirchow and Henle agree in the view that the phenomena of fluxion depend upon paralysis of the vessels, although these learned men differ as to the origination of this paralysis. Generally speaking, the view is becoming more and more predominant that the muscles of the vessels, like those of the heart, are under the influence partly of sympathetic, partly of cerebro-spinal nerves, and that the former cause the rhythmical (automatic) contractions of the vessels, while the latter regulate and obstruct these contractions. Irritation of the sympathetic fibres would increase the contraction of the vessels. Their division would be followed by paralysis of the muscles of the vessels and vascular dilatation, but the latter phenomenon might alsa be caused by irritation of the inhibitory cerebro-spinal nerves. The discovery by Aeby, Eberth, and Auerbach, that the blood capillaries are composed entirely of cells, might give rise to new hypotheses with regard to the irritability of the capillary cells, and their influence upon the dilatation and narrowing of the capillaries^ although even this would not solve the mechanical difficulty which opposes the notion of an active vascular dilatation. In the action of local irritation, and perfectly local dilatation of the vessels, we may adopt one of two theories, either that the irritation disturbs directly IRRITATION DILATATION OF THE VESSELS. 77 the function of the nerves of the vessels^ or of the living cell- substance of the capillary walls, or that this disturbance is due to reflex action. The investigators who have in most recent times paid continuous attention to these subjects^ allow that the protracted capillary dilatation in acute inflammation is dependent upon changes of the capillary walls, which may be the immediate efi'ect of the inflammatory irritation. Cohnheim thinks that the inflammatory irritation alters the walls of the vessels in such a peculiar way that they not only become more yielding to the pressure of the blood, but also softer; to this, however, we shall refer later on. Samuel finds that inflammation essentially consists in alteration of the relations subsisting between the blood, the wall of the vessels and the tissues. It is not at present possible to give a more definite account of the chemical and physical modahties of these changes of the vascular walls which are only known to us by their conse- quences. This theory is so far an advance against Lotze^s view, according to which the molecules of the capillary walls should separate from each other upon their nerve being irritated, as there does not appear, generally speaking, to be any nervous action in producing the capillary dilatations in the acute inflammation under our notice ; this agrees also with the statements of Schiff^ already alluded to, that the vascular dilatations which occur after division of the sympathetic are neither in themselves inflammation, nor do they, as a matter of course, induce inflammation. You have now enough material to ponder over ! No one of all the hypotheses which have been brought forward can lay claim to be a really complete explanation of the phenomenon of fluxion, though many of them may possibly contain the germ which may in time become perfectly developed. The recognition, however, of this truth, the separation of hypothesis from observation, is useful ; it does not obstruct the ever progressive spirit of inquiry, but con- tinually reinvigorates it ! Congratulate yourselves, that it is per- mitted to you and the coming generation to follow up this subject until it becomes perfectly clear. We now leave this question, and in the next lecture shall study the effect of the wound upon the injured tissue itself. 78 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. LECTURE VI. Changes in the tissue duriwj healing hy the first intention. Plastic infiltration. Inflammatory new formation. Development of the cicatrix. Anatomical indications of the process of inflamma- tion. Conditions, under lohich healing hy the first intention does not occur. Union of parts that have been completely separated. The dilatation of the capillaries and the exudation of the serum of the blood, usually accompanying it^ which we have hitherto recognised as the proximate effect of the wound, cannot of course by themselves produce organic union between the two flaps of the wound which are brought into apposition ; changes must take place on the surfaces of the wound, by which the latter become dissolved to some extent and blended into one ; just as you make two ends of sealing-wax soft by heat, in order to fasten them together, so here the substance itself must become the connecting material if there is to be a perfectly firm and intimate union. This is, in truth, the final result of every healing process, both in the soft parts, and in the bones, although at times the course is somewhat circuitous. Let us keep in mind the above diagram and suppose that only connective tissue with vessels has been injured, and that the ques- tion at issue is a reunion of this substance. Connective tissue con- sists, as you know, of cellular elements, and intercellular substance which generally appears fibrous. The cellular elements are partly the stable, y/^i?^^, long-known connective tissue corpuscles, that is, flat, nucleated, cellular bodies with long prolongations, which lie close to the connective tissue bundles, partly, the wandering cells discovered by Yon Reckhnghausen, which are identical in form, species, and vital peculiarities, with white blood cells and lymph cells, probably originate for the most part in the lymphatic glands, pass into the blood through the lymphatic vessels, occasionally PLASTIC INFILTRATION. 7^ wander out of the capillaries and fine veins into the surrounding tissue, there to become fixed tissue cells, or again enter into the lymphatics (as observed by Hering) and blood-vessels, or undergo metamorphoses not yet discovered. If the tissue of the flaps of the wound be examined some hours after the injury, it will be found quite full of wandering cells. These increase enormously from hour to hour, they infiltrate the fibrous tissue already softened by swelling, and even wander across from one flap of the wound to the other. While this is going on, the connective-tissue intercellular substance of the flaps of the wound gradually becomes converted into a homogeneous adhesive substance ; with the increase and accumulation of the cells, the in- tercellular substance perishes, being probably consumed by these cells, so that a time soon comes when the surfaces of the wound in apposition consist almost entirely of cells, which are held together by a very small quantity of intermediate tissue, which subsequently becomes firmer, and at last fibrous. The adhesive substance, which is situated partly in the tissue and its interstices, partly between the flaps of the wound, this organic wound-cement (IFiindJcUt) which sometimes in twenty-four hours holds the flaps of the wound so firmly together that they can be torn asunder only with difficulty, is probably fibrine. In the sketch below (Fig. 3) of the former diagram now further developed, you see in section the wound surfaces now united by newly formed tissue, which once for all we shall term inflammatory nev) formation or primary cellular tissue. Yirchow calls it granu- lation tissue ; Eindfleisch, germ tissue. The inflammatory new for- mation is preceded by a condition in which the still filamentary connective tissue is infiltrated with very numerous wandering cells, a state which may easily again become normal by reason of the atrophy of these cells, or by their wandering back into the vessels. This stage of cellular or plastic infiltration, in which the tissue is firmer to the touch than in serous infiltration, is always present, but in very varying degrees, and in very unequal distances at the edges of the wound, and it is often demonstrable only with the aid of the microscope. The development of inflammatory new forma- tion from the plastic cellular infiltration can always be followed in every specimen of recent wound flaps by making microscopical examination from the normal tissue towards the wound. The injury represents an inflammatory irritation, the effect of 80 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. which, as a rule, scarcely extends beyond the immediate vicinity of the irritated portion, and then very rapidly diminishes. In the vast majority of cases there will be at least a slight layer of coagulated blood between the flaps of the wound ; this extends also somewhat into the interstitial tissue of the flaps. Such a coa- gulum may interfere with the healing, as when from its extent, or other causes, it decomposes, or when it becomes converted into pus ; Fig. 3. Diagram representing the surfaces of the wound united by inflammatory new formation. Plastic infiltration of tissue. New formation of vessels. Magnified 300 — 400. but it may without suppuration become cicatricial tissue and com- pletely blend with the new formation in the flaps of the wound, or it becomes absorbed, having previously assisted in the mechanical adhesion of the wound. One of these two last events must occui for union by the first intention to take place. We shall hereafter describe how this comes to pass, and speak of the changes that tho ^coagulated blood undergoes during this process. INFLAMMATORY NEW FOEMATION. 81 We must now deal with the question, whence come the innu- merable wandering cells that infiltrate all inflamed tissues imme- diately after their irritation, as they do here the tissue of the tiaps of the wound ? Very recently this question has been explained in the following remarkable manner, which ten years ago would have been at once considered as the fancies of a visionary. Cohnheim made the following extraordinary observation : he introduced finely pulverised aniline blue into the lymph-sac of the back of a frog, then irritated the cornea of the animal with caustic and found that a number of wandering cells (lymph-pus cells) containing aniline, gradually collected at the cauterised spot ; hence the conclusion : at an irritated spot white blood-corpuscles wander from the vessels into the tissue ; these white blood-corpuscles form the inflammatory cellular infiltration. After Strieker had first described how, in the nictitating membrane of the frog just removed, he had witnessed the passage of red blood cells through the capillary walls, Cohnheim made the further observation on the mesentery of the living frog, that the white blood-cells wander into the tissue through the walls of the vessels, and he remarked in addition that this occurred to a very great extent in the dilated capillaries and veins when the in- flammation became increased by the drawing out and exposure of the mesentery. Although it afterwards appeared that an English observer, Aug. Waller, had already, many years previously, made similar observations on the mesentery of the toad and the tongue of the frog, yet the works of the German observers, Strieker, von Eeckhnghausen, and Cohnheim were quite independent of his, and to Cohnheim belongs the undivided honour of having correctly recognised the importance of his observations on the inflammatory processes, which he has constantly amplified up to the present time, and of having presented them in a way w^hich will greatly aff'ect and impress all modern pathology. (Fig. 4.) It is difficult for you, gentlemen, to imagine what an extraordi- nary impression these recent observations, which I have put before you now as simple facts, produced upon all histologists, because you are not acquainted with the former point of view from which the origin of inflammatory new formations, and also that of compli- cated organised growths, was regarded. In accordance with earlier observations our ideas on this subject were somewhat as follows. It was assumed, that the cells of the connective tissue, of which only one kind, the fixed, was known, increased greatly by division as a F 82 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. consequence of irritation, and that cellular infiltration thus resulted in acute inflammation. Place yourselves in imagination a few years back, at a time when nothing was known of the vital properties of young cells, of their amoeboid and locomotor actions, and we were only taught to deduce the course of the pathological processes from various stages of the diseased, but perishing tissue, as still in the normal process of development ; you will then readily under- stand that it was concluded without hesitation that the cells lying closely packed together in the inflamed tissue were formed out of Fig. 4. Vein and capillaries, from the mesentery of the frog, which had been exposed for several hours. Red blood-cells in circulation. Lateral position of white blood-cells which are seen wandering into the loose connective tissue of the mesentery. Magnified about 300 diameters. each other. This was, even, a great advance, which was only possible after the overthrow of the theory of eriuivocal generation ; for not long before, the opinion was firmly held that cells and tissue were produced from lymph-fluid, coagulated blood, and coagu- lated fibrine. The first observations on the divisions of cells in consequence of abnormal irritation, were made in England on carti- lage by Eedfern ; these were followed by the observations of Virchow INFLAMMATOET NEW FORMATION. 83 and His upon the inflamed cornea. It was seen in both cases that, after cauterization with nitrate of silver, or after the introduction of a seton, the tissue was filled with young cells ; in the original cells of the tissue, finger-biscuit shaped, then double nuclei, were seen, which were supposed to indicate a division ; young cells were seen lying to- gether in groups, whose origin from the tissue-cells appeared quite certain. Hence arose the idea that inflammation was a process in the tissues, which, directly independent of the vessels, was connected with a rapid luxuriant proliferation of the tissue-cells, with partial soften- ing and disintegration of the intercellular tissue. Yon Eeckling- hausen^s discovery of the two kinds of cells to be found in connective tissue, as well as his discovery of the various movements of the pus-cells, might well raise the question, whether the proHferation of the cells in irritation of the tissue resulted from the fixed or movable connective-tissue corpuscles, but this matter was not dis- cussed. Observations, however, were heaped upon observations, and we are now in the position to consider it in the highest degree pro- bable, that all young cells, which, in the beginning of inflammation we find abnormally in the connective tissue, are wandering white blood-cells. This view is not assented to by all the observers who have lately paid attention to these questions ; there is still a certain inclination in the minds of many to attribute to the stable cells of the connective tissue a share, as formerly supposed, in the acute process of suppuration. Yon Eecklinghausen expresses himself very reservedly on this point ; Strieker adheres to the view, that the stable connective-tissue cells, and those of the cornea, become filled on irritation with new plasma, that they increase by subdivision, and assist in the formation of the pus-cells, without in any way denying the wandering of the white blood-cells. Cohnheim, Key, Eberth, and others, have expressed opinions contrary to the correctness of these observations, or rather, against the correctness of the inter- pretation of the phenomena observed by Strieker. The observations in question are so troublesome, so difiicult, take up so much time, and are so confusing in their interpretation, that one cannot wonder that such apparently simple questions do not admit of a rapid solution. It is evident that in view of the numerous fallacies to which the most distinguished investigators of this interesting subject are exposed, it is only with the greatest circumspection that any gene- rally important propositions can be laid down. With regard to the 84 SIMPLE INCISED WOUNDS OE THE SOFT PARTS. inflammatory changes in connective tissue, so far as my observations^ and critical investigations extend, I may venture to support the account given in the preceding paragraph. As far as regards carti- läge, the views formerly adopted have at present undergone no change. Inasmuch as the hyaline substance of the cartilage pos- sesses no canals through which cells can pass, we can scarcely da otherwise than assume that the increase of the cells in the cartilage cavities, occurring after irritation, is produced by division of the protoplasm of the cartilage cells, preparations of which I will lay before you hereafter. It is true that this hyaline cartilage has not been observed for successive days in a state of life and irritation^ and therefore this observation is of somewhat inferior importance to those on living connective tissue. But there is no such acute sup- puration-process in hyaline cartilage, nor any such purulent infil- tration as occurs in connective tissue. With regard to the con- nective-tissue cells and those of the cornea, I must make this further assertion, that I consider a capacity for renovation and prolifera- tion to be probable, except for those cells of these structures whose protoplasm is metamorphosed up to the nucleus in the tissue, consequently into the stable connective-tissue corpuscles and those of the cornea of such adult animals whose tissues may be com- pared with those of the human species. It has never been dis- puted, that the protoplasm, where it still exists as such in the cells, therefore in the still growing tissues of young individuals, may also as such increase and divide when acted on by certain irritants ; possibly many differences in the views above alluded to may have their origin in the non- observation of these conditions. Similar conditions are apparent in the epithehal structures ; yet it has never- been asserted that tlie cells of the perfect epithelial tissues, the elements of the hair, of the nails, of the horny layer of the epidermis, the most superficial layer of scaly epithelium, can proliferate and be restored by irritation, whereas the continuous increase of the younger elements of these tissues is a physiological necessity for their growth, and cannot be denied. There is here only this difference, that the growth of these epithelial tissues goes on during - the whole of life, whereas the growth of the connective substance only continues up to a certain period of life, and in this latter structure, after the subsidence of growth, no young tissue- elements, with the exception of the wandering cells, are to be discovered. INFLAMMATORY NEW FOEMATION. 85 If there can no longer be any doubt, that by far the greater number of young cells which infiltrate the inflamed tissue, and which, under certain circumstances as we shall afterwards see, escape therefrom in the form of pus, are white blood-cells, or as we express it briefly, wandering cells, we have two questions before us, namely, why do so many cells wander into the inflamed tissue, and how do these often so enormous masses of wandering cells come into the blood, where do they originate ? There are various opinions with regard to the escape of the wandering cells through the walls of the vessels. My own view is as follows : the first change that we see in living tissue in a state of inflammation is dilatation of the vessels, this is immediately followed by increased transudation and accumulation of white blood-cells in the peripheral layer of the calibre of the vessel. The wall of the vessel now gradually becomes softer, through a chemical process in every inflammation whose action is at present unknown, so that the white blood cells by reason of their active movements gradually push themselves into, and finally through, the walls of the vessels. Enlargement of the vessels, lateral position of the white blood cells, and softening of the vascular wall, appear therefore to me to be the necessary requirements for the extensive wandering of the cells. Eecently, Cohnheim and Samuel have expressed similar opinions. Whence come the enormous quantity of white blood-cells, which escape in inflammation, is a question for physiology, and one which can only be answered by that science. Lymphatic glands and the spleen are the organs which first occur to us as possible sources, although it cannot be proved that with this enormous escape of cells there is also necessarily an extensive formation of lymphatic cells, yet this is extremely probable, and as we know from clinical experience that the lymphatic glands, in the neighbourhood of an inflammation, are almost always swollen, it is most natural to suppose that these are the source of the abnormally copious formation of wandering cells. In spite of the most zealous efforts, I have been unable to discover anything certain as to the morphological processes in this cell formation, .although I consider it very probable that the lymph-cells originate by a process of budding in the meshes of the lymph- sinus of the glands. To the above observations I must add one more remark, that during inflammation it not seldom happens that red blood-corpuscles ^Iso escape through the walls of the vessels ; according to Cohnheio^.^s experiments the increased intravascular pressure has a decided 86 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. influence over this process. According to Arnold, not only the red, but also the white blood-cells are especially prone to pass through the vascular walls, at those places where minute intervals (stigmata, stomata,) exist between the cells of the capillaries ; during inflammation it is particularly the connecting substance of these cells of the capillaries which swells and becomes so yielding, that fine currents of blood-serum pass through it, and enter the lymphatic canals of the tissue. Let us now return to our wound, and see what becomes of the tissue infiltrated with cells, of the infiammatory new formation, and how the cicatrix becomes developed therefrom. Whilst, at some distance from the wound, the cell infiltration extends slowly and sluggishly, the cells in the surfaces of the wound which are already loosely adherent, gradually assume a spindle shape, the inter-cellular tissue then becomes firmer, the spindle cells become converted into fixed connective-tissue cells, and the young cicatricial tissue at last assumes more and more the form of the normal fibrous, tendinous, connective tissue. It therefore appears, that the white blood-cells change into fixed connective-tissue cells, though this is still a point in debate, to which I shall subsequently return, for it is quite possible that this regeneration of the connective tissue takes a course of its own in a way at present unknown. Here again we have to encounter questions of various kinds. The newly formed, adhesive interlacing tissue very soon becomes firm, especially in healing by the first intention ; even after twenty-four hours, we find^ as already observed, its inter- cellular substance pretty firmly fibrinous, and the flaps of the wound are more or less infiltrated with this stiff substance ; it is only the early stiffening of the inter-cellular connecting substance, formed of transuded serum, and softened connective tissue, that explains why the union is generally so firm, even on the third day, that the flaps of the wound hold together even without sutures, for without such connective substance, the young cellular tissue could not possibly possess such an amount of coherence. This stiffening connective substance is most probably fibrine, which consists of the transudation arising from the vessels under the influence of the extravasated blood- corpuscles, and possibly also of wandering cells. We have learnt from the excellent experiments of Alexander Schmidt, that most exudations contain the so-called fibrinogenous substance, which by union with the fibrino-plastic substance in the blood and other tissues forms fibrine, as we recognise it in the coagulated state. DEVELOPMENT OF THE CICATRIX. 87 Very definite proportions of fibrinogenous and fibrino-plastic substance are required to form fibrine ; these favourable conditions occur in many inflammatory processes. Schmidt considers it probable that all firm fibrous tissue is produced and maintained by the fibrinogenous substance being precipitated from the blood in a certain manner round the cells, owing to these cells containing fibrino-plastic substance in a firm shape : for this, indeed, we must suppose certain specific actions of the cells, by which it would result that the product of coagulation would, in one place, assume the form of muscular fibres, in another, that of connective tissue. This view is very probable in the case before us, where it appears that fibrous connective tissue gradually forms out of the inter- cellular coagulated fibrine, although the correctness of this view is disputed. There is certainly no great quantity of fibrinous inter- cellular substance in the inflammatory new formation, but there is little doubt that the minute intervals between the cells are filled up by it. A little later, the young cicatricial tissue still appears to consist principally of spindle-cells very tightly pressed together, but then these spindle-cells diminish very greatly, especially by flattening ; many, indeed, perish completely, and there now results a fibrous, thoroughly connective-tissue intercellular substance which is regarded partly as metamorphosed fibrine, partly as the meta- morphosed protoplasm of the spindle-cells ; the cicatricial tissue finally remains stable in this condition. Thiersch, who has recently again minutely investigated the healing of wounds, is of opinion, that the apparently fibrinous intermediate substance is not fibrine, but only metamorphosed connective tissue. I will not deny that there may be a really immediate adhesion, an instantaneous growing together of the softened flaps of the wound, although this would very seldom happen. Some time ago, I caused Dr. Gussenbauer to make a complete series of experiments upon healing by the first intention, with reference to these assertions of Thiersch. He has not been able to confirm the observations of Thiersch, but like Güterbock, who has also been paying attention to this subject, has obtained results which mainly agree with the above description, which is the produce of my own earher studies. What has become of the closed ends of the vessels, while these changes have been gomg on in the tissue ? The coagulated blood in them is absorbed or organized ; the vascular walls send out shoots, which communicate both with the vascular loops in the opposite 88 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. flap of the wound, and with each other. (Fig. 3.) In this way, however, only the union, at first but scanty, of the opposed vascular loops, is accomplished ; these were already formed by the numerous meanderings and windings of the vessels which terminated in loops after the injury. This is not the place to enter into the details of these interesting formations of vascular loops ; their development, however, is not due simply to dilatation, but also essentially to interstitial growth of the walls of the vessels. The original, previously existing vascular connections are thus replaced by a newly-formed vascular network which is at first far more copious. Arnold has recently studied the process of vascular development in the most careful manner, and has seen the growth of the vessels, and the formation of vascular loops, proceed directly under his own observation in the tail of the tadpole. (Eig. 5.) Although the heart and the first vessels of the embryo appear to originate in this way, that, of the collection of cells of the middle germinal layer, destined for that purpose, the peripheral ones go to form the walls of the vessels, the central become blood-cells, yet this method of formation of vessels and blood does not appear to occur in a later stage, at least the most recent observations of Rokitansky and others on this subject, as well as some earlier ones of my own, liave not been generally accepted. According to Arnold''s experiments, the only way in which the vessels are formed in the growing embryo, appears to be by the development of shoots from the sides of the vessels. Formerly, with regard to the formation of the vessels of granulations and also of the vessels in many pathological new formations, I thought that it w^as necessary to assume another kind of vascular growth, namely, a formation of tubes by the apposition of spindle cells, as may be seen in a,ö, c, in Fig. 6 ; this I termed " secondary vascular formation " (as I have apphed the term ^' primary " to the process which occurs in the formation of the heart and vessels in the middle germinal layer) . The formation of shoots I have designated as " tertiary vascular development." However, after the more recent experiments, I willingly admit that the method termed by me ^' secondary vascular formation '' has no probable existence, and that I may have failed to observe the fine strand of plasma (the shoot) and the fine tube, around which a deposit takes place of the spindle cells developed from the young adventitia. I must not, however, omit to mention that Thiersch's more recent experiments 1'IG.=^. Gradual formation of the vessels seen in a, b, and c. Ten hours are sufficient for these changes to take place. After Arnold. Magnified 300 diameters. 90 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. have led him to repeat his former statement which then seemed to me but slightly probable_, that in the inflammatory new formation there existed a fine network of tubes connected with the blood vessels through the stigmata, this network being hmited only by the cells of the tissue, and not by proper walls ; this agrees completely with the more recent observations concerning the condition of the capillaries in inflamed tissues. According to this, there would certainly be blood vessels in this tissue, which are not circular canals, but irregular intercellular passages, possibly sometimes with only spindle cells for their boundaries. Fig. 6 Outlines of vessels from the vitreous body of the embryo of the calf. Arnold. Magnified about 600 diameters. After As a consequence of the restoration of circulation through the young cicatrix, the disturbances of the process caused by the injury now completely subside ; the redness and swelling of the borders of the wound disappear, and in consequence of the numerous vessels. OBSTACLES TO HEALING BY FIRST INTENTION. 91 the cicatrix appears as a fine red stripe. The consolidation of the cicatrix must now take place ; this is produced^ on the one hand, by the partial disappearance of the newly formed vessels, whose walls fall together, and thus become fine solid strands of connective tissue, and, on the other, by the intercellular tissue becoming firmer and containing less water, the cells as above mentioned, either assume the flat form of connective-tissue corpuscles, or disappear ; possibly some of them remain as wandering cells, and find their way back into the lymphatics or blood-vessels. To this condensation and atrophy of the cicatricial tissue its great contractile power is due, by means of which large broad cicatrices may sometimes be reduced to half their original size. It might at the first glance appear to you contradictory that an apparently superfluously large capillary network should be formed in the young cicatrix, to undergo for the most part subsequent obliteration. AVe cannot explain this apparent excess, but there are pretty numerous analogies in embryonic development ; the previous illustration (Fig. 6) will remind you that there is a period in the development of the foetus in which even in the vitreous body a capillary network eiists, which, as you know, disappears, leaving scarcely a trace behind it. In order not to fatigue you with so-called theoretical subjects, I now leave this field for a short time, and before we conclude the subject of healing by first intention as a point fully understood, I shall make a few practical remarks on the causes which may prevent this mode of healing, even when the flaps of the wound are in apposition. Healing by first intention does not take place : 1. When the flaps of the wound are brought together by plaster or sutures, but their tension, that is, their tendency to separate from each other is very great. Under these circumstances the plasters do not keep the wound perfectly closed, the sutures cut their way through the flaps of the wound, perhaps also the circu- lation in the capillaries is impeded by the great tension of the tissue, and thus the wandering of the cells and the development of the inflammatory new formation become disturbed. Only in the clinical wards can you form an idea as to the amount of the tension requisite for healing to go on, and as to the means which we possess for its relief. 2. A further impediment to healing is a large quantity of blood,. 92 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. effused between the flaps of the wound ; this acts, on the one hand, as a foreign body, and on the other, if it becomes decomposed, it /jhecks the healing process by the influence of decomposition. 3. Other foreign bodies, for example, sand, dirt, alkaline urine, isdces, &c., also retard the healing, partly mechanically, partly che- mically. These substances, therefore, must be carefully removed before union of the wound ; in wounds of the urinary bladder from the abdominal walls, it is not usual to attempt to close the skin wound; the urine w^ould force its way into the subcutaneous cellular tissue, there become decomposed, and set ap terrible mischief. 4. Lastly, from a contusion, the effect of which on the flaps of the wound we may have failed to notice, there may have been an extensive disturbance of the circulation and extreme comminution of tissue, which has been followed by partial death of certain parts, or -of the whole surface of the wound. Then, because there is no cell formation in the flaps of the wound, but only wdiere the tissue is 5till living, we can understand that the small shreds of the destroyed tissue lie as dead foreign bodies between the flaps of the wound, and must prevent healing by first -intention. If this mortification of the flaps of the wound, in which, moreover, there may be a temporary fibrinous adhesion, afl^ects only very small particles, it is possible that these may rapidly undergo molecular disintegration, and become absorbed: this mav often occur. When ■treating of contusions, we shall speak more in detail of this mortification of portions of the tissue, and their detachment from the healthy parts. Practical experience in judging wounded surfaces, the result of •many observations, will hereafter enable you in most cases to predict whether healing by first intention is to be expected or not, and you will thereby learn when it may be useful, even in doubtful cases to ^pply dressings to promote this union. You will occasionally hear accounts of remarkable cases, in which parts of the body completely separated have again become united. The fact appears to be perfectly established; I have never had the opportunity of making observations on such cases ; still in quite recent times very trustworthy men have reported that they have seen small portions of skin of the finger or nose, which have been removed by a blow or cut, again unite, after being carefully replaced and fastened on with plaster. formerly on a priori UNION OF PARTS AFTER COMPLETE SEPARATION. 93 grounds, I contended against the possibility of such healing, but must now admit it for theoretical reasons, the movements of the cells permitting us to suppose that the detached portion, if not too great, may very soon become restored to life, by the entrance of wandering cells. The experiments of Thiersch also, have made it extremely probable that the formation of intercellular passages for the blood takes place in the flaps of the wound ; through these passages blood may possibly circulate, though perhaps only slowly, through the portions which have been detached, even after twenty- four hours have elapsed. It is well known that we may success- fully transplant a twig from one tree to another, but the circulation in plants is not by pumping, but the flow of sap takes place only by cellular force; the analogy, therefore, is rather a distant one. It was certainly more remarkable that a cock's spurs could be successfully transplanted into his comb ; but between birds and men the difterence in the formative process is very considerable, and every immediate transfer of observations is inadmissible in practice. When speaking of the cicatrisation of wounds with loss of substance, we shall describe more minutely Reverdin's discovery, that small portions of skin with epidermis can be inserted into granulating surfaces, where they will go on increasing. In his history of plastic operations Zeis has collected all the cases of union of completely separated portions of the body, which medical literature contains. E,osenberger has brought this account down to most recent times, and communicates a number of cases carefully observed by him, in which portioiis of the nose and fingers which had been chopped ofi", again united after having been carefully joined together. He confirms the earlier observations, that the epidermis, and sometimes also, slight superficial layers of the parts to be healed, generally become gangrenous, while the healing- process goes on underneath. 94 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. LECTURE VII. visible to tlie nahecl eye in wounds with loss of substance. — Mimite processes in healing by granulation and suppu- ration. — IPus. — Cicatrisation. — Views as to ^^ inflammation.^^ — Demonstration of preparations illustrative of the healing of wounds. It now remains for us further to inquire what becomes of the wound, if, under the above circumstances, healing by the first intention does not take place. In that case we have an open wound before us, as the flaps gape, and the circumstances are the same as if the gaping wound had not been brought together, or as if a piece had been cut out, as in a wound with loss of substance. If we cover such wounds with some unirritating body, for example, a fold of linen dipped in oil, or with a thin sheet of gutta percha, and examine them daily (this is certainly seldom necessary during the first few days, and may be injurious), we shall find that the following changes occur. In from twenty-four to forty-eight hours, the borders of the wounds are sometimes slightly reddened, somewhat swollen, slightly sensitive to the touch, but they often exhibit no apparent change. Just as in healing by the first intention, these symptoms, even under these circumstances may be very slight, or entirely absent, as in old, relaxed, flabby skin, also in strong skin with thick epidermis. The above-mentioned slight symptoms of inflammation are best seen in the skin of healthy children; a very extensive, and daily increasing redness, swelling and pain of the parts about the wound denote an abnormal course. After the first twenty-four hours the surface of the wound has undergone but little change. All over it you still recognise the tissues pretty distinctly, although they have assumed a peculiar, gelatinous, greyish appearance (from the adherent fibrinous HEALING BY GRANULATION. 95 material) ; besides this, there are yellowish or greyish-red minute particles on the surface of the wound ; these, ou closer examination, will be found to be small, dead fragments of tissue, enclosed in gelatinous fibrine, but still firmly adherent. On the second day, more or less thin, reddish-yellow fluid is seen upon the wound, the tissues appear more uniformly greyish-red and gelatinous, and their boundaries begin to appear indistinct. The third day, the secretion from the wound is pure yellow and somewhat thicker, most of the yellowish, dead particles of tissue escape with the secretion, they become dissolved, and pass off with a portion of the fibrine in the form of small, yellowish, soft granules, and clots; the surface of the wound becomes more even and uniformly red. It becomes clean, as we say technically. If you had not bound up the wound (a stump after amputation, for instance), and had received in a vessel the secretion that escaped, this latter would be found on the first and second day to be bloody, brownish-red, then gelati- nous, dirty, greyish-brown, then dirty yellow ; at the points where the secretion escapes from the wound, fibrine not un- frequently stiffens in drops. If you carefully examine open wounds, or use a lens for this purpose, you will see even on the third day, numerous red granules, scarcely as large as a millet-seed, projecting from the tissue, small granules, granulations, fleshy warts. By the fourth or sixth day these have already become much more deve- loped, and they gradually coalesce into a finely-granular, bright-red surface, the granulating surface; at the same time, the fluid escaping from this surface becomes thicker, of a pure yellowish creamy consistence ; this fluid is pus, and when of the quality here described, it is good pus, pus honum et laudahile of the old authors. There are very many varieties of this normal course ; these chiefly depend upon the nature of the parts injured, and the kind of injury ; if large shreds of tissue on the surface of the wound die, the wound takes much longer to clean, and you may then some- times perceive for several days the white, adherent, dead fragments of tissue upon the surface of the wound, most of which is already granulating. Tendons and fascise are particularly prone to have their circulation so impaired even by simple incised wounds, that they die to an unexpectedly great extent from the cut surfaces, while there is but little death of the loQser cellular tissue and of the muscles. The reason for this undoubtedly is, on the one hand, the 96 SIMPLE INCISED WOUNDS OF TBE SOFT PAETS. deficient vascularity of the tendinous parts, and on the other, their firmness, which is an obstacle to any rapid softening and blending process at the border of the living tissues. The same thing occurs in bones, especially in the cortical substance of long bones, where it often enough happens that a layer of the injured bone perishes, and sometimes requires some weeks for its detachment. Other ob- stacles to active development of granulations are to be found in general constitutional states of the body ; you will see, for example, in very old, or very debilitated persons, or badly nourished children, that granulations would not only be developed very slowly, but also that, when formed, they will look very pale and flabby. Later on, at the close of this chapter, I will give you a short review of those anomahes of granulation which occur in daily experience in large wounds, and are to a certain extent normal, or at least customary. If we now return to the description that has been given of the normally developing granulation surface, you will notice subse- quently as the secretion of pus goes on, that the granulations become more and more elevated, and, sooner or later reach the level of the surface of the skin, and not unfrequently rise above it. With this process of growth, the individual granules become thicker and more confluent, so that they can scarcely be recognised as separate nodules, but the whole surface now assumes a glassy, gelatinous appearance. The granulations sometimes remain for a long time in this condition ; we have then to use various remedies to restrain the proliferating new formation within certain limits requisite for healing ; particularly at the periphery, the granula- tions ought not to project above the level of the skin; for it is there that the process of cicatrisation has to commence. You will now see the following metamorphoses gradually taking place : the entire surface contracts more and more and becomes smaller; on the border between skin and granulations, the secretion of pus dimi- nishes ; first a dry red border, about one millimetre broad, forms and advances towards the centre of the wound, and the more this advances and covers the granulating surface, it is followed by a pale bluish-white border which passes into normal epidermis. These two seams result from the development of epidermis, which advances from the periphery towards the centre ; cicatrisation takes place, the young border of the cicatrix advances perhaps one or two milli- metres daily until it finally covers the whole of the granulating surface. The young cicatrix then looks pretty red, and is thus CIOATEISATION AFTER GRANULATION. 97 sharply defined from the healthy skin ; it is firm to the touch, more so than the cutis, and is still very intimately connected with the subjacent parts. As time goes on, after some months, it gradually becomes paler, softer, more movable, and finally white ; it goes on diminishing in the course of months and years, but often remains whiter than the cutis during the whole of hfe. In consequence of the strong contraction which goes on in the cicatrix towards the centre, the neighbouring portions of skin are often very much drawn together, an effect which is sometimes very welcome, but sometimes very much the reverse, as when, for example, such a cicatrix on the cheek draws down the lower eyelid, and causes ectropion. You can easily understand that a wound and a cicatrix can only contract in all directions when the subjacent parts, as well as the borders, permit elongation ; wounds of bones, and wounds with stiff immovable borders cannot diminish in size by contraction, but only by cicatrisation, and therefore require much longer time for their cure. You will occasionally see it asserted, that the cicatrisation of the granulating surfaces may sometimes proceed from isolated patches of epidermis becoming developed among the granulations. This only holds good of cases where a portion of cutis with rete Mal- pighii has remained in the midst of the wound, as may easily happen, for example, in gangrenous wounds, as the caustic agent may penetrate to very unequal depths. Under such circumstances, epidermis immediately forms from a small portion of remaining papillary layer of the skin, that has any, even the thinnest possible covering of cells of the rete Malpighii ; at these spots there [are then the same conditions as when a blister lias been raised on the skin by cantharides plaster, by which the horny portion of the mucous layer of the cutis is raised by the very rapidly occurring exudation ; no granulations are afterwards formed if you do not continue to irritate the surface, but horny epidermal scales imme- diately develope from the mucous layer. If, however, there be no such remnant of rete Malpighii, we never have these island-like patches of cicatrix, but the formation of epidermis only takes place gradually from the periphery of the wound towards the centre. I am so certain about this, that I think surgeons who assert that they have seen anything different are in some way mistaken. The results of transplantation of portions of the skin with epidermis, as practised by Eeverdin, appear to me at any rate, to be very much G 98 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. in favour of the view that epithelial development takes place only from epithelium. Now that we have considered the external conditions of the wound, the development of the granulations, of the pus, and of the cicatrix, we must turn our attention to the more minute changes by which these external appearances are induced. Our best plan will be again to represent a relatively simple capillary network in the connective tissue, and to join thereto what we are now considering (Fig. i, p. 69). Imagine a crescentic piece to be cut out of it from above ; there will first be bleeding from the vessels, which will be arrested by the formation of clots as far as the next branches. There will then be dilatation of the vessels in the neighbourhood of the wound, though only of brief duration ; this is due partly to increased pressure, partly to fluxion ; an increased transudation of blood serum, consequently an exudation is also here a necessary consequence of the capillary dilatation from the causes above given, the transuded serum also contains some fibrinogenous substance, which, possibly by the influence of the newly formed cells, coagulates to fibrine in the most superficial layers of the tissue, while the serum escapes, mixed with blood plasma. The vascular network would now assume the form shown in Fig. 7, p. 99. It must generally be the case that at the surface of the wound more or fewer particles of the tissue will die, inasmuch as the vascular obstruction must, of course, seriously interfere with the nutrition of tissues but poorly supplied with vessels, and especially where the tissues are stiff the dilatation of the vessels will be impeded ; this superficial necrosis is certainly scarcely visible to the naked eye. Let us assume that the upper layer of the wound, shaded in the diagram, perishes in consequence of the changes in the condi- tions of its circulation. What will now take place in the tissue itself ? Essentially the same changes as in the united flaps of the wound ; wandering of white blood-cells through the walls of the vessels, the collection of masses of these cells in the tissue with the effects previously described, plastic infiltration, and inflammatory new formation. But, inasmuch as there is here no opposing wound surface with which the new tissue can blend, to be then quickly transformed into connective tissue, the cells which have escaped from the vessels at first remain on the surface of the wound ; the exuded fibrinous material on the surface of the wound becomes GRANULATION AND SUPPURATION. 99 soft and gelatinous, at the same time, the cellular infiltrated tissue of the surface of the wound assumes the same peculiarities; the soft connective substance in which the young vessels shortly grow, even if only present in small quantities, holds together the cells of the inflammatory new formation, whose number is constantly increasing. The granulation tissue is thus formed. Granulation tissue is therefore a highly vascular, inflammatory, new formation, a Diagram of a wound with loss of substance. Dilatation of the vessels. Magnified 300 — 400- new formation caused by inflammatory disturbance of nutrition. At first its growth is constant, and is in the direction from the base of the wound towards the surface; the tissue is, however, of diff'erent consistence in the various layers ; its superficial layer particularly is soft, and, in the uppermost strata, of fluid consistence, for here the intercellular substance is not only gelatinou« but fluid, this uppermost thin fluid layer, which is continually escaping and being constantly renewed from the granulation tissue by wandering of the cells, is the pus (see Fig. 8). 100 SIMPLE INCISED WOUNDS OP THE SOFT PARTS. The pus therefore, in this case^ has its origin in the granulation, tissue, and consists of young cells which have wandered from, the granulation vessels and also from the granulation tissue. We sav " the wound secretes the pus/' If we collect pus in a vessel,, and let it remain quiet, it separates into an upper, thin, clear layer, and a lower, yellow one; the former is fluid intercellular substance, the latter contains chiefly pus-corpuscles. These on microscopical examination are found to be round, finely punctated cells, of the size of white blood-corpuscles, with which they are, in fact, identical. But it is to be observed that these cells, as long as they are in the lymph and blood, exhibit, as a rule, only one large nucleus, but after they have escaped from the vessels they become so changed as to contain three to four small dark nuclei, which become particularly distinct on the addition of acetic acid, because it dissolves the pale granules of the protoplasm, or at least swells them so that the cell substance becomes transparent. This is the only morphological difference which is pretty constantly to be found between white blood-cells (which again are identical with lymph-cells) and pus-cells. The nuclei are not soluble in acetic acid. The entire globule is readily dissolved in alkalies. Fig. 8. d Q Pus-cells from fresh pus, Maguilied 400 diams. a. Dead without addition. b. Various forms that the living pus-cells assume in their amoeboid move- ments, c. Pus-cells after the addition of acetic acid. d. Pus -cells after the addition of water. At a we see pus-cells, as they usually appear, when we cover a drop of pus with a thin glass, and examine it under the micro- scope without any addition. The already mentioned observations of von Recklinghausen have shown that only the dead cells hav« this rounded form ; if we observe the pus-cells in the moist chamber PÜS-CELLS GRANULATION TISSUE. 101 on a warmed object table (according to M. Schultze) we get a most beautiful view of the amoeboid movements of these cells. These •movements, which go on only slowly and sluggishly at the tempera- ture of the blood, and by means of which the cells assume the most extraordinary forms [L), become much more rapid at a higher temperature, and, again, more sluggish at a lower one. The number of pus-cells in pus is so great, that in a drop of pure pus under the microscope the fluid intercellular substance is quite imperceptible. Chemical examhiation of pus is difficulty in the first place, because the corpuscles cannot be completely separated from the fluid, also because the pus obtainable in large quantities for chemical examination has usually been in the body for a long time, and may have changed morphologically and chemically ; and lastly, because protein substances chiefly are contained in pus, and it has not hitherto been quite possible to effect their separation. If we let pus from a wound stand in a glass, the clear, bright, yellow- serum becomes sometimes more, sometimes less, in quantity than the thick straw-coloured sediment which contains the pus-corpus- cles. Pus contains from lo to i6 per cent, of fixed constituents, chiefly chloride of sodium ; the ashy constituents are much the same as those of blood serum. Eecent examinations of pus have shown that myosin, paraglobulin, protagon, besides fatty acids, leucin, tyrosin, are constant constituents. In pus collected in the body, acid fermentation does not readily occur; pure fresh pus having an alkaline reaction becomes, however, sour if it is left standing for some time (several weeks) even in a covered glass, and protected from drying up by evaporation. Let us now return to the granulation tissue, where we have still an important part to consider, namely, the numerous vessels to which its red appearance is due. The extensive vascular loops that must form on the surface of the wound, and which in the diagram (Fig. 9, page 102) are much too fine and too few, commence, with the growth of the surrounding granulation tissue, to become more elongated and more and more tortuous ; toward the fourth or fifth day new vessels develope, as in healing by the first intention, in the form of fine, lateral, capillary communications, which may commence here partly as plasma shoots, partly as intercellular passages, and the tissue is soon traversed by an excessive number of vessels ; these have such an essential share in the appearance and thickness of the entire granulation surface, that it is hardly recognisable in the dead 102 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. ' body, where the fulness of the vessels is absent^ or at least, much less marked than during life, and consequently the entire tissue appears pale, relaxed, and much less thick. The question arises, whence come these remarkable, small, gradually confluent, red nodules, which are visible to the naked eye ? Why does not the surface look even ? This, indeed, is frequently enough the case ; the granules are by no means equally clearly defined; the explanation Fig. 9. r "■ A diagram of a granulating wound. Magnified 300—400. of the cause of their shape is, however, not so simple and easy. It is generally assumed that the granules are to be considered as an imitation of the papillae of the cutis, but apart from the fact that it is unintelhgible why such structures should be imitated in muscle and bone and that the granules are usually ten times as large as the cutaneous papilte, this is no real explanation. The appearance of i GRANULATION TISSUE. 103 the granules doubtless dejDends upon the arrangement of the vascular loops into distinct tufts and knots^ and upon certahi boundaries be- tween these separate groups of vessels. We might therefore assume that the vascular loops acquire this form without known cause. But it seems to me natural to compare them to the circumscribed capillary districts already formed in the normal tissues, and which are very numerous, especially in the skin and adipose tissue. You know that every sweat and sebaceous gland, every hair follicle, every fat lobule, has its own, almost closed, capillary network, and by the enlargement of this latter, the peculiar, closed, vascular forms of the granules might arise. In fact, in the cutis and in adipose tissue, you will see the individual fleshy growths particularly sharply and clearly defined, whereas this is less often the case in muscle, where such limited capillary districts do not occur. Whether this explanation is correct, can only be decided by artificial injection of freshly formed granulations, which are still connected with the base from which they have sprung. Till then, my explanation must be regarded as only an attempt to refer this pathological new formation to normal anatomical conditions. The above sketch (Fig. 9), in which^, on account of the great enlargement and small vascular districts which have been depicted, we can only recognise the commencement of the granulations in the small groups of the vascular loops, may serve you as a diagram of the development of the granulation tissue, with the distribution of its vessels, and of its relations to pus and to the subjacent matrix, as it has developed from Fig. 7. If the advancing growth of the granulations were not arrested at some limit, a constantly growing granulation tumour would be the necessary result. Fortunately this never, or at least extremely rarely occurs. You know already from the description of the external conditions, that the granulations as soon as they have reached the level of the skin, sometimes even earlier, cease to grow, become covered with epidermis, and retrograde to a cicatrix. The following changes then take place in the tissue. In the first place, in the granulation tissue, as in the flaps of the wound in healing by the first intention, there are a great number of cells which come to nothing. Not only the millions of pus-cells on the surface, but also cells in the depths of the granulation tissue disappear by disintegration and absorption ; it is very probable that even cells from the granulation tissue may pass back unaltered into 104 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. the vessels, as we shall see later on when treating of the organization of vascular thromboses. '^A^ .; <^h^ FattyMegeneratiün of cells from granulations. Granular cells. Magnified about 500. As the cells retrograde, very minute fat-granules gradually form in them in continually increasing numbers, not only in the round cells, but also in those which have already assumed the spindle form ; such cells, which are composed merely of the finest fat- globules, are generally called granular cells ; they are often found in old granulations. If the granulation tissue is thus diminished by atrophy and escape of the cells, and at the same time the new formation of cells ceases, something else very important must now happen, namely, the gradual consolidation of the gelatinous inter- cellular tissue to striated connective tissue, which is produced by the constantly increasing loss of water carried off by the vessels, and evaporated from the surface ; at the same time, the remaining cells assume the form of ordinary connective-tissue corpuscles. Accord- ing to the opinion of other observers, the original intercellular substance entirely disappears, and its place is taken by the protoplasm of the granulation cells, which become transformed into fibrous tissue. With these changes, which advance from the periphery towards the centre, the secretion of pus on the surface ceases; at the immediate circumference of the wound, on the condensing granulation tissue, epidermis becomes developed, and rapidly separates into a horny and mucous layer ; this formation of epidermis, according to J. Arnold, takes place by the division of a protoplasm, at first entirely amorphous, which is formed in the immediate vicinity of the existing border of epidermis. According to Heiberg, Eberth, P. A. Hoffmann, Schiiller, and Lott, the GRANULATION TISSUE. 105 epidermis grows by the formation of shoots from the epithelial ceLs, which are nearest to the border of the wound. Fig. Epithelial cells of the cornea of the frog sending out shoots at the margin of a wound (a). A few cells detached from such a border. Magnified about 600. After Heiberg. Lastly^ the superfluous capillaries must be obliterated ; only a few of these remain to keep up the circulation through the cicatrix. With their obliteration the tissue becomes drier and more tough^ and contracts more and more^ and thus it is often only some years after that the cicatrix acquires its permanent form and consistence. The whole process, like all these modes of healing, contains much that is remarkable, although its more minute morphological changes have been explained far better than before by recent investigations. The possibility, indeed the necessity, under otherwise normal conditions, of arriving at a certain typical termination is the most essential characteristic of those new formations which are produced by an inflammatory process. If the process of healing does not take this natural course, the reason will be, that either the general constitution or local conditions directly or indirectly interfere ; or because the organ attacked is so important for life, the consequences of the disturbance so severely afi'ect the entire organism, that there is death of the organ, or of the individual, due to this functional disorder. Every new formation, the result of inflammation, has always the tendency to advance to a certain point, to retrograde, 106 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. and to pass into the stationary condition of formed typical tissue, especially to be converted into cicatricial connective tissue ; whilst other new formations have no such natural termination, but generally continue to grow. Different as healing by the first and second intentions appears at the first glance, the morphological changes in the tissues are in both cases the same. You have only to imagine the borders of the wound in Fig. 3 (p. 80) to be separated, in order to obtain the same picture as Yig. 9 (p. 102) : observation teaches in the simplest manner that this is really the case ; if a wound almost healed by first intention, but not yet consolidated, be torn open, we have at once a granulating wound, which soon suppurates. You will often enough be convinced of this hereafter in practice. The above-mentioned processes of healing by immediate adhesion, and by the formation of granulations, have been described as the effect of traumatic iiifla^nmatioit, and we have dwelt upon the fact that the traumatic inflammatory process has this marked pecuHarity, namely, that the irritation in the tissue does not extend beyond the immediate neighbourhood of the injury, unless affected by any further accidental cause. I ask you carefully to bear in mind this very important limitation. Inasmuch as we have no precise knowledge with regard to the chemical changes and the action of the nerves in the inflamed tissue, whereas we are pretty accurately acquainted with the morphological processes, we confine ourselves for the present to these latter when we attempt to define and generalise our idea of " inflammation.^^ I wish for a few moments again to refer to some of our previous observations (p. "]% and 81). " Inflammation" is a modification of the normal physiological processes in the various tissues of the body, a "disorder of nutrition" (Yirchow), the histopoetic results of which you are now acquainted with, and you will subsequently hear of its destructive, deleterious effects. Originally a portion of the body was said to be " inflamed " if it was hot and red ; inasmuch as it was then also usually swollen and painful, this term was employed to indicate those processes which were charac- terised by the presence of the above symptoms in combination. The word " inflammation " had its origin at a time, when, strictly speaking, there were no pathologico-anatomical notions ; the earliest observers imagined that in this process there was something extraordinary going on in the tissues, that violent excitement took VIEWS AS TO INFLAMMATION. 107 place therein, and from the commencement this process has been mainly regarded as an intense exacerbation of the vital changes. But inasmuch as observers were as little able to comprehend it as we are now, they relied in part upon the symptoms which characterised the process, as we do now ; in part upon the results and conse- quences of its action, as novv-a-days; and thus, doubts not unfrequently arose as to whether it was still right to speak of inflammation when this, or that, symptom was absent, or not decidedly pronounced; — this is also the case with us. We know now, at any rate, that inflammation is not a thing which exists outside the body, and which, as such, gets into a part of the body, and there continues to exist, and which must be cast out like Beelzebub ; we have, on the other hand, exact knowledge of the manner in which " Tumor, Eubor, Calor, Dolor ^' are conditions of inflammation; yet, although acute inflammation is generally recognised as such, and correctly designated by every layman, the difficulty still remains just as great, clinically, as well as anatomically, of giving a clear logical definition of the form of disease, known as '' Inflammation." The word " Inflammation ^' is indeed so apposite for designating those processes for which it was at first chosen, that it would cause useless trouble to do away with it. We understand thereby the already minutely-described combination of processes in the tissues, which in our case are due to an irritant, in the first place purely mechanical, and acting once for all (the wound). How much hyperemia, how much exudation, how much fibrinous formation, how many chemical transformations of tissue, what amount of new formation of tissue is necessary, in order that we must designate the process as inflammation, cannot be exactly defined ; in the application of this word, there is much that is arbitrary, and many variations in the use of words. Objections have particularly been raised by surgeons as well as by anatomists, against designating as "inflammatory" the purely regenerative processes, that is to say, the new formations of tissue, which, in consequence of the disorders of nutrition produced by the injury, lead directly or indirectly to the adhesion of wounds, or to reparation of loss of substance, even though it be imperfect. If the process be regarded in a modern histological sense, it cannot well be separated from the inflammatory ones, however slight its extent and intensity may occasionally be. In a purely clinical point of view the distinction is easier to be made, for we certainly meet with numerous 108 SIMPLE INCISED VVOUNDS OF THE SOFT PARTS. cases in which there are none of the often mentioned four cardinal symptoms present in a marked degree at the borders of the wound ; but the difference between a slight redness, swelhng, and sensitiveness of the margins of the wound, and the most intense inflammation advancing over the whole of the injured part, is only one of degree. The use of terms has made another distinction; when a wound heals without any of the so-called symptoms of reaction (inflamma- tion) we do not speak of this as inflammation, but use this expression only where inflammatory symptoms are very prominent in the injured part. I thought it necessary at this stage to make you cognisant of these general considerations with regard to inflammation, the indi- vidual evident factors of which I previously brought before you in the changes of the vessels and tissue, in order that you may accustom yourselves to find your way through the difficulties of the subject. It will always be my endeavour in the course of these lectures, especially to explain to you the anatomico-physiological disorders as clearly as our present knowledge will allow, and at the same time to give you an historical account of the origin of the clinical theories and modes of expression which are now in use. Only in this way is it possible to fathom the nature and origin of our science ; without such knowledge, you will be continually grop- ing your way at the periphery of phenomena, and by confining yourself to single portions, you will fall into narrowness and hopeless dogmatism. Inasmuch as the great majority of men are intensely ignorant of subjects connected with the natural sciences, and seek and see in the physician rather the priest and idol, than the skilled adviser, you are sure to produce great practical results, even with a majestic display of medical ultraraontanism ; but you must then positively relinquish any intention of understanding, or certainly of promoting the development of mankind, a process which is ever advancing, and ever exhibiting greater freedom. It is not the object of these lectures to show you on prepara- tions, step by step, the morphological, microscopical changes of injured tissue ; you will find opportunity for this in the practical work of pathological histology, but I will show you at least a little, so that you may not tliink that the processes which I have described to you can only be demonstrated on diagrams. The cell-infiltration of the tissue after irritation by an incision HEALING OF WOUNDS PEEPAEATTONS. 10^' can be best seen in the cornea. I'our days ago I made an incision lege arils with a lancet-shaped knife in the cornea of a rabbit, and allowed the wound to f^ape for a moment, in order that the irritation might not be too slight; yesterday the incision was visible as a line line with slight milky cloudiness. I killed the animal, cut out the cornea carefully, and let it swell in pyrohgneous acid until this morning ; then I made a fine section through the wound^ and cleared it up with glycerine. ElG. 12. Incision of the cornea three days after the injury, a, a. The uniting substance - between the two sides of the incision. Magnified 300. In the above figure you see the connecting substance between the edges of the wound, in which there has been a considerable accumulation of cells between the lamellae of the cornea, where the corneal corpuscles lie ; these cells are here not so distinctly visible as when coloured by carmine, but the intermediate sub- stance between the edges of the wound is very clearly seen ; this consists almost entirely of cells, which would not, however, be sufiicient to make the union firm, unless they were agglutinated together by a fibrinous cement. The young cells have apparently passed out of the edges of the wound from the fissures between the corneal lamellse, and they probably do not originate in the connec- tive tissue between the margins of the wound; this latter, on the- contrary, is rather formed from them, under their influence. These fine corneal cicatrices, I may remark incidentally, subsequently clear up, so that they disappear, leaving scarcely a trace. The cells 110 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. which you see here in the preparation have probably all come from the vascular loops of the conjunctiva ; they are wandering cells. I must further remark, with regard to this preparation, that I have particularly selected it, because the intermediate substance is broad, and contains very many cells. When very small incisions are made through the cornea with the sharpest knife, the intermediary substance is so slight that it is difficult to see it ; the changes at the borders of the wound are then much less than in this case, and the fine cicatrix is invisible to the naked eye. Incision made through the cheek of a dog, as seen twenty-four hours afterwards. Magnified 300. You. see here (Pig. 13) a transverse section through a recently united incised wound in the cheek of a dog, as it appears twenty-four hours afterwards. The incision is well marked at a a, the edges of the wound are separated by a dark intermediate substance, which consists partly of pale cells, partly of red blood- corpuscles, the latter belong to the blood escaped between the edges of the wound after the injury. The connective- tissue fissures involved in the wound, in which the connective-tissue cells lie, are already filled with numerous young cells, and these cells have already pushed themselves into the extravasated blood between the edges of the wound. This preparation has been treated with HEALING OF WOUNDS — PREPARATIONS. Ill acetic acicl^ and you therefore no longer see the striation of the connective tissue, but the young cells are more distinct. Look particularly at certain strands and lines, rich in cells, that extend from the wound towards both sides {b b b) ; these are blood- vessels, in whose sheath very many cells are infiltrated, which have wandered through the walls of the vessels, or are just in the act of doing so. As to the transformation of the coagulated blood between the borders of the wound, the '' wound thrombus," we shall here- after describe it more fully when treating of cicatrices of the vessels at the end of this chapter. The following preparation (Fig. 14) shows you a young cicatrix nine days after the injury. Fig. 14. Cicatrix nine days after an incision, through the lip of a rabbit, healed by first intention. Magnified 300. The connective substance [a a) between the edges of the wound consists entirely of spindle- cells, closely pressed together, which are most intimately connected with the tissue on both sides of the wound. Fine sections cannot be made of granulation tissue just removed from a wound ; it is generally a difficult object for fine preparations. If, however, it be hardened in alcohol, the section coloured with carmine and then cleared up with glycerine, you have a specimea like Fig. 15, p. 112. The tissue appears to consist only of cells and vessels with very thin walls ; as the whole tissue is shrunken by the alcohol we see nothing 112 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. here of the mucous intercellular substance which is always present^ even if only in small quantities,, in healthy, recent granulations. Fig. 15. mi '#>fSÄÄ->-swjgi '^ 'm- sd m m. ^W Granulation tissue. Magnified 300. The tissue of the young cicatrix is particularly well seen in tlie following preparation (Fig. 16), which was taken out of a broad cicatrix following granulation and suppuration from the back of a dog, four or five weeks after the injury. Young cicatricial tissue. Magnified 300. The preparation has been treated with acetic acid, in order to show distinctly the arrangement of the connective-tissue cells, as they have been formed out of the granulation tissue; a a a are HEALING OF WOUNDS PREPARATIONS. 113 blood-vessels partly obliterated, partly conveying blood ; the con- nective-tissue cells are still relatively large, succulent, and mani- festly spiudle-sliaped, the intercellular substance, however, is richly developed. We must make injections if we wish to study the condition of the blood-vessels in the wound. This is somewhat difficult, and it often depends upon a lucky accident as to how soon we succeed. Tig. 17. ^' 'jM////////'"^'V//'7 ''f^''// X Horizontal incision through a dog's tongue, near the surface, made with a large knife. Front section through the tongue after injection and hardening, forty-eight hours after the injury. Magnified 70—80. After VVywodzoff. a a. Intermediate substance between the edges of the wound, consisting of fibrous-looking adhesive substance and extravasated blood. The section has passed through two layers of muscles cmssing each other. Formation of vascular loops, with dilatation, in both borders of the wound. Commencing elongation of the knots and formation of shoots into the connective substance. 114 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. Tig. i8. Similar section of dog's tongue as in Fig. 17. Cicatrix (a) ten days old. Anastomoses of the vessels from both edges of the wound everywhere visible. Magnified 70 — 80. After Wywodzoff, EiG. 19. Similar section of a dog's tongue as in Fig. 17. Cicatrix (a) sixteen days old. The vessels already considerably reduced and atrophied. Magnified 70— 80. After Wywodzoff. HEALING OF WOUNDS — PREPAEATIONS. 115 On this subject we possess the recent works of "Wywodzoff and Thiersch, whose results in all essential matters agree partly with one another, and partly with those of my investigations on this subject. Wywodzoff, who operated on the tongues of dogs, gives a series of representations of the condition of the blood-vessels in various stages of the healing of wounds ; a few of these I now lay before you without, however, going into the more minute details of the formation of vessels. (Figs. 17 — 21.) Fig. 20. Granulation vessels. Magnified 40. Fig. 21. Wound seven days old in the lip of a doer; liealiug by first intention. Injec- tion of the lymphatic vessels, a. Mucous membrane, b. Young cicatrix. Magnified 20. 116 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. This (Pig. 20) is a preparation, from the human subject, of granu- lations where the vessels were tolerably filled by natural injection ; the vascular loops are very close together and complicated at the surface ; in the deep parts the vessels are all paraUel. In conclusion, here is a preparation of injection of the lymphatic vessels of a dog's lip (Fig. 21). You see that the young cicatrix on the seventh day, when it still consists almost exclusively of cells, has no lymphatic vessels. These cease immediately at the young' cicatrix, where they only commence when the fibrillary connective- tissue bundles form. The granulation tissue also has no lymphatic vessels ; where the inflammatory new formation, where the primary cellular tissue forms, the lymphatic vessels are for the most part closed, partly by fibrinous coagula, partly by new cell-formatioUo These observations have also been confirmed quite recently by Lösch, of St. Petersburg, in his observations on traumatically. inflamed testicles. TRATIMATIO FBVEE. 117 LECTURE VIII. General reaction after injury. — Traumatic fever. — Theories resjoect- ing this fever. — Prognosis. — Treatment of simple injuries, and of the injured. Gentlemen, — You are now acquainted with tlie minutest pro- cesses, both superficial and deep, of the heahng of wounds, so far as it is possible to follow these at the bedside, and also by means of experiments and with the aid of such microscopes as we at present possess. As yet, however, we have not in any way referred to our patients y but if you have at all observed their condition, you will have remarked certain changes which up to the present time we are not altogether able to explain. Probably towards the evening of the first day our patient will become restless and will feel hot ; he will be thirsty and lose his >appetite ; he will have headache ; during the night he will be wakeful, and on the following morning unrefreshed. These sub- jective symptoms become more marked in the course of the following day, and towards evening we feel his pulse ; we find that it is more frequent than normal ; the radial artery is tenser and fuller than before ; the skin is dry and hot, and the temperature, when taken, is found to have risen ; the tongue is rather coated and quickly becomes dry. You will already know what is the matter, the patient has fever. Yes, he has fever. But then what is fever ? What is its cause? What relation have these objective and subjec- tive symptoms — so remarkably difi'erent — to each other? But a truce to your questions ! I can scarcely answer those you have »already propounded. By the word "fever" we understand that oft-described combina- -lion of symptoms which, in some shape or other, is almost always 118 SIMPLE INCISED WOUNDS OF SOFT PARTS. present in inflammatory disease, and which is apparently dependent upon it; we know its exact duration and its course in various diseases, and yet its cause, though better known than formerly, is still not fully understood. The febrile symptoms appear in varying degrees of intensity. Two of these are the most constant, increased frequency of the pulse and a rise in the temperature of the body. Both of them can be measured, the pulse by counting, the temperature by the thermometer. The frequency of the heart's beat may depend on a number of causes, and also on all kinds of mental excitement ; it pre- sents slight differences during sitting, lying, standing, and walking. We must, therefore, attend to a number of circumstances if we would avoid mistakes ; we may infer that mistakes can be avoided by the fact that the frequency of the pulse has for centuries past successfully served for estimating the intensity of fever. Besides this, an exami- nation of the pulse teaches many other things which it is important to know, viz. the quantity of the blood, the tension of the arteries, the irregularity of the heart beat, &c. ; so that even now-a-days the pulse is not to be neglected, although we have other and better means for estimating the amount of fever. The other, and in many respects more accurate, method of estimating the intensity as well as the duration of fever, consists in taking the temperature of the body with a sensitive thermometer, the scale of which is divided, after Celsius, into lOO degrees and each degree into ten parts ; it possesses this advantage also that the measurements, which, as a rule, should be taken at 9 a.m. and at 5 p.m., can be graphically given on a chart, thus allowing them to be easily and quickly perceived and read off. We are indebted to Y. Bärensprung, Traube and Wunderlich for the introduction of this plan into general usage. A series of observations on fever in the normal course of wounds (injuries) gives the following results : traumatic fever sometimes begins immediately after an injury, but more commonly on the second, third, or fourth day. The highest temperature attained, although this is rare, is 104° — 105° F. (40° — 40*5° C); as a rule it does not rise above 101° — 102° F. (38*5° — 39° C.) ; simple traumatic fever does not generally last more than seven days ; in most cases it only lasts two or three to five days, and in many cases it is entirely absent, as for instance in the small superficial incised wounds of which we have already spoken, and even sometimes after large operations such as amputations of the thigh and ovariotomy. EISE OF TEMPEEATÜRE IX INFLAMMATION. 119 Surgical fever generally depends on the condition of the wound; it is essentially of a remitting type, and the decline may take place either rapidly or slowly. If we are to consider surgical fever as a condition of reaction, we shall be led to the inference that the fever will be severe in pro- portion to the extent of an injury. If the injury be very small, there will either be no rise in the temperature, or the increase will be so small and so temporary that it will escape our observation. It might be almost supposed that a scale of injuries could be drawn up according to which the fever would be of longer or shorter duration, and of greater or less intensity, in proportion to the length and depth of the wound. This conclusion, however, even with considerable restrictions, is only approximately correct. Some patients, after very slight injuries, get violent fever ; while others even after extensive injuries have scarcely any. The causes of such differences lie chiefly in the fact that the healing of wounds may go on with more or less inflam- matory action ; the more definite and the more intense the inflamma- lory symptoms around a wound, the higher will he fever ; fever lasts just so long as the rnflamraation conti7iues. However, it does so happen that we can detect nothing about the wound, and yet the patient is feverish ; in such cases it is probable that the inflam- matory processes are deeply seated. It seems, too, as if individual idiosyncrasies, at present unknown to us, exert an influence on the amount and duration of traumatic fever. Before we proceed further to examine what relation the state of the wound bears to the general condition of the patient, we must first briefly refer to this general condition. The most prominent, and physiologically the most remarkable, symptom of fever is the rise in the temperature of the blood, and the consequent elevation of the temperature of the body. On the explanation of these mani- festations hinge all modern theories of fever. There is no ground for beUeving that to the already existing conditions which are con- stantly at work in an organism, for the purpose of maintaining an uniform temperature, any absolutely new ones are superadded during fever; it rather seems probable that a fever- temperature results from a change or modification of those conditions by which the normal temperature is kept up; they are no doubt easily and mutually transmutable. If you only consider that man and animals both maintain an almost identical temperature under the most 120 SIMPLE INCISED WOUNDS OP SOFT PARTS. varying conditions of atmosphere, in summer as in winter, in hot as well as in cold climates, you will easily understand that the condi- tions of heat production and heat radiation are exceedingly variable, and within certain limits may even produce abnormalities in the temperatures resulting therefrom. It is a in'iori clear that an increase of the temperature of the body may result/rowz a diminution of heat radiation under an uniform heat production, just as well as from increased heat prodttction under an uniform heat radiation (other relations of these factors to each other are possible, but I pass them by so as not to confuse you on this difficult question). The final decision of this physiological question does not at present seem possible ; it might perhaps be accomplished by determining and comparing the amount of heat produced during fever and in the normal condition by means of so-called calorimetrical experi- ments either on large warm-blooded animals or on man ; but at present there are many and serious obstacles in the way of such experiments. Liebermeister and Leyden have described methods of calorimetry which appear to me reliable, but I must not conceal the fact that both the methods and the conclusions of Liebermeister and Senator have been energetically contested. In regard to these questions, therefore, we are still too much thrown back on proba- bilities and hypotheses. As the production of heat chiefly depends on the oxidation of the constituents of the body, an increased amount of oxidation will naturally give rise to an increase of the temperature provided that the radiation of the heat remain the same. Now, as the amount of urea found in the urine is considered dependent on the combustion of nitrogenous materials, and since its quantity is generally increased during fever and the weight of the body rapidly decreases, as is known from the experi- ments of 0. Weber, Liebermeister, Schneider and Leyden, it is believed on this account, and as a result of the above-mentioned calorimetrical experiments, that the combustion is increased in fever ; in other words, that more heat is really produced than under normal circumstances, and more than can be utiHsed by the body in the same time. Traube holds other views regarding the production of this fever-heat ; he believes that every fever begins with a vigorous contraction of the vessels of the skin, especially of the smaller arteries, and that thus the radiation of the heat is lessened ; the heat is therefore stored up in the body, but is not produced in greater quantities ; although these views are expounded by the MODE OF OEIGIN OF FEVER HEAT. 121 author with wonderful ability and acuteness and are confirmed by the researches of Senator, I, in common with other pathologists, am unable to accept them, and chiefly because the premisses — the contraction of the cutaneous vessels — can only be applied to those cases which begin with rigors, and a rigor is no necessarily constant symptom of fever. In what follows therefore we shall assume that in fever there is an increased production of heat. As to the chief source of this heat, whether it be in the blood or in the great abdo- minal viscera or in the muscles, we must let physiologists decide. Eor us the question arises. How does the inflammatory process, and here especially traumatic inflammation, affect the temperature of the body ? The question is variously answered. I. At the seat of inflammation heat is produced in consequence of the vigorous tissue changes which are taking place ; the blood passing through this part is thus heated, and then diffuses the abnormal heat so acquired throughout the body. That this part really is hotter than a non-inflamed part is easily proved, especially in inflammations on the surface of the skin ; but it does not prove that more heat is produced — it may perhaps only depend on the fact that more blood is passing through the dilated vessels of the part in a given time ; if the inflamed part is not hotter than the blood which circulates through it, it is not probable that it produces heat. The researches on this point are not numerous, and are somewhat contradictory. The thermometric experiments of O. Weber and Hufschmidt on this point have given varying results ; the temperature of the wound and of the rectum (which is generally that of arterial blood) were mostly alike, some- times the former was higher than the latter, sometimes the reverse ; but the differences were never very great, it was only a matter of a few tenths. 0. Weber invented a new method, the thermo- electric ; by means of some very elaborate experiments the matter seemed quite decided, namely, that the inflamed part was hotter than arterial blood, and that sometimes the venous blood coming from an inflamed part was hotter than the arterial blood flowing towards it. These experiments were repeated in Königsberg by H. Jacobson, M. Bernhardt, and G. Laudien, but .with the final result of showing that no increase of heat was generated in the inflamed part ; more recently Mosengeil has taken the subject in hand, his results on the whole correspond with those of Weber. With such contradictory results before us it seems impossible to 122 SIMPLE INCISED WOUNDS OF SOFT PAETS. come to any conclusion on this point. We may, nevertheless, firmly lay down that in an inflamed part there is not produced so much heat as would appear necessary to raise the temperature of the entire body several degrees in one or two hours. 2. The irritation which is exerted on the nerves in the diseased part by an inflammatory process may be supposed to be conveyed to the vaso-motor (trophic) nerve centres ; the excitation of these centres would cause an increase in the amount of tissue change, and thus an increase of heat. This hypothesis, in favour of which there are some facts, as for instance the varying degrees of (so-called) febrile irritability, is a view I used to support, but seems to me to be no longer tenable ; it is contradicted by the experimental researches of Breuer and Chrobak, who showed that fever might occur even after division of the nerves through which communication could be kept up between the peri- pheral injury and the corresponding nerve centre. 3. Owing to the very nature of the process, the tissues at the seat of the inflammation undergo extensive chemical changes ; it is probable, therefore, that some of the products of these changes find their way into the blood either through the blood-vessels or the lymphatics ; such products may easily give rise to organic decom- position in the blood, as the result of which throughout the entire blood mass an increase in the heat production would result. We might even admit a more complicated theory of heat production through the interposition of the nervous system, and one which in many respects would be more applicable, namely, that the blood, altered by the absorption of inflammatory products, reacts on the vaso- motor centres in such a way that a disturbance in the regulation of the heat supply is produced, and in consequence a rise in the temperature takes place. The choice between these different hypotheses is difficult : each one at present has a certain show of probability. The latter theories have this in common, that a contamination of the blood by products from the diseased or injured part is taken for granted, and that they exercise a certain influence on the heat production, are, in other words, fever-producing materials (pyrogens). This has to be proved. It has been shown by the experiments of 0. Weber, myself, and others, that in most open wounds, especially in contused wounds, shreds of connective tissue decompose and die ; in many spontaneous inflammations the circulation ceases in some parts of the inflamed HEAT PEODUCED BY THE INFLAMMATOET PEODUCTS. 12^ tissues, hence decomposition sets in. Decomposing tissue, then, is an object which must be examined as to its power of setting up inflammatory action. If filtered infusions be injected into the blood of animals, they get violent fever, and not infrequently die with symptoms of collapse, somnolency, and simultaneous hsemorrhagic diarrhoea. The same effect is produced by injecting perfectly fresh pus : a less vigorous effect is produced by employing the juices and pus-serum, which may be squeezed out of an inflamed part : the secretion poured out hy a wound dimng the first forty -eight hours is esjjecially active. It will thus be seen that the products of the chemical decomposition of dead tissues as well as those of tissue changes in inflamed parts, produce pyrexia if they get into the blood. These products are of a very complex and varied nature : some of their elementary constituents are well known to possess pyrogenous attributes : thus by the injection of leucin, sulphuretted hydrogen, sulphide of ammonium, sulphide of carbon, and other products of decomposing tissue, fever may be produced, sometimes even by the simple injection of water. Decomposing vegetable matter also has a similar fever-exciting power. It may he stated therefore that there is no specific fever -jproducer ; hut that the number of fever-producing substances is immense. I will here mention that the stinking products of tissue decomposition are possibly the least noxious. I purposely distinguish the, for the most part, odourless decomposition products of acute inflammations, the poisonous nature of which we have just learnt by direct experiment, from such products of decomposing necrosed tissue as stink from the very first, though their pyrogenous influence may be the same. If a wounded man gets fever I conclude, whether the wound stink or not, that a phlogistic tissue-decomposition is taking place, and that its products have entered his blood. IS^ow that the pyrogenic action of inflammatory and decompo- sition-products has been proved beyond all doubt (you may explain it as you like), it becomes necessary to prove that they can be absorbed by the blood from the tissues, and to show how this takes place. For this purpose some of the before-mentioned mate- rial must be injected into the subcutaneous areolar tissue of an animal, where it can disperse itself among the meshes of the tissue ; the result, as regards fever, is identically the same as though the fluid had been injected directly into the blood; the pyrogenic poison therefore is absorbed from the connective tissue. I must 124 SIMPLE INCISED WOUNDS OP SOPT PARTS. just mention here that after a short time at the place where the injection of putrid fluid or of pus has taken place, there will be violent and often rapidly progressive inflammation. Thus, for instance, I once injected half a fluid ounce of putrid fluid into the leg of a horse : after the lapse of twentj-four hours the affected leg was swollen from top to bottom ; it was hot and painful, and the animal had violent fever : the same result ensued in a dog, into which I in- jected some fresh non-putrid pus : the injection of the secretion of an amputated stump almost always causes gangrenous inflammation. This local inflammation, caused by the action of pus or putrid fluids, I call pJdogogenous. Not all pyrogenic materials are necessarily phlogogenous : some are more so than others ; it depends perhaps whether the poisonous potentialities of the putrid fluids, with the nature of which as yet we are not very well acquainted, are contained in larger or smaller quantities. Whether these pyrogenic matters get into the blood through the lymphatics or whether through the capillaries is not finally settled, though they may diff'er somewhat in these respects. There is much in favour of the view that absorption ■chiefly takes place through the lymphatics. Samuel in his latest work on fever in general agrees with the etiology just given, and teaches that the increased temperature is due to an increased irritation of those nervous centres which preside over heat production. He declares against the acceptance of pyrogenous poisons, and urges much that is remarkable in favour of his views. He is of opinion that the altered condition of the blood, which is the very essence of fever, is always the same, although it is capable of being produced in so many various ways. In order not to allow the abstraction of blood or of water, or the injection of water or of blood, to count as pyrogenic causes in the widest sense, he introduces between the last-named inflammatory products and the nervous centre (which corresponds with the -diseased part) an always uniform putrescent condition of the blood {itio in partes) which is itself the real pyrogenic cause, the very 'essence of fever. We have yet to say something concerning the course of fever produced artificially in animals. The fever commences very early, often in one hour after an injection; after two hours there is always a very considerable rise in the temperature ; for instance, in a dog whose temperature in the rectum was io^*2° T. (39'2° C), I found it rise to 104*2° F. (40':^° C.) in two hours, and to PROGNOSIS AND TREATMENT. 125 105-5° F. (41*4° C.) in four hours, after the injection of pus. It matters httle whether the fluid be injected directly into the blood or into the cellular tissue. The acme of the fever may last from one to twelve hours^ or perhaps longer. Defervescence takes place sometimes by lysis, sometimes by crisis ; if the injections are repeated the fever sets in afresh; by the repeated injections of putrid fluids we can kill even the largest animals in a few days. Whether the animal dies as a result of a single injection depends upon the quantity and virulence of the injected material relatively to the size of the animal. A medium-sized dog after the injection of one gramme of filtered decomposing fluid would fever for a few hours, and after the lapse of another twelve might be perfectly well again. Hence the poison can be eliminated through tissue changes, and the disturbances which its presence in the blood gave rise to can again subside. I will here bring these observations to an end, and express the hope that I have made this very important subject, which will frequently occupy our attention, clear and intelhgible. I am firmly of opinion that wound fever, and inflaymnatory fever generally , chiefly depend upon a poiso7ied condition of the Mood, and that they can be produced by different materials which escape from an inflamed part into the blood. When treating of traumatic diseases we shall again recur to these questions. Now for a few words concerning the prognosis and treatment of suppurating wounds. The prognosis of simple incised wounds of the soft parts depends chiefly on the physiological importance of the injured part both as regards its relation to the rest of the body and the disturbance of the especial function of the part. You can easily conceive that injuries of the medulla oblongata, of the heart, of the large vessels within the great cavities of the body are absolutely fatal. Injuries of the brain and of the spinal cord seldom heal ; they almost always give rise to extensive paralyses, and are fatal through various secondary complications. Injuries of the large nerves produce paralysis of the parts below the seat of injury. Openings into the great cavities of the body are always dangerous wounds, and if an injury of the lung, intestine, liver, spleen, kidney, or bladder be superadded, the danger steadily in- creases ; it may even be said that many of these accidents are abso- lutely fatal. The opening of large joints is an injury which is not 126 SIMPLE INCISED WOUNDS OF SOFT PAETS. only dangerous as regards its function, it is frequently dangerous to life also from its secondary consequences. External circumstances, constitution, and temperament of the patient have also an important influence on the process of healing. Another source of danger lies in accidental diseases, which may affect the wound in its course, and of which, unfortunately, there are many ; of these we shall speak in a future chapter. Por the present you must rest satisfied with these suggestions, the further elucidation of which forms no inconsiderable part of clinical surgery. We can give the treatment of simple incised wounds in a very short space. We have already referred to the union of wounds without loss of substance, and to the proper time for the removal of sutures, and this is about all that we can regard as directly in- fluencing the process of healing. As in all rational therapeutics so here it is most important — (i) to remove all injurious influences which may tend to interfere with the typical course of the process, and (2) to watch carefully for any deviations from the normal standard, and to treat these therapeutically as they arise, if it is at all possible. If we confine ourselves firstly to local treatment, we have no means by which we can materially shorten the process of healing, per primam intentionem, or by granulations, or reduce the time to one half or less. Nevertheless, most wounds require a certain amount of attention, although slight injuries have healed up over and over again without ever having been seen by a surgeon. The first condition for the normal process of healing is ahsolute rest of the injured part, especially if an injury extends through the skin into a muscle. It is necessary, therefore, in cases where the wound is at all deep, that the patient should not only keep his room, but also that for a certain time he should keep his bed, since it is obvious that movement of the injured part, especially if a muscle, will materially interfere with the healing process. The second important condition is keeping the wound and its neighbour- ing parts clean. It has often been observed that it is by no means necessary to cover wounds which have been sewn up. But if it is desired to cover such wounds, either because the edges are red and swollen, or because it affect a part of the body on which the patient lies, or which must be covered with the bedclothes, it may be done in various ways. It used to be done thus : the edges of the wound were smeared with fine oil — almond oil was considered the best — MODE OF DRESSING WOUNDS. 127 and then a pad of lint soaked in oil was laid over it ; this was changed daily until the sutures were removed, or a linen compress from four to six folds thick, soaked in water or lead lotion, was laid over the wound, covered with waterproof^ and fastened on by one or two turns of bandage. For some time past as an immediate covering for all recent wounds I have employed moistened gutta-percha tissue, then on this a wet compress, and over all (in order that it should not become dry) a piece of waterproofing (varnished paper, gutta-percha tissue, or oiled silk) ; and finally a thick layer of cotton wool (which has been boiled with potash in order to get rid of its grease, and to be thus made more absorbent) is laid on and the whole fastened with one or two turns of bandage. Such a dressing can be easily removed without rewet- ting and without giving any pain. For wetting the compresses, and also the fine gutta-percha tissue which is laid next the wound such fluids are used as are capable either of lessening the secretion from the .wound, or of destroying the smell, that is, either antiseptic or deodorising fluids; and which also would destroy all possible infectious materials adhering to the dressings themselves (of which anon). In my own wards the following among other lotions have been in turns used : — solution of chloride of lime (as much lime as the water will dissolve), lead lotion, watery solutions of carbolic acid, carbolate of soda, sulphate of soda (about lo per cent, strong). I have not been able to make out any great difference in the action of these fluids, and on economical grounds I have generally stuck to the solution of chloride of lime. The frequency with which the dressing of a simple wound ought to be changed, entirely depends on the amount of the discharge : as a rule I advise that dressings, made according to the plan just given, should be changed twice a day for the first four days ; or if the discharge comes through the dressing during the first or second day, it ought to be changed immediately. Made in this way it is not now necessary, as it was formerly, to wash the wound or carefully remove a number of strips of charpie to the great dread and discomfort of our patient : if under certain circumstances it become necessary to syringe out a wound — and it is necessary in the case of deep wounds, of which we shall speak presently — we should either use an ordinary brass syringe, or an Esmarch^s wound-douche (irrigator), which con- sists of a cylindrical vessel about ten inches high and five inches across., having a short tap communicating with its lowest part, and to which 128 SIMPLE INCISED WOUNDS OF SOFT PARTS. india-rubber tubing with a nozzle is attached : if an assistant raises this irrigator, it will act as a syringe. It generally suffices, when changing the dressings, to wash the part with a bit of wool : it is not at all necessary that all traces of pus should be removed. In many cases this kind of dressing will answer for weeks : after awhile one dressing per day will suffice, aud later again a dressing every two or three days will be enough: cicatrisation goes on gradually, and the wound closes without any more ado. Quite irre- • spective of certain diseases of the granulations which we shall pre- sently consider, it happens very frequently that under one uniform treatment the healing process will nevertheless come to a standstill, that for days together cicatrisation will cease to go on, while the granulation surface assumes an unhealthy appearance. Under such circumstances it becomes desirable to change the kind of dressing in order to stimulate the granulations anew. Such a temporary arrest in the process of healing is common in almost all large wounds. Under these conditions camomile fomentations may be ordered ; that is, com- presses of several thicknesses, soaked in the hot fomentations and wrung out from time to time, may be laid on the wound, or lead lotion may be applied, or the granulations may be painted with a solution of nitrate of silver (3 — 5 grs. to the ounce). If the wound is not very large, ointment dressings may now be tried : the ointments are spread very thinly on lint or old linen; the most useful are, king's ointment (unguentum basiUcum), which consists of olive oil, wax, resin, suet and turpentine; or an ointment containing nitrate of silver (about 10 grs. to an ounce of any simple ointment, with an addition of a little Peruvian balsam). If the heahng is almost complete, a little zinc ointment may be used, or a bit of cotton wool may be stuck on, and the wound allowed to heal-over beneath the scab. A very peculiar, but in many cases an exceedingly useful, method for promoting the cicatrisation of a wound has been proposed by Reverdin. He discovered that a small bit of skin, cut off from the surface of the body by a fine pair of curved scissors, placed in contact with the granulating surface of a wound, and properly fastened on by adhesive plaster, not only would take root, but also that the transplanted epidermis would grow and become the centre of a cicatrising islet, from which the healing over of the wound proceeded just as it does from its natural edge. We have very frequently made use of this method of transplantation or grafting SKIN-GEAFTIXG. 129 the wound with epidermis in our wards, and seldom, indeed, with- out tlie wished-for result. Such grafts may be recognised by a some- what sunken, drier, reddish area, which forms around them about the third day, when the adhesive plaster is taken off ; these areas gradually increase, and then on the sixth or eighth day present a bluish appearance very similar to that presented by the cicatrising edge of an ordinary wound. I do not in any way under-estimate the practical value of this proceeding, and to me it is especially interest- ing as being an addition to our scientific knowledge. In it we have one of the most striking proofs not only of the self-depend- ence of cell life in the human tissues, but also and especially, of the facility with which the proliferative activity of the epithelium may be set at work (which in disease is due simply to a change in the nutritive materials which are supplied to it), while the papillary layer of the skin-graft does not grow. Thiersch, Minnich, and Menzel have made observations, from which it appears that epi- dermis may be successfully transplanted even eight hours, possibly longer, after death. The minuter details of the histological process of transplantation have been studied not only by Eeverdin, but also, and very carefully, by Amabile and Thiersch. Czerny has proved that buccal mucous membrane with squamous epithelium and nasal mucous membrane with columnar ciliated epithelium can be successfully grafted on wounds, and that these epithelia, though they retain their special character for a short time, yet finally become converted into epidermis. As regards constitutional treatment, we cannot do much with internal remedies to prevent or cut short the secondary fever. The patient should not overload the stomach after an injury, and so long as he is at all feverish he ought to take a slop diet. This he does almost spontaneously, for patients with fever rarely have any appe- tite ; even after cessation of the fever the patient ought not to live high, but should rather take only such nourishment as can be easily digested while he is lying in bed or confined to his room, where he can get no exercise. If the fever run high, and the patient desire something beside water to drink, he can have acidulated waters, such as lemonade or effervescing mixtures. Of ordinary lemonade they soon grow tired, preferring phosphoric or hydro- chloric acid with some fruit-juice in water, or currant vinegar, or water in which apples have been boiled, or toast and water (with a little lemon-peel and sugar) ; some patients prefer almond julep, or I 130 SIMPLE INCISED WOUNDS OF SOFT PAHTS. a fruit ice dissolved in water, or barley water. While leaving sucli matters to the taste of your patients and the housekeeper m great part, you nevertheless will do well just occasionally to give a look to it yourself. The surgeon should be just as au fait in the kitchen and in the cellar as in the dispensary ; it is no disadvantage even to have the reputation of being a gourmet. PROCESS OP HEALING. 131 LECTURE IX. Comhination of healing hy ]i)nmary and hij secondary intention. — Deep wounds. — 0])en treatment of wounds. — Liste/ s method. — Coccobacteria septica. — Union of granulating surfaces. — Healing under a scab. — Diseases of granulations. — Cicatrices in different ■in muscle ; in nerves, and their bulbous dilatation ; in ?, organisation of thrombus. — Arterial collateral circulation. To-day I must first of all add a few words about certain deviations from the ordinary course of the healing process^ which occur so often that one comes to regard them almost as normal, or, at all events, as not very infrequent. It is not uncommon for the two methods of healing, by primary and by secondary intention, to be seen side by side in the same wound. Por instance, a wound is completely brought together, and under certain circumstances you will observe that union by the first intention takes place at some places, while at others, on removing the sutures, the wound will open again, and" only finally and gradually close by granulation. It still more frequently happens that a large and deep wound, if partially or completely brought together, heals on the surface by the first intention, but goes on to suppurate deeper down. The reason why the wound does not heal completely along its entire surface, provided it is healthy and vigorous, lies herein, that either the apposition of its surfaces at the time of the first dressing was incomplete, or that blood or exudation gets in between the well- apposed surfaces ; this exudation does not firmly coagulate so as to hold them together until organic adhesions have formed ; on the contrary, it may decompose and may set up inflammation of the surfaces of the wound, which, under certain circumstances, may rapidly spread and give rise to most dangerous constitutional disturbance. The possible sequelse of such injuries should induce 132 HEALING BY PRIMARY AND BY SECONDARY INTENTION. US to bestow especial attention upon the mechanical conditions of^ and the probable chemical changes in wounds, which either from the first are deep wounds, or are likely subsequently to become such. It is quite clear that in all operations where the skin is incised (in order, for instance, to remove a deeply-seated tumour, or to take away a piece of necrosed bone) a cavity must result, which in cases where the skin is again brought together and sewn up becomes filled either with blood or air, unless, indeed, this can be prevented by completely arresting the haemorrhage, washing the wound, and accurately pressing the walls of the cavity firmly together. Still in wounds of an extremity, for instance, which penetrate the soft parts and reach the bone, the diff"erent layers of muscles alter their relative position to each other, so that the wound cannot be accurately closed. Experience teaches that in such and similar cases extensive wounded surfaces, even if at first they can be brought into accu- rate apposition, are extremely hable to be again separated by subsequent hsemorrhage or fluid exudations, and that such materials shut up in a wound, the external edges of which have become adhe- rent, are very apt to decompose. Meanwhile the region of the wound swells, often becomes painful, and an intense fever sets in. I will not anticipate by a description of the dangerous condition of septic infiltration, or of blood poisoning, what may result from this, but will only add that an early opening up of the wound and «a free exit for the decomposing fluids often sufiice to prevent tSe development of these processes. As to cause and eff'ect in such cas'cs there can be no doubt. Neither is there any doubt that a mere' collection of blood between the tissues is alone unable to set up such dangerous conditions, for simple contusions very fre- quently occur without any such complications at all. Consequently it is the putrid decomposition of the contained blood, and the intensely phlogogenous and pyrogenous attributes of the earliest exudation (p. loi), which create these dangers. In the treatment of deep wounds, therefore, our attention must be chiefly directed to these points, (i) to prevent any accumulation of blood and exu- dations between the edges of a wound; and in case this should not succeed (2) to prevent the decomposition of thesefluids, in order that they remain as harmless in the deep wound, and ulti- mately be as harmlessly absorbed as if the skin were not broken. Since the precautions against decomposition in the depth of a THE HEALING OF DEEP WOUNDS. 13S wound would be unnecessary, if there were neither blood nor extra- vasation to decompose, so it is evident that the most important precaution to take is to prevent auy collection of these fluids; obviously this could be most easily attained if deep wounds were not closed up at all, and if after all bleeding had ceased they were most carefully plugged with charpie, cotton wool, or any similar absorbent material, which should be renewed as often as it became saturated with the secretion from the wound. This method is hundreds of years old, and the results were satisfactory because no other methods were known. Nevertheless, the inflammatory reac- tion in wounds (although very much less than in the middle ages during the irritative treatment of wounds) was very great under this method, as we are now able to appreciate in consequence of im- proved plans of treatment. There happened very frequently progressive inflammations, pro- ceeding from wounds, which were at one time attributed to individual and constitutional causes, and then to the general influences of atmosphere, and especially of hospital air. It is only within the last twenty years that the correctness of the above-given treatment of deep wounds began to be questioned, and fresh methods resulting from different views to be sought after. This led to two entirely opposed plans of treatment ; to the treatment without any dressing (open treatment of wounds) , and to an absolutely air-proof method of closing the wound (method of occlusion). In the open treatment of wounds, which, except in injuries of the extremities, is beset with very great difficulties, the limb is so placed that the secretions from it may easily flow out into some suitable receptacle placed beneath it. The wound secretion during the first two days is dark, blood red^ and thin : during the third and fourth days it becomes light brown, then yellow, and very soon the pus serum will begin to separate from the soHd, flocculent conglomerating pus-cells : this secretion will not begin to smell within the twenty-four hours at the ordinary temperature of the room unless masses of putrid and decayed flesh or necrotic tissue extend into the wound and so convey decomposition directly into it : this absence of odour in the fresh secretion from wounds must strike every one, who from past experience well knows how dressings soaked with discharges stink, which have been left un- changed for about twenty-four hours. The high temperature of the body to which they are exposed is, no doubt, the chief cause of this rapid decomposition. If any one, however, be disiposed a prior? to believe 134 DEAINAGE OF DEEP WOUNDS. that under this ''open treatment" a retention of the discharge, with its evil consequences, is not hkely to take place, he will easily be able on trying this plan to convince himself that the object of the above treatment is not by any means attained by an absolute non-interference or even by a purposeless supervision, and that not only the nature of the wound and its position may materially interfere with the exit of the discharges, but also that separate cavities may be formed within the wounds by local adhesions along its borders, as though a suture had been put in, and that within these spontaneously-formed cavities the retained wound-secretion, having decomposed, may give rise to exactly the same serious troubles as were experenced under older methods of treatment. A great deal may be done at an operation by making the flaps in such a way that the discharges may easily and quickly flow off : this in accidental wounds is not always very easy; it requires a considerable experience. As regards the for- mation of " pockets '^ within large wounds ; we must as much as possible prevent it by daily breaking down all such adhesions or from the very first by putting into all angles and corners drainage tubes, through which any accidentally shut-in secretions may at once get out. (These drainage tubes, first introduced by Cliassaignac, are made of vulcanised india rubber, they are of different sizes, and have holes cut at intervals along their sides. The expression " drainage " is an agricultural term : fields are rendered dry by laying down at a certain depth below the surface a series of porous tiles, into which the water percolates, and through which it is carried off into properly constructed ditches.) The results, obtained as the outcome of a careful and lengthened experience of this method of carrying out the open treatment of wounds, have far excelled all previous ones. I first became aware of this plan of treatment through the observations of Bartscher, Vezin, and Burow, now more than ten years ago : they fully coincided with the views which I had formed as the result of my clinical and experimental observations and researches on the poisonous properties of early wound-exudations, and I have, until quite recently, most carefully carried out this method of treating all deep wounds of the extremities, whether the result of incision or of contusion. But since several of the most esteemed German surgeons have asserted that Lister^s very perfect antiseptic dressing gives stiU more brilliant results, I feel compelled to try the plan, however much I may differ as to the truth of the theories on which the plan of treatment is based. METHODS OF DEESSING DEEP WOUNDS. 135 There can be no doubt that it will be a great advantage to a wounded man, and also a triumph for our art, if we should succeed in making all deep wounds heal by the first intention, without any danger to the patient. In the open treatment of wounds it may certainly happen that the wound-surfaces having been placed in appo- sition heal by the first intention without any further artificial help ; but on the whole it is seldom that this is the case, though partial adhesion is frequent enough, and in the absence of fever and of pain the wound does not require to be reopened. This has been accom- plished either by the application of bandages, in order to press the cut surfaces together, or by sutures,, running deeply through the underlying soft parts, which are thus held together : but although this has succeeded sometimes, it was dangerous in those not uncommon cases where, in spite of the pressure, the surfaces became separated by blood or exudations, and the latter not having any means of escape mostly decomposed ; such dangers caused all conscientious surgeons to desist from this method. And when, a little later on, an effort was made to carry off these fluids by leaving open the corners of a wound and inserting oiled lint it was seldom found to have the desired effect. In my eyes Lister has the especial merit of having shown that all wound secretions are to be let out by inserting a number of drainage tubes into the wound, which are to be cut short on a level with its surface, even if the whole be covered in by an accurately adjusted dressing of absorbent materials and prepared wool. If blocking-up of the drainage tubes by the drying discharges be prevented by placing a bit of gutta- percha tissue (or, according to Lister, of silk protective) imme- diately in contact with the wound, we shall then have combined all the advantages of an open treatment, namely, the rapid discharge of all wound secretion with that of pressure, by means of which the adhesion of extensive raw surfaces with each other is so materially favoured. In order to prevent any of the discharge from decom- posing in the dressings, and lest such decomposition should be conveyed to the mterior of the wound, I think it safest to change the dressing frequently during the first few days, especially where there is much discharge. It is in the technical details, in the great cleanliness which is enforced at the operations, and the systematic rules which are laid down as to the dressings, that I see the great utility of Listeria method. Lister, however, was influenced by enth:ely different ideas in the construction of his 136 GEEM THEORY OF DISEASE. complicated system of dressing ; like myself he has for a long time been convinced that it is almost always a process of putre- faction in the wound itself, which gives rise to dangerous and' constitutional complications. But while I am of opinion that] the putrefaction of the injured and gangrenous tissues and of wound secretions (a special decomposition of albuminoid bodies with the formation of pyrogenous and phlogogenous matters) is a chemical' process, which necessarily results under certain circumstances in these tissues and without the cooperation of any new agencies. Lister, as is well known, accepts Pasteur's view, according to which putrefaction can only be set going through the influence of minute vegetable organisms, just in the same way that fermenta- tion, according to Pasteur's theory, can only be commenced through the influence of the yeast fungus. In connection with the question of animate and inanimate ferments I must refer you, gentlemen, ta organic chemistry; your teachers of this subject must explain to you these interesting and important subjects. In physiology you have become acquainted with the salivary, pancreatic, and gastric- juice ferments, which, although produced by the agency of cell- elements, are not themselves any longer living, and which, without possessing any of the mystic properties of an independent existence, act in a purely chemical manner; and in the same way I believe that a material may be formed during the necrosis of tissue, which to a certain extent may be regarded as the product of the last' vital action of a tissue, which possesses some of the qualities of a ferment, and at the same time acts as a phlogogen, and possibly as an intensely poisonous one as regards the function of the circulating^ blood. It appears to me to be far from proven that the admission of minute organisms (vibriones, Pasteur's bacteria) is absolutely necessary for the production of such a material. That they are' generally found in these fluids is perfectly true, but their presence can be explained by the fact that the germs of these little organisms are everywhere found both in air and water, and that they develops in putrefying fluids with especial ease and celerity. As we must often refer to these small organisms, about the importance of which there is, at present, so much discussion, T will' just give you a short description of such forms as are most frequently found in putrefying tissues and fluids. They are partly the smaller spheroids (micrococcus, /uiKpog, little, and 6 icofcKOCr a germ), partly the smallest rods (bacteria, to ßaKryjpiov, ther COCCO-BACTErxIA SEPTICA. 137 little rod), which are found either isolated or arranged in pairs,, sometimes in chains of four to twenty or more links (streptococcus, Ö (TTpETTTog, a chain, and kukkoq, a germ), often collected together in irregularly rounded and cylindrical masses by a kind of mucoid exudation (coccoglia, kokko^, and i) j\la, or yXoia, jelly). These elements as regards their size are exceedingly variable ; they vary in diameter from the smallest globule which is appreciable with the highest powers of the microscope to the size of a white blood-cell, and are sometimes moving, sometimes stationary. That these minute organisms are not of animal but of vegetable origin, and that they belong to the algee, is now generally recognised, although their systematic classification in botany and their ultimate relation to each other is still under discussion ; neither is their development as yet thoroughly explained, and even in most recent times assertions are not wanting that they result from " generatio sequivoca,'^ or, as it is at present called, " abiogenesis "" (that is, without the partici- pation of any living germ) . As a result of my own researches I am inclined to believe that all the above-mentioned forms belong to a plant which, seeing that it is composed of cocci and bacteria, and that it is generally found in putrefying fluids, I have named cocco-bacteria septica. The process of development of this plant I believe to be as follows : in dry air the dry germs of this plant are found, which, under the microscope, appear as the finest dust; when placed in water they swell and throw out, in greater or less numbers, small transparent globules (micrococci. Fig. 22 a). According to circumstances these take on the following different forms: — (i.) In their development by subdivision they exude a mucoid, tenacious material (gha), by means of which, like frog\s spawn, they are held together in clusters (coccogha or gliococci. Fig. 22 b). This form grows especially often on the surface of fluids as a very light brown tenacious film ; it penetrates also into the interstices of a tissue, and it may be found too in fluids as whitish-grey flocculi ; these varieties are always stationary. Under certain circumstances the glia round about the globules and cylinders becomes thickened into a membrane, and the cocci contents acquire motion and swarm out through a rent in the capsule (ascococcus, aaKog, a sheath). (2.) The individual cocci always subdivide in one direction, and some of them remain bound together by a delicate envelope like frog's spawn (Fig. 22 e}. These streptococci are sometimes moving ones and swim slowlj 138 VAETETIES OF BACTERIA. across tlie field of the microscope; they are, however, mostly stationary ; they are found both in fresh discharge from wounds and in pus also (and frequently in alkaline urine) in great quanti- ties wdthout there being any offensive odour either in the exudation or in the pus. Compared with the single micrococcus and the gliococcus, the streptococcus is that particular variety of the cocco- bacteria which is by far the most often found in decomposing wound- exudations and in the diphtheria of wounds (of which anon). In a state of absolute rest the streptococcus may form long threads running parallel with the surface (a so-called fungus bed [Pilz- raseu] ) ; this, however, in the living subject occurs but very FlCx. 22. Micrococci, Bacteria, &c. seldom, and it is very difficult to manage to see it under the microscope. (3.) The cocci develop into little rods, into bacteria. Each bacterion grows lengtliwise and then subdivides transverselv ; by means of this form of growth chains of bacteria are formed (Fig. 11 f), which also are either still or moving, and may form a fungus-carpet like the streptococcus ; or the subdivision of the bacteria may be complete, so that only single ones, or at most two together (diplobacteria) result, which are sometimes absolutely at rest, but very much more frequently are exceedingly active in their LIFE HISTORY OF BACTERIA. 139 movements. In some kinds of fluid the subdivision of bacteria takes place with great rapidity, and the rods are then much smaller; they, in fact, become almost square; finally, they appear rounded off, so that the differences between cocci and bacteria are characterised by an almost innumerable variety of transition forms. Bacteria thrive badly in wound-exudation, in pus, or stinking blood ; they are formed, however, and remain stationary in all the fluids of the dead body, and in watery infusions of all tissues ; in the latter they are very active in tlieir movements. All these vegetations require water in considerable quantity for their rapid development, and organic substances, especially nitro- genous compounds, for their assimilation; they can bear a partial withdrawal of their water for a short time, but if they are completely dried then they die ; even if they again partially swell out in water they seem to have lost their vegetative activity. They can with- stand a temperature of some degrees below freezing, and one almost at a boiling-point of water without dying, but the heat of boiling water kills them. TJiey can vegetate in fluids and moist tissues, which are completely shut off from atmospheric air until they have used all the air dissolved in these fluids, and then, unless more air is let in, the coccobacteria vegetations die, as they are quite unable to decompose water or any organic combination whatever. Under such circumstances many of these coccobacteria vegetations on the evaporation of fluids, which is very frequent in nature, might get into the atmosphere and hence be conveyed all over; but in dry atmosphere these vegetations dry up, die, decompose, and once again become organic, but now no longer organisable dust. It is provided that this shall not be so. As in the case of many still-water algae which possess the same vital characteristics and are not free from the danger of drying up, so also in single elements of coccobacteria, a quantity of very concentrated protoplasma runs together under certain conditions into a darkly contoured shining globule which by the above-mentioned properties may be easily distinguished from other cocci, if it be possible to distinguish them with certainty from firm fat-globules. These globules possess the properties of fungus spores and very resisting seed granules ; they may be com- pletely dried, exposed to far below zero, or heated over 212° (100° C.) , and shut ofi^ from the atmosphere for any length of time without losing their power of germinating ; on this account they are called " Dauersporen '^ (resting-spores) . They develope according to my 140 lister's method of dressing. observation under definite conditions very certainly and not seldom into bacteria ; nevertheless they sometimes form into masses of cocco- glia. I am unable to say whether single globules of streptococcus ever changed into " Dauersporen." These " Dauersporen " are the dry-air germs with which we commenced; for their development they require a quiet resting place either in or upon a fluid or on a very moist tissue. I have now given you in this short review a sketch of the results at which I have arrived in a morphological sense as the result of my researches on this subject. I must, however, especially mention that a more extensive examination of these obser- vations has not yet been made by botanists, and that I am com- paratively isolated in my views and at variance in them with many- other pathologists, who have earnestly occupied themselves with this subject. Most of them not only believe that each one of the forms described by me is a separate plant, but distinguish many- species of each kind, especially according to the diseases which they cause. I must also call your attention, for the sake of clearness, to the fact that most pathologists regards these algse as fungi, and others call all the above-described varieties shortly " Bacteria.^^ On these minute organisms, then, according to Pasteur and Kisber, putrefaction depends, at least that kind of putrefaction the products of which are both constitutionally and locally poisonous. If we succeed in preventing their admission into wounds and wound secretions, then there will, according to this view, be no more putre- factive decomposition of these secretions, even if some be retained deep down in a wound. Accordingly Lister prescribes a number of rules at an operation, and at subsequent dressings, all of which have for their object the destruction of the germs of bacteria whick may possibly get in either from the hands of the operator or hi& assistants, or from the sponges, instruments, and dressings which he uses, or from the surrounding air, at the time of operation and of each dressing. The operator and his assistants first of all carefully wash their hands with soap and water, and then rinse them thoroughly in a 5 per cent, solution of carbolic acid ; the skin over the part to be operated on is also carefully washed in the same manner and then wetted with the carbolic solution ; all instruments, sponges> and dressings which are to be used are placed in carbolic solution, by which it is supposed that all the coccobacteria germs are destroyed. In order to prevent any such germs getting in from the atmosphere, a 2 per cent, solution of carbolic acid is sprayed, by means ANTISEPTIC METHOD OF DEES SING WOUNDS. 141 of a special apparatus, over the wound, during the operation, and the ajjplication of the necessary dressings ; by means of this " spray '' the air surrounding the wound is carbolised, and the pulverised fluid settles in the form of a very fine and constant rain on the surface of the wound. We have already spoken of the occlusive dressing which, on account of the above-mentioned peculiarities, has received the special name of " antiseptic dressing,^' although the open method of dressing wounds and many other methods are equally antiseptic in their action. It would not be wise in this place to go more into the details, as our scope is the examination of principles. This appa- rently complicated system of Lister can be more easily carried out in practice than would appear from the description ; for the author has definite grounds for each act and rule of the process, and there is nothing either arbitrary or mysterious about it. If we inquire into the practical results of this method of treat- ment we mostly hear it favorably, and by some even enthusiastically spoken of. Although my own experience of Lister^s treatment of wounds is not yet very great, I am, nevertheless, able to recom- mend it on the whole as very practical; it is no doubt capable of more extended use than the open treatment of wounds, but whether the results of the latter in wounds of the extremities are equal to or excel those obtained by Lister's method is still a matter of dis- pute. On the whole, I can most strongly recommend you to exercise yourselves in the principles and practice of Lister^s treat- ment, for by it you will certainly get most favorable results. It is quite another thing, however, when we come to inquire into the correctness of the theoretical views which Lister holds, and to examine whether he accomplishes by this method of operation and of dressing what he strives for ; it has been amply proved that the same forms of coccobacteria are just as frequently found in the secre- tions of those wounds which have been treated after Lister's plan, with brilliant results and without any constitutional disturbance, as in the secretions from wounds treated on the ordinary plan. From this, then, it may be inferred ( i ) that the presence of these organisms in the discharges from wounds does not ijpso facto account for their phlogo- genous and otherwise poisonous properties ; (2) that Lister's method of dressing affords no guarantee for the destruction of the cocco- bacteria germs. On this subject it may no doubt be said, that it is not yet certain that these germs get into a wound oul^ from without ; it is quite possible that they are constantly being taken 142 directly into the blood from the inspired air ; and while under normal conditions they do not develope, yet that they may grow in the discharges from a wound. If this be possible, then the theory of Lister's method, in so far as it chemically deals with germs, no longer holds good. I therefore believe that in all those cases, certainly not very common ones, in which coccobacteria germs have been found in deeply- seated but absolutely closed wounds, which have never communicated with the air, no other explana- tion of their presence is possible than the one I have just given. This variance between the theory and practice of Lister's dressing, apart from the fact that to practise it exactly is very expensive, that carbolic poisoning more or less pronounced is very common, and that it not infrequently causes a dermatitis which is very painful and troublesome to the patient, has led to a constantly decreasing strength of the carbolic solutions, and even to a substitution of other less irritating antiseptics (sahcylic acid, by Thiersch; sulphide of sodium by Minich). Further, many variations in the method of dressing have crept in (Volkman, Bardeleben), the spray has been dis- pensed with and the wound after the completion of the operation has be3n washed out with concentrated antiseptic solution, &c., so that Lister's dressing has already been greatly modified, and yet each modification, it is said, gives as favorable results as the original method. All this tends to confirm me in the opinion I formed, on first hearing of this plan of treatment and its results, and which I expressed at the commencement of these observations. It is this, that the scrupulous cleanliness of and the very careful draining away of all the discharges from the wound are by far the most important factors in the success. Those surgeons more especially think very highly of this procedure, who formerly paid little attention to these points and who, according to old tradition, handed over the subse- quent dressings to the dirty hands of nurses or to careless students ; now every precaution as to cleanliness in each case is care- fully and systematically adopted.. The doctrine, too, of local infection is ever spreading, and is being energetically advocated ; it has directed our attention more and more to the necessity for a rational treatment of wounds, and has done much to pave the w^ay for the open treatment, for Lister's method, and for the introduc- tion of antiseptic applications. Gentlemen, we were led to make these observations on the peculiar conditions of deep wounds by the consideration of different combi- HEALING BT THE THIED INTENTION. 14S nations of healing by the first and by the second intention, and now we revert back again to these slight deviations from the normal course of healing. I must, however_, mention a kind of union of the surfaces of a wound which consists in the adhering together of two well and closely apposed granulating surfaces. This kind of healing, if you like, you may call heahng by the third intention : very seldom does it happen spontaneously. The reason of this is easily understood: the surface of the granulations is constantly secreting pus, and so long as this is the case the two surfaces are only apparently in contact, for between them is a layer of pus. One occasionally succeeds, it is true, in preventing any exten- sive formation of pus by pressing the two granulating surfaces together, and then they may adhere together ; this is best accom- plished either by drawing the edges of a wound firmly together by means of good adhesive plaster, or by the application of deep sutures ; and for this purpose it is well to choose metal ones» Unfortunately, even with these measures, the attempt to bring about a rapid union so seldom succeeds that it is only very excep- tionally employed. The best results are obtained by putting in secondary sutures made of metal ; they should be placed at least half an inch from the edge of the wound, and not applied until the sixth or seventh day, by which time the tissues will have become firmer and harder, and the sutures will therefore cut through less quickly. Lastly, there is another kind of healing, namely, healing of a surface-wound beneath a scab. This is only seen at all frequently in little wounds, which do not secrete much pus, for only in such cases does the pus dry up on the surface of the wound into an adherent scab ; in profuse suppuration the surface of the pus may dry owing to the evaporation of its water, but so long as fresh pus is being constantly poured out beneath, it is impossible to get an adherent scab. If, however, such a scab does form, the granu- lation tissue grows less copiously beneath it, possibly on account of the pressure of the hardening scab, and because it is less moist ; and thus the epidermis beneath the scab is more easily regenerated. A small wound may cicatrise completely before the scab falls off. The surface of the granulations, especially of large wounds, not infrequently assumes a different aspect to the normal appearance. There are certain diseases of granulations the characteristic forms of which I will now briefly sketch, although the varieties are so 144 VARIETIES OF GEANULATIOXS. numerous that you must learn tliem for yourselves from actual observation. The different kinds of granulating surfaces may be classed as follows : (1.) Proliferating fungous granulations. The expression "fungous" conveys nothing more than ^'^ sponge- (fungus) like;'' by fungous granulations we mean such as grow up above the level of the sur- rounding skin and lie over the edges of a wound like a fungus or a sponge. Their consistence is generally very soft, and the pus they secrete is sticky, glairy, and tenacious ; it contains fewer cells than laudable pus, and most of them, as also the granulation-cells, are filled with a quantity of fat-granules and a slimy substance; this latter is present also as an intercellular substance and in greater quantity than normal. These granulation masses also contain a quantity of well-formed mucous tissue (of Yirchow), as first pointed out by Eindfleisch. The formation of vessels may be very abundant, and the delicate tissue often bleeds from the slightest touch ; the granulations are often of a dark bluish colour. In other instances the development of vessels is sparse, often so much so that the surface is of a light rose colour, in places even of yellowish, gelatinous appearance, especially in ansemic persons, often also in children and in very old people. The most frequent cause of the development of such luxuriant granulations is some local impediment to the process of healing ; as for instance induration of the surrounding skin (so that the contraction of the cicatrix is interfered with) or a foreign body at the extremity of a narrow, granulating, fistulous wound. This abnormal proliferation is especially apt to occur in wounds which from their size can only close over slowly. It would appear as if the activity of the tissues sometimes becomes exhausted and no longer capable of producing the necessary condensation and cicatrisation ; hence the granulations are flabby and fungating. So long, then, as the granulations assume the characteristics just described, and overhang the edges of a wound, cicatrisation cannot proceed. The wound probably heals at last, but it is only after a very very long time. We possess abundant remedies for hastening the healing of such wounds ; caustics are especially useful, by means of which we can partially destroy the granulating surface and thereby excite a more vigorous growth from below. Or you may touch the granulations daily with the nitrate of silver stick, especially along the edges of the wounds, over which a white EEETHETIC GßANULATIONS. 145 scab will quickly form, and within twelve to twenty- four hours, or even less, fall off. You must repeat this mild cauterization according to circumstances, until, in fact, the surface of the granu- lations is quite even. Another and very good method is to bestrew the wound with powdered red oxide of mercury (Hydrargyrum oxydatum rubrum) ; this must also be repeated daily in order to improve the granulating surface. Pressure by means of strapping occasionally acts very well. If the granulations be exceedingly large and prominent^ you will succeed most quickly by removing a portion of them with the scissors, or with a sharp spoon; if there be any hsemorrhage it is readily arrested by means of a bandage. (2) Erethetic granulations. — Under this term we refer to such as are characterised by great pain on the slightest touch ; they are generally very prolific, and easily bleed. They are an exceedingly rare variety. In highly marked erethismus of the granulations they are so sensitive that even the slightest touch cannot be borne, and any and every kind of dressing is painful. Minor degrees of sensitiveness are common enough. On what this depends is not very clear, as granulation tissue itself does not contain anv nerves : in most cases handling them causes no pain ; sensation is the result of pressure conveyed from them to the subjacent nerves. In the cases above referred to, of great tenderness the nerves on the floor of the wound have probably degenerated in some peculiar way ; perhaps their finest endings have become thickened en miniature, as we shall pre- sently learn the larger nerve-trunks do. More accurate observations on this subject would be very valuable. We occasionally observe similar conditions in the cicatrices of large nerves ; we shall have to speak of this subject later on. In order to allay this very trouble- some pain, which not only interferes with the healing but also greatly irritates the patients, you must first try mild ointments, such as almond oil or simple ointment (consisting of oil and white wax), or poultices made of boiled oatmeal or linseed-meal, or warm fomenta- tions. Narcotic fomentations or poultices made with the addition of belladonna or hyoscyamus leaves are of no material benefit. If this does not avail, then do not hesitate to apply to the painful places, or even to the entire granulating surface, either caustic (nitrate of silver or caustic potash) or else the actual cautery, having previously given chloroform, or you may scrape off the entire mass of granulation with the sharp spoon. If this great sensitive- K 146 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. ness and irritation be due to hysteria or anaemia, then local means will not be of much avail ; you must endeavour to reduce this irri- tability by internal remedies, such as valerian, asafcetida, iron, warm baths, &c. (3) It further happens in large wounds, and especially also in fistulous granulations, that a membrane will form over some portion of the granulating surface, which may be easily detached, and which on a closer examination is found to consist of pus -cells, extremely adherent to each other. Although I have occasionally found between the cells some areolar filaments, yet this is not always the case, and we must therefore suppose that the cell contents, the protoplasm itself, is transformed into fibrine, as occurs in true croup, and espe- cially in the formation of false membranes on serous surfaces. Here, then, we have to deal with croup of granulations. The croupous membrane is re-formed in a few hours after its removal, and this goes on for several days together, till it either disappears spon- taneously or finally ceases as the result of treatment. Yery similar white spots are sometimes found on large granulating surfaces, which are not the result of fibrinous deposit either on or in them, but are probably due to plugging of local blood-vessels. Under unfavorable circumstances both these conditions may terminate in a destruction of the granulations, as also in true diphtheria of the wound, of which I shall speak later. Tortunately, however, it rarely goes on to this stage, and after awhile the appearance of the sore begins to improve and healing takes place in the usual manner. If such a disease of the granulations is accompanied by swelling, increased pain and feverishness, then we have really to do with an acute inflammation of the wound; the flabby granulation material becomes coagulated into a fibrinous mass, and the surface of the wound looks yellow and greasy. I shall refer to the causes of such secondary inflammations of wounds when treating of contusions later on. It cannot be denied that the entirely local manifestation of fibrinous exudations, both superficial and interstitial, strongly sup- ports the view which Yirchow has enunciated for croupous processes generally. It was formerly held that the blood was over- rich in fibrine in all inflammatory croupous processes, to which the ordinary form of acute inflammation of the lungs and pleura essen- tially belongs ; in consequence of this the increased quantity of fibrine, escaping from the capillaries in a fluid form, coagulated MEMBUAI^OÜS EXUDATIONS ON SURFACE OF WOUNDS. 147 partly on, partly in the substance of, the inflamed tissues, and so led to the formation of these pseudo-membranous deposits. Yir- chow, on the other hand, started the view that the tissues, owing to the inflammatory processes going on within them, acquire the power of coagulating the exuded fibrine with which they are infiltrated. I cannot here more fully enter into the various grounds on which Virchow bases this view, but will content myself by pointing out that in the present case of fibrinous exudation on a granulating surface it cannot b^ a question of a sudden or temporary fibrinous condition of the blood generally, but is evidently the expression of some purely local process, which may be easily stopped by purely local means. According to the already mentioned observations of A. Schmidt we may conclude that under certain forms of irritation the tissues throw out more fibrogenous material than usual. Yirchow had previously pointed out that by long-continued irritation simple serous exudations might become fibrinous or croupous. If cantharides be applied to the skin a blister full of serous exudation is quickly formed, that is, the epidermis is raised from the derma by a rapidly formed serous exudation from below ; now, if this blister be removed and the cantharides reapplied, in many cases the surface becomes covered after a few hours with a fibrinous layer, which will be found to contain innumerable newly formed cells, indeed to be composed of them entirely. The same result may be obtained by applying the blister to an already inflamed surface or to a recent cicatrix. The treatment of croupous inflammation of granulations is purely local ; we should carefully look for any possible source of fresh irritation and endeavour to remove it. Let the false membrane be removed daily and touch the exposed surface with nitrate of silver or paint it with tincture of iodine; under this treatment the abnormal condition of the granulations will soon disappear. (4) Besides the above-mentioned diseases of granulations there is a condition of complete relaxation and collapse in which they present an even, red, smooth, shiny surface, from which the tuber- culated granular appearance has completely disappeared, and from which, instead of pus, there is secreted a thin watery serum. This condition of granulations almost always recurs sub ß nein vitce ; you will constantly find it, as I have already remarked, on the dead subject. It is necessary to add something about cicatrices, as to their 148 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. secondary changes, their proliferation, and their appearance in diiferent tissues. Linear cicatrices of wounds which have healed by the first inten- tion seldom undergo any subsequent degeneration. Large broad cicatrices, if situated immediately on bone, very often open again, because either from traction, a slight blow or abrasion, the epidermis, which at first is very tender, gets torn ofiP, and a superficial sore, an excoriation of the cicatrix, is produced. Sometimes it happens that the young epidermis is raised into a blister by an exudation from the vessels of the cicatrix, into which also shght hsemorrhage may occur, so that the vesicle becomes distended with blood-stained serum. After removal of the bleb there remains an excoriation, as after simple abrasion of the epidermis. This abrasion of the scar, if it recur often, is exceedingly painful to tlie patient. You may best guard against such an accident by advising your patient to protect it either with cotton wadding or with a bandage. But if an exco- riation has occurred treat it with very mild and simple measures, such as sweet oil, glycerine, cerate, zinc ointment, or lead plaster. Stimulating ointments in such cases only enlarge the wounds, and on that account are to be avoided. When the granulating surface is once covered with epidermis, as already stated, a retrogressive change to firm connective tissue takes place, and it atrophies. In rare cases, however, the cicatrix takes on an independent growth and develops into a firm connective-tissue tumour. This only occurs in small wounds, which have suppurated for a long time and become covered with spongy granulations, and over which the epidermis has closed in some exceptional way. You know that it is the custom to pierce the ears of young girls, so that they can wear earrings. This small operation is done with a large needle either by the mother or the goldsmith, and immediately afterwards a small earring is introduced into the puncture. As a rule, the small hole quickly cicatrises, and the ring prevents its closing. In other cases inflammation and suppuration sets in ; the ring may even cut through the lobule in consequence of the long- continued suppuration, fungatiug granulations develop around the points of entrance and exit, and finally the attempt is given up and the ring removed. The openings now usually close immediately ; sometimes the granulations cicatrise and the cicatrix continues to grow, and on each lobe there forms a small connective- tissue tumour —a fibroma (or keloid, from KrjXi^j a stain, and tlEog, like), which FORMATION OF CICATRICES. 149 resembles a thick shirt-button drawn into the orifice of the ear ; as in other tumours,, there is independent growth. If you examine these tumours you will find them perfectly white on section and of a fibrous appearance ; like the cicatrix itself^ they are made up of a connective tissue, rich in cells ; they are, in fact, a proliferation, a hyperplasia of cicatrix. I have frequently observed these changes in the ear, and Dieffenbach also refers to a case in his ^ Operative Surgery/ I have also once seen these tumours in the neck ; they occurred at the orifices of a seton, and each one was as large as a chestnut. They must be carefully removed with the knife, and any subsequent granulations must be checked by the application of nitrate of silver. We have hitherto confined ourselves for the sake of simplicity to a description of the formation of granulations and cicatrices in connec- tive tissue; we must now refer to them as they occur in other tissues. Pig. 23. Cicatrix from the upper lip of a dog ; connective tissue at a ; the divided muscular fibres are for a short distance atrophied, and then terminate conically. Magnified 300. The cicatrix in muscle is at first almost entirely connective tissue ; at the ends of the primitive muscular fibres a degeneration first takes place, then within certain limits the production of cells ; the fibres next become rounded ofi", sometimes club-shaped, more frequently conical, and the extremities of the muscular fibres unite with the connective tissue of the cicatrix, just as they do with the tendons; the cicatrix in the muscle, in fact, becomes an inscriptio tendmea. 150 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Eor my own part, I have only studied wounds of muscle which have healed per primmn, and I have never seen anything which I could regard as a re-formation of muscular fibres. O. Weber has observed in a slight degree a new growth of muscular fibre in suppu- rating muscles ; this seems to occur especially in granulating muscle and in certain forms of tumours. Fig. 24. The extremities of divided muscular bundles from tlie biceps of a rabbit eight days after the operation ; a, b, c, old muscular fibres ; a, the contractile substance rolled up and heaped together ; the same in the fibres above d ; a, b, the same, with the sarcolemma drawn out to a point ; c, a number of young cells passing into the conically shaped sarcolemma, between them there is a delicately striped substance ; d, connective-tissue granulations ; e, the same with young free muscular fibres ; /, two young flattened muscular fibres ; y, ditto of difTerent size and isolated. Magnified 450 times. After 0. Weber. Weber is of opinion that young muscular fibres are principally formed by division of the protoplasmic substance of the extremities of the old muscular fibres, but considers it impossible to prove that muscular fibres may not also be formed from other young cells. As the result of his examination of older muscular scars, he believes that regeneration is constantly going on and that in process of time it becomes more complete than is generally supposed. Maslowsky EEGENEEATION OF MUSCULAR TISSUE. 151 believes in the transformation of wandering cells into muscular cells, but I do not think the results of his experiments with cinnabar are sufficient to prove his point. Gussenbauer has affirmed that a destruction of the contractile substance of the muscular fibres generally takes place after the injury, and that new young muscular elements are developed — on the same plan as in foetal development — almost entirely out of the cells contained within the old muscular fibres ; the amount of the new formation depends on the kind and duration of the irritation. Fig. 25. Tlie process of regeneration in striped muscular fibre after injury. Magnified about 500 times. After Gussenbauer. When a nerve is simply divided the cut extremities, by virtue of their elasticity retract ; they swell slightly, and then by a fresh development of true nerve-tissue they subsequenly reunite, so that the nerve power is again re-established through the cicatrix. In large superficial cicatrices new nerves develop, and even after the excision of portions of skin, the distant parts having been brought together 152 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. and united, new nerves will develop through the cicatrices and after a time complete power of conduction will be again acquired, as may frequently be seen in plastic operations. These facts are most remark- able and physiologically quite inexpHcable. Consider how remarkable it is that the nerve-fibres, motor and sensory, should again become united ; that, as we are bound to suppose, the self- same fibrils should become attached to each other as was the case before the injury, in order that conduction and localisation of sensation be not in'^any way interfered with, such as is really the case ! EiG. 26. Fig. 27. Regeneration of nerves. Fig. 26. — From a rabbit fifteen days after section ; young spindle cells im the nerve-ends, developed from the connective tissue, and ultimately connected with the neurilemma. Fig. 27.— From the frog ten weeks after section. Development of young nerve cells from spindle cells. Multiplied 300. After Hjelt. We cannot go more into details respecting these facts; I will only mention that the minuter processes, which have been most carefully studied by Schiff, Hjelt, and others, are som.ewhat as follows. There is first of all a degeneration of the medullary sheath, possibly also of the axis cylinder, for a certain distance from the injury, which is quickly followed by the production of cells in the neurilemma ; these develop into spindle cells and spread into the tissue which intervenes between the nerve-fibrils, and which extends' also between the cut extremities of the nerves. From these cells, as- EEGENERATION OF NERVE TISSUE. 153 in the embryo, new nerve-fibres are developed ; the fibres, which at first are very pale, are provided with a medullary sheath, and ultimately cannot be distinguished from ordinary nerve-fibres. The most recent researches on the ultimate significance of wan- dering cells in tissue regeneration, as also some original investi- gations on the reproduction of nerve-substance in tadpoles' tails after injury to the nerves, have shaken my former belief that such rege- neration proceeded from the spindle cells. It now seems to me much more probable that the divided axis cylinders grow out into young nerve-fibres; that the long-shaped spindle cells, which are undoubtedly present in the nerve-callus at certain stages of the process, either belong to the connective tissue of the neurilemma, or that they are detached nucleated fragments of young nerve-fila- ments. This view, the correctness of which I have not been able to verify by further experiments, appears to me to be very near the truth. The recent researches of Neumann and Eichhorst corroborate earlier observations as regards the immediate efi'ects of division, but they show that the young nerve-filaments really grow directly from EiG. 28. Nerves of rabbit; a, seventeen days, h, lifty days ; c, frog's nerve thirty days after division. Multiplied about 600 times. After Eichhorst. the axis cylinders of both the central and the peripheral extremities, that they meet and then grow into each other, just as primitive capillaries join with other vessels, and so become channels of com- munication between them (Arnold). The process of repair in 154 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. injured nerves, then, corresponds exactly with that in injured muscles. New young filaments branch out from the extremities of primitive fibres both in muscles and in nerves (fig. 28, a, compare with fig. 25) . Hence, then, it is now certain as regards muscles, vessels, nerves and epithelia, that they are not regenerated from a heaping up of proliferating connective-tissue-cells, nor from wandering cells, but by a budding out of their own tissue, that is, from cells which spring from the protoplasm of their own tissue. It seems possible that connective-tissue-cells also, at least such as still contain proto- plasm, send out offshoots in a similar way to the injured surface, in which nuclei ultimately develop, just as is the case in the growing nerves in the tadpole tails, which only subsequently become nucleated. On this point, however, further investigations are needed. In the mean time we may admit that the wandering cells also serve for the formation of young connective tissue. We have been so strongly predisposed in favour of the formation of tissue from cells ever since Lehmann first taught that newly formed tissue always results from young cells, that the idea of an inde- pendent growth of a finished structure without the aid of cells finds but little favour ; the formation of cells also by means of budding out, with subsequent development of a nucleus in the bud is a pro- cess, vi'hich histologists have long kept in the background and everywhere substituted for it cell subdivision ; botanists, on the contrary, in the development of vegetable tissue, attribute a most important role to this mode of tissue formation. It will be seen from the most recent observations, already referred to, that the walls of the capillaries, the axis-cylinder of nerves, the contents of muscular fibres, really do possess the power of growing out without the direct participation of new cells. Eokitansky has already claimed for the connective tissues the power of independent growth. Seeing the earnest and constant research which is being made in this direction, it will probably not be very long before we arrive at a proper conclusion concerning this point. In man, the regeneration of nerves takes place only within certain limits, which, it is true, cannot be very exactly defined. The com- plete regeneration of large nerve- trunks, such as the sciatic or median, does not take place, nor after excision of portions of a nerve-trunk if the extremities of the nerve be separated to the «xtent of about one centimetre (half an inch). A very accurate REGENERATION OF NERVES. 155 apposition of the ends of the nerve is absolutely necessary for their union^ since the transformation of the newly formed intermediary substance into nerve substance can certainly only take place through the agency of the nerve-extremities, although there may be differences of opinion as to the nature of this process. We shall presently find that similar conditions obtain in the healing of broken bones ; for bony union only results where there is a proper coaptation of the fragments. jSFow^ what is the condition of things in this respect in the tissue of the brain and spinal cord ? In man there is no regeneration after injury or loss of substance in consequence of spontaneous inflammation, or at least not suffi- cient to re-estabHsh function. It is true that, in animals, as Brown- Sequard has demonstrated in pigeons, regeneration with recovery from the paralysis which naturally affected all parts below^ the seat of injury, may follow complete section through the spinal cord, unfortunately this power of repair in nerves decreases in direct ratio with the higher development of vertebrates, and in man is least marked of all. In young salamanders it is well known that whole extremities grow again after having been amputated. It is a pity that this is not the case with man ! Nature, nevertheless, occasionally makes a fruitless attempt at regeneration as regards the nerves. It often happens that the nerve-extremities in a stump, instead of simply cicatrising, develop into club-shaped expansions. These nodules (amputation neuromata) consist of primitive nerve- fibrils all tangled together, which seem to have developed from the nerve-stump as though they were growing towards similar fibres coming from an opposite direction. Cicatrices in the continuity of a nerve sometimes remain knotty, owing to the formation within them of superabundant fibrils which become twisted on themselves. Such like small nerve tumours (true neuromata) are sometimes exceedingly painful, and have to be removed with the knife. There are also traumatic neuromata which are never painful, as I have seen in old amputation stumps. These proliferations of nerve scars are generally compared with hypertrophy of ordinary cicatrices and with growing masses of bone, which, although rarely, are sometimes found in great superabundance in the healing of fractures. The process of healing in the great vessels after injury, especially of arterial trunks, has been carefully and experimentally investigated. When a large artery is ligatured, whether after amputation or on account of injury or disease in its continuity, the tunica intima is 156 SIMPLE INCISED WOUNDS OP THE SOFT PARTS. ruptured when the ligature is drawn tight and the tunica muscu- laris and the adventitia are pressed together, so that their interior surfaces become accurately apposed. It is easy to satisfy yourselves of the frequent, though by no means constant, rupture of the tunica intima by the feeling of gentle crackling or grating which, not seldom, is appreciable to the fingers while in the act of liga- turing large vessels ; you may verify this too on the dead subject by removing the hgature and opening up the artery. Fig. 29. Club-like extremities of nerves in an old amputation stump of the arm. From a preparation in the Museum at Bonn. Copied from Froriep, ' Sur- gical Plates/ vol. i, pi. 113. It is generally believed that the artery becomes plugged with coagulated blood, a so-called thrombus (6 ^pofxßog, a clot of blood) from the point of ligature to the next branch, which is given off both at the central and at the peripheral extremity. The ligature destroys the enclosed tissue, which gradually softens, and when this process is complete the ligature drops off, or, as we tech- nically express it, "the ligature cuts through'^ or "comes away." When this takes place the arterial lumen must of course be perma- nently and securely closed, or otherwise haemorrhage would imme- diately occur. Under unfavorable conditions it sometimes happens FORMATION OF THROMBUS. 157 both in small, in middle-sized and in large arteries that the ligature comes away too soon, and then very dangerous and sudden secondary haemorrhage occurs. This may be expected if the arterial walls are diseased ; it is often quite impossible to ligature calcified arteries, because the ligature either does not occlude the lumen of the vessels or cuts its way through almost immediately. There are also conditions of softening of arteries (as, for instance, when portions of them have been for a long time exposed in an abscess cavity) in which a ligature would probably cut through while in the act of tightening it; in such cases it is of course desirable to apply the ligature at some spot further removed. Unfortunately haemorrhage may occur at the seat of ligature only too often, even in healthy men, as I had reason to experience during the late war ; this is because ligatures, even when apphed according to all rules of the art, sometimes cut their way out through the arteries too quickly, and before the organic plug has become sufficiently solid to successfully withstand the pressure of the oncoming blood wave, an unfortunate circumstance that con- siderably lessens the value of an operation, which is often absolutely essential to life. Let us now take into consideration what takes place in the end of the vessels from the period of coagulation of the blood until when the closure is complete ; experiments on animals and Fig. 30. accidental observations in man have taught us the following facts. The blood-clot, which at first lies loose in the vessel, gradually attaches itself more and more firmly to the wall of the vessel, and at the same time becomes more compact; it, however, remains red for a long time. It is only after weeks or months that it becomes decolorised, and then in the centre first, so that the remainder still retains a light yellowish colour. After the removal of the ligature the thrombus is so hard, and adheres so firmly to the vessel-wall, that its lumen becomes completely closed. This preparation (fig. 30) shows the formation of a thrombus in an artery after lis^ature in its continuity; the lower one. n /• 4.-L • • r XI XT ^ -^^ artery ligatured reaches as tar as the origin of the next branch, ^^ -^^ .? -. the upper one not quite so far. The former condi- Thrombus. tion should, according to most books, be the rule. After Froriep. 158 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. the latter the exception ; but according to m j own experience in the ligature of large arteries, this condition very frequently occurs. The plugging of a vessel by means of a solidifying blood-clot is, however, only a temporary condition, because the thrombus does not remain as such for any length of time ; it becomes converted into cicatricial tissue and atrophies : this takes place in the course of months or years, during which time the closure of the artery has become com- plete at the divided spots by the blending together of its walls. If you examine such an artery some months after its ligature you will see nothing of the clot, but will find that the artery ter- minates in a conical point among the connective tissue of the cicatrix. The changes which we have just sketched can be followed with the naked eye ; they show that the changes which take place in the blood-clot essentially consist in its solidification and in its in- creasing adhesion to the wall of the vessel. Let us now study these changes microscopically. If you examine the recent blood-clot, you find it to consist of red corpuscles, a few colourless corpuscles, and of a fine irregularly arranged fibrillated network, the coagulated fibrine. Take a thrombus from a small or medium-sized artery, two days after ligature you will find it harder than before and more difficult to break up ; the red corpuscles are little altered, the white ones are considerably increased (in number) ; some show two and three nuclei, as usual, others single, pale oval nuclei with nucleoli ; some of these cells are twice the size of a white blood-corpuscle. The fine fibrils of the fibrine are bound up into a firm, almost homo- geneous mass. If you further examine a six days^ old thrombus_, the red blood-corpuscles have almost disappeared ; the fibrine is, if possible, firmer and more homogeneous, and still more difficult to tear ; a large number of spindle cells with oval nuclei are visible. Erom what has been said, it is evident, then, that a number of formative cells early appear in the blood-clot, the further develop- ment of which will be given further on. As a more exact idea of the changes in the thrombus, and of its relation to the arterial wall can be obtained by making transverse sections of thrombosed arteries, let us make use of such for our further studies. The annexed dia- gram (fig. 31) represents a transverse section of a recent thrombus in a small artery. The delicate central mosaic work is formed by the compressed red blood-corpuscles, among which are a few round white blood-cells (which have been rendered visible by staining with OEGANIZATION OF THEOMBUS. 15^ carmine) ; then comes the tunica intim a, which is arranged in regular folds, within which the blood-clot becomes firmly adherent ; then the Fig. 31. Kecent thrombus in transverse section. Magnified 300. tunica muscularis, and lastly the tunica adventitia with a network of elastic fibres^ to which on the right side a little loose connective tissue is attached. Fig. 32. Thrombus six days old. Transverse section. Multiplied 300. This preparation (fig. 32) is the transvers.e section of a thrombosed artery of the sixth day, from the human subject. Here nothing more can be seen of the red blood-corpuscles, but in their place is an ex- ceedingly fine network of fibrils ; the white cells are much increased 160 SIMPLE INCISED WOUNDS OP THE SOFT PARTS. in numbers, and mostly round, while in the tunica adventitia and the surrounding connective tissue the infiltration of cells has already taken place. Fig. 33. Thrombus of ten days ; a^ organized thrombus ; h, tunica intima ; c, tunica muscularis ; d, tunica adventitia. Magnified 300. If we now examine a thrombus ten days old (fig. '^'^ in a large muscular branch of the thigh (after amputation), we shall find a number of spindle cells, some of which will be arranged in loops, which subsequently become vessels; the intercellular substance is markedly fibrillated and rendered transparent by acetic acid. Finally blood-vessels are formed in the thrombus, as may be seen in the following preparations (figs. 34 and 35). According to the researches of O. Weber it is established that the vessels of the thrombus anastomose partly with the thrombosed vessel itself and partly witli its vasa vasorum (fig. 35). The process of healing in veins which have been divided trans- versely at first sight appears much simpler than in the arteries; even the large veins of the extremities collapse when cut across and appear to heal up without further trouble, when the blood has been arrested at the next valve above ; about these valves a coaguluni forms, often more extensively than we desire. Blood-clots extending in the direction of the heart will occupy our earnest attention a little later on. OEGANIZATION OF THROMBUS. 161 I have more recently observed, however, that the intima of a divided vein does not by any means always simply collapse and become adherent; but that a small thin clot is formed, which becomes organized just in the same manner as arterial thrombus. If we may draw any conclusions from the few preparations which I have here demonstrated, it results that a cell infiltration takes place into the coagulated blood-clot, which leads on to the develop- ment of connective tissue ; in short, the thrombus becomes organ- ized. The thrombus however is not a permanent structure; it Fig. 34. Completely organized thrombus in the posterior tibial artery of man; a, thrombus with vessels blended with the innermost layer of the intima; h, lamellae of the tunica intima ; c^ tunica muscularis traversed by a number of connective tissue and clastic fibres ; d, tunica adventitia. Magnified 300. After Rindfleisch. disappears gradually, or rather is reduced to a minimum, a state it shares with many other new formations, the results of in- flammation. There are special reasons which induce me to investigate a little L 162 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. more thoroughly the organization of thrombus. The importance of this process is very extensive^ and one which you can hardly appre- ciate at present ; but later on, when we come to consider diseases of vessels, and new growths generally, you will then be better able to appreciate it fully. I do not think as the result of my investigations up to the present time, that I am in a position to withdraw the statement, that coagulated fibrine may be converted into an intercellular ^iG. 35- ha ah Longitudinal section of the ligatured extremity of the femoi:al artery of a dog fifty days after the operation. Thrombus injected ; a a, tunica intima and media ; h b, tunica adventitia. Magnified 40. After 0. Weber. connective tissue by the aid of cells^ although I must needs leave it undecided, whether it be the result of a true metamorphosis, or of a gradual substitution of nucleated protoplasm for the shrinking fibrine. The attempt has often been made to attribute the origin of the constantly increasing number of cells in the thrombus to OEGANIZATION OP THEOMBUS. 163 the arterial wall; the arteries, like the veins, are lined by an internal epithelial coat, which to some extent represents the innermost layer of the tunica intima. These epithelial cells, and also the nuclei of the striped lamellae of the intima have been claimed by some authors as the natural source of the new cells ; which thence grow into the thrombus. Thiersch has Fig. 36. d Portion of transverse section of the femoral vein of man, with an organised vascular thrombus, eighteen days after amputation of the thigh ; a a, tunica intima; hb, media; c c, adventitia; d d, surrounding connective tissue; Th, organized thrombus with vessels ; the layers of fibrine in the peripheral portions of the thrombus are still distinctly appreciable. Magnified 100. accepted this view in his most recent work. I must admit, that formerly I was much opposed to the acceptance of this doctrine, that the' blood could organize out of itself connective tissue with blood-vessels ; but now, as the result of the study of transverse sec- tions of thrombosed arteries I am inclined to accept the view. 164 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Since the proliferation of fixed tissue cells in inflammation has become somewhat doubtful, we may also doubt the proliferating power of the arterial endothelium. But then, whence come the young cells ? I do not doubt that many of them are white blood- cells, which, in part, were shut up in the clot, and in part wandered into it, as was shown by the observations of v. Recklinghausen and Bubnoif. As regards the red blood cells, it appears that they gradually unite with the exuded fibrine, change their form, and then become intercellular substance : they next lose their colouring matter, which becomes separated as granules or crystals of hsema- toidin. Little as we know in general whence blood cells come, and whither they go, it is no longer doubtful that these white cells get into the blood from the lymphatic vessels, and that they are formed in the lymph glands as well perhaps as in the connective tissue elsewhere. Hence they are cells, which originate directly from connective tissue cells or from masses of protoplasm related to con- nective tissue. Now are these cells, when enclosed in a blood-clot, still alive ? Can they, when arrested here, convert themselves into tissue? It is for the present quite impossible either to affirm or deny this point absolutely. Since Bubnoff has shown that wandering cells penetrate into a thrombus and may continue to move about in it, it is no longer possible to argue that the white blood- cells (with which the wandering cells are identical), contained in the original thrombus, cannot also move about, and become converted into tissue. But whether wandering cells can pene- trate the arterial walls as easily as the walls of veins must for a time remain undecided, for BubnofF's experiments only relate to venous thrombi. Some of my investigations on this subject have convinced me that fine granules of cinnabar do pass through the walls of the carotid artery (for instance) of a dog, into the thrombus, but I have not been able to convince myself that these granules were conveyed by the wandering cells. Tor the present therefore it remains undecided where the numerous wandering cells in an organizing blood-clot originate, and how they arrive there. Tschausoff, in a recently published work, has drawn attention to the fact that a large proportion of the larger thrombi disintegrate, which is quite true ; he however goes too far in denying the provi- sional organization of the thrombus, and in attributing directly to the disintegration of the coagulum the adhesion of the walls of the vessel, a result which, as the termination of the whole process, I ORGANIZATION OF THROMBUS. 165 have all the while had in view. Some recent investigations on the formation of vessels by Arnokl, as also some observations on tubercle to which we shall hereafter refer, furnish us with new material in support of the view, that the wall of the vessel itself and its lining endothelium are chicflj concerned in this tissue formation ; and in a still more recent work, Uiedel has almost conclusively shown that the greater part of the young tissue which is formed in the thrombus, proceeds from the endothelium. Thus the views on this point have vacillated for years past. As already remarked, peculiarly favorable conditions of nutrition are necessary for the blood-clot to become organized. It is an absolute law in the human organism, that non-vascular tissues, which are nourished by cell-product alone, have no great extent ; look at the articular cartilages, the cornea, the tunica intima of the vessels, all these tissues consist of thin layers : in other words, the cells of the human body, unlike vegetable cells, are unable to carry the nutritive fluids to an unlimited distance ; they can convey them only in a limited manner, and at certain distances new vessels must be formed in order to convey and carry off these fluids. A blood-clot consisting of cells and coagulated fibrine, is at first a non- vascular cell-structure, which can only maintain its existence when in thin layers. This will be gathered from observations to which we shall frequently have occasion to refer ; namely, that large clots either are not organised at all, or only organised in their peripheral layers, while the central parts disintegrate. It is manifest there- fore that in healing by the first intention a thin layer of blood between the edges of the wound does no harm, but that a larger quantity of blood interferes with healing, and possibly prevents it altogether, a fact which you can often enough verify in the wards. The doctrine of the formation and organization of thrombus has seriously occupied surgeons and anatomists since John Hunter, and even now is not by any means to be regarded as settled. AYe have had to discuss this doctrine here, if only on account of its general histiogenetic interest, though in recent times it has become very doubtful, whether it has such an important bearing on the results of ligature, as has hitherto been ascribed to it. Porta some time ago pointed out that the early closing up and healing of the tissue surrounding an artery were as important as the organization of the thrombus itself. Surgeons too have always kept this point in view, and have insisted on the necessity of trying to secure healing by the 166 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. first intention by a careful operation and by careful after treatment. It has now become quite evident through the extensive practical results of acupressure, that the infiltration of the tissues by the coagulation of organizable lymph even after forty-eight hours suffices to hold the compressed or twisted ends of the arteries quite firmly, even such arteries as the femoral ; though Kocher has shown that the thrombus in an artery after acupressure is not absent, yet it is often so small that it could not possibly withstand the force of the blood current in a large artery forty-eight hours after closure. Let us now turn our attention to the condition of the circulation after ligature of one of the larger arteries in its continuity. Suppose, on account of haemorrhage in the leg, that we have had to tie the femoral artery ; how does arterial blood get into this leg ? how will the circulation be re-established ? In the same way as after Fig. 37. Fig. Fig. 37.— Carotid artery of a rabbit injected six weeks after ligature. After Porta. Fig. 38. — Carotid artery of a goat injected thirty-five months after ligature. After Porta. closure of certain capillary districts, the blood, in consequence of increased pressure, presses through the nearest open vessels, and these in consequence dilate; and so too after closure of the ESTABLISHMENT OF COLLATERAL CIRCULATION. 167 smaller and medium sized arteries. The blood, under increased pressure, streams through the branches next above the thrombus, and thanks to the free anastomosis both in the long and transverse axes of the limb, it thus reaches other arteries, through which it quickly arrives at the peripheral extremity of the ligatured vessel. An arterial collateral circulation is, in fact, established through the branches of the hgatured artery. Without such an occurrence, Fig. 39. Femoral artery of a large dog injected three months after ligature. After Porta. the part of the body below this point would not receive any more blood and would die ; it would either dry up or slough. The arterial anastomoses are fortunately so plentiful, that even after ligature of large trunks, such as the axillary or femoral, this condition seldom happens ; with diseased arteries, nevertheless, which do not readily dilate, gangrene of the corresponding limb may occur after ligature of the main vessels. The way in which these new arterial anasto- 168 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. moses form varies greatly. Years ago Porta instituted some very important investigations on this point, and as the results of his numerous experiments gave the following as the chief types of collateral circulation : (i). Direct collateral circulation, that is, some well- developed vessels spring up which convey the blood directly from the central to the peripheral extremity of the artery. These connecting vessels are, for the most part, dilated vasa vasorum and the vessels of the thrombus; it might even happen that one of these connecting vessels might so dilate as to appear like the main trunk regenerated. (2). Indirect collateral circulation, that is, the anastomoses between the next largest branches of the main vessel become much developed, as in the case from which this drawing was taken (fig. 39). The most typical examples of these two varieties of collateral circu- lation have of course been chosen ; for if you examine the numerous drawings in Porta's book, or if you repeat an experiment for your- selves, you will find that these two varieties are generally combined ; the division possesses, therefore, no other worth than that of con- venience. It is an excellent anatomical exercise to picture to your- selves how, after ligature of the different arterial trunks of one or other of the extremities of the trunk, the blood arrives at the parts beyond the ligature ; you will find the plates of arterial anastomosis in Krause^s ' Handbook of Anatomy ' of great service to you. These anatomical relations are also thoroughly exhausted in Conrad Martin LangenbecFs work on ' Surgery ' in the chapter on aneu- rism. The reversed blood current, which not unfrequently takes place in these collateral circulations, occurs with marvellous rapidity if the anastomoses are free ; thus, if the common carotid artery in a man be ligatured and the artery be divided peripherally, the blood will stream out of the peripheral extremity with immense force, that is backwards, as if from a vein. In all such cases, when an anas- tomosis of an artery which has to be ligatured is free, we must apply a ligature both to the central and to the peripheral end if a portion of the artery has to be cut out, or otherwise we shall certainly get hsemorrhage. This is an important rule, and one which is often neglected in practice. LECTURE X. CHAPTER IL ON SOME PECULIARITIES OF PUNCTURED WOUNDS. Punctured wounds, as a rule, heal quichly joer priman. Needle pricks ; needles remaining in the hody, their extraction. Punc- turedioounds of nerves. Punctured wounds of arteries. Aneu- risnij traumatic, varicose, aneurismal varix. Punctured wounds of veins. Bleeding. Most punctured wounds are simple wounds, and heal, as a rule, by the first intention ; many of them are at the same time incised wounds if the instrument have a certain breadth ; many resemble contused wounds if the instrument with which they are inflicted is blunt, in which case there is more or less suppuration. We con- stantly make punctured wounds with our surgical instruments, as with acupuncture needles, fine long needles which we occasionally use for the purpose of examining whether, and how deeply the bone is involved beneath a tumour or an ulcer ; also with acupressure needles, which we employ for the purpose of arresting haemorrhage ; with the trocar also, a three-edged sharp dagger, which is surrounded with a closely fitting canula ; we use this instrument for the purpose of drawing off fluids from various cavities. Dagger, sword, knife, and bayonet wounds are often to be regarded both as punctured and incised wounds, or punctured and contused wounds. If these wounds are uncomplicated with injury of the larger arteries or veins, or with injury to the bones, or if they do not penetrate into any of the great cavities, they seldom require any special treatment. The commonest punctured wounds are those made by needles ; they occur for the most part in women, and how seldom is a doctor 170 PECULIARITIES OF PUNCTURED WOUNDS. required ! Such an injury only becomes complicated when the needle or a broken-off portion of it penetrates deeply into the soft parts, and cannot be readily extracted. This may happen in dif- ferent parts of the body, as when a person accidentally sits down on a needle, or falls on one, or in some other accidental way. If a needle has penetrated deeply under the skin the symptoms are usually so slight that the patients seldom experience any pain from it, in fact, are often quite unable to tell whether the needle has really entered, or to say where it is situated. These bodies seldom pro- duce any external evidence of inflammation in the soft parts, but many remain in the body for months, years, or even throughout the whole life without giving rise to any unpleasant consequences, provided they do not enter a nerve trunk. A needle seldom remains stationary at the spot where it enters, but wanders about, that is, it is driven about to other parts of the body by muscular contraction ; it may thus travel for some distance through the body, and turn up again in quite another region. Examples of this have been observed where hysterical women, for the purpose of attracting the attention of medical men, have intentionally thrust needles in large numbers into different parts of the body; these needles made their appearance first in one place, then in another. Even needles that have been swallowed may pass without danger through the walls of the stomach or intestines, and come to light at any part of the abdominal wall. B. v. Lagenbeck once found a pin in the centre of a vesical calculus ; on close inquiry, it was discovered that the patient had swallowed it when a child. The pin must have passed through the intestine into the bladder, where the triple phosphates were deposited on it in layers, and so gave rise to the calculus. Dittel has observed a similar case. If needles have remained in the soft parts for a considerable time without giving rise to pain, or if needles, which are wandering from within outwards, come to the surface and close beneath the skin, they often give rise to a little suppuration, and the sensation of pricking becomes more definite ; you must then make an incision into the painful place ; a little thin pus will be found in the abscess cavity, together with the needle, which may easily be extracted with the forceps. Why these bodies, which for months may be driven about in different parts of the body should give rise to sup- puration, when they at length arrive beneath the skin, is quite incomprehensible. You must, however, for the present be satisfied NEEDLES IN THE BODY: HOW THEY TEAVEL. 171 with the fact that it is so. The following interesting case may help to make the course of such an injury a little more intelligible. An idiotic deaf and dumb female, about thirty years of age, was brought into the Zurich Hospital with the diagnosis " typhoid." We could obtain nothing further of the history either from the woman herself, nor from her friends, who themselves were not over bright. The patient, who would often remain in bed for days together, had complained for some days past of pain, which she referred to the right ileo-ccecal region; she was rather feverish too. On examina- tion, a swelling was found at this spot, which increased in size during the next few days; it was painful on pressure; the skin became red and fluctuation distinctly evident. It was easy to recognize that this was not a case of typhoid, but you may imagine what a variety of diagnoses was made as to the seat of the suppura- tion, for an abscess quickly formed ; it might have been an inflamma- tion of the ovary, a perforation of the vermiform appendix or an abscess in the abdominal wall, &c., though there was something to say against each one of these views. In the course of a few days the inflamed skin became very thin; the abscess concentrated itself close to the anterior superior spine of the ilium, one finger's breadth above Poupart's ligament. I now made an incision into the skin, and let out a quantity of fsecal-smelling, brown coloured, decomposing pus ; while examining the abscess cavity with the finger, I perceived deep down in it, a hard, rodlike, solid body, which, however, was but slightly prominent. I commenced to extract it with a pair of forceps, and pulled and pulled until I had extracted a medium- sized knitting needle, almost a foot long ; it was somewhat rusty and seemed to point towards the pelvis. The abscess cavity was covered with granulations ; I endeavoured to find the sinus which the needle must undoubtedly have left behind, but failed to do so ; it must have closed almost immediately, and was lost in the granulations. The abscess required a long time to heal ; it did, however, finally close without any ill results, and the patient was discharged in about a month. When I showed the unfortunate cretin the needle she only laughed in her idiotic repulsive manner. This was all we could learn about it ; it may possibly have stirred up some faint recollection of the needle in her mind. It is most probable that the patient had inserted the needle either into the vagina or rectum, a kind of procedure to which, unfor- 172 PECULIARITIES OE PUXCTUEED WOUNDS. tunately, women, who are not idiots, are incredibly prone, as you may read in DieffenbacVs ^ Operative Surgery ' in the chapter on the extraction of foreign bodies. It is not impossible that the needle in this case passed up near the portio vaginalis uteri into the caecum, and from the fact that the pus contained air, we may fairly argue that there had been a communication, if even only a tem- porary one, with the gut. This cannot be regarded as at all sure, seeing that pus, when in proximity with the intestines may decom- pose and give rise to stinking gases, even when there is no com- munication with the intestine past or present. The extraction of recently penetrated needles may often be very difficult, as patients are not seldom quite uncertain as to their position, and often, from shame, will not acknowledge how the needles got in (into the bladder for instance). Before an incision is made into the skin, the spot at which the foreign body is believed to be felt, must be fixed with the left hand ; this is absolutely neces- sary, lest the needle should change its position during the incision. Occasionally the foreign body may be felt more or less distinctly, and pressure on it causes sharp pain : such and similar manipulation must guide us in our incisions. After the skin has been incised, we must endeavour to seize the needle with a good pair of dissecting forceps : tense bands of fascia, especially about the fingers, may easily deceive us, for with forceps our sense of touch is always uncertain. If the needle cannot be found, we may let the parts be moved about somewhat; this may get the needle into a position in which it will be easier to seize hold of. The extraction of foreign bodies, which is very much facilitated by the use of Esmarch^s bandage, requires a certain amount of practice and of manual dexterity, which is only acquired with time : an innate mechanical talent is extremely valuable in this matter. Besides needles, fine pieces of glass occasionally heal up in a wound. A short time ago I extracted a blackthorn, seven lines in length, which had lain for eleven years immediately beneath the skin of the leg without causing any marked pain. Punctured wounds, made with instruments which are not very sharp, are occasionally interrupted in this process of healing : the external wound heals by the first intention, but after a few days inflammation and suppuration set in in the deeper parts, and the wound either opens again and the whole tract suppurates, or the pus breaks out at some other point. This subsequent conversion of FOEEIGN BODY IN THE AKM. 173 a simple puncture into a deep wounrl is especially apt to occur if a foreign body, as for instance, the point of a knife, remains behind, or when the injury is inflicted with a blunt instrument. You must always bear in mind the possibility of such foreign bodies being left behind, when you examine these wounds ; endeavour, if possible, to see the instrument with which the wound was caused; inquire particularly too as to the direction which the instrument took, in order that you may the better know what parts have been injured. Often in unfavorable cases there is remarkably little inflammation or suppuration of the track of the wound. Thus a short time ago, a man presented himself at the Chnic, who the day before had fallen on to his arm from only a moderate height from a tree while engaged in lopping off the smaller branches. The left arm for some inches below the elbow was swollen on its dorsal surface ; on its inner surface, just above the wrist, a small excoriation was visible ; the arm could be flexed and extended without pain, but pronation and supination were interfered with and painful. There was no fracture of the bones of the forearm ; the bones were certainly not broken completely, but at the seat of the swelling on the dorsal surface of the limb, two centimetres (a little less than one inch) below the elbow, I could distinctly feel, immediately beneath the skin, a solid body, which could be depressed, but which immediately sprang up again into its former place. It gave one the impression that a piece of bone had been partially detached and lay close below the skin. However incomprehensible it might seem, that such a piece of bone could be detached without a solution of continuity of either radius or ulna from a simple fall on to the ground, I never- theless ordered the patient to be chloroformed, and renewed the attempt to reduce the projecting portion of bone. I did not how- ever succeed. As it lay so close to the surface, and must infallibly have come through the skin within a very short time, I cut down on to it, in order to extract it. To the astonishment of us all, I drew out, not a fragment of bone, but a small twig of the tree, five inches long, which had been very firmly held between the two bones of the forearm. It was at first difficult to explain how this bit of a branch had got into the arm, though on a closer examination of the before-mentioned excoriation on the inner surface of the arm, it was found to be an incised wound, which had almost closed. The foreign body must have penetrated so quickly that the patient did not perceive it. After the extraction the swelling entirely disap- 174 PECULIARITIES OF PUNCTURED WOUNDS. peared, there was but little discharge from the wound, and in eight days it was completely healed. These favorable results as regards the healing of punctured wounds have led to what we now call subcutaneous operations ; they were first introduced into surgery by Stromeyer and Dieffenbach, and consist in introducing a narrow pointed knife under the skin, and dividing, for different purposes, tendons, muscles, or nerves, with- out making any further wound than the simple puncture, through which the tenotome (tendon-knife) is introduced. The healing process under these circumstances is rapid and almost always takes place by the first intention, while with the open treatment there is nearly always suppuration and not seldom extensive necrosis of the tendon beside. We shall have to speak further of this matter in the chapter on deformities (see Chap. XYIII) . It was formerly said that the absence of the irritating influences of the external atmosphere accounted for this rapid healing of such subcutaneous wounds. After the correctness of this argument had been extensively questioned, it was next said that healing took place promptly because no cocco -bacteria germs could get into such wounds. This view too has found little acceptance. Eor the present, then, let us be satisfied with the bare fact. If the puncture has penetrated one of the large cavities of the body and caused injury here, the prognosis must always be doubt- ful, and must be given guardedly, according to the physiological importance, and the greater or less liability to dangerous inflam- matioji of the affected organs. As a rule, a punctured wound of this kind is not as dangerous as a gunshot wound. We will not further pursue this subject, but will pass on to consider punctured wounds of the nerves and vessels of the extremities. PuDctured wounds of nerves produce paralysis of variable extent, according to the extent of the wound. Regeneration naturally occurs more readily when the whole width of the nerve has not been divided. A totally different effect however is produced when a foreign body, such as the point of a needle, or a small bit of glass, is left behind in a nerve trunk, where, as in other tissues, it may heal in. The nerve cicatrix which holds this foreign body may remain exceedingly painful on the least touch, not unfrequently there are severe pains running excentrically ; neuralgia may be set up ; nay more, the most severe forms of nervous disease, both acute and chronic, may be developed. Epileptiform seizures with an aura. WOUNDS OF NERVE AND ARTERIAL TRUNKS. 175 that is, a preliminary pain in the scar which ushers in the attack, have been observed as the result of such injuries. Some surgeons beheve also, that tetanus may be produced by such nerve irritation, but this appears to me to be very doubtful : of this anon. The extraction of the foreign body generally suffices to cure the first variety, which is classed as a reflex epilepsy. Punctured wounds of the larger arterial trunks or of their larger branches may bring about various results. A very small puncture closes almost imme- diately through the elasticity and contractility of the arterial coats : there is not always even bleeding, any more than there is always an escape of faeces from a minute puncture of the intestine. If the wound be slit-like, the bleeding would probably be insignificant, pro- vided the wound do not gape very much. In other cases, however, severe haemorrhage is the immediate result. If compression be at once applied and a suitable bandage carefully put on, one generally succeeds, not only in arresting the haemorrhage, but also in getting the wound of the artery as well as that of the soft parts to firmly close. If the bleeding cannot be arrested, as already pointed out, we must immediately proceed to ligature the artery either by enlarging the wound above and below the seat of injury, or at some higher place in its continuity. The closure of an arterial wound takes place in the following manner : — A blood-clot forms in the more or less gaping wound of the arterial wall; this clot projects shghtly into the lumen of the vessel, but externally it is larger, and covers the vessel somewhat like a mushroom. This clot becomes organized into connective tissue, in the same way as was described in intra- vascular thrombus, and so a permanent organic closure of the opening takes place without any narrowing of the lumen. This normal course of things may be complicated by the little plug which projects into the interior of the artery, giving rise to a deposit of fibrine from the circulating blood, and in this way to closure of the artery by clot-formation — arterial thrombosis in fact — but this is very rare. If it should take place, the same result would happen as after ligature ; there would be development of collateral circulation, and eventually obliteration of the vessel by organization of the entire thrombus. Punctured wounds of arteries do not always follow such a favorable course. In many cases a swelling is remarked shortly after the accident at the seat of injury, which gradually increases in size, and which is both seen and felt to pulsate synchronously with 176 PECULIARITIES OF PUNCTURED WOUNDS. the heart's systole. If we place a stethoscope over the swelling, we hear a distinct blowing and whirring sound. If we compress the main artery of the limb above the tumour, the pulsation and whirring sound immediately cease and the tumour decreases some- FiG. 40. Artery wounded at its side, with clot ; 4 days after the injury. After Porta. what in size. We call such a tumour an aneurism {dvavpvvu) — to dilate), and this particular form, the result of accident, a false aneu- rism, in contradistinction to a true aneurism, which arises sponta- neously as the result of various kinds of arterial disease. How does this swelhng form and what is it ? Its origin is as follows : the external wound is closed by pressure, so that blood can no longer escape by it ; but it nevertheless escapes from the artery, which is not yet firmly closed by the clot, into the soft parts around, and continues to burrow among these so long as the blood pressure is stronger than the resistance which the tissues oppose to its spread. In this way, a cavity filled with blood is formed in direct communication with the artery. Some inflammation is set up in the tissues around the blood, wdiich coagulates in part ; this plastic infiltration leads on to the formation of connective tissue, which forms a sac, into the interior of which the blood streams in and out, while the peripheral portions become filled with layers of coagulated blood-clot. The bruits which we hear in them are produced partly by the flow of the blood through the narrow open- ing, partly by its friction against the blood-clots, and partly by its regurgitation back again into the artery. Such a traumatic aneurism may occur secondarily, that is, the arterial wound may heal at first, but on removal of the bandage the young cicatrix may give way and the blood will then stream out. It is not always from punctured wounds that traumatic aneurisms arise. They may be caused by rupture of the arterial coats either by traction or bruising without any external wound. A. Cooper relates the following interesting case in his ' Lectures on Surgery :' A gentleman when out shooting was jumping over a ditch, and while doing so experienced a severe pain in the ham, which at once prevented his walking. An aneurism quickly formed in the popli- CAUSATION OF ANEUEISM. 177 teal space which had to be operated on. The artery was partially torn in the act of jumping. It suffices for the production of an aneurism that the tunica intima and muscularis be torn through. If the tunica adventitia remain uninjured the blood-stream may separate it from the tunica media, and in this way what we call a dissecting aneurism is the result. Cases of punctured wounds with Fig. 41. r^/f Traumatic aneurism of the brachial artery. After Froriep. Surgical plates, vol. iv, pi. 483. subsequent aneurism occur especially in military practice, but not unfrequently also in civil practice. I recently saw a boy with an aneurism of the femoral artery as large as a lien's egg; it was situated at about the middle of the thigh, and had resulted from a wound with a penknife on to which the boy had fallen. I operated M 178 PECULIARITIES OF PÜNCTÜEED WOUNDS. the other day on an aneurism of the radial artery which had deve- loped in a shoemaker as the result of a prick by an awl. An aneurism is a tumour which communicates either directly or indirectly with the orifice of an artery. Such is the usual definition. The communication is direct in the case just described of simple traumatic aneurism. But, nevertheless, the anatomical conditions of this tumour may be much more complicated. For instance, in venesection at the bend of the arm (that is, intentionally opening a vein in order to abstract blood), the brachial artery may be wounded. This is one of the most frequent causes of traumatic aneurism, or rather used to be when bleeding was more common. In such a case, besides dark venous blood, a bright red stream would be immediately recognised ; the whole arm should be bound up and the artery compressed. In most cases both openings will heal up without any evil consequences. But it occasionally happens that an aneurism subsequently forms. This may be of the simple form just described, or the openings of the two vessels may so grow together that the arterial blood flows directly into the vein as into an arterial branch, and it then meets the stream of the venous blood. Fig. 42. Aneurismal varix ; a, brachial artery. After Bell. Froriep's surgical plates, vol. iii, pi. 263. This causes obstruction to the venous current, and gives rise to sacculations and to dilatations of the veins which we generally term varices; in this especial instance the varix is spoken of as aneuris- ANEURISMAL VARIX : VARICOSE ANEURISM. m mal^ because, like an aneurism, it communicates with an artery. Another condition may also occur, namely, the formation of an aneurism between the artery and the vein, that is, both artery and vein communicating with the aneurismal sac. Tig. 43. Varicose aneurism ; a, brachial artery ; b, median vein. The aneurismal sac is slit open. After Dorsey. Froriep's surgical plates, vol. iii, pi. 263. We call this condition varicose aneurism. There may be numerous varieties in the relations of the aneurismal sac and of the vein and artery to each other, but these are only interesting as curiosities; they neither alter the symptoms nor the treatment, and fortunately have no special names given to them. In most cases, in which arterial blood flows directly or indirectly through an aneurismal sac into veins, a dilatation takes place, and a thrill may both be felt and heard in them and which is occasionally perceptible also in the arteries. It is probably caused by the meeting of the two currents. The thrill, however, is not characteristic of varicose aneurism, since this condition can be produced simply by pressure on the veins ; it is present too in many forms of heart disease. But if in addition to the thrill a slight pulsation can be felt in veins distended by the above cause, then we shall be more Hkely to arrive at a correct diagnosis. Some little time back I had the opportunity of seeing several aneurisms which were the results of gunshot wounds ; in three cases which affected the femoral artery and the external iliac the thrill was so strongly marked that injury to the artery and also to the vein, with communication between the two, was necessarily 180 PECULIARITIES OF PUNCTURED WOUNDS. (diagnosed; in one case the post-mortem examination proved this to be correct. In none of these cases were there any varices ; hence we must assume either that they are not necessarily formed as the result of a communication between artery and vein, or that they only result in the course of years. Aneurisms of arteries, if they remain small, scarcely ever produce any great inconvenience. In the generality of cases, however, the aneurismal sacs become larger and larger; disturbances in the functions of the affected limb come on, and, finally, the aneurism may burst and lead to fatal hsemorrhage. Treatment must consist, in the majority of cases, of ligature of the arterial trunk, but of this later on. I have considered it desirable to explain to you in this place the development of traumatic aneurisms because they generally occur in practice as the result of punctured wounds ; in surgical handbooks they are usually treated of under diseases of the arteries. Of spontaneous aneurisms and their treatment we shall speak in a separate chapter. Punctured wounds of veins heal exactly like those of arteries, so that I need not add anything to what has already been said. Perhaps I may just remark that extensive clots form far more readily in veins than in arteries ; thus, traumatic venous thrombosis is far more common after venesection than arterial thrombosis is after punctured wounds of the arterial walls, and what is far worse, the first form of thrombosis entails much more serious results than the latter. Of this you will hear more at a future time, perhaps more than you care for. We have already referred to venesection, a little surgical operation which was frequent enough formerly. We will briefly describe the method of performing the operation, although you will more quickly and more thoroughly understand it by once seeing it done than by any description I can give you of it. If I were to try and tell you under what circumstances venesection ought to be practised, I should have to enter very deeply into the science ©f medicine; a large book might be written on the subject of the indications, the contra-indications, the admissibility, the utility, and the evils of venesection. I prefer, therefore, to pass over this subject in silence, as over other things which you may learn from daily observation in the clinics in a few minutes ; whereas without some special case for demonstration several hours would be required for its explanation. I will only just refer to the historical fact, that whereas in olden times venesection took place from any of the VENESECTION. 181 subcutaneous veins, now-a-days the operation is almost always done at the bend of the elbow. When you wish to bleed, first apply a bandage to the arm sufficiently tight to cause obstruction in the peripheral veins ; for this purpose a well-adjusted pocket handker- chief answers very well, or the scarlet bleeding bandage furnished with a buckle may be used. If this bandage has been properly applied the veins of the arm begin to swell, and at the bend of the arm, the cephalic and basilic, and their corresponding median veins present themselves. You open whichever vein is most prominent. The arm is flexed to an obtuse angle, you fix the vein with the thumb of the left hand, then with a lancet or with a fine-pointed straight scalpel in the right hand, you plunge into the vein and make an incision about half a centimetre long (quarter of an inch). The blood streams out; you allow as much as is necessary to flow, and then occlude the wound with your thumb ; next remove the bandage from the arm, and the bleeding will cease almost spontaneously ; the wound must now be closed with pad and bandage, and the arm kept at rest for three or four days ; by this time the wound will have healed. Easy as this opera- tion is in the generality of cases, it, nevertheless, requires practice. Puncture with the lancet or scalpel is to be preferred to the phle- botome ; this latter instrument was much used formerly, but is now very justly going out of use ; the phlebotome is a fleam which is plunged into the vein by means of a spring ; the instrument, in fact, is allowed to operate instead of being safely guided by the hand. There are many mechanical obstacles which may interfere with venesection. In very fat people it is often difficult either to see or to feel the veins through the skin. We then make use of other means besides compression, for we order the forearm to be put into warm water ; this causes a stronger afflux of blood to the part. The fat, even after opening the vein, may prevent the flow of blood by its little lobules covering over the opening. In such a case you must quickly cut them ofi" with a pair of scissors. Occasionally a mechanical hindrance to the flow of blood is produced by the arm assuming a different position either through flexion or extension after the puncture, so that the opening into the vein no longer corresponds with that in the skin ; this may be remedied by again altering the position of the arm. There are other causes also which interfere with the flow of blood ; for instance, the opening may be too small, a frequent occurrence with beginners, or the compression 182 PECULIARITIES OF PUXCTÜEED WOUNDS. is too weak ; this is to be remedied by tightening the bandage, or, on the contrary, the bandage may be too tight and the artery compressed so that little or no blood can get into the arm ; this of course is to be remedied by loosening the bandage. A way of helping the flow is to cause the patient to open and shut the hand rhythmically, so that the blood may be forced on by the muscular contractions. LECTURE XL CHAPTER III. ON SIMPLE CONTUSIONS OP THE SOET PARTS. 'Causes of contusions. — Nervous shock. — Suhcutaneous rupture of vessels. — Rupture of arteries, — Ecchymosis. — Absorption. — Termination in fibrinous swelling s^ in cysts , in suppuration y in sloughing. — Treatment. The skin may or may not be broken by the striking of a blunt tody on the soft parts : thus we distinguish between contusions with and contusions without skin wounds. We will first consider these latter. Contusions are caused either by the falling of heavy objects on to the body^ or by their striking severely against it^ or by the body falling or striking against hard solid substances. The immediate consequence of such a bruise is a crushing of the soft parts, which may be of the most variable degree of severity ; in some cases we can hardly appreciate any change at all, in others the parts are bruised to a pulp. Whether the skin suffers a solution of continuity from such a blow depends on various circumstances, e.g. the form of the object which inflicts the blow, the force with which it strikes, and the nature of the parts below the skin. For instance, the same force which would produce contusion of the muscles of the thigh without injuring the skin would cause a wound of the latter if applied over the crest of the tibia, because the sharp edge of the tibia would itself almost cut through the skin. The elasticity and the thickness of the skin have also to be taken into con- sideration ; not only do they vary in different persons, but also in different parts of the same body ; so that in a simple contusion we cannot directly recognise the amount of injury but only indirectly. 184 SIMPLE CONTUSIONS OF THE SOFT PARTS. and this from the state of the nerves and vessels, and from the sub- sequent course of the case. The first symptom of contusion of nerves is pain, as it is in wounds, but then the pain is duller and more indefinite, although it may be very severe. In many cases, especially after striking against a hard body, the patient feels a peculiar tingling, numbing sensation in the affected part ; this feeling, which extends consi- derably beyond the seat of injury, is produced by the shock which the nerve substance has suffered. Tor instance, if we strike the hand or a finger rather severely, only a small portion is actually contused, and yet not unfrequently there is concussion of the nerves of the whole hand, with severe dull pain and tingling, on account of which the fingers cannot at first be moved : there is also almost complete loss of sensation. This condition quickly passes off — generally in a few seconds, and then we experience a pecuhar burn- ing pain in the contused part. We have no other explanation of this temporary condition except that the substance of the nerves, most probably the axis cylinder, undergoes some molecular change as the result of the concussion, which again spontaneously passes off. These symptoms of shock do not by any means accompany all cases of contusion ; they are absent in most cases where a heavy body strikes a limb at rest. In contusions of the head, however, they are not unfrequently of great moment, for in these cases we have not only commotio cerebri, we get also contusio cerebri ; or we may have simply the former, as the result, for instance, of a fall on to the feet, or on to the seat, whence the shock is conveyed to the brain, and the severest symptoms, even death may result, without any appreciable anatomical changes in this organ being dis- covered. Concussion is a process which we prefer to locate in the nervous system, and we speak of a cerebral and of a spinal con- cussion. Still the peripheral nerves may be shaken with the symptoms above given ; but since the local injury is the more pro- minent, the nervous condition is perhaps too much overlooked. A severe concussion of the chest may give rise to the most serious symptoms through shock to the heart and lung nerves, whereby the circulation and respiration are for a longer or shorter period dis- turbed. Nor can we entirely deny the reflex action of a concussed nerve, especially of the sympathetic, on the brain. Doubtless some of you, when wrestling or boxing, have sometimes received a blow on the abdomen : what horrible pain ! Por the moment a feeling of NERVOUS SHOCK. 185 faiiitness comes over you; this is the effect on brain and heart; one has to hold one^s breath and gather up one's strength in order not to fall outright. Concussion of the ulnar nerve frequently occurs from a blow on the elbow ; the severe dull pain^ which runs up to one's fingertips even, is known to most of you. Compression of sensory nerves is believed to cause contraction of the cerebral vessels, as recently shown by experiments on rabbits. Possibly this explains too the faints which follow severe pain. All these are symptoms of concussion in the peripheral nerves. As we are not aware of what specially takes place in the nerves, we cannot judge whether these changes have any and what influence on the further course of contusions and of contused wounds ; we cannot then here further consider the nerves. Reliable observations seem to show that concussion of peripheral nerves may be followed by motor and sensory paralysis of the muscles of a part, but on account of many complications it is very difficult to prove any con- nection between the two. We must distinguish contusions from concussion of nerves. In the former, individual portions of a nerve trunk or the entire thickness of a nerve trunk may be destroyed to a greater or less extent and degree by the violence applied, so that we may even find them softened to a pulp. Under such circum- stances a corresponding paralysis results, from which we are able indeed to recognise the affected nerve, and the extent of the injury it has received. On the whole, such contusions of nerves without open wounds are rare, because the chief nerve trunks are situ- ated deeply between the muscles, and are hence less liable to direct injury. It is acknowledged, a priori, that other tissues and organs are influenced by shock just as are the nerves, and that disturbances not only of the ordinary functions of a part, but also of the nutritive or growing powers, temporary or permanent, may be brought about^ Such disturbance of function may have an important influence on the further course of the reparative changes after accidents ; many- surgeons regard this as the chief cause of the severe inflamma- tory processes, with their easily decomposing exudations and infil- trations, so often met with after injuries. I am far from denying the influence of a severe concussion on a bone; for instance, the medulla and vessels may be torn, although the bone is not frac- tured ; the consequences of such an injury under certain circum- stances may be much more extensive and far-reaching than a mere 186 SIMPLE CONTUSIONS OF THE SOFT PAETS. fracture from overstraining ; nevertheless, we must not attribute the sometimes very severe after-effects of contused wounds entirely to this cause. Contusion of vessels is often sufficiently obvious, and is recog- nised by the presence of blood, which, owing to injury of the walls of the smaller vessels, especially of the subcutaneous veins, becomes extravasated. Subcutaneous haemorrhage is thus an almost constant result of contusion. It would be even more considerable than it is if the wound of the vessels in this class of injuries were clean cut, and remained open ; but generally this is not the case ; contused wounds of vessels are rough, uneven, jagged, and these inequalities all offer so many hindrances to the escape of the blood ; the friction is so great, in fact, that the blood pressure is no longer able to overcome it, fibrinous coagula attach themselves to these points, spread into the interior of the vessels, and so a mechanical plugging of the vessel — a thrombosis — takes place. The contusion of the wall of a vessel, through which an alteration in its structure is brought about, can alone cause coagulation of the blood ; for Brücke has shown that a healthy living intima is an important condition for the preservation of the fluid condition of the blood within the vessels. We shall again refer to this subject under contused wounds. The resistance of the soft parts prevents an excessive extravasation of blood, because both muscles and skin exercise a natural com- pression ; thus, it rarely happens that subcutaneous hsemorrhages in the extremities, even when they proceed from large vessels, are immediately dangerous to life. Of course it is quite different with haemorrhages into the large cavities of the body; here the emi- nently moveable soft parts cannot offer any sufficient impediment to the escape of the blood from the vessels; such haemorrhages are thus then not unfrequently fatal ; death may result in one of two ways, either from the amount of blood poured out, as into the thorax or abdomen, and partly from the compression which the extravasating blood exercises on the surrounding organs, as on the brain, which may not only be destroyed by the quantity of blood, but also compressed in various directions and so rendered incapable of performing its functions. Haemorrhages into the brain thus rapidly cause paralysis, and often also sensorial disturbance ; we call these haemorrhages into the brain, and also the train of symptoms which they produce apoplexy (from airo and TrXijcraoj, to beat away, to knock down). CONTUSION OF BLOOD-VESSELS. 187 If a large artery in an extremity be torn, the conditions are the same as in a punctured wound which has been sewn up or compressed; a traumatic aneurism, a pulsating blood-tumour, as described in the last lecture, may result. This, in proportion to the large number of contusions which daily occur, is a very rare accident ; it is to be explained partly by the fact that the arterial trunks are deeply seated, and partly because their walls are tough and elastic and thus they are very much less often torn than the veins. Nevertheless, a short time ago we had in our wards a case of subcutaneous rupture of the anterior tibial artery. A strong heavy man had broken his leg, but the skin was uninjured. The seat of fracture was about the middle of the tibia, and a little higher up in the fibula ; a rather large tumour quickly formed at the seat of the injury, it pulsated considerably ; this pulsation could be both seen and felt on the anterior surface of the leg. A loud murmur was distinctly audible in it, and I was able to demonstrate it to my class. The leg was put up in a splint and bandage, but we pur- posely avoided the application of an immovable dressing, in order that we might the better observe the further course of the traumatic aneurism, which had manifestly formed here. We renewed the dressing every three or four days, and were able to convince our- selves that the tumour gradually became smaller and pulsated less and less every day, until, at the end of a fortnight, the pulsation had entirely ceased. This aneurism was cured by the compression which we made with the bandage. The healing of the fracture too progressed uninterruptedly ; and the patient, at the end of eight weeks from the accident, had recovered complete use of his limbs. Subcutaneous haemorrhages after contusions are most frequently due to rupture of the subcutaneous veins. The exudations produce visible symptoms, which vary according to the quantity of the extravasated blood and its distribution in the tissues. The more vascular the part, the more severe the contusion, the greater is the extravasation. Extravasated blood, when it is poured out slowly, burrows between the layers of connective tissue, especially into the subcutaneous tissue, or into the inter- muscular planes. In this the tissue becomes infiltrated with blood, and swelling results. These diffuse and subcutaneous haemorrhages are called sugillations (fr. suggillatio — extravasation), or suffusions. The looser and more yielding the tissue, the easier is it to tear apart, and hence then the more extensive will be the infiltration if 188 SIMPLE CONTUSIONS OP THE SOFT PAETS. the blood can slowly but continuously escape. Thus we usually find extravasations into the eyelids or scrotum of considerable extent, because here the subcutaneous connective tissue is so very loose. The thinner the skin the more easily and the more quickly do we recognise the infiltrated blood ; it shows through the skin, and penetrates into it, giving it a bluish colour. But beneath the ocular conjunctiva extravasated blood looks quite red, because this membrane is so transparent and thin. Extravasations of blood in the cutis itself appear as red spots (purpura) or as stripes (vibices) ; in this form they are seldom the result of contusion, but are rather caused by spontaneous rupture of vessels. It may be that in some persons the vessel walls are peculiarly thin, as in bleeders, of whom we have already spoken, or that, in consequence of some unknown chemical changes in the blood, the vessels become brittle and liable to tear, as in scurvy, in [many forms of typhoid, and in purpura hsemorrhagica. Contusions of the cutis may gene- rally be recognised by the deep blue-brownish colour, sometimes also by the stripping off of the epidermis, or as it is technically called, excoriation. If a quantity of blood escapes suddenly from the vessels, and is poured out into loose cellular tissue, a more or less circumscribed cavity results. This form of effusion of blood is called ecchymosis, ecchymoma, or hsematoma, a blood tumour; whether the skin is discoloured or not depends on how deep the blood lies beneath it ; in deeply seated effusions of blood, diffused as well as circum- scribed, we often get no discoloration of the skin, directly after an accident especially. We can only recognise swelling, the rapid development of which, however, immediately after an accident, Jit once suggests its nature ; this swelling feels soft and tense. A circumscribed effusion presents the very characteristic feeling of undulation — a sense of fluctuation. You can obtain the clearest idea of this feeling by filling a bladder full of water and then pal- pating its walls. The detection of fluctuation is of great importance in surgical practice, for there are numberless cases where it is important to distinguish whether a given tumour is solid, or is one containing fluid or very soft tissue. How best to undertake this examination in undivided cases you will learn in the wards. Some of these effusions of blood have received special names according to the localities in which they occur. Thus effusions of blood, which not unfrequently occur on the scalp of newly-born in- SUBCUTANEOUS EFFUSIONS OF BLOOD. 18^ fants,are called cephalhsematoma (from Kerf) aXi t , the liead_,and aTfiaTouj, to besmear with blood). The extravasation which forms in the labia majora either after contusion, or spontaneously from rupture of dis- tended veins, has received the euphonious name of episioha^matoma or episiorrhagia (from Itvuglov, the external genitals) . Effusions of blood into the pleurae and pericardium also have special desig- nations — hsematothorax and hsematopericardium, &c. Now-a-days little importance is attached to these high-sounding Greek and Latin names ; it is necessary, nevertheless, that you should know them, partly in order that you may understand them whenever you see the terms in your medical books, and partly because it enables us to express ourselves more briefly and more readily. The subsequent course and symptoms of these subcutaneous effusions of blood are very characteristic. Let us first consider diffuse extravasations ; in such cases, immediately after the accident, we are quite unable to say how extensive the hsemorrhage has been or still is. If you examine a contused part two or three days after the injury, you will observe that the discoloration is much more extensive than on the first day ; even this appears to extend subse- quently, that is, it becomes more appreciable. The extent is at times quite incredible. We once had under care a man with fracture of the scapula ; at first the discoloration was very slight, although a large fluctuating swelling was present ; on the eighth day the whole of the back from the neck down to the region of the gluteal muscles had assumed a dark bluish colour, and looked as if it had been painted. These extensive extravasations are espe- cially common after fractures of the leg or arm. These dark blue or bluish-red discolorations, with which the skin is never tender or much swollen, do not fortunately remain ; some further changes set in, the first of which is another change of colour ; the blue and red become brownish, then green, and lastly yellow. This peculiar play of colour has given rise to the expression of " beating one black and bine ;" that is, giving one a sound thrashing. The final colour, the yellow, usually remains for a long time, even for months ; and then this also disappears, and no external trace of the extravasation remains. If we now inquire how these various discolorations of the skin are brought about, we find if we have an opportunity of examining blood extravasations in different stages that it is a colouring matter of the blood, which gradually undergoes these metamor- 190 SIMPLE CONTUSIONS OF THE SOFT PARTS. piloses and gives ris^ to these varying shades of colour. When blood escapes from the vessels, and gets into the connective tissue, the fibrin coagulates. The blood serum permeates the connective tissue and gets back again into the vessels ; it is reabsorbed. The colouring matter of the blood leaves the corpuscles ; it too gets in a state of solution into the connective tissue. The fibrin and the blood corpuscles break up for the most part into fine molecules, are become absorbed as such by the vessels. A few of the white cor- puscles perhaps, as in thrombus, may possibly be further developed. The blood-colouring matter which pervades the tissues undergoes certain subsequent changes which are not very well understood^ until it is finally converted into a permanent colouring matter, which is no longer soluble in the fluids of the organism — hsematoidin. Fig. 44. Granular and crystallised hsematoidin, orange and red colour. Magnified 400. As in a thrombus, this is partly granular, partly crystalline. In its pure condition it is of a dark orange or of a ruby-red colour ; when sparingly distributed, it gives the tissues a yellowish colour, when more plentifully present, a deep orange tinge. Absorption of the extravasation always takes place in diffuse suggillation, because the blood is widely distributed in the tissue, and the vessels which have to do the work have not suffered from the contusion ; this is the most desirable, and under favorable cir- cumstances the most frequent termination of subcutaneous and intermuscular effusions of blood. In circumscribed effusions — in ecchymoses — the case is some- what different. It depends in the first place on the extent of the effusion, and next on the state of the vessels in the surrounding tissues ; the more numerous they are, the less are they injured by SUBCUTANEOUS EFFUSIONS OF BLOOD. 191 the contusion^ the more likely is it that absorption will take place. Nevertheless,, absorption in large effusions of this kind is at the best uncertain. There are various causes which prevent this ; first of all, a thickening of the connective tissue around the effused blood, as around a foreign body (as also in traumatic aneurism), takes place, by means of which the blood becomes encapsuled; then on the interior surface of this sac fibrin is deposited in layers, and fluid blood remains in its centre. Thus the vessels around this blood tumour can only absorb a very limited amount of fluid, because they are separated from the fluid parts of the blood by a thick wall of fibrin. We here get the same conditions as are present in large adhesive exudations into the pleural cavity ; the layers of lymph which are deposited on the chest walls interfere with reabsorption. It can, in fact, only take place under these circumstances by molecular disintegration of the fibrin, and by its becoming fluid again ; or after it has become organised and pro- vided with lymph and blood-vessels. This is not at all uncommon in the pleura. There are many other terminations for these extra- vasations. Tor instance, the fluid portions of the blood may become entirely absorbed, and a firm hard swelling arranged in concentric layers (like an onion) remain behind. This happens every now and then with extravasations into the labia majora, and in this manner a fibrous tumour results. These connective-tissue tumours may also form in the uterus under like circumstances. Many heematomata become organised into connective tissue ; they may also take up salts of lime, become calcareous, and calcify ; on the whole this is a rare termination, but one which does happen, for instance, in effusion of blood into large goitres, and also occa- sionally in the walls of large traumatic aneurisms. Another way is the transformation of the blood tumour into a cyst. This is observed in the brain, also in soft tumours. Many of the cysts in goitres, along with other modes of origin, may possibly be explained in this manner. By a cyst or encysted tumour we mean a sac or cavity with more or less fluid contents. The contents of a cyst resulting from extravasation of blood are of a darker or lighter colour according to their age ; the blood-colouring matter may entirely disappear, and the contents become quite white in colour, or be only tinged by molecules of fat. In large circumscribed extravasations you will find well-formed crystals of hsematoidin less abundant, and less often than in smaller and more diffuse extra- 192 SIMPLE CONTUSIONS OF THE SOFT PARTS. vasations : in the former fatty degeneration of the elements of the blood is more manifest, and this leads rather to the production of crystals of Cholesterine. The capsule which encloses these old blood effusions is formed partly by organisation of peripheral portions of the blood-mass, and partly from the surrounding structures. Suppuration of circumscribed extravasations is far more common than the last two metamorphoses which we have just described, but this is not so common as reabsorption. The inflammatory process around, and the plastic processes in the peripheral portion of the extravasated blood through which, in the two preceding instances, the thickened connective tissue which enclosed the blood was deve- loped, assume a more acute character in the case we are about to describe ; here also a Kmiting layer is formed, but not slowly and gradually as in the last cases, but by a rapid cell-development ; this plastic infiltration of the tissue does not lead on to the development of connective tissue, but to suppuration ; the inflammation spreads to the cutis, and this also suppurates from within outward, and finally perforates ; the pus, mixed with blood, is then evacuated, the walls of the cavity fall together, shrink and close up : in this way healino" takes place. We shall have to speak of this mode of healing when treating of abscesses ; we are accustomed to call any pus- tumour, that is, a circumscribed collection of pus anywhere beneath the skin, an abscess, and thus we speak of the above process as the suppuration of extravasated blood. This process may take place very slowly ; it may even last three or four weeks, but, unless dangerous from its position, it generally runs a favorable course. We recognise the advent of this suppu- ration by an increasing inflammatory redness of the skin, the increase in size of the swelling, the increasing pain, occasionally accompanied by fever, and lastly by the thinning of the skin at the point where perforation finally takes place. Lastly, there may be rapid decomposition — sloughing of the extravasation, in fact ; fortunately this is rare. In this case the tumour becomes hot and tense, exceedingly painful ; the temperature generally rises to a considerable degree; rigors and other severe symptoms may also occur. This termination, which only occurs after very severe contusions, and with subsequent acute secondary inflammation, is the most serious of all, and indeed the only one, which calls for immediate surgical interference. VAEIETIES OF CONTUSED WOUNDS. 193 'Whether there shall be absorption^ suppuration^ or drcompositioii of an extravasation depends not only on the amount of the eö'used blood, but more especially on the degree of contusion which the ' tissues have undergone ; so long as these can return to their normal condition absorption of the effused blood is probable ; if, on the contrary, the tissues are destroyed and break down aiul decompose, then the suppuration and sloughing will extend also to the blood ; briefly, the effused blood will undergo the same fate as the con- tused tissues. The differences which characterise the course of subcutaneous contusions and those which are open (compound) contused wounds are so remarkable that surgeons have long had them under con- sideration. Absorption of the extravasated blood, and molecular disintegration of the contused and dead tissue without any decom- position, often indeed without any symptoms of inllammation, ara the rule in cases of slight subcutaneous contusions ; suppurations and sloughing are the exception; but in contused wounds, on the contrary, suppuration and sloughing of the contused tissue ordinarily occur, formerly the unfavorable influence was sought in the contact of the contused tissue with the air, especially with the oxygen of the air; more recently pure air is considered less injurious ; it is only air rendered impure by the germs of minute organisms which is dangerous. To protect contused wounds from these germs is the object which has intlueiiced Lister in the plan of construction of his antiseptic dressings ; he endeavours to obtain (artificially) the same conditions for contused and deep- seated wounds as obtain in subcutaneous contusions, in order to get the same result, that is, absorption without either inflammation or decomposition. I must refer the reader to what has already been said on this subject (p. 135). We cannot accurately judge the extent of the contusion of muscles, tendons, and fasciae in cases where the skin is uninjured; the extent of the extravasation, however, may sometimes help us, but it is at best an uncertain guide ; of more importance is the amount of functional activity of the affected inuscle, though here again the results obtained must be carefully weighed; the amount of force which has operated on the part will lead to the most reliable estimation of the amount of damage done. The heal- ing of contused muscles takes places, as in wounds, by molecular degeneration of the contused part and subsequent absorption. In N 194 SIMPLE CONTUSIONS OF THE SOFT PAETS. suppuration of the extravasated blood the muscular elements are discharged with the pus, and then subsequently a formation of connective tissue and also of new muscular fibres may take place. The largest extravasations, both diffuse and circumscribed, are generally accompanied by injury to the bones. It will be better to consider injuries to bones in a separate chapter. AYhen a portion of the body is so injured as to be either in part or entirely incapable of living, it becomes cold, bluish-red, or brownish-red, and then black ; it begins to mortify, and the pro- ducts of decomposition get into the neighbouring tissues and into the blood ; the local inflammation and also the fever take on unusually severe forms. As this is the same for contusions either with or without wounds, we shall speak of it later on. The object of the treatment of simple contusions (contusions without wounds) is to conduct the process to the most favorable termination possible, that is, to absorption of the extravasation ; when this takes place, the injuries sustained by the soft parts also progress favorably, because the whole process remains subcu- taneous. We simply refer here to those cases where the contusion of the soft parts and the extravasation alone require treatment ; in cases comphcated with fracture it is the latter which must before all be treated, and the extravsaation itself will scarcely require any special measures. If we are called to a contusion which has just occurred it becomes our duty to arrest the hsemorrhage if it seem to be still going on. This will be best secured by compression, which, when possible, is to be obtained by well-applied bandages. "When a child falls on to the head, or knocks its forehead, it is the custom in North Germany for the mother or nurse to take the handle of a spoon or the blade of a knife and press it firmly on to the injured part, in order to prevent the formation of bruise-marks. This is a very useful popular remedy ; by this timely compression the further escape of blood is prevented on the one hand, and on the other the blood which does escape is made to distribute itself in the surrounding tissues and not allowed to collect at any one point; an ecchymosis just forming may in this way be transformed into a simple bruise ; the blood is thus more readily absorbed. But we rarely see the injury sufficiently early, and so in a vast majority of cases we have to deal with an injury either of a bone or of a joint as well as with a contusion, which latter then of course falls into the back ground. TREATMENT OF CONTUSIONS. 195 The use of cold, applied by means of ice enclosed in a pig's bladder or an india-rubber bag, or cold-water applications to which it is a popular custom to add vinegar or liquor plumbi, are the means to be employed in recent contusions ; they no doubt fre- quently prevent much subsequent inflammation. You must not, however, count too much on these remedies ; the means by which the absorption of extravasated blood is best furthered are by uniform compression and absolute rest of the part. Thus it is best to apply wet bandages to the extremities, over which wet cloths may be applied, which must be renewed every three or four hours. Other remedies which usually act favorably in acute inflammations of the skin, such as mercurial ointment, are of little avail in these cases. I must not forget arnica ! This remedy is so honoured by some families and physicians that it would be considered unpardon- able to neglect prescribing it in contusions; compresses soaked either with an infusion or with water to which some of the tincture has been added may be applied. Belief is all-powerful; some believe in arnica, some in lead lotion, others in vinegar, as the most powerful external absorbent. Probably the faith in arnica would somewhat decrease if the public was aware that eczema and ery- thema of the skin not infrequently follow its use. In all cases doubtless the efi'ect is due to the moisture and to the changes in temperature consequent on its application ; the capillaries are kept constantly active, at one time contracted, at another dilated, and so they are best adapted for absorption because they are active. Difi'use extravasations of blood, with only moderate contusion of the soft parts, are generally absorbed without much treatment. If a circumscribed extravasation does not materially alter in the course of about fourteen days, there is nevertheless no indication for active interference. The tumour must be painted with diluted tincture of iodine once or twice daily, and compressed by means of an appro- priate bandage: under such treatment it will not unfrequently subside in the course of a few weeks. If it become hot, and the skin over it inflamed, reddened, and painful, we must be prepared for suppuration; even the continued application of cold will now seldom alter the course, though it may possibly moderate it. And now, in order no longer to retard the suppuration which we cannot prevent, we may apply hot fomentations, either with folded cloths, wrung out of hot water, or with poultices ; we now quietly await the course of events ; if no aggravation of symptoms occur, if the 196 SIMPLE CONTUSIONS OF THE SOFT PAETS. patient feel pretty well, we may wait patiently for suppuration ; the skin will gradually thin at one place (though this may not take place for weeks), and at last an opening will be made, the pus will discharge itself, the walls of the cyst will fall together, and in a short time healing will be complete. At the commencement of this lecture I mentioned a case where, after fracture of the scapula, an enormous, partly diffuse, partly circumscribed extravasation was formed. Here was a highly fluctuating swelling, which persisted and was not absorbed ; though the diffused portion was rapidly removed, it was five weeks after the accident before the suppuration broke through, and then between two and two and a half litres of pus were evacuated. Eight days later this enormous cavity was healed up, and the patient left the hospital quite cured. If, in the course of the suppuration of an extravasation, the tension of the swelling should rapidly increase, and a high temperature with rigors occur, you may infer that decomposition of the contents of this tumour has set in. With such symptoms the putrid fluids must be quickly let out. This is best done by making a free inci- sion through the skin, whenever the anatomical relation of parts will allow it ; otherwise several smaller incisions must be made, and in such a position as will allow a free exit for the discharge. These incisions of course entirely alter the aspect of the case, for you have made a subcutaneous contusion into a compound one. Other con- ditions now come into play, which we will consider in our next lecture. We must, however, just mention, that in case of extensive gangrenous breaking down of the soft parts after such contused wounds, amputation is indicated, although, without simultaneous fracture of the bones, such unfavorable cases rarely happen. LECTURE XII. CHAPTEE IV. CONTUSED AND LACERATED WOUNDS OE THE SOFT PARTS. Mode of occurrence of these loounds ; their appearance. — Slight hcemorrhage in contused wounds. — Earli/ secondary hcßmorrhage. — Gangrene of edges of the ivoiind ; influences ivhich effect the slower or more rapid detachment of necrosed tissue. — Indi- cations for ]irimarij amputations. — Local complications in con- tiosed ivounds. — Decomposition. — Putrefaction. — Septic inflam- mations, — Contusions of arteries ; late secondary haemorrhage. The causes of contused wounds, of which we have to speak tO'day, are the same as those of simple contusions, except that in the former the force employed is usually much greater than in the latter; it depends also on the form of the wounding instrument, whether it is such as to divide the soft parts easily, and further on the part of the body struck, whether the skin over it is particularly thin, or whether it is supported on a firm subcutaneous basis. The kick of a horse, a blow from a stick, the bite of an animal or a mail, being run over, injuries with blunt knives, with saws, kc, are frequent causes of contused wounds, j^^othing, however, cause more contused wounds than rapidly revolving machine wheels, iron rollers, circular saws, spinning machines, and machines with wheels and cogs. All these instruments, the productions of an ever-advancing industry, are the causes of much mischief amongst the working classes. Men and women, adults and children, with crushed fingers, smashed hands, jagged and lacerated arms and fore- arms, are always to be found in the surgical wards of any large hos- pital. If to these we add the now somewhat rarer cases of railway 198 CONTUSED AND LACERATED WOUNDS OF SOFT PAETS. accidents, and those caused by the blasting operations of building tunnels, &c., you will see, not only how much sweat, but also how much blood, cling to the evidences of modern culture. At the same time it is not to be denied that the chief cause of these acci- dents for the most part is the carelessness, often indeed the fool- hardiness, of the working man. Daily contact with dangerous machines renders people at last careless and rash, and many pay for this with their lives. Gunshot wounds for the most part belong to the class of con- tused wounds ; but as they have many peculiarities of their own, we shall consider them in a separate chapter. Lacerated wounds, and the complete tearing out of portions of a limb, will be considered towards the end of this chapter. Contused wounds from all the above-named causes are very frequently complicated by the most varied and often dangerous fractures ; for the present, however, we shall leave these injuries out of consideration and treat only of the soft parts. The appearance of a wound generally indicates whether it is due to incision or contusion. You are already familiar with the charac- teristics of a clean-cut wound, but I have already pointed out to you some cases in which a contused wound may resemble an incised wound and vice versa. Contused wounds, just as incised wounds, may be accompanied by loss of substance, or may consist in a simple solution of continuity. The edges of these wounds are for the most part very uneven and shreddy, especially the edges of the skin ; the muscles sometimes look as if they had been chopped, and shreds of the soft parts in larger or smaller pieces, not infre- quently in large flaps, hang down into the wound stained with the blood, which is either stagnated or effused within them. Tendons are occasionally ruptured or torn out, fasciae are torn, the skin around the wound, often to a great extent, is separated from the muscles, especially if the contusing was combined with a tearing and a twisting force. The degree of destruction of the soft parts is naturally very vari- able, and its extent cannot always be accurately ascertained, as we cannot always see how far the contusion and tearing extend beyond the wound ; often enough during the subsequent course of a wound we may convince ourselves that the contusion extended much further than the size of the wound indicated and that the separation of muscles, the tearing of the fasciae, the effusion of blood, have SLIGHT H^MOEEHAGE IN CONTUSED WOUNDS. 199 extended far beyond the portion of skin which was ruptured. It is an unfortunate circumstance that the external wound affords no guide for judging of the extent and depth of the contusion, and thus it is very difficult to correctly estimate the extent of such an injury at the first examination, and thus while the outward appear- ance of the wound gives the layman no idea of the danger, the experienced surgeon soon recognises the gravity of the case. Since the injury, especially when done by machinery, is very rapidly inflicted, the pain is not great, nor is the pain of contused wounds shortly after their infliction particularly severe ; in fact, the greater the injury and more crushed a part is, the less considerable is it. This is easily explained by the nerves in the region of the wound being completely crushed and destroyed, and consequently incapable of conducting impressions ; besides this, the so-called concussion (" stupor ^^) of the injured part, to which I referred in the last lecture, here comes into play. At first sight it seems remarkable that these contused wounds bleed so little, if at all, even though large veins or arteries be crushed or torn. There are authentic cases on record where after complete crushing of the femoral or axillary artery no primary haemorrhage took place. This certainly is not of frequent occur- rence; in many cases after a complete rupture of an artery of such large size, there is a constant oozing of blood, if not an actual spirt, and such, coming from the femoral artery, for instance, would quickly cause death. I have already pointed out how the arrest of haemorrhage takes place in smaller arteries, but I will make it clear to you by giving an illustration. A railway labourer was run over by an engine, the wheel of which passed over his left thigh just below the hip-joint. The unfortunate man was imme- diately brought to the hospital on a stretcher ; apparently he had lost much blood by the way, and on his arrival he was very pale and bloodless, but perfectly conscious. After complete removal of his tattered clothes, we found a horrible mangling of the soft parts of the region mentioned. The bone was smashed into about thirty pieces, the muscles were crushed into a pulp, and hung out of the wound in shreds ; the skin was ploughed up as far as the hip-joint. At no. point of this immense wound did an artery spirt, but blood constantly welled up from the deep parts in no inconsiderable quantities, while the general condition of the patient plainly showed that he had already lost blood to a considerable extent. It was 200 contijSt:!.) and laceeated wounds of soft parts. obvious that nothing short of exarticulation at the hip would avail ; yet in the then condition of the patient this was not to be thought of, for the additional loss of blood (EsmarcVs method was then not thought of) which such an extensive operation would necessarily have entailed would certainly have been fatal. Before all things, then, it became necessary to arrest the haemorrhage which probably came from a tear in the femoral artery. I first of all endeavoured to find the femoral artery in the wound, while it was compressed higlier up, but the muscles were all so much mis- placed, twisted, and their anatomical relations so altered, that it could not be quickly done, so I proceeded to ligature the femoral artery below Poupart's ligament. After this was done most of the bleeding ceased, though not entirely on account of the rich arterial anastomosis, and so, as no regular bandage could be applied on account of the extensive lacerations, I applied a tourniquet just below the spot where I meant to ex articulate, and screwed it firmly up. The bleeding now left off; we administered various restora- tives in order to bring the man round ; he had wine and warm drinks, so that towards evening he had again so far recovered that the temperature had gone up to normal, and the radial pulse was again fairly good. I should have postponed an operation until the following day but that, in spite of ligature and tourniquet, the hsemor- srhage again commenced as the hearths power increased, and I feared the man might bleed to death during the night. I therefore per- formed exarticulatio femoris with the able help of my assistants, and did it as rapidly as I could. The loss of blood during the operation was not considerable absolutely, but it was relatively much for the already debilitated patient. At first all seemed to go on favorably, the spirting vessels were all tied, the wound was dosed up, and the patient put back to bed; he soon, however, became very restless and dyspnoea set in : this increased more and more and finally convulsions occurred ; the patient died two hours after the operation. The examination of the femoral artery of the smashed extremity showed a lacerated wound, situated in the upper third of the thigh, involving a third of the calibre of the vessel. Not only the shreds of the tunica intima, but also the other arterial coats, had curled themselves up into the lumen of the vessel, so that the blood escaped from it with great difficulty ; the surrounding structures were com- pletely saturated with blood. In this case no clot had formed CHASSAIGNAC'S ECRASEUE. 201 in the artery, as the escape of blood was too free to permit of this ; yet when you come to consider that the artery was injured in its entire circumference, you will easily see how the torn shreds of the arterial coats, pressing from all sides into the lumen of the vessel, might have rendered the escape of blood still more difficult or even impossible; in that case a thrombus would have formed, which would have plugged the vessel and then have gradually organized or have broken down and putrefied. If no haemorrhage had followed the partial contusion of the artery, for instance, if the entire con- tusion had been a simple one (with no external wound), probably a clot would have formed in the artery at the spot injured by the con- tusion, a clot or thrombus in the wall of the vessel (ein wand- ständiges Gerinnsel) ; in such a case the contusion of the artery might have been followed by preservation of its calibre — a result which is said to have sometimes been observed. Apply the conditions above described of a contused large artery to the smaller arteries, and you will quickly see how much more easily complete spontaneous closure of the lumen of the vessel may take place, partly by the rolling in of the brittle torn tunica intima, and partly by the contraction of the tunica muscularis, and also by the shreds of the adventitia ; so that in such-like contused wounds haemorrhage may be entirely absent. These observations led to the invention by the French surgeon Chassaignac of an instrument by means of which a diseased part of the body may be taken off ; he terms the operation ^^ ecrasement,'^ and the instrument an " ecra- seur.''' It consists of a strong loop of metal, made up of a number of small links rivetted together, which is placed around the part about to be removed ; the loop is then tightened with the aid of a rackwork apparatus, contained within the handle of the instrument, which is hollowed for that purpose. And indeed, if the instrument be properly handled, not a drop of blood need be lost ; and although this method found little sympathy among surgeons at first, because contused wounds are avoided as much as possible in operative sur- gery, yet for certain cases its practical value is beyond all question. Healing of wounds caused by '^ ecrasement'"' takes place with unusually little local or constitutional reaction ; secondary inflam- mations are associated with this class of wounds less frequently than with clean-cut wounds; nevertheless, his operation is applicable only in a relatively smaU number of cases. There is yet another point to consider, which tends to limit 202 CONTUSED AND LACEEATED WOUNDS OF SOET PARTS. haemorrhage in extensive contusions^ and that is, the depression of the heart's action caused by the injury ; this is probably produced by reflex action. Persons who are seriously injured, quite irre- spective of the loss of blood and of injury of nerve-centres^ are usually stupid and stunned ; we have no German word to express this state of depression, and so the English word " shocF^ is used. It signifies a condition of great depression after an injury. The fright of the injury, and all thoughts about it, which follow in rapid succession, probably combine to produce a considerable mental depression, which has a paralysing effect on the hearths action. Still, even in persons who are not much mentally affected by an accident, such as is the case in old soldiers who have been frequently wounded, or in persons of a very phlegmatic disposition, the shock of an accident is not entirely absent, and thus we are led to the conclusion that shock is really due to reflex causes. Contusions of the abdo- minal viscera have a more depressing effect on the nerve-centres than even contusions of the extremities, as I have already pointed out. In connection with this subject the so-called " Klopfversuch'' (per- cussion experiment) of Golz is interesting. If a frog be repeatedly struck on its abdomen with the handle of a scalpel, it will become temporarily paralysed through anaemia of the brain ; the abdominal vessels dilate widely in consequence of paresis of their walls, and thus appropriate a great portion of the blood, so that the remaining vessels and even the heart become bloodless, while the latter only feebly contracts. Then when the patient has recovered from this mental and phy- sical depression, and when the heart is again acting with its former or even with more vigorous energy, haemorrhage may take place from vessels which at first did not bleed. This is a variety of secondary haemorrhage, such as occurs after operations, when the chloroform narcosis has passed off. The patient must therefore be carefully watched during this period in order to guard against such dangerous haemorrhages, especially if, in consequence of the posi- tion of the wound, there be any reason to suspect that a large artery has been injured. We will next examine somewhat more attentively the local changes which are taking place in the wound. Though the processes which take place in contused wounds, the superficial changes as well as the ultimate healing of the wounds, are essentially the same as in incised wounds, there are yet con- HEALING OF CONTUSED WOUNDS. 203 siderable diflPerences in the manifestations of these processes in the two cases. One very important point to remember is that in con- tused wounds the nutritioii of the edges of the skin and of the soft parts is more or less extensively interrupted or may be even com- pletely destroyed. [More anatomically expressed this signifies that the circulation^ the nutritive juices, and the nerve influences are more or less absent from the edges of contused wounds in con- sequence of the injury sustained by the vessels, tissues, and nerves. Thus the contused and gangrenous edges of such a wound cannot possibly heal by the first intention, since this process abso- lutely requires complete vitality of the wound surfaces. These contused wounds, the edges of which have been injured, always heal by granulation. This observation has led to the practice of never putting in sutures in contused wounds, and of not even closing them with strapping. You may consider this as the general rule. There are of course exceptions to it which you can only learn by practice in the wards, and concerning which I will for the present only just remark, that occasionally large loose skin flaps are adjusted into their proper position, not in the expectation that heal- ing by the first intention will take place, but in order to prevent too great retraction and too much atrophy afterwards. Contusion, laceration, tearing, are variously combined, but it depends in each case whether or not the edges of the wound are capable of repair. The formation of granulations and suppuration subsequently are the same as in wounds with loss of substance, only with this differ- ence that repair takes place more slowly, and in many places even more imperfectly. Occasionally also, no doubt, in incised wounds with loss of substance, there is loss of a superficial layer of tissue if the nutrition is not adequate ; but this is very insignificant in comparison with the extensive flaps of tissue which sometimes slough after contused wounds. These shreds of dead (necrosed) skin, fascice, tendons, hang from the wounds for days, and even weeks, while other parts are granulating luxuriantly. The process of detachment of dead from living tissue takes place as follows : — along the margin of the uninjured, healthy tissue, and proceeding from it, an infiltration of new cells gradually takes place which leads to the formation of granulations and of new blood- vessels ; the surface of these granulations soften and pus is formed. As a result of this softening, to a certain extent a dissolving and melting away of the tissue, the cohesion of the parts naturally ceases 204 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. and the dead tissue which on account of its fibrous nature still clings to the living, must at last fall off. Thus a portion of the surface of a contused wound will almost always become gangrenous or necrotic (from vsKpog, death, and ri ydjypaiva from ypaivu), to consume) — expressions which are used synonymously for parts in which both circulation and innervation have ceased, and which are dead. The spot at which the detachment of the gangrenous portion takes place is called the line of demarcation. I will endeavour to make this process of separation of the dead from the living tissue by means of the formation of granula- tion and suppuration a little more intelligible by the following diagram. EiG. 45. The process of separation of necrosed tissue in contused wounds. Magnified .300. Diagramatic. a. Contused necrotic portion, b. Living tissue. The •upper portion of a represents the surface of the wound. In the portion of tissue here represented the edge of the wound THE LINE OF DEMAECATION. 205 is supposed to be so contused that the circulation has ceased, and it is no longer nourished^ the blood in its vessels has coagulated as far as the shading extends in the drawing. Cell infiltration and inflammatory new growth is commencing at the extreme edge of the living tissue, betweeii a and h where the vessels terminate in loops; these loops dilate, and increase by a process of budding, and multiply ; the infiltration in the tissue is increased by the wandering cells, just as if this were the edge of the wound. Granulations form, the surface of which breaks down, that is, the surface adjoin- ing the necrosed part ; so that the latter naturally falls off because its adhesion with the living tissue has ceased. The separation of the necrosed portion then is brought about by the formation and suppuration of granulation tissue. When the dead tissue has fallen off, the subjacent suppurating layer of granu- lations comes to light, as it was already developed before the necrosed portion was detached ; what you here see in connective tissue is true also of other tissues, bone not excepted. In many cases it is possible to judge from the fresh edges of the wound how much of them will necrose, but not by any means in all cases, and it is never possible to foretell exactly where the line of demarcation will appear. When the skin is badly contused it usually has a dark blue or violet appearance and is cold to the touch; in other cases there appears to be no change in it at first, but in a few days it becomes colourless and absolutely devoid of sensation ; then it turns to a grey colour, or if it dry up completely, to a greyish black or brownish black. The variations in colour depend chiefly on the amount of coagulated bloody which is contained in the vessels, or as a result of their rupture in the tissue itself. The healthy skin, on the contrary, is bounded by a rose-red line which gradually diffuses itself. This redness is the result partly of collateral dilatation of the capillaries, and partly a congestive and inflammatory symptom, which we have already spoken of at length ; it is the redness of reaction about the wound which has been described elsewhere, for the healthy surface of a wound only begins where the capillaries are charged with circulating blood. Much less frequently, and often not at all, can we foretell from first appearances how much muscle, fascia, or tendon will slough off. The time required for the dead tissue to be separated and detached 206 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. from the living, greatly varies with the different tissues. It chiefly depends on the vascularity of a part ; the richer a tissue is in capil- laries the softer it is, and the more easily do cells spread through it; and, according to its structure, the richer it is in cells which are capable of organization, the more quickly will the formation of granulations and the separation of the dead portion take place. All these conditions best obtain in the subcutaneous cellular tissue, least so in tendons and fasciae; the cutis, in this respect, occupies an intermediate position. The conditions for the bones are most unfa- vorable ; the separation of the dead from the living bone takes place most slowly, but of this anon. A rich supply of nerves seems to count for little in the process. But there are many other influences which hinder the rapid separation of the necrosed parts, or, what is the same thing, retard the formation of granulations and of pus. Among these may be mentioned the continued action of cold on a wound, such as may be affected by the application of ice. As a result of the low tempera- ture the vessels are kept in a state of contraction, the movements of leucocytes are retarded, and the cell proliferation diminished. The contrary obtains by the application of constant warmth; by this means we increase the blood-flow to the capillaries, and compel them to dilate, as you may see by the redness which immediately appears even on healthy skin when you apply a hot poultice. Besides this, it is well known that warmth favours cell-movements. It is altogether impossible also to foretell the influence of the ■constitutional peculiarities of the patient himself on the course of the above processes, but in general we may say that they are more energetic in young, strong muscular individuals, and more mode- rated and sluggish in weakly individuals. But in this one is often mistaken. The course of contused wounds is particularly unfavorable in old drunkards. Prom what has been said you will be able to gather that contused wounds require a much longer time to heal than the generality of simple incised wounds. It will also be evident to you that there may be circumstances which necessitate the amputation of a limb, as when the soft parts are completely smashed and lacerated. There are, indeed, cases in which the soft parts are completely torn away from the bone, leaving nothing but the latter, so that on the one hand no cicatrization could take place ; on the other the extremity, COMPLICATIONS OF CONTUSED WOUNDS. 207 even if healing were to take place after months or years, would be absolutely useless ; thus it is better to remove it at once. Moreover, complete detachment of the skin alone from the greater part of an extremity may, in rare cases, render amputation necessary, as in the following case: — A little girl, about ten years old, had her right hand caught between the rollers of a spinning machine ; she forcibly drew back her arm, so that the entire limb might not be destroyed. The hand again made its appearance, but the skin from the tips of the fingers to the wrist remained between the rollers. The skin was torn all around the wrist, and it now came off like a glove. When the patient was brought to the hospital, the injured hand looked like an anatomical dissection ; we could see the tendons work in their sheaths, when extension and flexion move- ments (which were in no way interfered with) were made ; no joint was opened, no bone broken — what was to be done ? A fairly large experience of such machinery accidents had taught me that fingers which have been entirely deprived of their skin almost inva- riably become gangrenous : thus we should have had an extraordinary stump of a hand which, under the most favorable circumstances, would have been nothing more than an unwieldy cicatrized stump ; it was doubtful, indeed, whether a permanent cicatrix would have formed at all, and several months would have been necessary to obtain even this doubtful result. Under such circumstances it was better to do an amputation above the wrist at once, and this was done. Tour weeks later the child left the hospital and was sent home; her employer provided an artificial hand with some simple mechanism, in order to compensate her, as far as he could, for the injury she had sustained. Fortunately such cases are rare. In similar injuries of single fingers we mostly leave the process to itself, so that no more is lost than that which is absolutely incapable of living. We must always remember this principle in the surgery of the hand, that every inch — every line, more or less — is of great importance, and that single fin- gers, and especially the thumb if it be at all possible, must be preserved, for such fingers, if only partially movable, are infinitely more useful than the most elaborate artificial hand that can be made. With regard to the foot and the lower extremity other considerations have to be taken into account ; of these we shall speak again when we come to the subject of compound fractures. Still it would be a happy thing if these sad mutilations and the 208 CONTUSED AND LACEEATED WOUNDS OF SOFT PARTS. slow healing were the only dangers which beset patients with con- tused wounds ! Unfortunately there is a whole string of local and general complications which directly or indirectly endanger life ! We will here refer to those complications which may be called local, and reserve the general ones for a separate chapter. Considerable danger may arise from the possible infection of the healthy surrounding tissues by the decomposing products of the wound. Putrescent matters act as ferments on other organic com- binations, especially on fluids wherein they are contained ; they bring about decomposition more quickly than it would ensue spon- taneously. You may almost wonder why extensive decomposition of parts which have been injured, but not actually destroyed, does not more frequently occur. In most cases, however, coagulation and adhesion of the soft parts and regenerative cell reaction set in so quickly along the borders of the living tissue, that a sort of living wall is formed by these means, which acts as a barrier to the passage of the putrid matter ; the granulation surface also \\\\en once formed is particularly resistent to such influences. In many places a popular remedy is to apply cowdung and other dirty sub- stances to ulcers ; this scarcely ever causes any extensive putrefac- tion or granulating wounds. But if you apply these substances to fresh wounds, and bind them on in such a manner that the tissue becomes mechanically impregnated with the putrid material, the wounds will in many cases become gangrenous even to some depth down, and then finally an energetic and vital cell-proliferation opposes itself to the putrefactive ferment. The reason why putrid substances act so detrimentally on fresh wounds, and scarcely at all on granulating wounds, is, I imagine, to be found partly in the gelatinoid nature of the granu- lation tissue, which is often several millimetres thick, and partly in the fact that putrid substances are chiefly absorbed by the lym- phatic system. Thus, if you inject one drachm of putrid fluid into the subcutaneous tissue of a dog, you will produce inflammation, fever, and septiccT.mia ; but if, having first produced a large granu- lating surface, you daily apply to it lint soaked in stinking pus, you will scarcely get any visible results at all. Putrid fluids can no doubt get into the veins and capillaries through the walls of these vessels, but experience teaches us that septic wounds are accompanied by lymphangitis more frequently than by phlebitis. I shall again refer to this point. PUTREFACTION IN CONTUSED WOUNDS. 209 The more the tissues are saturated with fluid, and the more their vital activity is interfered with by a contusion, so much the more will they, on account of their lowered vitality, be disposed to putre- faction. The cases, therefore, in which great cedematous swelling supervenes after contusion are more dangerous in this respect. This oedema readily comes on, because laceration and contusion often intercept the venous and lymphatic circulation far beyond the limits of the wound. For example, a forearm caught beneath a stone weighing several hundredweight; probably there is only a small skin-wound, but yet the muscles are extensively smashed, and there is contusion of the tendons and fascise of the whole of the forearm, contusion and laceration of most of the veins ; great cede- matous swelling will quickly set in, because the blood is being driven through the arteries into the capillaries with additional energy. Great iudeed will be the disturbance in the circulation and in the whole course of nutrition ! It must soon become evident where the blood can still circulate and where not. At the wound there commences first a decomposition of the dead parts, this passes on to the stagnant humours, and, under unfavorable circumstances, spreads more and more, the whole extremity as far as the shoulder swells tremen- dously, the skin becomes red and shining, tense, painful, and covered with blisters, for beneath the epidermis also serum exudes from the capillary vessels of the skin. All these phenomena usually develop themselves on the third day after the injury, frequently with frightful rapidity. The whole of the extremity may become gan- grenous in consequence of this disturbance of the circulation. In other cases, only the fascise, tendons and shreds of skin perish, whilst cellular infiltration of the whole of the connective tissue of the extremity (of the subcutaneous cellular tissue, the perimysium, the neurilemma, the sheaths of the vessels, the periosteum, &c.) follows, which leads to suppuration. Towards the sixth or eighth day the whole extremity may become thoroughly charged with pus already in a state of complete decomposition. Theoretically speaking, a cure is conceivable in such cases, i. e., we might believe that the process ■could become arrested, and the pus and dead tissues come away through appropriate openings in the skin. But this seldom occurs in practice ; if the state of things just described exist to the extent mentioned, nothing but speedy amputation can save the patient, and that not always. This kind of infiltration may be described as ichoro-serous ; it is so at first only, soon becomes ichoro-sup- 210 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. purative, and finally entirely suppurative. Essentially, it is an inflammation of the cellular tissue resulting from a local septic infection, a septic plilegmonous inflammation, the products of which have a great tendency to decomposition which eventually leads, however, to extensive suppuration and necrosis of tissue in case the individual survives the blood infection always present under such circumstances. The earlier such processes become arrested, the more favorable the prognosis ; the patient^s danger increases with the advance of the local phenomena. We must now refer once more to the arteries in cases of the coming away of dead portions of tissue. It may be the case that an artery is bruised in such a manner that its continuity is not exactly destroyed, and that the blood flows on through it, but a portion of its wall is dead and comes away from the sixth to the ninth day, or even later. Whenever this occurs, hsemorrhage will at once supervene proportionate to the size of the artery and the size of the opening. These secondary Jmmorrhages, which gene- rally occur suddenly, are extremely dangerous, because they affect the patient unexpectedly, sometimes during sleep, and not unfre- quentiy are first noticed only after much blood has been lost. There is another way in which a late arterial secondary hsemorrhage may occur, viz. from suppuration of the thrombus, or of the wall of the artery ; I observed one case of this latter kind in the third week after an important operation in the immediate neighbourhood of the femoral artery, close below Poupart^s ligament, in which the artery, however, was not injured. The hsemorrhage, in this case, occurred in the night. As the wound had always looked healthy and the patient had for some time been sleeping the whole night, and we had been saying the day before that he might get up the next day, there was no nurse in the patient''s private room; he awoke in the middle of the night of the twenty-second day after the operation, found himself swimming in blood and rang at once for the nurse, who immediately fetched the assistant-surgeon, who found the patient insensible already. He at once compressed the artery within the wound, and everything was done, while I was being fetched, to revive the patient. I found him pulseless and uncon- scious, but breathing, and the action of the heart could still be heard distinctly. While I was preparing to tie the femoral artery, the patient died ; he had bled to death. A very melancholy case ! An otherwise strong, healthy man, in the flower of his age, within a SECOXDARY ARTEEIAL H^MOEEHAGES. 211 short time of a cure, was doomed to lose his life in this miserable way. I liave seldom been so depressed by any case ! And yet no reproach could be made to any one j the circumstances had, as it happened, been very favorable ; the nurse chanced to be awake in the adjoining room, the surgeon was only one story lower in the same house and in not more than three or four minutes at the bed- side of the patient, but the haemorrhage must have been gohig on for a considerable time before the patient ,awoke. He was only awakened by the moisture which he felt in the bed. The post- mortem showed that a small portion of the femoral artery had sup- purated and become perforated. Fortunately, it is not always a femoral artery that bleeds, nor is the bleeding always so violent, neither does it always occur in the night ; we need not, therefore, allow so rare a case of bad luck to destroy the interest we take in our art. Such arterial haemorrhages usually commence to an unim- portant extent from suppurating wound-cavities, and are soon checked by styptics or compression ; but the haemorrhage then recurs more violently after a few days, and is more difficult to arrest; eventually the bleedings are repeated more and more quickly, and the patient becomes more excited and more distressed. In all cases of violent arterial secondary haemorrhages imme- diate compression is the first remedy ; every nurse, male or female, ought to know how to compress the arterial trunks of the extremi- ties ; these people, however, easily lose their heads, as in the case described above, and in their first anxiety run for the surgeon instead of compressing the artery themselves and sending some one else for him. Compression is here a palliative means only; it may happen that the hasmorrhage ceases therefrom ; but if it be consider- able, and you are sure where it comes from, I advise you strongly to tie the respective arterial trunk at once within the wound, or, if this cannot be done quickly, in loco electionis, for this is the only certain means. You must do this the more quickly if the patient be exhausted. Remember that a second or third such haemorrhage ■will certainly cause death. On that account you must, in courses of operative surgery in the dissecting room, practise the tying of arteries before all other operations, so that you may become so expert therein as to be able to perform this operation when half asleep. Precisely in such cases much harm is done by unnecessary loss of time in employing styptics, which, for the most part, act here only as palliatives, or not at all. The tying of an artery is a 212 CONTUSED AND LACERATED WOUNDS OF SOFT PAETS. trifle for one who has his anatomy in his head and has made good use of his time in the courses of operative surgery ! Anatomy ! gentlemen ! anatomy ! and once more anatomy ! A human life often depends upon the certainty of your knowledge of that science. While on the subject of secondary hsemorrhages, let us also speak here oi parenchymatous secondary Immorrhages. The blood issues from the granulations as from a sponge; we nowhere see a bleeding, spirting vessel; the whole surface bleeds, especially at each change of the dressing. This may depend upon many circumstances ; very fragile, easily destroyed granulations, in other words, faulty organisa- tion of the same, may be the cause, and this faulty organisation of the granulations may again have its origin in a generally diseased condition of the whole organism (bleeders' disease, scurvy, septic or pyaemic infection). Local causes in the vicinity of the wound may also exist, e. g. if extensive, slowly formed coagula of blood occur in the secondary veins, the circulation in the vessels of the granula- tions w^ould be so much interfered with, the blood-pressure so much increased, that not only would serum perhaps exude from them, but also ruptures of vessels take place. It is true that I have not yet had an opportunity of verifying this by post-mortem examinations, but I have seen only few cases of such parenchy- matous secondary haemorrhages. The last explanation sounds very plausible; it originated, so far as I know, with Stromeyer, who ■calls such hsemorrhages " phlebo-static." According to their origin it may be more or less difficult to arrest such hsemorrhages ; in most cases, ice, compression, styptics will be expedient here ; in more serious cases, the tying of the arterial branch, although this has some- times failed. This kind of hsemorrhage mostly occurs in indivi- duals much reduced by suppuration and fever, and is, therefore, an evil omen as to the general condition of the patient. LECTURE XIII. Advancing suppurations originating in contused wounds. — Secondary inflammations of wounds ; their causes ; local infection, — Febrile reaction in contused wounds, secondare/ fever, suppurative fever, fever-rigors, their causes. — Treatment of contused wounds ; immersion, ice-bladders, irrigation; critique of these methods of treatment. — Incisions, counter- openings. — Drainage. — Cata- plasms. — Open treatment of wounds. — Lister s method. — Pro- phylaxis against secondary inflammations. — Internal treatment of the severely wounded. — Quinine. — Opium. — Lacerated wounds, subcutaneous tearing of muscles and tendons, tearing out of Hi The granulating surface formed in a contused wound is, for the most part, very irregular, and often presents many corners and pockets ; the contused wound does not suppurate on its surface only, but also the surrounding contused parts suppurate. The skin in the vicinity of the wound will often be found to be undermined by pus. The inflammation and suppuration often spread unexpectedly between the muscles, along the bones, and in the sheaths of the tendons, perhaps because the pus formed is absorbed by the lymph- atic vessels, then decomposed, and thus causes fresh inflammation. Fortunately, such processes not unfrequently become arrested at the end of the second or third week, but the advance of the destructive process of suppuration may continue ; it creeps on in the continuity of the sheaths of the tendons and of the cellular tissue ; fresh nests of suppuration show themselves sometimes at one point, sometimes at another, the injured part continues swollen, oedematous, the granulations are of a dirty yellow colour, puffy, spongy. If we make pressure in the vicinity of the wound, pus flows slowly out of smaller or larger openings which have formed themselves spon- taneously, and this pus, which stagnates in the depths of the wound. 214 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. is not imfrequently thin and ill-smelling. If this process continue long, the patient becomes weaker and more distressed, and has high and continuous fever ; a wound which appears unimportant at first, in the neighbourhood of the hand, perhaps, may have caused fright- ful swelling and a very unfavorable general condition of the patient. It is in the sheaths of the tendons in the neighbourhood of the hand and foot especially that deep, insidious suppurations spread further and further, from which the inflammation may extend to the joint of the hand or foot, as, reversely, inflammations of the joints of the extremities easily extend to the sheaths of the tendons. These conditions may take a very unfavorable turn and must be most carefully watched. From continuous fever, as well as from considerable daily formation of pus, the strongest men may become frightfully emaciated in a few weeks, and die with symptoms of febrile marasmus. We are now acquainted with two forms of inflammation which may supervene upon contused wounds : — ist, rapidly progressive septic inflammation of the cellular tissue, which occurs in the wound in the course of the first three or four days, (rarely within twenty- four hours after the injury, and equally rarely after the fourth day), and which is partly the immediate result of the injury, and depends partly upon local infection by decomposing humours and decompo- sition-ferments which develop themselves in the decaying tissues on the surface of the wound ; 2nd, progressive, suppurative inflamma- tion of the cellular tissue, which, especially in wounds of the hands and feet, may supervene from necrotic shreds of tissue during the cleansing of the wound, while the pus is not ichorous, although butyric acid is not unfrequently formed in it and gives it a bad odour. Now, if the wound is already thoroughly cleansed and granula- lation has commenced, if the inflammatory process has become cir- cumscribed, and the wound is beginning to cicatrise, you will, perhaps, think that nothing more can go wrong with it. But such is, unfortunately, not the case ; fresh inflammation, followed by serious consequences, may set in. These seco7iclary progressive inflamma- tions in and near suppurating wounds, occurring later on and even several weeks after the injury, sometimes as unexpectedly as a flash of lightning from a clear sky, are of great importance and often highly dangerous ; they have almost always a suppurative character and may, just as frequently as the primary progressive suppurations. ADVANCING SUPPURATIONS IN CONTUSED WOUNDS. 215 prove fatal by very intense, phlogistic, suppurative general infection, in many cases also by the dangerous nature of their site, especially in wounds of the head. These cases have something so striking, so tragical about them as to call for our special attention. Assume that you have brought a case of severe contusion of the leg, with fracture, successfully through the first dangers : the patient is free from fever, the wound is granulating very well, and even beginning to cicatrise. Suddenly, in the fourth week, the wound begins to swell, the granulations become croupous, finally infiltrated with fibrin (diphtheritic), the pus thin, the whole extremity swells, the patient has again high fever, perhaps with repeated rigors. These phenomena may disappear and everything return to the normal groove, but the result is often bad ; in a few days, the strongest, healthiest man may become a corpse. I saw a case of this kind in Zurich in the person of a brother officer wounded in the head; it may serve as a warning example. This youth received a sabre cut on the left side of the head ; the bone was injured quite superficially; the wound healed quickly by the first intention, only a small spot continuing to suppurate. As the patient felt quite well, he paid no attention to the small wound, went out, and regarded himself as being in perfect health. Sud- denly, in the fourth week, he had severe headache and fever after a walk. On the following day, about a teaspoonful of pus was found to have collected beneath the cicatrix, and let out by an incision. This had not the hoped-for good effect upon his general condition, the fever continued, delirium, followed by sopor, set in in the evening, and on the fourth day this fine young man was dead. It was easy to diagnose that suppurative meningitis existed here, and this was confirmed at the post mortem. Although the bone at the point exposed of the size of a pea, which had so long kept up a slight suppuration, was but little discoloured by an inconsiderable suppurative infiltration, yet the suppuration upon, in, and beneath the dura mater was decidedly greatest at the point corresponding to the wound, so that the fresh inflammation had undoubtedly pro- ceeded from the wound. I saw a perfectly similar case, which also terminated fatally, a short time ago here in Vienna, in private prac- tice, in a man who had received an apparently unimportant injury high up on the forehead, near the roots of the hair, from splinters of a soda-water bottle which had burst. He had been quite well up to six days before his death, and had attended to his business. 216 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. The inflammations which occur under such circumstances have generally, as already remarked, a diffused suppurative character, but other forms supervene or occur independently, viz., an ulcerative^ diphtheritic form of inflammation of the skin, or hospital gangrene^ or inflammation of the trunks of the lymphatic vessels {lympJian- goitis), and a specific form of capillary lymphangoitis of the skin, also erysipelas or erysipelatous ir)fiammation, lastly also inflammation, of the veins (phlehitis). All these processes may not unfrequently be observed mixed with each other. We shall study these diseases. more closely later on when speaking of incidental wound- diseases. But we must occupy ourselves here with the causes of the already- mentioned secondary inflammations before we pass on to the treat- ment of contused wounds, though we of course anticipate somewhat by so doing. All these forms of inflammation and also their reactions- upon the organism are so closely connected with each other that it is impossible to speak of one set without mentioning the other. As causes of the secondary inflammations in and around suppura- ting wounds during the healing process we may mention the follow- ing: — I. Intense congestion at the wound, which may arise from da violent movement of the injured part^ or from violent general exertion, or from exciting drinks, intense emotion, in short, from everything which causes violent excitement. Such congestions are very specially dangerous in cases of wounds of the head. Hyper- semia from obstructions, e. g. from too tight dressings, may similarly be very detrimental. 2. Talcing cold locally or generally. Of taking cold as a phlogogenic principle we know scarcely any- thing beyond the simple fact that, under certain circumstances not easily to be defined more exactly, a sudden change of temperature causes inflammations, especially at a locits minoris resistenticB in an individual; in a wounded individual the wound is always to be regarded as a so-called locus minoris resistentia. The danger of taking cold in wounded persons was no doubt much over-estimated formerly, but I cannot quote distinct instances thereof. 3. Mechan^ ical irritation of the wound. This is of great importance. Healthy, non-irritating, undecomposed pus of a wound is never absorbed by uninjured granulations, but if the granulations are destroyed by mechanical manipulations, e. g. by unskilful dressings, many probings, and such like manoeuvres, in consequence of which the wound always bleeds afresh, fresh inflammations may be occasioned thereby. Any foreign bodies remaining in the wound also play an SECONDARY INFLAMMATIONS OF WOUNDS. 217 important part, e.g. fragments of glass, sharp pieces of lead or iron, sharp splinters of bone ; for the first processes which occur in the wound (septic phlegmonous inflammation, primary gangrene), the presence of such foreign bodies is of less consequence, but if, partly from muscular movements, partly from the movements communi- cated to the tissues by the arteries, the sharp edges of a foreign, body are made to rub constantly against the tissues, violent inflam- mation occurs after some time. 4. Chemical ferment-liJce irrita- tions of loounds, amongst which I may mention first soft foreign bodies, e. g. pieces of cloth, paper wads, which enter the tissues in shot - wounds ; these substances become impregnated with the wound-secretions, in combination with which the organic substances (paper, wool, &c.) become decomposed and then act directly in the wound as irritants or ferments. I am incHned to think that the necrotic splinters of bone act deleteriously chemically rather than mechanically ; they always contain in the Haversian canals or in the medulla some decomposing organic substances ; all such necrotic fragments of bone have an ichorous smell if we extract them ; if the surrounding granulations become partially injured by the sharp edges of such a fragment of bone, the ichor from it enters the opened lymphatic vessels or perhaps also the blood-vessels, and thus excites not only local but also and at the same time general infec- tion. Necrotic shreds of tendons and fascia in the deep parts of suppurating wounds may be followed by the same consequences^ although this happens more rarely. Bare cases are met with, especially in hospitals, in which we are unable to recognise any of the above-mentioned causes; such occurrences then naturally excite unusual alarm, and it has been sought to explain them by an especially deleterious action of the hospital air, especially of such as is charged with the smell of pus. There are many reasons for doubting that the deleterious substances are in a gaseous form ; if the ventilation be good, the air in the hospital may be kept pure, and yet this does not prevent the evil consequences in question ; neither can we produce inflammations by any of the gases developed from pus or decomposing substances, except perhaps by sulphuretted hydrogen when taken up by water and iüjected into the subcutaneous cellular tissue. Putrid fluids and pus are not likely to be taken intentionally from one patient and placed upon the wounds of another. That the neighbour- hood of a wound may, under certain circumstances, be infected 218 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. by the pus of the wound and a fresh inflammation produced, has been mentioned above. There scarcely remains anything left us, therefore, except to assume that the substances thus acting deleteriously are dry and in the form of dust; they may, indeed, float in the air of the hospital, or they may exist in the dressiugs, the lint, or the compresses used for dressing the wounds, or on the forceps, sounds and sponges brought into contact with the wounds. Can it be fungi or any other organic germs of a nature hitherto inscrutable ? This is, indeed, possible, for every cubic foot of air occasionally contains a quantity of such organic germs, and in a hospital especially, such germs of organic beings of an animal or a vegetable nature may be developed and fixed in wound-secretions, sputse, excrements, and vessels containing urine, the more so the more such easily decomposing secretions and excretions are allowed to accumulate in ill-arranged privies, &c. Por the present we must be content with conjectures on this point. We can, on the other hand, experiment with dried putrid substances and dried pus, by reducing them to a fine powder and introducing them into the healthy tissues of animals. Such experiments have been made by O. Weber and me, and it has been shown by them that animal as well as vegetable putrid dried substances, and also dried pus, act phlogogenically under certain conditions ; if we pulverise these sub- stances, stir them quickly with a little water, and inject them into the subcutaneous cellular tissue of animals, we thereby cause pro- gressive inflammations just as with decomposing fluids and pus. That in a hospital such deleterious bodies in the form of dust may exist in the dressings, bedclothes, and perhaps on instruments, must, a priori, be admitted. In short, it is possible that the direct dele- terious effect of hospital air on many wounds depends upon the cir- cumstance that very fine putrid or purulent matters in the form of dust adheres to the dressing materials, or instruments, and that in them the ferments are contained. That deleterious, infectious matters may also enter the body otherwise than through wounds, especially through the lungs, can- not be doubted ; we explain to ourselves thereby, in fact, the origin of all infectious diseases, that substances find their way into the organism which act as organic poisons upon the blood and upon the whole organism; but whether these disease-elements which cause the infectious diseases occurring chiefly in the wounded enter the LOCAL INFECTION. 219 organism otherwise tliaii through the wound is a question the answer to which must depend very much upon the particular inter- pretation of the cases observed. We will return to this subject later on, in connection with incidental wound- diseases. You will probably believe that you have caught me contradicting myself as I told you in yesterday"? lecture that no molecular bodies enter the tissues through uninjured granulating surfaces. I must still assert this as holding good in ordinary cases ; a healthy^ un- injuredj granulating surface is an essential defence against infection through the wound. But if the infectious matter itself is extremely irritating, so that the granulating surface is destroyed thereby and decays, a way is thus opened for the entrance of the poison into the tissues. More than this ! there are certain matters which may be introduced from the pus-cells into the granulation-tissue, and per- haps still further. Strew the granulating surface in a dog with finely-powdered carmine, and some of the cells will take up the fine granules of carmine and enter with it into the substance of the granulations ; after some time, you find cells with carmine in the granulation-tissue. I regard this as an abnormal retrograde move- ment of the pus-cells;. concerning which we may otherwise assume that they advance from the granulation-tissue to the surface of the wound ; of course no one has seen this. In any case, however, the above experiment serves to explain that molecular bodies also can penetrate from without into the tissues of the edges of wounds, and when these matters are sharply decomposing or corrosive, or contain in themselves phlogogenic poisons, they will cause violent inflam- mation. These considerations will render you very anxious con- cerning the fate of the wounded, for an absolute defence against such dangers appears unattainable. But I must here at once remark for your consolation that not all the molecular organisms which are contained in the atmosphere by milliards flourish on wounds, and that they are not all phlogogenic. In my opinion, not every micrococcus acts phlogogenically as such, but only those which originated in certain products of inflammation in decompos- ing pus, in putrid urine, in decomposing-tissue fluids, and there took up the ferment. This, it is true, is the most common form of micrococcus which occurs in hospitals, and especial energy is, therefore, called for to prevent their development in such institu- tions. How this is to be effected will be stated further on. Febrile reaction in contused wounds is generally more violent 220 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. than in incised wounds ; this is, according to our assumption, explained by the fact that, in consequence of the decomposition which takes place to a much greater extent in contused than in incised parts, more products of such decomposition find their way into the blood. If the phlogistic and putrid poison possess espe- cially intense qualities in a given case, or if an unusual quantity of it be taken up (particularly in diffused septic inflammations), then the fever assumes the character of the so-called putrid fever ; the state of things brought about in this manner is called sejüoemia ; we shall occupy ourselves therewith more fully later on. If the inflammatory process becomes progressively suppurative from the wound onwards, a correspondingly persistent inflammatory or suppurative fever will be kept up ; such a fever has the character of 2ifebris remiitens, or in more severe cases, of 2^, febris continua remittenSj with very steep curves and occasional exacerbations, which are for the most part dependent upon progressions of the inflammation, or upon circumstances which facilitate the absorption of pus. If we speak of the fever which frequently accompanies the circumscribed traumatic inflammation, or perhaps must always accompany it, as simple wound-fever^ we may call the later occurring fever " secondary fever ^' or '^ suppuration-fever.'^ Such a fever may become associated immediately with the wound-fever, if the inflam- matory process become at once progressive ; but the wound-fever may have ceased entirely, the wound may have begun to heal, and if secondary inflammations such as we have just discussed in detail now attack the wound, fresh suppuration-fever is always combined with these; in short, inflammation and fever here always run parallel to each other. The fever, it is true, sometimes appears to precede the secondary inflammation, but this often results therefrom that the first and perhaps extremely slight changes in the wound have escaped observation. At all events, we must see the urgent necessity, on every fresh febrile movement which we observe in the patient, of searching for the inflammation-nest which may be the cause of it. Par be it from me to assert that it is necessary to mea- sure the temperature of all the wounded ; every surgeon experienced in the observation of patients will undoubtedly know how it stands with his patient without measuring the temperature, just as an expe- rienced physician can diagnose pneumonia without auscultation and percussion ; but, that taking the temperature is, under certain circumstances, a great aid in diagnosis and prognosis, no one doubts FEBRILE ACTION IN CONTUSED WOUNDS. 221 who has acquired a fitting knowledge of the import of the tem- perature of the body. It stands therewith as with every other aid to observation ; it is not difficult to detect dulness on percussion at a part of the chest where it ought not to exist, but to recognise the value of this dulness correctly in a given case is a thing that must be learnt; the same holds good also for observations of the tem- perature ; we must learn_, for instance, to recognise whether a low temperature in the case before us means good or evil. Experiences teaches us that secondary fevers are frequently much more intense than the primary wound-fever; while it very rarely in- deed happens that the wound-fever commences with rigors — shght shivering after great losses of blood and violent shocks is not usually accompanied by an increase of temperature — a secondary fever by no means unfrequently commences with severe rigors. We will here examine more closely this peculiar phenomenon. Eigors have always been regarded as a symptom essentially depen- dent upon blood-poisoning ; if we now conceive of fever in general as a state of intoxication, we must seek for some special cause of rigors. Observation shows that the rigors of fever, which are always followed first by heat and then by sweating, are always associated with a very rapid rise of temperature, and if we examine by the thermometer the blood-temperature of a patient during such rigors, we find that it is high and rises rapidly. The blood is driven out of the vessels of the surface into the internal organs, and Traube, as already remarked, attributes to this the abnormal febrile rise of the temperature of the blood. We will leave this an open question for the present, but, in any case, there occurs so great a difference between the temperature of the air and that of the body that the patient experiences a feeling of cold. If you draw off the bed- clothes of a fever patient who is lying wrapped up in bed and does not feel cold, he will at once begin to shiver and tremble. A man has a kind of conscious feeling for the state of equilibrium in which the temperature of his body stands to the temperature of the surrounding air ; if the latter be raised quickly he immediately feels more warmth, if it be lowered quickly he at once begins to shiver and tremble. This trival fact leads us to a further observation; this sensibility to warmth and cold, this conscious feeling of differences of temperature, differs greatly in individuals ; it may also be greatly increased or diminished by the mode of life ; some persons always feel too hot, others always too cold, while to others again 222 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. the temperature of the air is very much a matter of indifference. The nervous system plays a great part here. More minute studies by Traube and Jochmann have^ in fact, shown that the nervous excitability of the individual contributes greatly thereto to determine whether, with a rapid increase in the temperature of the blood, the change is felt very intensely or not, that, therefore, in torpid indi- viduals or in comatose conditions, rigors do not so readily occur in fever as they do in excitable persons already weakened by long-standing disease. I cannot do otherwise than confirm this from my own observations. Now if I am convinced in a general Avay that rapid increase of temperature accompanied by rigors occurs mostly where there is a sufficient degree of irritability if a considerable quantity of pyrogenic material is introduced suddenly into the blood, I am by no means prepared to deny that the quality of such pyrogenic material also enters into the question. Of this quality we know nothing chemi- cally, but we can assume differences in it therefrom that not only the febrile symptoms but also their duration often differ so much that this cannot depend solely upon differences of powder of resist- ance in the patient. According to my observations, absorption of pus and of perfectly fresh products of inflammation disposes much more to rigors than absorption of ichor, which otherwise acts much more dangerously and as a stronger poison. I do not wish to tire you with too many questions of this kind, and will, therefore, return to the subject in the section which refers to general incidental wound-diseases and diseases of inflam- mation, which you may regard as the continuation of these reflec- tions upon fever. I will only observe further that septic as well as suppurative primary and secondary inflammations may occur with incised wounds also, especially with greater operation-wounds, (after amputations and resections). If we have included the discussion of these conditions with contused wounds, this has been done because the latter much more frequently become complicated in the manner described than ordinary incised wounds. Let us now direct our attention to the treatment of contused wounds. A contused wound requires, in very many cases, no further treat- ment than an incised wound ; the conditions for healing without artificial aid are present in both cases. All that is required in the case of a contused w^ound is to obviate from the first, if possible. • TEEATMENT OF CONTUSED WOUNDS. 225- incidental damaging conditions^ or at least so to control them that they shall not become dangerous. We can do something in both respects. It has always been assumed, and that correctly^ that the air with its oxygen and its ferments very especially faciUtates the decomposition of dead organic substances and therefore also of contused parts ; to act preventively in this respect means^ to close the wound against the air and, for the purpose of avoiding warmth also as a promoter of decomposition, to place the injured part in a cold temperature. We attain both these objects simultaneously if we place the injured parts in a vessel containing cold water, the temperature of which we can regulate by adding pieces of ice as required. This treatment is called '^^ immersion " or the "cold continuous water-bath ;" I first saw it employed with excellent results by my earliest surgical teacher Baum, in Göttingen ; it is only really applicable for the extremities, for the leg as far as the knee, for the arm somewhat above the elbow. A suitable arm- or foot-pan filled with cold water is placed in the patient^s bed and the injured extremity is left constantly day and night therein. The patient must be placed in such a position that he can lie quite comfortably, and that the limb is nowhere pressed upon by the edge of the pan ; this is easily done, and you may see such appa- ratuses in my clinique. Tor injuries of the hand, which are the most frequent, a mug with cold water suffices in private practice. Tor parts which we cannot keep in this simple way in cold water, we seek to prevent the access of atmospheric air by putting on moist linen compresses, which may easily be adapted to the injured part; upon these is placed an india-rubber bag, (or in place of this a pig^s bladder), filled with ice, which is to be renewed as the ice melts. It is still more effectual to pack a limb completely hi ice in a pan, after wrapping it up in thick folds of linen. A third method of applying cold water is the so-called irrigation. For this, special apparatuses are required ; the injured extremity is placed in a tin trough which has an escape pipe. Above the limb an apparatus is fixed from which cold water drops continuously from a moderate height upon it. Lastly, we may simply cover the wound from time to time with fresh compresses which have been dipped into iced water. I have become familiar with all these modes of treatment in practice ; not one of them acts with certainty prophylactically in 224 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. my opinion ; in contused wounds of the hands and feet,, the water- bath is the most effectual, since extensive after-suppurations very rarely occur with it. If we would obtain the same favorable results with the ice treatment, we must cover not only the wound but also the whole neighbourhood of it with ice bladders, i. e. pack it in ice. With the use of cold compresses we shall only produce sufficient cold effect by renewing them every five minutes, for they become w^arm very quickly, and the usual treatment with cold applications means but little more than keeping the surface of the wound moist ; this is, therefore, strictly speaking, not a special mode of treatment, but the majority of small contused wounds heal spontaneously in this way, as I have already remarked, without being brought by cold under unnatural conditions. Irrigation is not a bad mode of treatment, but very troublesome, and it is fre- quently very difficult to prevent the bed from becoming wet with it ; the behaviour of the wound does not differ in its further course from that with the more simple immersion, or ice treatment, so that I have not taken occasion to occupy myself further with irrigation. In Prance this method is employed by many Paris surgeons and held in great esteem. I have still some special observations to make concerning the water-bath, since we are leaving entirely out of the question here wounds of bones and joints. I know of no coutra-indication for con- tused wounds of the hand, forearm, foot, or leg; in the majority of cases the hsemorrhage is so slight in these injuries, and so soon ceases of itself, that the patient may very soon, often immediately after the injury, immerse the limb in cold water without there being any danger that hsemorrhage will occur ; but the blood adhering to the injured part must be removed previously, tlie water itself be perfectly clear and transparent, and if it become turbid from the wound secretions must be kept clear by being changed frequently. Also if the injury be of two or even three days' standing, the water bath may still be employed with advantage; after this it is of little use. If the patients lie conveniently in bed with the pans, they are more content and freer from pain with this treatment than with any other. As regards the temperature of the water, it may vary greatly without producing any considerable change in the state of the wound ; only the ice temperature and the very high temperatures attainable with poultices produce a somewhat dif- ferent appearance of the wound. With temperatures from 54'5° TREATMENT OP CONTUSED WOUNDS. 225 to 93*75° and 99*5° the wound presents no difference of appear- ance ; perhaps at the higher temperatures suppuration is set up someivhat more rapidly^ but the difference is certainly very sHght. It follows from this that we may adapt the temperature to the wish of the patient. On an average, patients at first prefer a cooler temperature (54*5° to 6675°), later on a warmer one (87 "5° to 95°), but there are patients who complain of shiverings on the first day if the temperature of the water sink below 66*75°. We see from this that it is not of much importance whether we employ the so-called 2var7n or cold water-bath. In some individuals an incon- venience arises on the third or fourth day which renders immersion unbearable to a few of them, viz. the strong swelling of the epi- dermis of the hand or foot, and the sensations of tension and burn- ing which accompany it and somewhat resemble the effect of a blister ; the thicker and more callous the epidermis was, the greater this inconvenience becomes, but it may be prevented by rubbing the injured hand with oil before placing it in the water, and by throwing into the water a handful of salt, which does no harm to the wound. One important question is : how long shall the continuous immersion be employed? Only by the aid of a pretty extensive experience can one lay down rules for this. I have found that from eight to twelve days of continuous immersion suffice. After that time the limb is no longer kept in the water during the night, but is wrapped in a wet cloth, over which oiled silk is placed and kept in position ; a few days later, this latter treatment suffices also during the day, while the water-bath is used morning and evening, or in the morning only, that the wound may be bathed and cleansed for half an hour or an hour. Finally, we discard the water altogether and treat the granulating, cicatrising wound according to the simple rules already laid down. The changes which take place with this treatment of the wound differ somewhat from those described previously ; in the first place, everything goes on much more slowly ; it sometimes happens, especially with the cold water-bath treatment, that the contused wound looks as fresh after four or five days as if it had been made quite recently ; we observe the same thing also for a considerable time with the treatment with bags of ice. This is not so remark- able as it at first appears, since experience has shown that the decomposition of organic matter proceeds more slowly in deep P 226 CONTUSED AND LACEEATED WOUNDS OF SOFT PAETS. water than in the air. Later on, the pus usually remains lying as a flaky, semi-coagulated layer upon the wound and must be washed or syringed off that we may see the granulations beneath it, which are often watery and rather pale. This examination is of great importance and saves us from illusions concerning the efficacy of the water-bath in cases of suppuration in deep cavities, for we might think that the pus would flow from the wound directly into the water and become diffused in it, so that it would only be necessary to place the suppurating part in the water to keep it clean. The water-hath does not favour the escape of the pus at all, is, in facty preventive of it ; the pus formed on the granulating surface or in the cavity coagulates at once in contact with the water and remains, for the most part, lying in the wound ; washing or syringing is required for its removal ; by the swelling of the granulations the escape of the pus from the deeper parts of the cavity is rendered altogether impossible. It follows from this that in cases with suppurating cavities the water-bath is of no value whatever, but rather does harm, and that a limb with a contused wound must be taken out of the water as soon as deep, progressive suppurations commence from the wound, but a temporary foot- or arm-bath for half an hour is not interdicted. If no progressive processes of suppuration are set up, and we leave the wounds two, three, or four weeks in the water, no especial harm will result therefrom, but the healing process will be very much protracted ; the parts continue much swollen in the water, the granulations are watery (rendered oedematous artificially) and pale, while the cicatrisation and contraction of the wound does not commence. If you now take the limb out of the water the wound soon contracts, in a few days the granulating process appears stronger, the pus more healthy, and the healing process advances. I must now say a few words concerning the continuous ice- treatment I will assume that you have covered the contused wound at once with bags of ice. Here also you will find that the throwing off of the contused parts goes on very slowly and tha?t no bad smell becomes developed in the wounds, unless large portions of tissue should become gangrenous. To prevent stench altogether, if possible, I first place upon the wound Hnt steeped in chlorine water and renew it frequently. If we continue this treatment for four or six weeks, all the necessary processes in the wound will go on slowly and sluggishly ; in like manner also the cicatrisation and ■DEAINAGE. 227 contraction of the wound occurs very slowly under the influence of the ice^ and this method will, therefore, be unsuitable wherever it is desired to expedite the definitive healing process. Most surgeons are of opinion that, by ])laciDg bags of ice upon the fresh wound^ we can prevent violent inflammations. You will therefore find that, in the majority of contused wounds, ice is at once placed upon them. This is sometimes very acceptable to the patient because it relieves pain, but its prophylactically antiphlogistic effect is, in my opinion, very slight. Tor centuries already men have sought for such a remedy, as well as for a prophylactic in inflammations of internal organs. By the application of ice to fresh wounds we can neither prevent entirely ichoro-serous infiltration nor suppurative inflammations ; such, at least, is my opinion ! Many believe, as already remarked, in the prophylactic effect of ice, and are con- vinced that with this means alone they can save persons severely wounded. I have become convinced that the dangerous incidents affecting wounds not unfrequently occur in spite of ice and are often absent when ice is not used, although the nature of the injury would lead us to expect them. We can by no means always succeed, with the aid of cold, in preventing the extension of the suppurations proceeding from wounds; sometimes the oederaatous skin becomes more and more red and painful, and if you make pressure upon it, there flows slug- gishly from some corners of the wound pus which is often thin and serous, but sometimes also tolerably consistent. Under such cir- cumstances, an escape must be provided for the retained pus, especially if it be ill- smelling or ichorous, so that it may come away easily, and for this purpose it is often necessary to make pretty deep incisions in the soft parts, and to keep them open. When this must be done, how we can best set about it in individual cases, and where incisions must be made, all this you must observe and learn in the clinique. For sounding such suppurating cavities I prefer a slightly bent silver catheter, which I introduce from the wound to the bottom of the suppuration-canal, then press the point from below against the skin and there make the incision. For the extension of these so-called counter- opening Sj as well as of other wounds, a knife is used which is pretty long, straight or bent^ and provided with a knob at the point {Pott's knife). These counter- openings should, in general, not exceed o'8 inch in length, but when necessary, several of this length may be made; it is not 228 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. advisable, without urgent cause, to lay open the soft parts of the whole forearm or leg longitudinally, as was taught formerly, because* the skin afterwards contracts so much that the healing of the wounds eventually requires an unusually long time. To prevent the new openings from closing up again quickly, which however seldom happens, you may draw a number of silk threads through the suppuration -canals, tie them together and leave them for a short time. Instead of these setons of silk threads or strips of linen, drainage-tubes of india rubber have been used recently, as mentioned above. When making such counter-openings, you will not unfre- quently meet with dead tendons, or shreds of fascia, or foreign bodies. These must be removed. Many of our former colleagues would have shaken their heads dubiously if they had heard that we had spoken so much at length of the treatment of contused wounds and secondary inflammations without saying anything about poultices. Tempora mittantur ! I^ormerly, poultices belonged as certainly to suppuration wounds as a lid to a box, and now ! years have passed in my wards in which poultice cakes have not once been applied to their original purpose ! The employment of moist warmth, whether in the form of poultices, or of thick cloths steeped in warm water, is incapable of arresting the progress of suppurations in the cellular tissue ; with long con- tinued use of moist warmth, granulations assume a flabby appear- ance, the soft parts swell greatly, and the healing process is not promoted. Moreover, poultices can only act energetically as moist warmth when they are renewed frequently ; the employment of them is troublesome ; they readily become sour, and sometimes they are burnt, and the whole mess cannot be properly looked after in a hos- pital ; one poultice, covered with pus, is taken oif, fresh pulp is put in and often immediately used for another patient. In many hos- pitals, at least one half of the surgical patients have poultices; hundredweights of the various poultice-materials are consumed every month in the surgical wards. In my division they are almost entirely banished ; I will give you, at the right moment, the cases in which we may still use them with advantage. Little, therefore, as I can recommend the use of moist warmth as an ordinary mode of treatment of wounds, I still regard it as very suitable in all those forms in which an extensive, hard (fibrino- diphtheritic) infiltration of the cellular tissue exists. In these cases the moist warmth is not only agreeable to the patient, because it OPEN TREATMENT OF WOUNDS. 229 renders the tense skin soft and pliable, but it also appears to favour the resolution of the coagulated products of inflammation, either because they may become absorbed, or because they must be thrown off with the necrotic tissues with copious suppuration. I employ, in such cases, wrapping up in warm, moist cloths, over which a waterproof covering is placed. I have not said anything of the necessity of absolute rest for any injured part of the body ; it may appear extraordinary to you that I should speak of this at all, as it would seem to be a matter of course. I attach very especial importance to it, for since delete- rious substances may be taken up from the wound into the blood, every muscular movement in itself, as well as every congestion in the wound occasioned thereby, in short, everything which gives an impetus to the stream of the blood and lymph in the neighbourhood of the wound, may eventually prove detrimental. Further, the raised position for the injured part is also not to be neglected when it is practicable. That gravitation plays an impor- tant part in the movement of the blood is easily proved ; let one of your arms hang down loosely by your side, without any muscular tension, for about five minutes, and you will feel a distinct sense of weight in the hand, while the veins on the back of the hand will be seen to be much swelled ; if, on the contrary, you keep the arm for some time raised in the air, the hand will become pale and thmner. So long as weakly persons remain in bed in a horizontal position, they will appear, for instance, much fuller in the face than if they had held the head upright during the day. For inflammations of the hand, Yolkmann has recently recommended very strongly verti- cal suspension of the arm as a powerful antiphlogisticum ; I also have employed this method in consequence thereof, and found it very efficacious in cases of inflammations of the skin, but for deep- seated inflammations of the wrist-joint it appears less useful. Perhaps, in the future, the water-bath, the ice treatment, and poultices will fall more and more into the background in presence of the open treatment of wounds, from which I have seen very good results in contused wounds as well as in incised wounds with cavities, and in presence of the Lister method of treating wounds, about which all those are enthusiastic who have had frequent oppor- tunities of employing it for contused wounds. The so-much dreaded access of air to the surface of a wound, even of the air in ill-ventilated hospital wards, is not, in my opinion, so deleterious 230 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. as dressings and sponges of doubtful cleanness. The assertion that air is detrimental to suppurating wounds rests mainly upon the observation that tlie access of air to the cavities of abscesses with rigid walls and to serous sacs generally causes an increase of the suppuration. Apart therefrom that in many of these cases it is by no means proved that it is always precisely the access of air which causes an exacerbation of the process of inflammation, the circum- stance especially in fault is, that the air in suppurating cavities is warmed by the temperature of the body and charged with watery vapour from the pus. This confined air now becomes a regular breeding place for those minute organisms with the increase of which decomposition-ferment so rapidly increases, and which are, indeed, always contained in greater or less number in the air. Every observant housewife knows that pieces of meat hanging in a draught of air keep better than pieces of meat put into a cupboard and covered, even if the air in the latter is kept cool by ice. Air moving freely and becoming changed causes no inflammation in wounds ; confined air is, no doubt, very dangerous. That a wound ireated/rom the first by the open method has no bad smell, unless larger shreds become gangrenous in it, I have stated already ; that is also the reason why flies do not make use of these open wounds for depositing their eggs upon them, while they readily creep into the] dressing for that purpose. I must confess that I was very agreeably surprised by these observations, because I feared that the flies would render the open treatment of wounds in summer impos- sible. The longer I carry out the open treatment of wounds the more satisfied I am with it ; you will yourselves have opportunities for convincing yourselves of tliis in my clinique. No method of treatment of wounds furnishes an absolute guarantee against inci- dental wound-diseases; each method must be studied. Thus, in the open treatment of wounds, superficial adhesions of individual wound-pockets may take place, in which decompositions of secre- tion [develop themselves ; we must know how to recognise such conditions early and to obviate them. Many surgeons now strongly advocate the method of the occlu- sion of wounds by thoroughly disinfected dressings and early intro- duction of drainage tubes to carry off" the wound secretions, and by the application of antiseptic dressing-materials after the methodical instructions of Lister. It is asserted that by this method an equally mild course is PROPHYLAXIS AGAINST SECONDARY INFLAMMATIONS. 231 obtained as in subcutaneous contused wounds, tbat the dead shreds of tissue do not become decomposed, but shrink up without stench and are thrown off with very Kttle suppuration, that the clots of blood either become organised directly, or pass out of the wound in the form of inodorous, grey fragments, that acute septic, or pro- gressive, suppurative inflammations never occur with it, and that the severe, incidental wound-diseases, of which we shall speak later on, never become developed with it. I cannot do otherwise than recommend strongly to you the employment of this method. Generally speaking, I recommend you as well for the period of your studies as for your future practice to study and observe thoroughly one of the methods of treatment recommended to you, to master one thoroughly, and not to allow yourselves to become unsettled in your principles of treatment without strong cause, or to be led into too frequent change by every new fashion. As regards the treatment of secondary inflammations, a careful prophylaxis is first of all to be recommended ; avoidance of con- gestive states of the wound, of taking cold, of all mechanical or chemical irritation, and above all, careful avoidance of infection. What can be effected in the latter respect by ventilation and the proper use of disposable spaces in a hospital will be spoken of later on when we deal with incidental wound-diseases in general. Por avoiding local infection of the wound by dressing-materials or in- struments, the following must be borne in mind. We must be very careful about the dressing, the cleansing of the wound, and the choice of compresses, lint, and wadding ; in this I can put up with any amount of pedantry ; we must see to the greatest cleanliness in the mattresses, straw-bags, bed-clothes, oiled silk, in short, every- thing about the patient. The bleeding of the wound while the dressing is being applied is easily avoided by the new methods in use. We sprinkle all the parts of the dressing-material with a solution of chloride of lime, carboHc acid, or other antiseptics ; for the removal of pus, sponges should never be used, nor, in operations, more than can be avoided ; cleansing should be eff'ected by syringing, or with wadding sprinkled with antiseptic solutions. If we are compelled to use sponges, we should take new ones and disinfect them at once with hy permanganate of potash or carbolic acid. In the chlorine water (equal parts of aqua chlori and water), or in the solution of chloride of lime (lo parts of chloride of lime dissolved in 500 parts of water and filtered), no organic bodies 232 CONTUSED AND LACEEATED WOUNDS OF SOFT PARTS. subsist permanently at the ordinary temperature of a room, any more than in alcohol, lead-watee, the solution of acetate of alumina (alum 20 parts, acetate of lead 35 parts, water 400 parts, filter, according to Burow sen.), in salts of sulphuric acid (sulphate of soda 50 parts, glycerine 250 parts, water 450 parts), or the stronger solutions of hypermanganate of potash. Lister recom- mends carbolic acid as an especially efficacious antiseptic ; it may be diluted with oil (5 per cent.), with glycerine or water (from I to 5 per cent.), and the carbolic oil may be made into a paste with scraped chalk, then spread upon tin-foil and the wound shut off from the air therewith. " Deodorising powder,^' i. e. coal tar mixed with sulphate of lime (gypsum bituminatum) strewed dry upon ichorous wounds, is a very useful preparation for wounds that are not too deep. You must pay especial attention to the cleanliness of the instru- ments with which you touch the wounds, to the sounds, forceps, knives, scissors ; everything must be wiped before the operation, or if suspicious, rubbed with cleansing powder. It requires the full, internal conviction of the necessity of all these precautions to induce us to take them. Lister^s method gives distinct, detailed instruc- tions on all these points. If, in spite of every precaution, decomposition, gangrene, or phlegmonous inflammation occur in contused wounds, or in their vicinity, we must abandon the dressing with the protective imme- diately upon the wound. We must enlarge all the wound and pus cavities, and fill them up with pads of lint or wadding which have been steeped in a strong, antiseptic solution. After many experi- ments I always return to the use of acetate of alumina; it acts very energetically for drying up and deodorising, without replacing the ichorous smell by another equally disagreeable. It is true that the dirty blackish- grey colour which results from the formation of sul- phuret of lead from the sulphuretted hydrogen of the ichorous pus and the lead contained in the antiseptic solution is an unpleasant but harmless concomitant. Until the acetate of alumina has thoroughly penetrated the mortified shreds of tissue, the dressing must be changed frequently, or the solution of the acetate poured every two hours upon the lint lying in the wound. When the wound begins to cleanse itself, dressing once a day suffices : upon simple, granulating wounds the acetate of alumina has too drying an effect and also causes irritation and pain. We then pass on to INTERNAL TREATMENT OF THE SEVERELY WOUNDED. 23S dressings with the protective^ and finally to dressings with simple ointment. After the acetate of alumina, solutions of chloride of lime act most powerfully, but since their antiseptic effect depends upon the development of chlorine alone, it is temporary only^ and these dressings must be changed frequently to effect good deodo- rising or disinfecting results. Glycerine is a very good disinfectant and acts extremely well if poured freely upon the dressing every two hours. If applied to wounds in large quantity from the first, it extracts so much water from the necrosed shreds of tissue that no foul smell arises; if decomposition has already set in, it acts very slowly as a deodoriser ; after three or four days^ free application, wounds often become so red and sensitive that the use of it must be stopped. Solutions of chloride of zinc are also recommended for washing out ichorous cavities ; I have often found the superficial cauterising action to be very transient. Concentrated solutions of carbolic acid in oil or water (5 per cent, and more), frequently have a very acute, alarming^ poisonous effect when apphed to large surfaces, and are not so effi- cacious as acetate of alumina for deodorising and drying up necrosed tissue. I have had no experience of the antiseptic value of the salicylic acid recommended by Kolbe and Thiersch, or of the sulphate of soda so highly spoken of by Polli and Minnich. Are we to prescribe for our patients in such cases anything beyond cooling drinks and medicines, regulation of the diet, &c. ? The remitting fever not unfrequently accompanying such suppura- tions makes the patient languid, low-spirited, and often sleepless. Two remedies are here suitable : quinine and opiates — quinine as tonic and febrifuge, opium, and particularly morphia, as narcotic, especially in the evening, to procure rest during the night. I usually adopt the following plan with such patients. So long as there is little or no fever with progressive suppurations, I give nothing ; if there is much fever towards the evening, I give in solution or powder during the afternoon, one or more doses of quinine (about 4^ grains to the dose), and at bedtime gr. /^ths — -j\jtl^s of muriate of morphia or gr. i4^th of opium. As soon as the fever ceases I omit these remedies. You should be espe- cially sparing of the opium when it is not required, because it occasions constipation. Yet a few words now concerning lacerated toounds. These are generally of less serious import than contused wounds^ and that 234 CONTUSED AND LACERATED WOUNDS OF SOFT PARTS. because they are, for the most part, more observable, and we have no reason to fear that the injury extends deeper than we can recog- nise ; we see how far and where the skin, muscles, nerves, and ves- sels are torn. Heahng by the first intention may be tried and not unfrequently succeeds, while the edges of the wound are often viable ; suppuration will, it is true, generally occur. But stop ! not always are the lacerations exposed to view ; there are also subcuta- neous ruptures of muscles, tendons, and even of bones, although there has been no contusion. Some one wishes to jump over a ditch and takes the necessary run, but fails to get over, falls, feels severe pain in one leg, and limps with it. We examine him and find immediately above the tuberositas calcanei a hollow into which a thumb may be placed, the movements of the foot are imperfect, especially extension. What has happened ? Through the violent muscular action the tendo Achillis has been torn away from the calcaneus. Something similar occurs with the tendon of the quadriceps femoris at its attachment to the patella, with the patella itself, which may be torn through in the middle, with the liga- mentum patellae, with the triceps brachii, which becomes torn away from the olecranon, and generally takes with it a piece of the latter. These are some examples of the subcutaneous rupture of tendons ; I have seen subcutaneous rupture of the rectus abdominis muscle, vastus externus cruris, and other muscles. Simple subcutaneoiLs ruptures of muscles are not serious injuries; they are easily recognised by the disturbance of function and by the visible and still more palpable hollow which shows itself at once but afterwards becomes masked by the extravasation of blood. The treatment is simple : rest for the parts, which must be placed in such a position that the ruptured ends may be brought into con- tact by relaxation of the muscle, cold compresses, applications of solution of lead for some days ; after eight or ten days the patients can generally get up again without pain. A band of connective tissue is formed at first, which soon becomes so thickened by short- ening and shrinking that a firm, tendinous cicatrix is formed ; the course is exactly the same as after the subcutaneous division of tendons, of which I shall speak later on in the chapter upon contractions. Disturbance of function rarely results to any considerable extent, but there is sometimes a slight weakness in the limb and loss of the more delicate movements, especially in the hand. LACERATED WOUNDS, ETC. 235 Tig. 46. Fig. 47. Fig. 48. Fig. 46.— Middle finger torn out with all its tendons. Fig. 47. — Proximal end of brachial artery (torn through). Fig. 48.— Arm torn out with scapula and clavicle. 236 CONTUSED AND LACEEATED WOUNDS OF SOFT PARTS. To cause subcutaneous ruptures of muscles and tendons of this kind by crushing^ powerful crushing forces would be required ; such a contusion would probably run an unfavorable course ; extensive suppurations and necrosis of the tendons might well be looked for. You see in this case also how different may be the course in inju- ries apparently similar,, according to the manner in which they have been occasioned. In injuries by machinery there is often such a strange combination of contusion, twisting, and laceration, that a prognosis of the course of such cases is often very difficult even for a surgeon of great experience. Especially worthy of mention is the generally favorable course when smaller or even larger members are torn out, as e. g., the hand. I have seen two cases of tearing out of fingers, one of which I will describe to you shortly : — A bricklayer was working upon a scaffolding and suddenly felt it fall from under him ; from the roof of the house against which the scaffolding had stood hung down a loop of rope ; the falHng man caught hold of this, but only succeeded in seizing it within the loop with the middle finger of the right hand ; he hung thus for a moment and then fell to the ground, but fortunately the distance was so short that he did not sustain any injury therefrom. He had lost the middle finger of the right hand, however, which had been torn out between the first phalanx and metacarpal bone, and left hanging in the rope. Attached to the finger were found the tendons of the two flexor and of the extensor muscles. The man dried the finger and tendons and afterwards carried it in his purse as a memento of the event. I saw a perfectly similar case in the clinique at Zurich (fig. 46). The healing process went on without any serious inflammation of the forearm, and did not really require any artificial help . I also saw two cases of evulsion of the hand in Zurich; in one of these sufficient skin was left to admit of spontaneous healing, in the other amputation of the forearm was necessary. Both cases termi- nated favorably. It sometimes happens in war that arms and legs are torn away at the joints by large cannon-balls. I have also seen a case in a boy of fourteen in which the right arm was so completely torn away from the chest with the scapula and clavicle that it was only attached at the shoulder-joint by a bridge of skin two inches broad (fig. 48). The axillary artery did not give a drop of blood ; the extremity was closed by torsion (fig. 47). The poor boy died soon after the injury. Evulsions of whole extremities are generally soon fatal ; a LACEEATED WOUNDS, ETC. 237 considerable number escape, however. A pupil of mine, Dr. Pernitza, railway surgeon in Yienna, recently showed me a powerful young man who had had the whole of one arm torn off with the clavicle but without the scapula ; the healing process went on uninterruptedly. LECTURE XIV. CHAPTEE Y. ON SIMPLE FRACTURES OE BONES. Contusion and Concussion of Bones , various kinds of Fractures. — Symptoms, method of diagnosis. — Cottrse and pJienomeiia recog- nisable exteriorly. — Anatomical character of healing process and callus- formation. — Sources of ihe inUam^natory process of ossification, histology. Gentlemen, — We have hitherto occupied ourselves exclusively with injuries of the soft parts ; it is time for us to pay some atten- tion to the bones. You will find that the processes which nature estabhshes to attain here also, as far as possible, the restitutio ad integrum, are essentially the same as those with which you are already familiar. The circumstances are, however, more com- plicated, and can only become intelligible if we already fully under- stand the healing processes in the soft parts. Every layman knows, in a general way, that bones may be broken and become healed quite solidly ; this can only happen by the aid of bony matter, as you can easily recognise a priori, and hence it follows, further, that bony tissue must be formed anew therefor; the cicatrix in the hone generally consists of hone : a very important fact, for if it were not SO5 if the fractured end only became united by connective-tissue, then would the long cylindrical bones especially not become firm enough to support the body, and many persons would continue to be cripples for the rest of their lives in consequence of the simplest fractures. But before we follow the processes of the healing of bone into their minutest details — a study always prosecuted with great interest by surgeons — I must point out to you many things concerning the causes and symptoms of simple fractures of bone ; SPECIAL CAUSES OF FRACTURE OF BONE. 239 I say ^^ of simple or subcutaneous fracture of hone" as con- trasted with fractures complicated with wounds of the soft parts. Man may come into the world with bones already broken ; the bones of the foetus may break in the womb either from abnormal contractions of the womb itself, or from blows or pushes during pregnancy, and such an intra-uterine fracture generally heals with considerable dislocation ; the vis medicatrix oiaturce is, as we shall also see on other occasions, more skilled in internal medicine than in surgery. Fractures of bone may naturally also occur at any age, but they are most frequent from twenty-five to sixty years of age, and that for the following reasons. The bones of children are still pliable and therefore do not break so easily ; if a child falls, it does not fall heavily. Old people have, as it is expressed in ordinary language, brittle, friable bones, i. e., anatomically speaking, at an advanced age the medullary canal becomes wider, the cortical substance thinner ; but old people are seldom in danger of having their bones broken, because they are prevented by their want of strength from doing heavy or dangerous work. The age at which working men are compelled to undertake hard work is the period during which there is most frequent opportunity for injuries generally and espe- cially for fractures. That fractures of bone occur so much less fre- quently in women than in men has its cause in the nature of the occupations of the two sexes, as it is easy to understand. It likewise depends upon purely external circumstances that the long cylindrical bones of the extremities, especially those of the right side, break more frequently than the bones of the trunk. That diseased bones and such as are weak in themselves should break more easily than healthy bones is a matter of course ; certain diseases of bones dispose to fracture_, therefore, especially the so- called " English disease or rickets,'^ which depends upon defioient deposition of salts of lime in the growing bones and occurs in children only ; further, softening of the bones or " osteomalacia," which results from abnormal widening of the medullary canal and thinning of the cortical substance and which, when highly deve- loped, is accompanied by perfect softness and pliability of the bones. The two following are more special causes of fractures of bone : I . External violence, the most frequent cause ; the action may differ as follows : the force, e. ^., a blow or thrust, affects the bone in such a manner that the latter is crushed or split exactly at the 240 ON SIMPLE FRACTUEES OF BONES. point of impact; here the force has caused the fracture directly ; or the bone, especially if it be a cylindrical one, is bent beyond what its elasticity admits of, and breaks like a stick which is bent too much; here the force acted indifectly only upon the point of frac- ture. With the latter mechanism you may put in the place of the single cyHndrical bone an entire extremity, or the vertebral column as a whole, regarding them as flexible to a certain extent, and carry over thereto the conception of the indirect effect of the force. Let us take a few instances of this : if a heavy weight fall upon the forearm when at rest, the radius and ulna are broken by direct force; if a man fall upon his shoulder and his clavicle be broken obhquely at its middle, this fracture is caused by indirect force. In both these forms of injury there is generally contusion of the soft parts; in the latter case, however, more or less distant from the point of fracture, in the former, at the point of fracture itself, which is, of course, to be regarded as somewhat more unfavorable. In a case of powerful direct action of force upon a bone it does not always follow that a fracture will be produced; it is in itself evident that a long series of injuries must exist, from contusion of the periosteum to complete crushing of the bone. Now, the periosteum was perhaps strongly crushed, or the bone was, at the time of the accident, also somewhat compressed, but recovered by its elasticity the normal shape, while the bony tissue was nowhere broken into. The medulla may here have been greatly contused. Lastly, sHght injuries may have occurred to the spongy portion which are not always set right entirely, although the form of the cortical substance is not visibly changed. All these direct injuries to bones caused by strongly compressing forces are included under the name of contusion of hones. Concussion of a lone may be occasioned as well by direct as indirect force, and have as con- sequences lacerations of the medulla with extravasations of blood. Pain and disturbances of function will be more severe after these injuries than after injuries to the soft parts ; a certain diagnosis of the degree of the force-effect can often be formed only from the further course of things. Concussions of bone with contusions, especially, e.g., a fall upon the great trochanter, are often followed by long-continuing ostitis, which does not, indeed, often terminate in suppuration, but in the formation of osteophytes, sclerosis, and, in persons of advanced age, long-continued, sometimes permanent disturbance of function. VAEIOUS KINDS OP FRACTUEES. 241 2. Muscular contraction may, although under rare circumstances, be the cause of fracture : as I pointed out to you already in connection "with subcutaneous laceration of muscles, the patella, the olecranon, or a part of the calcaneus may be broken off by muscular contraction. The manner in which bones break in these different applications of force is very varied, but some types exist with which you must become acquainted : firstly we may distinguish between incomplete and complete fractures. Amongst the incomplete fractures again we observe different forms : fissures, i. e. cracks, tears ; these are most frequent in the flat bones, but are also met with in the cylindrical bones, especially as longitudinal fissures in connection with other fractures ; the fissures may gape or appear Hke a simple crack in a glass. Infraction, or crooking, is a partial fracture, which generally occurs only in the very elastic, soft, and especially rachitic bones of children ; you may most easily imitate this form by bending the shaft of a quill until the concave side of it gives way ; in the clavicle also such partial fractures are not uncommon in children. What is understood by chipping off is also evident ; knives belonging to machinery, sabre-cuts, &c., are the most frequent causes thereof. Lastly, the bone may be perforated although its continuity is not interrupted, as in a wound with a pointed instrument through the scapula, or a clean shot through the head of the humerus ; the latter form of injury is usually called a jperfo rated fracture. In the case of complete fractures we speak of transverse fractures, oblique fractures, longitudinal fractures, serrated fracttor es, simple and multiple fractures of the same bone, and comminuted fractures: expressions which are all intelligible in themselves. Lastly, we must mention that in certain individuals, up to about the twentieth year, an interruption in the continuity of the cartilages of the epiphyses may occur, although this is very rare and the cylindrical bones much more readily break at another point. It is often easy to recognise whether a bone is broken, and the diagnosis can be made with certainty by laymen ; in other cases, the diagnosis may be very difficult, sometimes, indeed, we can only conclude upon the probability of a fracture. Let us go through the symptoms briefly one after the other. rirst of all accustom yourselves to begin by looking at every in- jured part closely and comparing it with the sound one; this i.s Q ■242 ON SIMPLE FRACTURES OF BONES. especially important with the extremities. You may frequently recognise, by the mere observation of the injured extremity, what the injury is. You ask the patient how the injury occurred, caus- ing him, meanwhile, to be undressed carefully, or if this gives too much pain, having the clothes and boots cut off, so that you may see the injured part plainly. The manner and force of the injury and the weight of the object which may have fallen upon the part will already give you an approximative idea of what you have to expect. If you find the extremity crooked, the thigh, for instance, bent convex ly outwards and swollen, if livid spots show themselves at the same time beneath the skin, and the patient cannot move the limb without great pain, you may conclude with certainty that a- fracture exists. You here require no further examination to establish the simple fact of the bony fracture and need not for that purpose put the patient to pain. But to ascertain the position and direction of the fracture, you must examine it with your hands. This is necessary less on account of the treatment to be adopted than to enable you to predict whether and how a cure may be effected. In such a case you have formed your diagnosis at a glance, and it will often be easy for you in surgical practice thus to ascertain the true state of things if you accustom yourselves to a thinking use of your eyes, and if you acquire a certain readiness in judging of the normal outhnes of the body. You must, nevertheless, under- stand quite clearly how you have come to this rapid diagnosis. The first thing was the nature of the injury, plus the deformity ; the latter depends thereon that the two or more fragments of bone have got out of their right places. This dislocation of the fragments is the consequence, partly of the injury itself (the fragments are